Female Reproductive Flashcards
Danger Signals
D_______ Breast Mass/Breast Cancer
P_____ Disease of the Breast
In_______ Breast Cancer
(1)-(1) associated Hereditary Breast and Ovarian Cancer
O_____ Cancer
E_____ Pregnancy
Dominant Breast Mass/Breast Cancer
Paget’s Disease of the Breast
Inflammatory Breast Cancer
BRCA1-BRCA2 associated Hereditary Breast and Ovarian Cancer
Ovarian Cancer
Ectopic Pregnancy
(1)
Recent or acute onset of a red, swollen, and warm area in the breast of a middle-aged woman (median age 59 years) that is rapidly growing. Symptoms develop quickly. May have breast tenderness or itching. Can mimic mastitis. Often, there is no distinct lump on the affected breast. The skin may be pitted (peau d’orange) or appear bruised. Suspect in women with progressive breast inflammation that does not respond to antibiotics. Most women with this have lymph node metastases, and one-third have distant metastases when diagnosed. More common in African Americans, who are usually diagnosed at a younger age. A rare but very aggressive form of breast cancer (1%–5%).
Inflammatory Breast Cancer (IBC)
(1)
Adult to older female with a dominant mass on one breast that feels hard and is irregular in shape. The mass may be attached to the skin/surrounding breast tissue (or is immobile). Among the most common locations are the upper outer quadrants of the breast (the tail of Spence). Skin changes may be seen, such as the “peau d’orange” (localized area of skin that resembles an orange peel), dimpling, and retraction. Mass is painless or may be accompanied by serous or bloody nipple discharge. The nipple may be displaced or become fixed. Order a mammogram and refer the patient to breast surgeon. Be aware that up to 15% of women with breast cancer will have a negative mammogram. An ultrasound can detect the mass. Refer to breast specialist for a diagnostic biopsy. The most common sites for metastatic disease are the bone (e.g., back pain), liver (e.g., jaundice, abdominal pain, anorexia, nausea), lungs (e.g., dyspnea, cough), and brain (e.g., headache).
DOMINANT BREAST MASS/BREAST CANCER
(1)
Patients with a personal (or family history) of breast, ovarian, prostate, or pancreatic cancer may benefit from a hereditary cancer risk evaluation (genetic counseling) so that they can find out their risk for these cancers.
BRCA1- AND BRCA2-ASSOCIATED HEREDITARY BREAST AND OVARIAN CANCER
BRCA1- AND BRCA2-ASSOCIATED HEREDITARY BREAST AND OVARIAN CANCER
- BRCA1 and 2 inherited in a (1) pattern
- Up to 6% of (1) cancer and 20% of (1) cancer cases
- (1) ethnicity higher risk for BRCA1/2 mutations
- Men with BRCA mutations higher risk for (2) cancers
- BRCA1 and 2 inherited in a autosomal dominant pattern
- Up to 6% of breast cancer and 20% of ovarian cancer cases
- Ashkenazi Jew ethnicity higher risk for BRCA1/2 mutations
- Men with BRCA mutations higher risk for breast and prostate cancers
BRCA1- AND BRCA2-ASSOCIATED HEREDITARY BREAST AND OVARIAN CANCER
Screening for those with family history? How?
Start screening 10 years earlier than age that family member was diagnosed
Screening with annual mammogram, annual breast MRI, and clinical breast exam every 6-12 months
For example, if a sister was age 35 when diagnosed with breast cancer, then screening for breast cancer by MRI can start at the age of 25 years.
(1)
Older female reports a history of a red-colored rash that is scaly (resembling eczema) and starts on the nipple and spreads to the areola of one breast. Some women complain of itching, pain, or burning sensation. The skin lesion slowly enlarges and evolves to include crusting, ulceration, and/or bleeding on the nipple. Up to half of women will have a breast mass. Rarely, can be found in men.
PAGET’S DISEASE OF THE BREAST
(1)
Reproductive-age sexually active female with pelvic pain that may be diffuse or localized to one side, sometimes accompanied by vaginal bleeding. Pain onset may be abrupt or more gradual. Pain can be dull or sharp (but usually not crampy). If intraperitoneal bleeding, the pain may radiate from the middle to the upper abdomen, and/or it may be referred to the shoulder. May shuffle instead of walking normally to decrease jarring of pelvis. Reports amenorrhea to light menses in the previous 6 to 7 weeks.
ECTOPIC PREGNANCY
Ectopic Pregnancy
- Risk Factors = current use of (1) device, tubal _______, in vitro _________
- Majority occur where?
- Diagnostics (2)
- Leading cause of _____ for women in first trimester of pregnancy in ED
- Refer to ___
- Risk factors include prior ectopic pregnancy, current use of an IUD, tubal ligation, and in vitro fertilization (IVF).
- Majority (96%) of ectopic pregnancies occur in the fallopian tube.
- Definite diagnosis is by serum quantitative chorionic gonadotropin level and transvaginal ultrasonography.
- Leading cause of death for women in the first trimester of pregnancy in the United States.
- Refer to ED.
(1)
Typical patient is a middle-aged or older woman with vague symptoms of abdominal bloating or abdominal discomfort, low-back pain, pelvic pain, dyspareunia, and changes in bowel habits. Other symptoms are unusual lower abdominal or lower back pain and/or unusual tiredness or fatigue. Most patients (75%) are diagnosed when it has already spread, which accounts for the poor overall survival rate. Five-year survival with distant metastases is 25%, but if caught at stage 1 disease, it is >90%.
Ovarian Cancer
Ovarian Cancer Screening
(1) lab testing
(1) imaging
Efficacy of both?
CA-125
Transvaginal US
There are currently no laboratory or imaging tests that can detect it at early stages. Annual “CA 125” testing alone lacks sufficient specificity for screening average-risk patients. For women who are at higher risk of ovarian cancer, transvaginal ultrasound was found to perform poorly in detecting early-stage epithelial ovarian cancer.
Ovarian Cancer
Look for family history of ____ or more first- or second-degree (cousins, aunts, uncles) relatives with a history of ovarian cancer or a combination of ovarian and breast cancer, especially in women of (1) ethnicity with a first-degree relative (or second-degree relatives on the same side of the family) with breast or ovarian cancer.
Women with high-risk family history should be referred for ______ counseling and testing (e.g., ____ mutations, _____ syndrome). Screening can start ____ years before the earliest age of first diagnosis of ovarian cancer in a family member.
Look for family history of two or more first- or second-degree (cousins, aunts, uncles) relatives with a history of ovarian cancer or a combination of ovarian and breast cancer, especially in women of Ashkenazi Jewish ethnicity with a first-degree relative (or second-degree relatives on the same side of the family) with breast or ovarian cancer. Women with high-risk family history should be referred for genetic counseling and testing (e.g., BRCA 1/2, Lynch syndrome). Screening can start 10 years before the earliest age of first diagnosis of ovarian cancer in a family member.
Normal Breasts
- Puberty in girls starts with breast ____ (tanner stage ___) and ends at stage V
- During puberty what is common symptom and appearance of breasts for both girls and some boys?
- What part of the breast do majority of breast cancers occur?
- Puberty in girls starts with breast buds (Tanner stage II) and ends at stage V.
- Tender, Asymmetrical breasts common during puberty, it is common for both girls and some boys (45%) to have breasts (gynecomastia)
- “Tail of Spence” upper outer quadrant of the breasts is where the majority of breast cancer is located
Normal Breasts
(1) = benign fluid filled cysts that are round to oval in shape, highest prevalence in women 35-50 yo
(1) = most common type of solid breast tumor, consists of fibrous tissue that can range from a few mm to 2.5 cm in size
Benign fluid filled cysts = fluid filled cysts that are round to oval in shape, highest prevalence in women 35-50 yo
Fibroadenomas = most common type of solid breast tumor, consists of fibrous tissue that can range from a few mm to 2.5 cm in size
Fibroadenomas
(1) Imaging test of choice
(1) to confirm diagnosis
(1) higher levels can make them grow, while low levels can make them shrink
Are they associated with breast cancer?
Ultrasound = imaging test of choice
Needle biopsy needed to confirm diagnosis for some
Estrogen - higher levels make them grow, lower levels (menopause) can make them shrink
Not associated with Breast CA except for complex fibroadenomas
Breast Cancer
% risk associated for women with BRCA1 or BRCA2 gene mutation for breast CA?
Risk factors for breast cancer in men (3)
Diagnostic test for breast cancer (or any type of solid tumor) is?
Women with BRCA1 or BRCA2 gene mutation (or both) have up to a 72% risk of being diagnosed with breast cancer in their lifetime.
Risk factors for breast cancer in men are cryptorchidism, positive family history, and BRCA 1/2 mutation.
The diagnostic test for breast cancer (or any type of solid tumor) is the tissue biopsy.
(1)
Bright-red bumpy tissue with an irregular surface on the cervical surface around the os (Figure 1). It is a benign finding. It is made up of glandular cells (same cells that are inside the cervical os). It is more friable (bleeds easily) compared with the squamous epithelial cells on the surface of the cervix. It can change in size (or shape) and will disappear or regress over time.
Cervical Ectropion
Cervical Ectropion
Common finding in (2) women
Women taking birth control pills
Pregnant women (due to high estrogen)
Cervical Ectropion
What should you do if someone has this when performing a pap, why?
Important to sample the surface of the transformation zone (TZ) area when performing a Pap test. The TZ is the area where the ectropion transitions to the smooth cervical surface of squamous epithelial cells. Abnormal cells are more likely to develop (due to metaplasia) in the TZ.
Normal Cervical and Vaginal Mucus
Varies from scant (“___”), th____ white, r____ white (white and clear mucus) to cl____ stringy mucus.
After menses, vaginal discharge is sc____.
During midcycle, a large amount of ____-____ mucus (the mucus ____) is normal, except if the patient is on hormonal contraceptives (which _____ the mucus plug).
Can be mixed with blood and appear as a ___ to dark-br______ color during the menstrual cycle.
Varies from scant (“dry”), thick white, runny white (white and clear mucus) to clear stringy mucus.
After menses, vaginal discharge is scant.
During midcycle, a large amount of runny, clear mucus (the mucus plug) is normal, except if the patient is on hormonal contraceptives (which thicken the mucus plug).
Can be mixed with blood and appear as a red to dark-brownish color during the menstrual cycle.
Normal Uterus
(2) parts of uterus
(2) parts of uterus endometrium
(1) (uterine leiomyoma or myoma) can enlarge the uterus. They can be asymptomatic or may cause heavy menstrual bleeding (menorrhagia), pelvic pain or cramping, and bleeding between periods.
- Fibroids usually?
- Fibroids can cause urgency if presses on?
- Fibroid rarely are?
Uterus = uterine corpus and uterine cervix
Uterus endometrium = glandular epithelium and stroma
Fibroids (uterine leiomyoma or myoma) can enlarge the uterus. They can be asymptomatic or may cause heavy menstrual bleeding (menorrhagia), pelvic pain or cramping, and bleeding between periods.
- Fibroids usually benign
- Fibroids can cause urgency if presses on bladder
- Fibroid rarely are malignant and cause uterine cancer (leiomyosarcoma)
Normal Ovaries
Hormones produced by ovaries (3)
(1) = condition with multiple cysts on ovaries
* What happens to hormone levels in PCOS? results in S/S of a____, hir_____, ____menorrhea, insulin _____
What happens to the ovaries during menopause? What does it mean if you feel a palpable ovary during menopause? What should you do?
Ovaries produce estrogen, progesterone, and small amount of testosterone (androgens)
Polycystic ovary syndrome (PCOS) = condition with multiple cysts on ovaries
- Higher levels of estrogen and androgen levels in PCOS. Results in S/S of acne, hirsutism, oligomenorrhea, insulin resistance
Ovaries atrophy during menopause. Palpable ovary always abnormal. Workup for ovarian cancer using pelvic/intravaginal US and refer to gynecologist
Benign Variants
(1) nipples form a V-shaped line on both sides of the chest down the abdomen and are symmetrically distributed
Supernumerary nipples form a V-shaped line on both sides of the chest down the abdomen and are symmetrically distributed
Menstrual Cycle
Typically ___-day menstrual cycle
(3) phases, days what to what?
28-day menstrual cycle
Follicular Phase (Days 1-14)
Ovulatory Phase (Day 14) Midcycle
Luteal Phase (Days 14-28)
Follicular Phase
Day 1-14
- Each month (1) hormone is produced by anterior pituitary
- FSH function =
- (1) is produced by the developing follicles (“eggs), there is the predominant hormone during the first 2 weeks of menstrual cycle
- Estrogen function = (1) known as the _____ phase
- Each month FSH hormone is produced by anterior pituitary
- FSH function = maturation of follicles in woman’s ovary
- Estrogen is produced by the developing follicles (“eggs), there is the predominant hormone during the first 2 weeks of menstrual cycle
- Estrogen function = stimulate development and growth of endometrial lining known as the proliferative phase
Ovulatory Phase
Midcycle Day 14
- (1) secreted by anterior pituitary, which induces ovulation and maturation of _____ follicle on day 14
- The follicle migrates to the fimbriae of the (1)
- It takes about __ days for the egg to move through the fallopian tube, where conception can take place
- Luteinizing hormone (LH) secreted by anterior pituitary, which induces ovulation and maturation of dominant follicle on day 14
- The follicle migrates to the fimbriae of the fallopian tube
- It takes about 5 days for the egg to move through the fallopian tube, where conception can take place
Luteal Phase
Day 14-28
(1) predominant hormone during last 2 weeks of cycle
This hormone is produced by (1) and helps stabilize the endometrial lining
Progesterone = predominant hormone during last 2 weeks of cycle
It is produced by corpus luteum and helps stabilize the endometrial lining
Menstruation
What happens to levels of estrogen and progesterone during menstruation?
This then stimulates the _____ → _____ and the cycle starts again
Estrogen and progesterone fall drastically during menstruation
This then stimulates the hypothalamus → anterior pituitary (FSH) and the cycle starts again
Fertile Time Period
Time period of highest chance of pregnancy?
- What does vaginal mucous look like during this time? This sign is used in the (1) method of birth control to indicate fertile period of cycle
- There are now ovulation kits that can detect urinary (1) - false positives in women with (3)
Sexual intercourse 1-2 days before ovulation offers highest chance of pregnancy
- Copious amounts of clear mucus that feels thin and elastic in vagina → cervical mucus method of birth control to indicate fertile period of cycle
- Ovulation kits detect urinary LH - false positives in women with PCOS, ovarian insufficiency, and menopause
LH in urine appears 12 hours after it is in serum (released by anterior pituitary)
Conception
Conception occurs when?
- As the fertilized egg travels down the fallopian tube into the uterus it continues to ____ until it becomes a _____
- The blastocyst implants into the _____ where it becomes an _____
- It can take 3-4 days for the fertilized egg to fully implant in the uterus
- The placenta is fully formed by ___-___ weeks
- Estrogen and progesterone levels ____, along with (1) which is produced by the placenta
- Pregnancy lasts (1) days or (1) weeks
Conception occurs when sperm fertilizes the egg
- As the fertilized egg travels down the fallopian tube into the uterus it continues to divide until it becomes a blastocyst
- The blastocyst implants into the endometrium where it becomes an embryo
- It can take 3-4 days for the fertilized egg to fully implant in the uterus
- The placenta is fully formed by 18-20 weeks
- Estrogen and progesterone levels increase, along with human chorionic gonadotropin (HCG) which is produced by the placenta
- Pregnancy lasts 280 days or 40 weeks
Cervical Cytology
(1) Test = _____-based cervical cytology is used to screen for cervical cancer
- High false-____ rate 20-45%
- The test is called (1), which is read by a computer, is now more popular in US than conventional pap smear kit
- What is a sign of inflammation when performing the pap? What should you then rule out?
- Some females have slight ____ after a pap test
Pap Test = liquid-based cervical cytology is used to screen for cervical cancer
- High false-negative rate 20-45%
- The test is called Thinprep, which is read by a computer, is now more popular in US than conventional pap smear kit
- If cervix bleeds easily when brush is inserted to obtain the sample, may be a sign of inflammation. Rule out cervicitis
- Some females have slight spotting after a pap test
Cervical Cytology
- Can you perform a pap test or liquid based cytology during the menstrual period?
- When is the best time to perform a pap test in relation to period?
- 2-3 days before pap test, what should you advise the patient to avoid doing?
- DO NOT perform pap test or liquid based cytology during menstrual period
- Best time to perform Pap test is at least 5 days after period stops
- 2-3 days before pap, patient should avoid douching, vaginal foams/medicines, tampon use, and vaginal intercourse
USPSTF Guidelines for Cervical Cancer Screening
Type of exam, screening interval
< 20 yo =
21-29 yo =
30-65yo =
< 20 yo = DO NOT screen
21-29yo = liquid based cytology or pap test Q3 years
30-65yo = liquid based cytology or pap test Q3 years or cotesting with HPV every 5 years
USPSTF Guidelines for Cervical Cancer Screening
>65 yo =
Hysterectomy =
>65 yo = Can stop screening if not high risk*
Hysterectomy = Can stop screening if not high risk*
ACOG Guidelines
Those that need more frequent cervical cancer screening include
- ____ positive women
- history of (1)
- (1) exposure
- HIV positive women
- history of cervical cancer
- DES exposure
Liquid-Based Cervical Cytology Test (ThinPrep)
- Insert the broom-shaped plastic brush into the cervical __ and rotate in the ____ direction for ____ turns.
- If a ________ zone is present, make sure that it is included. Place the brush in the liquid medium and swish gently.
- Remove brush and cover with the plastic cap.
- The cervical cytology test is read by a ______, and abnormal results are reviewed by a cytologist and/or pathologist.
- Insert the broom-shaped plastic brush into the cervical os and rotate in the same direction for five turns.
- If a transformative zone is present, make sure that it is included. Place the brush in the liquid medium and swish gently.
- Remove brush and cover with the plastic cap.
- The cervical cytology test is read by a computer, and abnormal results are reviewed by a cytologist and/or pathologist.
Conventional Pap Smear
- Use wooden _____ to scrape cervical surface (_____cervix).
- Then insert the brush into the cervical __ (endocervix) and twist gently in a circle.
- Smear the ____ slide with ____ samples. ____ the liquid fixative on the glass slide and label.
- By sampling the ectocervix first, the chances of bleeding are minimized.
- Use wooden spatula to scrape cervical surface (ectocervix).
- Then insert the brush into the cervical os (endocervix) and twist gently in a circle.
- Smear the glass slide with both samples. Spray the liquid fixative on the glass slide and label.
- By sampling the ectocervix first, the chances of bleeding are minimized.
(1)
Standardized system that is used for reporting cervical cytology results.
- Satisfactory specimen has both?
- If a woman is being treated by pelvic radiation or is pregnant, what should you do?
- Lubricants or excessive blood can do what?
The Bethesda System
- Satisfactory specimen has both squamous epithelial cells and endocervical cells but the absence of endocervical cells is not unusual
- If woman is being treated by pelvic radiation or is pregnant, make sure this info is included in the cytology requisition
- Lubricants or excessive blood can interfere with results
(1)
Term that is used to describe cervical cells that look mildly abnormal but the cause cannot be identified (infection, irritation, or a precancer)
Atypical Squamous Cells of Undetermined Significance (ASCUS)
ASCUS Work-Up
If someone has ASCUS what should you do depending on age?
- Age 20 years or younger =*
- Age 21 to 24 years =*
- Age 25 to 29 years =*
- Age 30 years or older =*
- Age 20 years or younger:* Do not perform Pap if younger than 21 years.
- Age 21 to 24 years:* Preferred is repeat Pap test in 12 months (acceptable is reflex HPV test).
- Age 25 to 29 years:* Preferred is reflex HPV test. Acceptable is repeat Pap test in 12 months.
- Age 30 years or older:* Cotesting for high-risk HPV. If HPV positive, refer for colposcopy.
(1)
Term used to indicate presence of cervical cells that definitely look abnormal. A possible precancer is present and requires more testing and possible treatment.
Atypical Squamous Cells and Cannot Exclude a High-Grade Squamous Intraepithelial Lesion
Atypical Squamous Cells and Cannot Exclude a High-Grade Squamous Intraepithelial Lesion (ASC-H)
Workup for all ages includes?
- Age 21 to 24 years:* Refer for colposcopy.
- Age 25 to 29 years:* Refer for colposcopy.
- Age 30 years or older:* Refer for colposcopy.
Atypical Glandular Cells
Overall what does it mean?
- More common in _____ women (ages 40–69 years). Risk of cancer goes up with age.
- There are several subcategories. Follow-up test depends on atypical glandular cell (AGC) subcategory.
- Follow-up tests include c______, endo_____ sampling, and endo____ sampling.
Associated with premalignancy or malignancy in 30% of cases
- More common in older women (ages 40–69 years). Risk of cancer goes up with age.
- There are several subcategories. Follow-up test depends on atypical glandular cell (AGC) subcategory.
- Follow-up tests include colposcopy, endocervical sampling, and endometrial sampling.
(1)
Cervical cells show changes that are mildly abnormal; usually caused by an HPV infection.
Workup
- Age 21 to 24 years:*
- Age 25 to 29 years:*
- Age 30 years or older:*
Low-Grade Squamous Intraepithelial Lesions
- Age 21 to 24 years:* Repeat Pap test in 12 months.
- Age 25 to 29 years:* Refer for colposcopy.
- Age 30 years or older:* Preferred is repeat Pap test in 12 months; acceptable to refer for colposcopy.
(1)
Lesions that suggest more serious changes in the cervix than low-grade squamous intraepithelial lesions (LSILs). They are more likely than LSILs to be associated with precancer and cancer.
Workup
- Age 21 to 24 years =*
- Age 25 years or older =*
High-Grade Squamous Intraepithelial Lesions
- Age 21 to 24 years:* Refer for colposcopy.
- Age 25 years or older:* Refer for immediate excisional treatment or colposcopy. It can be done by LEEP (loop electrosurgical excision procedure) with cervical conization or surgery of the cervix.
HPV DNA Test (Reflex HPV Testing)
HPV types ___ and ___ cause nearly all cases of cervical cancer. Women are exposed to high-risk HPV through (1)
_______ vaccine (males or females) is given at age __ or __ years (or as young as ages 9 through 26 years). If given before age 15 years, a ___-dose series is required. The second dose should be given __ to __ months after the first dose (0, 6–12).
If first dose of Gardasil given at age 15 years or older, a _____-dose schedule is recommended (0, 1–2, 6).
If the vaccine schedule is interrupted, do you have the vaccine series over?
Gardasil is not recommended for those older than ____ years, but some adults aged 27 years or older may benefit from HPV immunization (Centers for Disease Control and Prevention [CDC], 2019).
HPV types 16 and 18 cause nearly all cases of cervical cancer. Women are exposed to high-risk HPV through sexual intercourse.
Gardasil (males or females) is given at age 11 or 12 years (or as young as ages 9 through 26 years). If given before age 15 years, a two-dose series is required. The second dose should be given 6 to 12 months after the first dose (0, 6–12).
If first dose of Gardasil given at age 15 years or older, a three-dose schedule is recommended (0, 1–2, 6).
If the vaccine schedule is interrupted, vaccine doses do not have to be repeated (no maximum interval).
Gardasil is not recommended for those older than 26 years, but some adults aged 27 years or older may benefit from HPV immunization (Centers for Disease Control and Prevention [CDC], 2019).
(1)
A specialized “microscope” used to visualize the cervix, obtain cervical biopsies, and gain access to the cervix during cryotherapy or laser ablative therapy. The diagnostic test for cervical cancer is a ______ of the cervix, which is obtained during this procedure.
Colposcopy
A specialized “microscope” used to visualize the cervix, obtain cervical biopsies, and gain access to the cervix during cryotherapy or laser ablative therapy. The diagnostic test for cervical cancer is a biopsy of the cervix, which is obtained during a colposcopy.
Colposcopy Procedure
A vaginal ______ is used to expose the cervix.
After the cervix is studied, it is washed with (1), which helps remove mucus and causes the abnormal areas of the cervix to turn a bright-_____color that resembles leuko_____ (____whitening).
Biopsy samples are obtained from the ______ areas on the cervix, cervical ___ (glandular cells), and ______ junction.
After a colposcopy, a small amount of cramping and bloody spotting is _____ (red, brown, black) in the next few days after the procedure. Rx (1) or analgesics can be used for the pain as needed.
A vaginal speculum is used to expose the cervix.
After the cervix is studied, it is washed with acetic acid 3% to 5% (vinegar), which helps remove mucus and causes the abnormal areas of the cervix to turn a bright-white color that resembles leukoplakia (acetowhitening).
Biopsy samples are obtained from the acetowhitened areas on the cervix, cervical os (glandular cells), and squamocolumnar junction.
After a colposcopy, a small amount of cramping and bloody spotting is normal (red, brown, black) in the next few days after the procedure. Nonsteroidal anti-inflammatory drugs (NSAIDs) or analgesics can be used for the pain as needed.
(1)-(2)
Treatment for abnormal superficial cervical cells.
Ablative Treatment
Cryotherapy, Laser Therapy
Treatment for abnormal superficial cervical cells.
(1)
Device that is used like a scalpel to cut through the cervix (conization) to treat cervical cancer and obtain cervical biopsy specimens. Depending on the result of the biopsy (size, depth, and severity), the cancerous cells can be removed by cryotherapy for mild lesions, laser ablation, or surgical conization of the cervix.
Loop Electrosurgical Excision Procedure
(1)
Useful for helping with the diagnosis of fungal infections (hair, nails, skin). Works by causing lysis of squamous cells, which make it easier to see
(2)*
Vaginal specimens do not require this to visualize (1) organism
Potassium Hydroxide Slide (KOH slide)
hyphae and spores
Vaginal specimens do not require KOH to visualize Candida.
(1)
A test for bacterial vaginosis (BV).
A positive result occurs when a ____, ___-like odor is released after one or two drops of KOH are added to the slide (or a cotton swab soaked with discharge).
Whiff Test
A positive result occurs when a strong, fish-like odor is released after one or two drops of KOH are added to the slide (or a cotton swab soaked with discharge).
(1)
Used as an adjunct for evaluating herpetic infection (oral, genital, skin).
A positive smear will show (1) in squamous epithelial cells. Not commonly used.
Tzanck Smear
A positive smear will show large abnormal nuclei in squamous epithelial cells. Not commonly used.
Exam Tips
Recognize menopausal female body changes. If ______ ovary (abnormal), rule out ovarian _____ and order an intravaginal ______.
Palpation of postmenopausal women’s breasts will feel ____ with ____ volume and may be pen____.
Be familiar with physical breast exam findings (h____ -___egular mass that is not ______) and follow-up of breast cancer.
Recognize menopausal female body changes. If palpable ovary (abnormal), rule out ovarian cancer and order an intravaginal ultrasound.
Palpation of postmenopausal women’s breasts will feel softer with less volume and may be pendulous. (hanging loosely)
Be familiar with physical breast exam findings (hard irregular mass that is not mobile) and follow-up of breast cancer.
Exam Tips
Pap/cytology and HPV testing are not recommended before age ___ years, even if sexually active, or if the person has an STD or sexually transmitted infection (STI) or has multiple sex partners. Can perform (1) exam to check for pelvic inflammatory disease (PID) and test for chlamydia/gonorrhea.
Do not confuse ______ biopsy with colposcopy, a test used to visualize the cervix and obtain cervical biopsy.
Pap/cytology and HPV testing are not recommended before age 21 years, even if sexually active, or if the person has an STD or sexually transmitted infection (STI) or has multiple sex partners. Can perform bimanual gynecologic exam to check for pelvic inflammatory disease (PID) and test for chlamydia/gonorrhea.
Do not confuse endometrial biopsy with colposcopy, a test used to visualize the cervix and obtain cervical biopsy.
Clinical Pearls
Using a small amount of K-Y Jelly to lubricate the tips of the speculum (in patients with ____ vaginitis to reduce pain and vaginal bleeding), does this affect pap results?
In reproductive-aged females who present with acute abdominal or pelvic pain, always perform a (1)
Girls and teenagers have larger _____. Some adult women on (1) pills may develop ectropion.
Cervical cancer 5-year survival rates: _____, 92%; _____ spread, 56%; distant ______, 17%.
Using a small amount of K-Y Jelly to lubricate the tips of the speculum (in patients with atrophic vaginitis to reduce pain and vaginal bleeding) will not affect the Pap test results.
In reproductive-aged females who present with acute abdominal or pelvic pain, always perform a pregnancy test (use good-quality urine human chorionic gonadotropin strips).
Girls and teenagers have larger ectropions. Some adult women on birth control pills may develop ectropion.
Cervical cancer 5-year survival rates: Localized, 92%; regional spread, 56%; distant metastasis, 17%.
Infertility
=
There is up to an ___% chance of becoming pregnant within 1 year of unprotected sexual intercourse.
In the United States, approximately 50% of pregnancies are un______. Women seeking to prevent pregnancy can choose from several options with varying degrees of reported effectiveness
Infertility is defined as having unprotected sex for 1 year with failure to achieve pregnancy.
There is up to an 85% chance of becoming pregnant within 1 year of unprotected sexual intercourse.
In the United States, approximately 50% of pregnancies are unplanned. Women seeking to prevent pregnancy can choose from several options with varying degrees of reported effectiveness
Contraception
Most Effective Options (3)
Less Effective Options (5)
Least Effective Options (5)
Most Effective Options = Implant, IUD, Sterilization
Less Effective Options = Injectable, Pills, Patch, Ring, Diaphragm
Least Effective Options = Condoms, Withdrawal, Sponge, Fertility Awareness monthy tracker, Spermicide
Contraception Patient Education
Vasectomy or Hysteroscopic sterilization =
Injectable = get repeat injections on ____
Pills = take a pill each ____
Patch, Ring = Keep in ____, ch____ on time
Diaphragm = use correctly every time you have _____
Condoms, Sponge, Withdrawal, Spermicides = use correctly everytime you have ____
Fertility awareness based methods = ab____ or use ____ on ____ days. Newest methods (standard days method and two day method) may be the easiest to use and consequently more effective, what are these methods?
Vasectomy or Hysteroscopic sterilization = use another method for first 3 months
Injectable = get repeat injections on time
Pills = take a pill each day
Patch, Ring = Keep in place, change on time
Diaphragm = use correctly every time you have sex
Condoms, Sponge, Withdrawal, Spermicides = use correctly everytime you have sex
Fertility awareness based methods = abstain or use condoms on fertile days. Newest methods (standard days method and two day method) may be the easiest to use and consequently more effective, what are these methods?
- The Standard Days Method (SDM) is a fertility awareness-based family planning method that identifies a 12-day fertile window during which women with regular menstrual cycles (26–32 days long) should abstain from sex or use a barrier method to prevent pregnancy*
- The TwoDay method is* a variation of the cervical mucous method.
Minors and Contraception
According to the Guttmacher Institute (2020), there are ___ states and the District of Columbia that explicitly allow all individuals to consent to contraceptive services.
Some states require a specified age (e.g., age ___or older) to consent to such care.
Approximately 24 states permit minors to consent to contraceptive services in certain circ_______.
M______ minors or em______ minors do not need parental consent.
According to the Guttmacher Institute (2020), there are 23 states and the District of Columbia that explicitly allow all individuals to consent to contraceptive services.
Some states require a specified age (e.g., age 14 or older) to consent to such care.
Approximately 24 states permit minors to consent to contraceptive services in certain circumstances.
Married minors or emancipated minors do not need parental consent.
A list of state requirements in regard to minors obtaining contraceptive services with/without parental consent is available at https://www.guttmacher.org/state-policy/explore/ minors-access-contraceptive-services.
Rule Out Pregnancy
According to the CDC (2016), a healthcare provider can be reasonably certain that a woman is not pregnant if she has no symptoms or signs of pregnancy and meets the following criteria:
- When after start of normal menses? (or after an induced or spontaneous abortion)
- Has had no (1) since the start of last normal menses
- Has been correctly and consistently using a reliable method of _______
- Is within ___ days postpartum
- Exclusively _______ or for the vast majority of time (>85%) and is_____hoeic and
- Check if pregnant with urine pregnancy test before starting?
- At least 7 days or less after start of normal menses (or after an induced or spontaneous abortion)
- Has had no sexual intercourse since the start of last normal menses
- Has been correctly and consistently using a reliable method of contraception
- Is within 4 days postpartum
- Exclusively breastfeeding or for the vast majority of the time breastfeeds (>85%) and is amenorrhoeic and <6 months postpartum
- Check if pregnant with urine pregnancy test before starting hormonal and IUD contraception
Combined Hormonal Contraception
(1) + (1)
Works in a synergistic manner by stopping ovulation (inhibits ___ surge) and thickening (1)
There are several types of (3)
Estrogen and Progesterone
Works in a synergistic manner by stopping ovulation (inhibits LH surge) and thickening mucus plug
There are several types of oral contraceptives, transdermal patch, and vaginal ring
Combined Oral Contraceptives
9% Typical Use Failure Rate
Monophasic Pill =
Biphasic Pill =
Triphasic Pill =
Ethinyl Estradiol and Drospirenone =
Extended Cycle Oral Contraceptive =
Monophasic Pill = Loestrin FE 1/ 20
Biphasic Pill = Ortho-Novum 10/11, Mircette, Jenest
Triphasic Pill = Ortho Tri-Cyclen, Cyclessa, Tri-Norinyl, Tri-Levlen, and Triphasil
Ethinyl Estradiol and Drospirenone = Yaz/Yasmin
Extended Cycle Oral Contraceptive = Seasonale
(1)
21 consecutive days of estrogen/progesterone (same dose daily). For the last 7 days of the cycle, the placebo pills contain iron supplementation (7 days of iron pills).
Loestrin FE 1/20
(Monophasic Pill)
(3)
Contains two different progesterone doses (two phases). The progesterone dose increases about halfway through the cycle
Ortho Novum 10/11, Mirette, Jenest
Biphasic Pills
(5)
Contains 21 days of active pills and 7 days of placebo pills. The dose of hormones varies weekly for 3 weeks (“_____”). Progestin used is norgestimate. Indicated for acne.
Ortho Tri-Cyclen, Cyclessa, Tri-Norinyl, Tri-Levlen, Triphasil
Contains 21 days of active pills and 7 days of placebo pills. The dose of hormones varies weekly for 3 weeks (“triphasic”). Progestin used is norgestimate. Indicated for acne.
(2)
Ethinyl Estradiol and Drospirenone
24/4 formulation (24 days hormones/4 days placebo pills)
- Uses drospirenone (a ______ analog) as the ______ component
- Results in ____ menses and lower rates of ______ bleeding
- Consider for women with a____, P____, hir____, or (1) disorder
- Higher risk of (1) and hyper_____
Yaz 28, Yasmin
- Uses drospirenone (a spironolactone analog) as the progestin component
- Results in lighter menses and lower rates of unscheduled bleeding
- Consider for women with acne, PCOS, hirsutism, or premenstrual dysphoric disorder disorder (PMDD)
- Higher risk of DVT and hyperkalemia
Yaz 28/Yasmin Monitoring
(Ethinyl Estradiol and Drospirenone)
Labs: check _____ level if patient is on (3) Rx or has kidney disease
Labs: Check the potassium level if patient is on an angiotensin-converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), or potassium-sparing diuretic or has kidney disease.
(1)
Extended-Cycle Oral Contraceptive Pills
84/7 formulation =
This method typically results in _____ periods per year, although breakthrough bleeding is not uncommon during the first few months.
Seasonale
Extended-Cycle Oral Contraceptive Pills
84 days hormones (3 months) of estrogen/progesterone with 7 days placebo pills
This method typically results in four periods per year, although breakthrough bleeding is not uncommon during the first few months.
Literally 1 period per season
Combined Oral Contraceptives Non-Oral Forms
(2)
Absolute and relative contraindications for nonoral forms of combined estrogen–progesterone method of contraception are the same as oral contraceptives.
Cervical Ring
Ortho Evra Transdermal Contraceptive Patch
Both have 7% Typical Use Failure Rate
Cervical Ring
(1)
Plastic cervical ring that contains EE =
It is left inside the vagina how long, then removed for how long?
Educate patient on how to apply =
The ring should fit snugly _____ cervix.
Do not use NuvaRing if (1) aged > ___years
NuvaRing
Plastic cervical ring that contains EE = Etonogestrel and Ethinyl Estradiol
It is left inside the vagina for 3 weeks (21 days), then removed for 1 week (when woman has her period).
Educate patient on how to apply = Fold in half and insert into vagina
The ring should fit snugly around cervix.
Do not use NuvaRing if cigarette smoker aged > 35 years
Ortho Evra Transdermal Contraceptive Patch
How long should you wear the patch for, then how long should you take it off for?
Higher risk of (1) bc releases higher levels of estrogen compared with oral contraceptives
Absolute and relative contraindications for combined estrogen-progesterone method of contraception are the same as oral contraceptives
Patch can be worn on b____, chest (except ____), upper ____, a___, ab_____
Wear a new patch 1 week at a time for 3 weeks in a row. During the fourth week, do not wear a patch.
Higher risk of VTE bc releases higher levels of estrogen compared with oral contraceptives
Absolute and relative contraindications for combined estrogen-progesterone method of contraception are the same as oral contraceptives
Patch can be worn on back, chest (except breast), upper back, arm, abdomen
Absolute Contraindications to Hormonal Contraceptive Use
“My CUPLETS”Mnemonic
My Migraines with focal neurological aura
C CAD or CVA
U Undiagnosed genital bleeding
P Pregnant or suspect pregnancy
L Liver tumor or active liver disease
E Estrogen-dependent tumor
T Thrombus or emboli
S Smoker aged 35 or older
Relative Contraindications to Hormonal Contraceptive Use
- ______ headaches
- Migraines and >__ years
- Migraines with focal _____ findings are an absolute contraindication because of increased risk of stroke
- _____ <35 years
- Fr_____ or cast on lower extremities
- Adequately controlled ______
- Migraine headaches
- Migraines and >35 years
- Migraines with focal neurological findings are an absolute contraindication because of increased risk of stroke
- Smoker <35 years
- Fracture or cast on lower extremities
- Adequately controlled hypertension
Absolute Contraindication to Hormonal Contraceptive Use
Any condition (past or present) that increases the risk of blood clotting
- History of ____phlebitis or thrombo_____ disorders (e.g., DVT)
- Genetic _______ defects, such as factor V Leiden disease
- Major _____ with prolonged immobilization
Smoker older than the age of 35, >15 cigarettes per day
- Also considered a ____ contraindication because women __35 years who smoke can take the pill (if no other contraindications exist)
Any condition (past or present) that increases the risk of blood clotting
- History of thrombophlebitis or thromboembolic disorders (e.g., DVT)
- Genetic coagulation defects, such as factor V Leiden disease
- Major surgery with prolonged immobilization
Smoker older than the age of 35, >15 cigarettes per day
- Also considered a relative contraindication because women <35 years who smoke can take the pill (if no other contraindications exist)
Absolute Contraindication to Hormonal Contraceptive Use
Any condition that increases the risk of strokes
- Migraine with ___ or (1) symptoms or migraine without aura at age 35 years or older
- History of C___ or T___
- Hyper_____ (if systolic blood pressure [SBP] >160 mmHg or diastolic BP [DBP] >100 mmHg)
Inflammation and/or acute infections of the ____ with elevated (1) tests
- In acute infection or inflammation of the liver (e.g., ____nucleosis) with elevated LFTs, estrogen is contraindicated
- When LFTs are back to normal?
- Hepatocellular _____ or malignant (hepatoma)
- Cholestatic _____ of pregnancy
Any condition that increases the risk of strokes
- Migraine with aura or focal neurological symptoms or migraine without aura at age 35 years or older
- History of cerebrovascular accidents (CVAs) and transient ischemic attacks (TIAs)
- Hypertension (if systolic blood pressure [SBP] >160 mmHg or diastolic BP [DBP] >100 mmHg)
Inflammation and/or acute infections of the liver with elevated liver function tests (LFTs)
- In acute infection or inflammation of the liver (e.g., mononucleosis) with elevated LFTs, estrogen is contraindicated
- When LFTs are back to normal, can go back on birth control pills
- Hepatocellular adenomas or malignant (hepatoma)
- Cholestatic jaundice of pregnancy
Absolute Contraindications to Hormonal Contraceptive Use
Known or suspected _______ disease
- Moderately to severely impaired cardiac function
- Complicated v_____ heart disease (risk atrial fibrillation, history of subacute bacterial endocarditis)
- (1) artery disease
- D______ with vascular component
- Autoimmune disorder (1)
- Hypertension if SBP is ≥____ or DBP ____ mmHg
- Two or more risk factors for _____ cardiovascular disease (such as older age, smoking, diabetes, hypertension)
Known or suspected cardiovascular disease
- Moderately to severely impaired cardiac function
- Complicated valvular heart disease (risk atrial fibrillation, history of subacute bacterial endocarditis)
- Coronary artery disease (CAD)
- Diabetes with vascular component
- Systemic lupus erythematosus
- Hypertension if SBP is ≥160 or DBP 100 mmHg
- Two or more risk factors for arterial cardiovascular disease (such as older age, smoking, diabetes, hypertension)