CH 8 Female MDT Flashcards
Fibrocystic condition
Painful breast masses are often:
Multiple and bilateral
Fibrocystic condition
Pain often worsens during:
Premenstrual phase of the cycle
Fibrocystic condition
What is considered a causative factor?
Estrogen
Fibrocystic condition
Increased risk in women who:
Drink alcohol
Most frequent lesion of the breast
Most common age is 30-50
Fibrocystic condition
Symptoms:
- Breast pain or tenderness
- Discomfort worsens during premenstrual cycle
- Fluctuation in size of masses
- Multiple or bilateral
- No lymphadenopathy
Fibrocystic condition
Imaging for fibrocystic condition
Mammography
U/S (Used alone when patient is <30 y/o)
Diagnostic testing for fibrocystic changes
Core needle biopsy
All suspicious lesions should be biopsied by a:
General Surgeon
Treatment for mild to moderate discomfort from fibrocystic changes
NSAIDs
Patient education for fibrocystic changes
Avoid Trauma
Wear supportive bra night and day
Decreasing dietary fat intake
Consider eliminating caffeine
Vitamin E, 400IU Daily
Monthly self exam just after menstruation
Common benign neoplasm occurs most frequently in young women
Usually within 20 years after puberty
Fibroadenoma
Symptoms:
- Round/Ovoid
- Rubbery
- Discrete
- Relatively moveable
- Nontender mass 1-5 cm in diameter
Fibroadenoma
Imaging for Fibroadenoma
U/S
All breast masses should be referred to _________ for further evaluation and work up
General Surgery
Breast mass
Biopsy is negative, what is the next step of treatment?
No treatment is necessary
What may be necessary for large or rapidly growing fibroadenomas?
- Larger than 3-4 cm
- Rule out phyllodes tumor
Excision
Lesion of the breast
Produces a mass
Commonly seen after breast surgery/injections or trauma
Fat necrosis
Fat necrosis if untreated
Gradually disappears
Safest course when dealing with Fat necrosis
Biopsy
Fat necrosis is common after:
Segmental resection
Radiation therapy
Flap reconstruction after mastectomy
MVA
Assault
Female breast carcinoma
__ in eight American women
_____ most common cancer in women
_____ leading cause of cancer death
One
Second
Second
What is the most significant risk factor for female breast carcinoma?
Age
Risk rises rapidly until early 60’s, peaks in 70’s, then declines
Female breast carcinoma
Reproductive history associated with female breast carcinoma
Nulliparous or late first pregnancy (after age 30)
Menstrual history associated with female breast cancer
Early menarche (under 12)
Late menopause (after 55)
Most reliable means of detecting breast cancer before a mass can be palpated
Mammography
Most slow growing cancers can be identified by mammography at least ___ years before they are palpable
2 years
Mammography screening for women age 40-49
Shared decision making with patient
Suggested every 2 years
Mammography screening for women age 50-74
Every 2 years
Mammography screening age 75 and older
Only recommended if life expectancy is greater than 10 years
Imaging for High Risk female breast carcinoma patients
MRI
U/S
Female Breast Carcinoma
__% of patients with a (usually) painless lump
__% discovered by the patient
70%
90%
Rare symptoms associated with female breast carcinoma
Axillary mass or swelling
Back or joint pain
Jaundice
Weight loss
Signs
- Single, nontender, firm to hard mass with ILL-DEFINED margins
- Mammographic abnormalities and no palpable mass
Female breast carcinoma EARLY SIGNS
Signs:
- Skin or nipple retraction
- Axillary lymphadenopathy
- Breast enlargement, erythema, edema, pain
- Fixation of mass to skin or chest wall
Female breast carcinoma LATE SIGNS
Laboratory findings associated with female breast carcinoma
Increase Alkaline Phosphatase
Increase Serum Calcium
Imaging for female breast carcinoma
Mammography
U/S
MRI
Diagnostic procedure of choice in both palpable and image detected abnormalities
Core needle biopsy
Treatment for female breast cancer
Surgical resection (Mastectomy)
Radiation
Systemic Therapy (Chemo, Targeted, Bisphosphonates)
Most reliable indication of female breast carcinoma prognosis
Stage of cancer
Female Breast Carcinoma
Recurrences occur most frequently within the first ___ years
2-5 years
Female breast carcinoma
Patients are examined every 6 months for the first:
2 years
Female breast carcinoma
Patients are examined annually after:
2 years (first 2 years is every 6 mo)
A new primary breast malignancy will develop in ___% of patients
20-25%
If female breast carcinoma is metastatic, it will travel to:
Bone
Liver
Lungs
Brain
Incidence is only 1% of all breast cancer
Male breast carcinoma
Male breast carcinoma
Average age occurrence is:
70
What increases the risk of men with breast cancer?
- Prostate cancer
- First degree relatives of men with breast cancer
- BRCA 2 mutation
Signs:
- Male patient usually presents with a painless lump
- Hard, ill defined, nontender mass beneath the nipple or areola
- Gynecomastia
Male breast carcinoma
Imaging for male breast carcinoma
Mammography
U/S
Treatment for male breast carcinoma
Modified radical mastectomy
Radiation
Adjuvant systemic therapy
Prognosis for 5 year survival
- Node negative disease __%
- Node positive disease __%
Positive 88%
Negative 69%
Serous nipple discharge most likely suggests
Benign fibrocystic changes (FCC)
Bloody nipple discharge most likely suggests
Neoplastic papilloma
Carcinoma
Nipple discharge
If there is bloody discharge, the bloody duct and mass if present should be:
Excised
Nipple discharge with an associated mass more likely suggests:
Neoplasm
Bilateral nipple discharge is most likely:
Non-neoplastic (Endocrine etiology)
Common causes of Nipple Discharge in non-lactating women
Duct ectasia (FCC)
Intraductal papilloma (FCC)
Carcinoma
Milky discharge in the non-lactating woman may occur from:
Hyperprolactinemia
Nipple discharge
What lab levels are used to rule out pituitary tumor?
Serum prolactin levels
What class drugs can cause elevated prolactin levels which lead to lactation in men and women?
Antipsychotic
Nipple discharge
Oral contraceptives or estrogen replacement may cause what type of discharge?
Clear, serous or milky discharge
Nipple Discharge
Purulent discharge is associated with:
Breast Abscess
Labs for nipple discharge
Cytological evaluation of discharge
Imaging for nipple discharge when localized is not possible or in the absence of a palpable mass
Mammography
U/S
Treatment for Nipple Discharge
Refer to a breast clinic, OB/GYN, or General Surgery
Most discharge is ______ especially if bilateral
Benign
Follow up for a patient with nipple discharge if there are no signs of malignancy
Re-examined every 3-4 months
Normal menstrual bleeding lasts an average of:
5 days
Range of days for normal menstrual bleeding:
2-7 days
Mean blood loss per menstrual cycle is:
40 ml
Blood loss over 80 ml
Menorrhagia
Bleeding between periods
Metrorrhagia
Bleeding that occurs more often than every 21 days
Polymenorrhea
Bleeding that occurs less frequently than every 35 days
Oligomenorrhea
Classifications of descriptive terms denoting the bleeding pattern
Heavy
Light
Menstrual
Intermenstrual
Etiologies of Abnormal Uterine Bleeding
PALM-COEIN
Polyp Adenomyosis Leiomyoma Malignancy Coagulopathy Ovulatory Dysfunction Endometrial Iatrogenic Not yet classified
Structural etiologies of AUB
Polyp
Adenomyosis
Leiomyoma
Malignancy
In adolescents AUB is usually from:
Anovulation (not ovulating)
AUB-O
AUB from ovulatory dysfunction
Once regular menses is established, what is the most common cause of AUB?
AUB-O
AUB in women 19-39 is often the result of:
Pregnancy
Structural lesions
Anovulatory cycles
Hormonal contraceptives
Endometrial hyperplasia
AUB
Depending on the amount of blood, you could have signs of:
Anemia
AUB diagnosis depends on:
History of duration and amount of flow, associated pain, relationship to LMP
History of present illnesses
History of medications
History of coagulation disorders
Complete physical exam
Pelvic Exam
Labs for AUB
CBC
HCG
Thyroid function tests
Coagulation studies
Gonorrhea and chlamydia
Pap Smear
Endometrial Sampling
Imaging for AUB
Transvaginal US
Sonohysterography or Hysteroscopy
Treatment for AUB
ALL patients should:
Refer to OB-GYN
AUB can be secondary to:
Submucosal myomas
Infection
Early abortion
Thrombophilia
Pelvic neoplasm
AUB Treatment
Progestin (to oppose estrogen)
NSAIDs
AUB can cause:
Anemia
Infertility
Postmenopausal bleeding is _______ until proven otherwise
Cancer
Important tool in evaluating the etiology of bleeding
Transvaginal ultrasound measurement of the endometrium
Recurrent variable cluster of troublesome physical and emotional symptoms that develop during the 5 days before the onset of menses and subsides within 4 days after menstruation occurs
Premenstrual syndrome (PMS)
When emotional or mood symptoms predominate along with the physical symptoms and there is a clear junctional impairment with work or personal relationship
Premenstrual dysphoric disorder (PMDD)
PMS
Intermittently affects ___% of premenopausal women
40%
PMS primarily affects what age range?
25-40
PMS
__% symptoms are severe
5-8%
Signs/Symptoms
-Bloating, breast pain, ankle swelling, sense of increased weight, skin disorders, irritability, aggressiveness, depression, inability to concentration, libido change, lethargy, food cravings
PMS
PMS
Work up for the patient includes
Support for both emotional and physical distress
Daily diary of all symptoms for 2-3 months
-Record severity of problems
PMS
If symptoms occur throughout the month rather in the two weeks before menses, she may have:
Depression or other mental health disorders
Treatment for mild to moderate PMS
Aerobic exercise
Reduction of caffeine, salt and alcohol
Increase Calcium (1200mg/day)
Vitamin D or magnesium
Increase complex carbohydrates
Alternative therapies (acupuncture/herbal)
Medications for PMS
Hormonal contraceptives
When mood symptoms predominate, what has been shown to be effective in relieving tension, irritability, and dysphoria?
SSRIs (Antidepressants)
SSRIs are contraindicated in:
Patients taken MOAI in the past 2 weeks
Results from:
- Pathogens
- Allergic Reactions
- Vaginal Atrophy
- Friction during coitus
Vaginitis
History taking for Vaginitis should include
Onset of LMP
Recent sexual activity (use of products)
Contraceptives, tampons, or douches
Changes in medications or use in antibiotics
Signs/Symptoms:
- Vaginal irritation
- Pain
- Unusual or malodorous DISCHARGE
- Bimanual exam shows inflammation, cervical motion tenderness, adnexal tenderness
Vaginitis
What predisposes patients to Candida infections?
Pregnancy
Diabetes
Antibiotics
Corticosteroids
Heat, moisture, occlusive clothing
Pruritus, vulvovaginal erythema, white curd-like discharge that is not malodorous
Vulvovaginal Candidiasis (Yeast infection)
Sexually transmitted protozoal flagellate
Trichomonas
Pruritus and a malodorous frothy, yellow-green discharge occur, along with diffuse vaginal erythema
Strawberry Cervix
Trichomonas
Polymicrobial disease that is not sexually transmitted, chronic in nature
Overgrowth of Gardnerella and other anaerobes
Increased malodorous discharge without obvious vulvitis or vaginitis
Bacterial Vaginosis (BV)
Labs for Vaginitis
KOH
Wet Prep
NAAT urine testing
Vaginal pH
Vaginitis KOH
Branched hyphae and budding yeast in:
Candidiasis
Vaginitis KOH
Positive whiff test (amine or fishy odor)
BV
Vaginitis Wet Prep
Motile flagella is found in:
Trichomonas
Vaginitis Wet prep
Clue cells is found in:
BV
NAAT urine testing is for:
Chlamydia and gonorrhea
Vaginal ph
Frequently greater than 4.5 in:
Trichomonas
BV
Treatment for vulvovaginal candidiasis
Fluconazole
150mg tab
Treatment for Trichomonas
Metronidazole
2g PO x1
500mg BID x7
TREAT BOTH PARTNERS
Treatment for BV
Metronidazole 500mg BID x7 days
Clindamycin vaginal cream 2%, 5g once daily x7 days
Treatment for Chlamydia
Doxycycline
100mg BID x 7 days
Treatment for Gonorrhea
Ceftriaxone
500 mg IM x 1 dose
What may cause the Bartholin duct to be obstructed?
Trauma or infection
Bartholin gland infection usually:
Resolves
Pain disappears
Signs/Symptoms
- Periodic painful swelling on either side of the introitus
- Dyspareunia
- Fluctuant swelling 1-4 cm in diameter later to either labium minus
- Tenderness is evident of active infection
Bartholin’s Gland Abscess
Labs for Bartholin’s Gland Abscess
Culture of drainage
- Chlamydia
- Gonorrhea
- Other pathogens
Treatment for Bartholin’s Gland Abscess
Manual aspiration or incision and drainage of abscess
Antibiotics if STI is suspected
Warm Soaks
Marsupialization (OB/GYN)
Bartholin’s Gland Abscess
Women under ___ years of age, asymptomatic cysts do not require therapy unless they’re large or cause problems with intercourse
Under 40
Bartholin’s Gland Abscess
Women over age __, biopsy or removal are recommended to rule out vulvar carcinoma
Over 40
Cervical dysplasia starts in _____ because of hormonal changes and pH of tissue
Puberty
Infection with HPV may lead to cellular abnormalities. Over a period of time this can lead to:
Cervical dysplasia or Cancer
All atypia (abnormal cells) must be observed and treated if:
Persistent or worsening
CIN
Cervical Intraepithelial Neoplasia (CIN)
Cervical dysplasia presumptive diagnosis is made by an ________ of an asymptomatic woman with no grossly visible cervical changes
Abnormal PAP smear
All visible abnormal cervical lesions should be referred to:
OB/GYN for biopsy and therapy
In immunocompetent women, cervical cancer screening should begin at age:
21
USPSTF recommends screening for cervical cancer in women aged 21-65 with cytology every ___ years
Or, 30-65 screening with a combination of cytology and HPV every __ years
3 years
5 years
Cervical cancer with HPV testing, alone or in combination with cytology in women younger than age 30 is not recommended because:
HPV can “go away” in younger women
USPSTF recommends against cervical cancer screening for women older than age ___ with no prior history
65
What puts you at a greater risk for Cervical Intraepithelial Neoplasm (CIN)?
HIV
Immunosuppression
Exposure to diethylstilbestrol (DES) in utero
Previous treatment for CIN 2, CIN 3, or cervical cancer
Diagnosis for Cervical Dysplasia is made by:
Papanicolaou Smear
Colposcopy
Biopsy
Diagnostic procedure with a colposcope, dissecting microscope with various magnification lenses, used to provide an illuminated, magnified view of the cervix, vagina, vulva, or anus
Colposcopy
Women with Atypical squamous cells of unknown significance (ASC-US) with a negative HPV must be followed up in _____ for a repeat Pap smear and HPV co-testing
1 year
If HPV screen is positive, what diagnostic procedure is indicated?
Colposcopy
All patients with SIL or atypical glandular cells should undergo:
Colposcopy
What is necessary for diagnosis and planning of treatment for Cervical Dysplasia?
Colposcopically directed punch biopsy and endocervical curettage
Associated with a high percentage of all cervical dysplasia and cancers
HPV
What can prevent cervical, vaginal, and vulvar cancers and low grade precancerous lesions caused by HPV?
Vaccination
What vaccination for HPV is recommended for females and males ages 9 and older?
Gardasil
HPV
In addition to vaccination, preventive measures include:
Limiting the number of sexual partners
Using a condom for coitus
Smoking cessation
Cervical Dysplasia
Biopsies should precede treatment, except in cases of:
HSIL (High grade squamous intraepithelial lesions)
Cervical Dysplasia
Treatment for High grade squamous intraepithelial lesion (HSIL)
Loop Electrosurgical Excision Procedure (LEEP)
Treatment effective for noninvasive small lesion visible on the cervix
Cryosurgery
Cervical Dysplasia
Treatment minimizes tissue destruction
Colposcopically directed
CO2 Laser
Cervical Dysplasia
Treatment: Wire loop is used for excision
LEEP
Cervical Dysplasia
Treatment for cases of severe dysplasia or cancer in situ
Conization of the cervix
Most common benign neoplasm of the female genital tract
Leiomyoma (Fibroid) of the uterus
Discrete, round, firm, often multiple uterine tumor composed of smooth muscle and connective tissue
May cause miscarriage and pregnancy complications because they interfere with implantation
Leiomyoma (fibroid) of the uterus
Leiomyoma
Symptoms for which females seek treatment
Pelvic discharge
Abnormal uterine bleeding
Pain
Labs for Leiomyoma (Fibroid)
CBC
-Iron deficiency anemia
Imaging for leiomyoma
Transvaginal U/S
MRI with contrast
Hysterography / hysteroscope
Leiomyoma
Imaging to confirm presence and monitor for growth
Transvaginal U/S
Leiomyoma
Imaging to assess location within the muscle and blood flow to the tumor
MRI w/ contrast
Contraceptive
Can help decrease bleeding associated with fibroids
LNG IUD
Treatment for leiomyoma
NSAIDs
Hormonal therapies
Complications from leiomyoma
Infertility
Anemia
Need for C-section delivery
Recurrence is common
Surgical complications
Any patient with symptomatic (anemia, pain, AUB) fibroids should be:
Referred to gynecologist
Disposition for a suspected torsion of fibroid and hemorrhage
MEDEVAC
Carcinoma of the endometrium
Abnormal uterine bleeding is present in __% of cases
90%
All post-menopausal bleeding require:
EVALUATION
Carcinoma of the endometrium
Pap smear is frequently: ______
Pain is usually: _______
Negative
Late symptom
Second most common cancer of the female reproductive tract
Adenocarcinoma of the endometrium
Adenocarcinoma of the endometrium most often occurs at what age?
50-70
Risk factors for adenocarcinoma of the endometrium
Obesity
Nulliparity (unopposed estrogen)
Diabetes
Polycystic ovaries with prolonged anovulation (unopposed estrogen)
Unopposed estrogen therapy
Extended use of tamoxifen (estrogen blocker for breast cancer)
Family history of colorectal cancer
Labs for Adenocarcinoma of the endometrium
Biopsy of endometrial tissue
Pap smear
Imaging for Adenocarcinoma of the endometrium
Vaginal U/S
Hysteroscopy
Treatment for Adenocarcinoma of the endometrium
Surgery
Post-operative radiation
Chemotherapy
Overall 5-year survival of Adenocarcinoma of the endometrium:
80-85%
Adenocarcinoma of the endometrium
Strongest predictor of prognosis
Depth of cancer invasion into the myometriumis
All patients with concern of endometrial carcinoma should be referred to:
GYN oncologist
Ectopic growth of the endometrium outside the uterus, particularly in the dependent parts of the pelvis and in the ovaries
Endometriosis
Principle manifestation of endometriosis
Chronic pain
Infertility
Signs/Symptoms
- Dysmenorrhea
- Chronic pelvic pain
- Dyspareunia
- Abnormal uterine bleeding
- Infertility
- May be asymptomatic
Endometriosis
Physical exam may show:
- Tender nodules in the cul-de-sac or rectovaginal septum
- Cervical motion tenderness
- Adnexal mass or tenderness
Endometriosis
Definitive diagnosis of endometriosis is made only by:
Histology of lesions removed at surgery (Laparoscopy)
Imaging for endometriosis
Transvaginal U/S (presence of pelvic or adnexal mass)
Treatment for endometriosis
NSAIDs
Hormonal therapy
Endometriosis treatment
Inhibit ovulation for ___ month preventing cyclic stimulation of endometriotic growths inducing atrophy
4-9 months
Surgical treatment for endometriosis that reduces pain and promotes fertility
Laparoscopic ablation of endometrial implants
Surgical treatment for endometriosis that is the definitive therapy for those with intractable pelvic pain, adnexal masses, or multiple previous ineffective conservative surgical procedures
Hysterectomy
Complications of endometriosis
Infertility
Chronic pain
Reoccurrence
Any patient suspected of having endometriosis should be referred to:
OB/GYN
Polymicrobial infection of the upper genital tract
Pelvic Inflammatory Disease (PID)
PID is commonly associated with:
Gonorrhea & Chlamydia
Endogenous organisms, including anaerobes
Influenzae
Enteric gram-negative rods
Streptococci
Most common in young, nulliparous, sexually active women with multiple partners and is a leading cause of infertility and ectopic pregnancy
Pelvic Inflammatory Disease (PID)
The use of ________ of contraception may provide significant protection from PID
Barrier Methods
PID is more likely to occur when:
History of PID
Recent sexual contact
Recent onset of menses
Recent insertion of IUD
Partner has sexually transmitted disease
Acute PID is highly unlikely when:
Recent intercourse has not taken place (within 60 days)
Women with cervical motion pain, uterine, or adnexal tenderness should be considered to have _____ and be treated with _______
PID
Antibiotics
Signs/Symptoms
- Lower abdominal pain
- Chills and fever
- Menstrual disturbances
- Purulent cervical discharge
- Cervical and adnexal tenderness
- Subtle or mild symptoms of postcoital bleeding, urinary frequency, low back pain
PID
Labs for PID
Endocervical culture
- Chlamydia
- Gonorrhea
- Other pathogens
Pregnancy Test
Imaging for PID
Vaginal U/S
Laparoscopy
Imaging used to diagnose PID when diagnosis is not certain or if the patient has not responded to antibiotic therapy after 48 hours
Laparoscopy
Early treatment of PID
Cefoxitin 2g IM and Doxycycline 100mg PO BID x14 days
Ceftriaxone 500mg IM and Doxycycline 100mg PO BID x14 days
Metronidazole 500mg PO BID x14 days
Treatment for severe PID
Cefoxitin 2g IV Q6h and Doxycycline 100mg PO/IV Q12h
Complications of PID
Tube-ovarian abscess
Long-term sequelae in 1 in 4 women
PID
Risk of ______ increases with repeated episodes of salpingitis
10% after first episode
25% after a second episode
50% after a third episode
Infertility
PID
MEDEVAC if you suspect:
Tube-ovarian abscess
Pregnant
Unable to tolerate outpatient regimen
Not responding to outpatient therapy within 72 hours
Severe illness (nausea, vomiting, high fever not controlled)
Surgical Emergency can not be ruled out
Ovarian tumors are common. Most are ______.
Benign
Leading cause of death from reproductive tract cancer
Malignant ovarian tumors
Women with ___ gene mutation have increase risk for ovarian cancer
BRCA
Most women with both benign or malignant ovarian neoplasms present with:
Symptomatic or nonspecific GI symptoms or pelvic pressure
Women with advanced ovarian malignant disease may experience what kind of symptoms?
Abdominal pain
Bloating
Palpable abdominal mass with ascites
Once an ovarian mass has been detected, it must be:
Categorized as functional
Benign neoplastic
Potentially malignant
Labs for Ovarian mass
Tumor marks serum
-Cancer antigen 125
HCG
Lactate dehydrogenase
Alpha fetoprotein
Imaging for Ovarian mass
Transvaginal ultrasound
Treatment for malignant ovarian mass
Surgical evaluation by GYN oncologist
Treatment for benign neoplasms in the ovaries
Tumor removal or unilateral oophorectomy
Ovarian cancer is usually diagnosed after advanced disease ___% of the time
75%
Ovarian cancer 5 year survival:
__% Early Disease
__% Local Spread
__% Distant Metastases
89%
26%
17%
Malignant mass is suspected, what should be done?
Surgical evaluation by GYN oncologist
Polycystic ovarian syndrome (PCOS) - common endocrine disorder affecting ___% of reproductive age women
5-10%
Symptoms:
- Chronic anovulation with abnormal menses
- Polycystic ovaries
- Hyperandrogenism
Polycystic Ovarian Syndrome
PCOS is associated with :
Hirsutism
Obesity
Increased risk for diabetes and cardiovascular disease
Increased risk of endometrial cancer secondary to unopposed estrogen secretion is caused by:
Polycystic Ovarian Syndrome
Signs/Symptoms
- Menstrual disorder (amenorrhea to menorrhagia)
- Infertility
- Skin disorders (secondary to increased androgens)
- Insulin resistance
Polycystic Ovarian Syndrome (PCOS)
Labs for Polycystic Ovarian Syndrome (PCOS)
FSH
LH
Prolactin
TSH
Hemoglobin A1C
Lipid Profile
Imaging for PCOS
Transvaginal U/S
Treatment for PCOS
Weight loss and exercise
Metformin therapy
- Attempting fertility: Ovarian stimulation with medications/surgery
- Not attempting fertility: Combined Contraceptive
- Treatment for hirsutism
PCOS
Increase Risk of:
- Infertility
- Cardiovascular disease
- Diabetes mellitus
- Endometrial cancer
- Ovarian torsion
Regular monitoring of lipids, glucose and Hgb A1C (metabolic syndrome)
Any patient suspected of having PCOS should be referred to:
Physician supervisor or GYN
A type of sexual pain disorder with recurrent or persistent genital pain associated with sexual intercourse that is not associated with lack of lubrication or vaginismus
Dyspareunia
Most common cause of dyspareunia (painful intercourse) in premenopausal women
Vulvodynia
Dyspareunia is characterized by what symptoms?
Sensation of burning
Pain
Itching
Stinging
Irritation
Rawness
NO PHYSICAL EXAM FINDINGS
Sexual pain disorder with recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina
Vaginismus
Vaginismus interferes with sexual intercourse and results from:
Fear
Pain
Sexual violence
Negative attitudes towards sex
Labs for dyspareunia
UA
Gonorrhea and Chlamydia
KOH
Wet Prep
Imaging for dyspareunia
Transvaginal U/S
Treatment for vaginismus
Sexual counseling and education
-Education on using lubrication
Botox injections in refractory cases
Treatment for vulvodynia
Topical anesthetics
Tricyclic antidepressants
SSRIs
Gabapentin
Physical therapy
Any patient with concerns of dyspareunia or vaginismus should be referred to:
Physician supervisor or GYN
Couple is said to be infertile if pregnancy does not result after ____ of normal (2x/week) sexual activity with no contraceptives
1 year
__% of couples experience infertility at some point
25%
Infertility
Male partner contributes ___%
40%
Initial testing of infertility includes:
Private consultations with each partner
Pertinent history
GYN history
Basic labs
Labs for infertility
CBC
Gonorrhea testing
Chlamydia testing
TSH
Semen analysis
Infertility
In the absence of identifiable causes ___% will achieve pregnancy within 3 years
60%
Infertility
Couples who do not achieve pregnancy within ___ years may be offered ovulation induction (IVF)
3 years
Women over the age of ___ are given a more aggressive approach to for fertility
35
__% of the 213 pregnancies in 2012 were unintended
45%
Mechanism of action:
Suppression of ovulation by inhibition of GnRH, LH, FSH, and the mid-cycle LH surge.
Combined Oral Contraceptives (COC)
Effects the endometrium rendering less suitable for implantation
Thickening of cervical mucus to prevent penetration by sperm
Impairment of normal tubal motility
Progestin
The failure rate for COC’s if using them perfectly
0.3%
Typical failure rate for COC’s
8%
COC’s are ideally started on:
First day of the menstrual cycle
COC
If an active pill is missed at any time, and no intercourse occurred in the past 5 days, what should be done?
Two pills taken immediately
Backup method used for 7 days
COC
If intercourse occurred in the previous 5 days while missing a pill, what should be done?
Emergency contraception should be used immediately
Pills restarted the following day
Backup method used for the next 5 days
Contraceptive Advantages:
- Lighter menses
- Improvement of dysmenorrhea symptoms
- Decreased risk of ovarian and endometrial cancer
- Improvement in acne
- Functional ovarian cysts are less likely
- Frequency of developing myomas is lower
- Beneficial effect on bone mass
Combined Oral Contraceptives
Contraindications for what contraceptive?
- Pregnancy
- Thromboembolic disorders
- Stroke/CAD
- HTN >160/100
- Breast Cancer
- Undiagnosed vaginal bleeding
- Age >35 and smoking >15 cigarettes daily
- Migraine with aura
Combined Oral Contraceptives (COCs)
Contraceptive that is highly dependent on consistent use
Must be taken with precise accuracy within 3-hour window every day
Progestin Minipill
What contraceptive is recommended in patients who are >35, who smoke, have DVT, thromboembolic disorders, and diabetes with vascular disease?
Progestin Minipill
What contraceptive can cause the following:
- Bleeding irregularities
- Ectopic pregnancies are more frequent
- Side effects like weight gain and mild headache
Progestin Minipill
Injectable progestin (DMPA) is given SubQ or IM every __ months
3 months
Nexplanon, single rod progestin implant is effective for:
3 years
Transdermal contraceptive patch, Ortho Evra, is applied consecutively for
___ weeks and ___ weeks off.
3 weeks and 1 week off
Contraceptive
Ring users may experience an increase incidence of:
Vaginal discharge
Contraceptive devices that are highly effective with failure rates similar to those achieved with surgical sterilization
Intrauterine Devices
IUD pelvic infections are increased for the first ____ following insertion
1 month
Copper IUD can cause:
Heavier menstrual periods
Bleeding between periods
More cramping
Treatment for a patient who’s missing IUD strings
Pelvic U/S
GYN referral
Male condom types
Latex
Polyurethane
Animal Membrane
Failure rates of couples who use condoms perfectly ___%
__% become pregnant after 1 year
18%
2%
Female condom types
Polyurethane
Synthetic nitrile
Calendar method
Length of menstrual cycle has been observed for at least __ months
8 months
Basal body temperature
Body temperature must be taken at:
Upon awakening, before any activity
Basal body temp
A slight drop of temperature occurs ___ hours before ovulation:
12-24
Basal body temp
A rise of 0.4C occurs:
1-2 days after ovulation
Basal Body temp
Risk of pregnancy increases starting __ days prior to ovulation
5 days
Basal body temp
Risk of pregnancy peaks at:
Day of ovulation
Basal body temp
Risk of pregnancy is zero by:
Day after ovulation
Emergency contraceptives should be started as soon as possible and within:
120 hours (5 days)
Emergency contraceptive that is more effective than levonorgestrel, especially between 72 and 120 hours, particularly for overweight women
Ulipristal 30 mg
Naturally occurring miscarriage
Spontaneous Abortion
Electively performed abortion
Induced
DoD funds abortions ONLY if:
Endangered life of service member if the fetus were carried
Pregnancy is a result of an act of rape or incest
Vasectomy
Which part of the male anatomy is severed and sealed through a scrotal incision under local anesthesia?
Vas Deferens
Vasectomy
Semen analysis __ months after procedure to confirm sterility
3 months
Female sterilization is often achieved with:
Tubal ligation
Intentional sexual contact characterized by the use of force, threats, intimidation or abuse of authority or when the victim does not or cannot consent
Sexual Assault
Treatment for Sexual assault victims
MEDEVAC
Ships that are capable of receiving a sexual assault victim
LHA/LHD
CVN
All urine or blood pregnancy tests rely on the detection of:
HCG
Signs/Symptoms:
- Amenorrhea
- Nausea and vomiting
- Breast tenderness and tingling
- Urinary frequency and urgency
- Weight Gain
Pregnancy
“Quickening” perception of first movement noted at ___ week of pregnancy
18th
Pregnancy
Softening of the cervix occurs around __ week
7th
Cervix becomes bluish to purple due to increased blood supply at the 7th week of pregnancy
Chadwick sign
Pregnancy
Uterine fundus is palpable above the pubic symphysis by ____ weeks from the LMP. Reaches the umbilicus by ____ weeks
12-15
20-22
Pregnancy
Fetal heart tones can be heard by doppler at ___ weeks of gestation
8-10
Labs for pregnancy
HCG
Imaging for pregnancy
Transvaginal U/S
Treatment for pregnancy
MEDEVAC
Referral to Obstetrics
Pregnant service members can serve aboard a ship until ___ week of pregnancy, while in port or during short underway periods
20th week
Pregnancy service members aboard ships require a medical evacuation in less than __ hours
6 hours
Patient education for pregnant females
Prenatal vitamins
Decrease caffeine to 0-1 cup
Use only medications prescribed or authorized by an OB provider
__% clinically recognized pregnancies terminate in spontaneous abortion
20%
Abortion
- Bleeding or cramping occurs, but pregnancy continues
- The cervix is not dilated
Threatened abortion
Abortion
- Products of conception are completely expelled
- Pain ceases, but spotting may persist
- Cervical os is closed, some blood in the vaginal wall
Complete Abortion
Abortion
- Cervix is dilated
- Some portion of the products of conception remains in the uterus
- Only mild cramps are reported
- Bleeding is persistent and often excessive
Incomplete Abortion
Abortion
- Pregnancy has creased to develop, but the conceptus has not been expelled
- Sx of pregnancy disappear
- Brownish vaginal discharge but no active bleeding
- Pain does not develop. Cervix is semi firm and slightly patulous
- Uterus becomes smaller and irregularly softened
- Adnexa are normal
- Women may be indicated for abortifacient and curettage
Missed Abortion
If HCG is low or falling during pregnancy, this indicates:
Abortion
Abortion
All tissues recovered should be sent to:
Pathology
Imaging for abortion
Transvaginal U/S
Treatment for abortion
- Stabilize patient
- MEDEVAC
- Products of conception put in a specimen bottle
- Analgesics
Any female with vaginal bleeding, positive HCG and abdominal pain is _______ until proven otherwise
Ectopic Pregnancy
Ectopic pregnancy occurs __% of first trimester pregnancies
2%
Risk factors for Ectopic Pregnancy include a history of:
Infertility
Pelvic Inflammatory Disease
Ruptured Appendix
Prior Tubal Surgery
One of the most common causes of maternal death during the first trimester
Undiagnosed or undetected ectopic pregnancy
What increases the chances of ectopic?
Scarring of fallopian tube
Signs/Symptoms
- Severe lower quadrant pain (Sudden, stabbing)
- Backache
- Adnexal tenderness
- Shock 10% of the time
Ectopic
Ectopic pregnancy
HCG qualitative will be:
Greatly lower than expected
Imaging for ectopic:
Transvaginal ultrasound
Treatment for Unstable Ectopic
MEDEVAC
Surgical (Laparoscopy)
Medical treatment for a stable patient with an early ectopic
Methotrexate 50mg IM
Ectopic
Repeat tubal pregnancy occurs in __% of cases
10%
Causative agent for Mastitis
Staph aureus
Mastitis is rare in:
Nonlactating breast
Mastitis
Biopsy is indicated in:
Nonlactating breast when non-responsive to antibiotics
Signs/Symptoms
- Frequently begins within 3 months after delivery
- Starts with an engorged breast and a sore or fissured nipple
- Unilateral Cellulitis (Red, tender, and warm)
- Fever and Chills
Mastitis
Lab findings in Mastitis
CBC: Leukocytosis
Imaging for Mastitis
Breast U/S
-Evaluate for abscess
Antibiotic Treatment for MSSA Mastitis
Cephalexin
Clindamycin
Antibiotic Treatment of MRSA Mastitis
Trimethoprim/sulfamethoxazole
Clindamycin
Treatment for Mastitis
Antibiotics
Regular emptying of breast (nursing is safe for infant)
NSAIDs (MOTRIN is safe in lactation)
Follow-up for Mastitis
48 hrs to ensure improvement
Mastitis
In the absence of improvement within ___ hours of initiating antibiotics patients should be referred to supervising physician of or GYN for further evaluation
72 hours
Failure of menarche to appear
Amenorrhea
Absence of menses for 3 consecutive months in women who have passed menarche
Secondary Amenorrhea
Terminal episode of naturally occurring menses
Usually after 6 months of amenorrhea
Menopause
Most common cause of secondary amenorrhea in premenopausal women
Pregnancy
Etiologies of Amenorrhea
Pregnancy
Hypothalamic-Pituitary causes
Hyperandrogenism
Uterine Causes
Premature ovarian failure
Menopause
Functional amenorrhea
Hypothalamic-Pituitary causes
-Low levels of GnRH affecting FSH & LH levels
Early menopause
Before age 45
Premature menopause
Before age 40
Menopause normal age
48-55
Further work up for Amenorrhea
HCG
FSH LH TSH Prolactin Testosterone (hirsutism or virilization is present)
Imaging for amenorrhea
Transvaginal US
- Confirm Pregnancy
- Identify PCOS or uterine abnormalities
MRI (pituitary tumor is suspected)
Women with premature menopause have a:
__% increased risk of coronary disease
__% increased risk for stroke
__% increased overall mortality
50%
23%
12%
Adnexal torsion is an ischemic condition almost always associated with:
Ovarian Enlargement (masses or cysts)
Ovarian enlargement causes the ovary to:
Twist
-Blocks blood flow
__% of torsions occurs on the right side
70%
Signs/Symptoms
- Sudden onset severe unilateral lower abdominal pain
- May develop after episodes of exertion or athletics
Nausea and vomiting
Possible palpable adnexal mass
Ovarian torsion
Labs for ovarian torsion
HCG
CBC (Leukocytosis is found with necrosis)
Imaging for Ovarian torsion
Transvaginal U/S with Doppler
Treatment for ovarian torsion
MEDEVAC
SURGERY
Torsion ovarian conservation surgery
Cystectomy
Surgery for ovarian torsion with gross necrosis
Oophorectomy
Indications to perform a urethral catherization
Diagnostic or therapeutic drainage of bladder
Reliable and frequent assessment of urine output
Contraindications for urinary catheter
Known or suspect urethral injury
- High riding / free-floating prostate
- Blood at the urethral meatus
- Perineal hematoma
Female urethra lies in the:
Superior fornix of the vulva
Female catheter
Cleanse the enter area with ___ swabs soak in antiseptic
Clean the labia (front to back) with __ swabs
Clean the urethral meatus with __ swabs
4-5
2
2
Female catheter
Advance the catheter until urine returns, then advance it ___ cm further
4-5cm (1-2in)
Most common mistake in catheterization of the female bladder is to:
Mistake the urethra for the vagina
Male Catheter
Sterilize the glans and urethral meatus with __ swabs dipped in antiseptic
3-4
Male Catheter
Advance the catheter to the ___ of the tube even if urine is obtained earlier
Hilt
