CH 8 Female MDT Flashcards by Brandon Bazeluk

Fibrocystic condition

Painful breast masses are often:

Multiple and bilateral

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Fibrocystic condition

Pain often worsens during:

Premenstrual phase of the cycle

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Fibrocystic condition

What is considered a causative factor?

Estrogen

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Fibrocystic condition

Increased risk in women who:

Drink alcohol

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Most frequent lesion of the breast

Most common age is 30-50

Fibrocystic condition

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Symptoms:

Breast pain or tenderness
Discomfort worsens during premenstrual cycle
Fluctuation in size of masses
Multiple or bilateral
No lymphadenopathy

Fibrocystic condition

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Imaging for fibrocystic condition

Mammography

U/S (Used alone when patient is <30 y/o)

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Diagnostic testing for fibrocystic changes

Core needle biopsy

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All suspicious lesions should be biopsied by a:

General Surgeon

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Treatment for mild to moderate discomfort from fibrocystic changes

NSAIDs

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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

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Common benign neoplasm occurs most frequently in young women

Usually within 20 years after puberty

Fibroadenoma

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Symptoms:

Round/Ovoid
Rubbery
Discrete
Relatively moveable
Nontender mass 1-5 cm in diameter

Fibroadenoma

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Imaging for Fibroadenoma

U/S

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All breast masses should be referred to _________ for further evaluation and work up

General Surgery

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Breast mass

Biopsy is negative, what is the next step of treatment?

No treatment is necessary

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What may be necessary for large or rapidly growing fibroadenomas?

Larger than 3-4 cm
Rule out phyllodes tumor

Excision

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Lesion of the breast

Produces a mass

Commonly seen after breast surgery/injections or trauma

Fat necrosis

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Fat necrosis if untreated

Gradually disappears

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Safest course when dealing with Fat necrosis

Biopsy

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Fat necrosis is common after:

Segmental resection

Radiation therapy

Flap reconstruction after mastectomy

MVA

Assault

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Female breast carcinoma

__ in eight American women

_____ most common cancer in women

_____ leading cause of cancer death

One

Second

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What is the most significant risk factor for female breast carcinoma?

Age

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Risk rises rapidly until early 60’s, peaks in 70’s, then declines

Female breast carcinoma

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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:

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)

Vaginitis Wet Prep Motile flagella is found in:

Trichomonas

Vaginitis Wet prep Clue cells is found in:

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:

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

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

__% 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

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

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