Chapter 33

Question 1

Women’s Health Initiative

Answer 1

• study to address the common causes of death, disability, and poor quality of life in postmenopausal women:
  
  • cardiovascular dz
  • breast cancer
  • colorectal cancer
  • osteoporosis

Question 2

Healthy People 2020

Answer 2

• promote normal weight
• emphasis on prevention of breast cancer, cervical cancer, colorectal cancer, effects of osteoporosis, STDs& adolescent pregnancies
• reduce breast cancer deaths
  
  • inc utilization of mammograms
• reduce cervical cancer deaths
  
  • inc utilization of pap test
• inc FOBT screening
• reduce vertebral fractures
• reduce incidence of gonorrhea, chlamydia, and syphilis

Question 3

health hx as it relates to health maintenance

Answer 3

• identifies risk factors for conditions
• focus depends on the woman’s age
• gather info on: dietary intake, physical activity, habits, and sexual practices
• assess use of prescription, OTC, and illicit drugs
• ask about use of CAM
• family hx: can identify risk factors for DM, hyperlipidemia, heart dz, osteoporosis, and thyroid dz
  
  • important for post menopausal women who have a dec in estrogen–>inc risk of CAD
• psychosocial assessment

Question 4

physical assessment

Answer 4

• assess BP, temp, pulse, respirations, and weight at each visit
• height is taken yearly:
  
  • loss of height, abnormal curvature of the spine, and thickening of waistline w/ absence of weight gain are important to identify osteomalacia (softening of bones) and osteoporosis (inc porosity of bones)
• heart: auscultate to determine rate, rhythm, presence of fluid
  
  • assess pulses and sensation
    
    • if there is an absence of sensation–>circulation problems (often go along with DM)
• if high risk for DM, check A1C
• if high risk b/c of multiple sexual partners, then assess for STDs, HIV, and infection

Question 5

breast exams

Answer 5

• breast self exam: BSE: done monthly, 1 week after menses (b/c hormones are the lowest)
  
  • emphasis on breast self awareness: women’s awareness of normal appearance/feeling of her breasts
  • if post-menopausal, do BSE on the same day every month
• clinical breast exam: CBE: done by HCP every 1-3 yrs for women ages 20-39 yo and yearly for women over 40

Question 6

how is the CBE performed?

Answer 6

Inspection:

• woman in upright: inspect for size, symmetry, clor, skin changes
  
  • inspect nipples and areolae for dize, color, retraction, any asymmetry
• raise arms above head and have HCP inspect sides and underportion of breasts and asymmetry and any differences
• place hands on hips and press down to reveal dimpling and masses

Palpation:

• while upright, arms relaxed at sides, the axillary, supraventricular, and suprasternal LNs are palpated
• lie supine with a pillow under the shoulder to stretch tissue and flatten breast:
  
  • use flat part of first 3 fingers to palpate breast, rotate fingers against breast chest wall
  • normal: firm, lumpy, nodular, tender, thickened
  • abnormal: raisin, watermelon seed, or grape feeling b/c masses are felt
  • compress nipples to detect presence of discharge

Question 7

mammography

Answer 7

• can screen for cancer or dx a palpable mass
• recommended annually for women over 30
  
  • if high risk: may need earlier or more frequent mammography
• many women have not had a mammogram b/c:
  
  • lack of HCP’s recommendation
  • expense
  • fear of radiation exposure
  • fear of pain
  • reluctance to hear bad news
• usually covered by health insurance, medicare, or medicaid
• should be scheduled after menstrual period, b/c breasts are less tender, so less discomfort

Question 8

vulvular self exam

Answer 8

• should be performed by all women over the age of 18 and by those younger than 18 if they are sexually active
• includes visual inspection and palpation of the female external genitalia to detect signs of precancerous conditions or infections
• woman should use a hand held mirror to see her external genitalia
  
  • should examine in a systematic manner
• report any new moles, warts, or growths of any kind; ulcers, sores; changes in color; areas of inflammation or itching

Question 9

pelvic exam

Answer 9

• should be scheduled b/w menstrual periods
• do not douche or have sexual intercourse 48 hours before exam
  
  • do not use vaginal meds, sprays, or deodorants
• have woman empty bladder before exam
• if woman has had FGM, must avoid displaying shock/aversion and may need to use a pediatric speculum
• if adolescent’s first exam, explain the exam before having pt undress
• usually done in a lithotomy position
  
  • may have to use side lying in a frail elderly woman
• equipment: gloves, speculum, slides, cotton swabs, fixative agent, cytobrush and spatula

Question 10

pelvic exam: external organs, speculum exam, bimanual exam

Answer 10

• inspect external organs for: degree of development/atrophy, distribution of hair, characterof hymen, cysts, tumors, inflammation, urinary meatus, Skene’s glands, scarring
• speculum is used to inspect the vagina and cervix
  
  • use only use water or water based lube to lubricate so it doesn’t interfere with cytology results
  • not size/shape/color of cervix
  • take samples for Pap test, gonorrhea/chlamydia test
• bimanual exam: info about uterus, fallopian tubes, and ovaries
  
  • HCP inserts gloved and lubricated index/middle fingers into vaginal introitus

Question 11

cervical cytology or pap test

Answer 11

• often combined with test for HIV
• most useful procedure for detecting precancerous and cancerous cells that may be shed by the cervix
  
  • also identifies viral, fungal, and parasitic conditions
• take samples of the superficial layers of the cervix and the endocervix
  
  • taken where most lesions develop at the squamocolumnar junction
  • in postmenopausal women, the squamocolumnar jucntion recedes into endocervix so cervical specimens obtained are important
• tissue is placed on slidess and then immersed in fixative soln and sent to the lab

Question 12

classification of cervical cytology

Answer 12

• Bethesda system devised to offer standard terminology and there are 3 elements:
  
  • statement of specimen adequacy
  • general categorization: normal or abnormal
  • descriptive dx regarding abnormal cytology
• f/u depends on the nature of abnormality and whether it is persistent
• if woman has persistent atypical cells of undetermined significance, she will have paps at 3-6 mos intervals and a colposcopy

Question 13

rectal exam

Answer 13

• inspect anus for hemorrhoids, inflammation, and lesions
  
  • spincter tone is also assessed
• can test for FOBT to look for colorectal cancer beginning at age 50
• special instructions for FOBT:
  
  • avoid aspirin and NSAIDs for at least 7 days before collection
  • avoid raw meat, raw fruits/veggies, horseradish, and vit C for 72 hours prior to test
  • collect specimen from 3 consecutive stools
  • return slides in 4-6 days

Question 14

other screening tests for women

Answer 14

• colonscopy q 10 yrs after 50 yo
• bone density starting at age 65 or if risk
• testing for STDs
• fasting glucose testing at least q3 yrs after age 45 to test for DM
• urinalysis for UTI
• tyroid function tests
• test for genes assoc with cancer including: BRCA 1, BRCA 2, or p53 genes
• testing for CA-125 which is elevated with ovarian cancer
• FOBT yearly

Question 15

immunizations for women

Answer 15

• influenza vaccine: yearly
  
  • require about 2 wks to become effective
• hep B vaccine:if woman has not had the vaccine
• rubella vaccine: if woman has never had vaccine/infection and is not pregnant
• tetanus and diphtheria vaccine every 10 years
  
  • Tdap should be substituted to those adults age 19-64 –>often given before discharge after childbirth
• HPV: series of 3 vaccines given b/w the ages of 9-26 but usually started for females/males between 11-12
  
  • should start before sexually active
• pneumonia vaccine: q10 yrs