Final Flashcards
How does age impact Sexuality? (4)
- Age does not affect the woman’s capacity to have an orgasm
- intensity of orgasm may decrease as women age.
- sexuality does not decrease with age
- lower testosterone and estrogen w/ age
5 Phases of sexual response
Motivation (desire, libido) – affected by medications, personality, temperament, medical conditions, lifestyle, environmental stressors
Arousal: a state of release of neurotransmitters
Genital congestion (autonomic response): increased blood flow; clitoral swelling and vulvar engorgement, vaginal lubrication; in males, erection
Orgasm: rapid contraction of pelvic muscles
Resolution: wellbeing, neurotransmitters prolactin, ADH, oxytocin released
6 components of positive sexual attitudes and behaviors
Being present: thinking to stop, arousal to take over, ”utter immersion and intense focus”
Authenticity: being able to be fully oneself with partner
Connection: heightened intimacy during sexual encounter
Sexual and erotic intimacy: deep sense of caring
Communication: verbal and nonverbal (touch)
Transcendence: heightened mental, emotional, physical, relational, and spiritual states of mind.
6 medication categories that cause sexual dysfunction
- Antihypertensives (ACEI, beta blockers, beta agonists, diuretics)
- Antiulcer medications (omeprazole,cimetidine)
- Antidepressants
- Antipsychotics
- Anticonvulsants
- Narcotics
4 populations at high risk for altered sexual function
- Adolescents: Early sexual activity, risk for AIDS/HIV, limited knowledge
- Disabilities: ignorance (not acknowledging their need for information about sexual health), poor decision making, developmental issues
- Newly unpartnered: new sexual paradigm; HIV/AIDS, STIs
- LBGTQ: high-risk behavior, men-men sex higher risk for AIDS/HIV
5 domains of SDOH
- Neighborhood and Built Environment
- Social and Community Context (including impact of racism)
- Health Care Access and Quality
- Education Access and Quality
- Economic Stability
4 health disparities related to racism for women
- Black women and American Indian/Alaska native 3-4x higher maternal mortality rate
- Black women and American Indian 2x higher severe maternal complications (cardiomyopathy, embolism, eclampsia, LBW, preterm birth)– even if college educated compared to white high school graduates
- Black infants 2x higher infant mortality
- biological weathering (elevated cortisol, increased BP, shortening of telomeres) due to systemic racism -> maternal complications (hypertension, early onset chronic conditions, preterm births)
5 Ps of Sexual health history
Partners: Number and gender of sexual partners; particularly > 1 partner in 12 months or a partner with other partners
Practices (sexual behavior)
Protection from infection
Past hx of infection
Pregnancy Prevention (assess contraception use and desire for pregnancy)
Difference b/w the following terms:
- Infant Mortality
- Neonatal Mortality
- Maternal Mortality
- Perinatal Mortality
- Stillbirth
- Infant Mortality - death of a live birth between birth and the first birthday
- Neonatal Mortality - death of a live birth between birth and < 28 days
- Maternal Mortality - death of a woman during pregnancy or within one year of pregnancy (CDC) not related to accidental or incidental causes
- Perinatal Mortality - includes stillbirths
- Stillbirth - an infant @ birth who demonstrates no signs of life such as breathing, heartbeat or muscle movements
5 Leading Causes of infant mortality
- congenital malformations (birth defects)
- Prematurity and LBW
- SIDS
- accidents
- r/t maternal complications of pregnancy
3 systemic disparities for women of color in healthcare setting
o Reduced diabetes screening in postpartum period
o Less pain meds given during labor and postpartum
o lower rates of epidural admin
Follicular phase of the Ovarian Cycle (3)
- 1st day of menstruation and lasts 12-14 days
- Graafian follicle matures due to Luteinizing and follicle-stimulating hormones (LH and FSH)
- Graafian follicle produces estrogen
Ovulatory phase of Ovarian cycle (3)
- Begins when estrogen levels peak and end with release of oocyte(egg) from graafian follicle
- LH increases 12-36 hrs before ovulation
- Before LH increases, estrogen decreases and progesterone increases (prep of corpusm luteum)
Luteal phase of Ovarian cycle (4)
- Begins after ovulation and lasts 14 days
- Cells of empty follicle form corpus luteum (high levels of progesterone and low levels of estrogen)
- If pregnancy occurs, corpus luteum releases high levels of progesterone and low levels of estrogen until placenta matures
- If no pregnancy, corpus luteum degenerates, progesterone decreases, and menstruation starts
Stage of the endometrial cycle: proliferative phase (2)
- After menstruation and preparation for implantation
- Endometrium becomes thicker and more vascular (due to increased estrogen))
Methods of Contraception: Abstinence
Type
Advantages (4)
Disadvantage
Type: natural
Advantages
- No fail rate
- No contraindications
- No exposure to STIs
- Readily available
Disadvantages
- requires consistency to be effective
Methods of Contraception: Natural Family Planning/ Fertility awareness methods
Type
Advantages (3)
Disadvantages (3)
Type: natural
Advantages
- No side effects OR contraindications
- Acceptable in catholic church
- Low-to-no cost
Disadvantages
- Need regular menstrual cycle
- Strict record keeping (Must frequently monitor body functions: temperature, vaginal mucus production and consistency)
- complete abstinence needed during fertile periods
Methods of Contraception: Withdrawal/ coitus interruptus
Type
Advantages (2)
Disadvantages (3)
Type: natural
Advantages
- no costs
- no contraindications
Disadvantages
- Does not protect against STIs
- Disrupts sexual intercourse
- High failure rate
Methods of Contraception: Lactational Amenorrhea Method (LAM)
Type
Advantages (2)
Disadvantages (2)
Type: natural
Advantages
- no costs
- no contraindications
Disadvantages
- Must exclusively breastfeed or do infant suckling
- More effective with barrier method
Methods of Contraception: Condoms (male or female)
Type
Advantages (3)
Disadvantages (5)
Type: barrier
Advantages
- Available OTC
- Protects against STI (and labia in female condoms)
- No systemic effects
Disadvantages
- Allergic reactions possible
- Must be applied at time of intercourse (may be disruptive)
- More effective with spermicides
- need proper size and not expired
- female condoms difficult to place
Methods of Contraception: Vaginal sponge
Type
Advantages (2)
Disadvantages (2)
Side effects (3)
Type: barrier
Advantages
- Placed before intercourse and left up to 30 hours (can protect against repeated intercourse)
- OTC
Disadvantages
- Must leave in place 6 hrs post-intercourse
- Increased infection risk
Side effects: irritation, discomfort, allergic reactions
Methods of Contraception: Cervical cap
Type
Advantages (2)
Disadvantages (2)
Type: barrier
Advantages.
- No systemic effects
- Leave in up to 48 hrs for repeated intercourse
Disadvantages
- Leave for 6 hrs after coitus
- Limited availability (size based on OB history)
Methods of Contraception: Diaphragm
Type
Advantages (3)
Disadvantages (3)
Side effects (3)
Type: barrier
Advantages
- size based on provider exam
- No systemic or hormonal effects
- Leave in up to 24 hrs for repeated intercourse
Disadvantages
- Need additional spermicide for repeated intercourse
- Leave for 6 hrs after coitus (place 6 hrs prior
- Not good with allergies due to spermicide
Side effect
- increased risk of yeast infection, cystitis, and toxic shock syndrome if used > 24 hrs
Methods of Contraception: Spermicidal gel, cream, foam
Type
Advantages (2)
Disadvantage
Side effects (2)
Type: barrier
Advantages
- Available OTC
- Foam can be emergency contraceptive
Disadvantages
- Frequent use contraindicated if at risk for HIV
Side effects: allergic reaction, irritation
Methods of Contraception: Combo estrogen and progesterone OC
Type
Advantages (3)
Disadvantages (3)
Type: hormonal
Advantages
- Suppresses ovulation
- Reduces risk for endometrial and ovarian cancer
- reduce risk of benign breast disease, anemia, acne, painful menses
Disadvantages
- prescription only
- side effects
- must be taken daily
Methods of Contraception: Progestin only
Type
Advantage
Disadvantages (3)
Type: hormonal
Advantages
- Can be used during lactation
Disadvantages
- prescription only
- side effects
- One pill a day at same time each day
Methods of Contraception: Depo-provera (medroxyprogesterone acetate)
Type
Advantages (3)
Disadvantages (3)
Type: hormonal
Advantages
- Can be used during lactation
- One injection, 4 times a yr.
- stops menses
Disadvantages
- Prescription only
- Delayed fertility return (1 yr)
- shot every 12 wks (compliance needed)
Methods of Contraception: Contraceptive patch
Type
Advantages (2)
Disadvantages (3)
Type: hormonal
Advantages
- New patch applied each week for 3 weeks then removes for 1 week (greater compliance)
- Usually applied anywhere but the breast
Disadvantages
- Prescription only
- Less effective for obese women
- Need backup if patch removed more than 24 hrs
Methods of Contraception: vaginal ring
Type
Advantages (2)
Disadvantages (2)
Type: hormonal
Advantages
- Ring inserted in vagina for 3 weeks then removed one week
- May be left in 28 days w/ immediate replacement after removal
Disadvantages
- Prescription only
- may cause vaginal irritation or discharge
Methods of Contraception: Emergency Contraceptives
Type
Advantages (4)
Disadvantages (2)
Type: hormonal
Advantages
- Reduces risk of pregnancy from one unprotected coitus but does not induce abortion
- OTC for women over 17 yrs. (prescription for younger)
- Suppresses ovulation
- only contraindication is confirmed pregnancy
Disadvantages
- Cannot be regular birth control
- Must take within 72-120 hrs of intercourse
Methods of Contraception: IUD (copper or hormonal)
Advantages (6)
Advantages
- Can be placed during postpartum period and during lactation
- Highly effective (3-5yrs for hormonal, up to 10 yrs for copper)
- Copper can be emergency contraceptive within 7 days of intercourse
- Useful for teens or women with contraindications to other hormonal methods
- Quick return to fertility
- Often stops menses
Methods of Contraception: Hormonal implants (Nexplanon- subdermal
Type
Advantages (4)
Disadvantages (3)
Type: Long-acting reversible contraceptive; hormonal but progestin-only
Advantages
- Minimal discomfort once placed
- Can be placed during postpartum period and during lactation
- Lasts several years (up to 3 yrs)
- More effective than sterilization
Disadvantages
- Must be removed eventually
- minor surgical procedure
- irregular menses bleeding
Methods of Contraception: Vasectomy
Type
Advantages (2)
Disadvantages (3)
Type: sterilization
Advantages
- Highly effective
- safe and easy recovery
Disadvantages
- Discomfort for 2-3 days
- Need another contraceptive for 2 days until sperm tests indicate procedure success
- Difficult to reverse
Methods of Contraception: Tubal Ligation (bilateral salpingectomy)
Type
Advantages (2)
Disadvantages (3)
Type: sterilization
Advantages
- Highly effective
- Immediately effective (unless tubal occlusion then 3 months till effective)
Disadvantages
- Surgical procedure
- Bleeding at incision site
- Difficult to reverse
Combo mifepristone-misoprostol OR methotrexate and misoprostol
Indication
Side effects (5)
Precautions (5)
- Indication: medical abortion within 70 days of gestation; takes days to weeks to be complete
- Side effects: heavy bleeding, severe cramping, nv, fever, chills
- Precautions: not recommended with ectopic pregnancy, IUD in place, long-term corticosteroid use or adrenal failure, anticoagulant therapy, porphyria
When is medical abortion preferred over surgical abortion? (4)
- uterine fibroids
- congenital uterine anomalies
- introital scaring
- asthma (acts as weak bronchodilatory
4 signs and symptoms to report to HCP post-abortion
- heavy bleeding (>2 maxi pads soaked in an hr. for 2 hrs straight)
- severe abdominal or back pain—may be products of conception retained
- foul-smelling discharge
- fever (above 100.4 F, 38 C)– infection
Surgical abortions
- suction curettage/aspiration (3)
- dilation and evacuation (3)
Suction curettage/aspiration
- most common abortion
- Only for first trimester
- Cervix is dilated and thin plastic tube inserted in uterus and suctions pregnancy out
Dilation and evacuation
- 2nd trimester after 13 weeks of pregnancy
- Fewer complications than medical abortion
- Anesthesia is used then fetus is removed through vagina then suction removes excess tissue
Breast Cancer Screening Recommendations (4)
- Mammograms (annual from age 40 yrs or 10 yrs prior based on fam risk)
- MRI screening and mammogram for high-risk w/ known BRACA1 or BRACA2 mutation or family hx
- Monthly self-breast exam (done after menses starting at puberty)
- Clinical breast exam (annual from 40 yrs)
6 breast signs of breast cancer
- lump (usually in duct vs lobe, bump, hard lump; may be benign)
- skin dimpling
- change in skin color or texture (red, sores, growing vein)
- nipple changes (inversion, pulling inward, crust)
- clear or bloody fluid leaking out nipple (Spontaneous (needs further eval); Elicited (normal if milky color and nonbloody)
- Pain (usually from hormonal changes i.e., perimenopause OR cysts)
Cervical Cancer Screening Recommendations (4)
- Pap tests every 3 years for 21-29 yrs.
- Pap test and HPV test every 5 years for 30-65 yrs.
- Women > 65 can stop cervical cancer screening if they have not had any precancerous cells found in the previous 10 years.
- Women w/ total hysterectomy can stop screening unless hysterectomy due to cervical precancer or cancer.
Women screening recommendations for the following:
- Colonoscopy
- Eye exam
- Hearing test
- Colonoscopy every 10 years for 50-75 then based on risk
- Eye exam at 40 yrs. then every 2-4 yrs, 1-2 yrs. for 65+
- Hearing test every 10 years till 50 then every 3 year
Women screening recommendations for the following:
- Blood pressure
- Type 2 diabetes
- DXA scan (for osteoporosis)
- Cholesterol
- STI tests
- Blood pressure every 1-2 yrs
- Type 2 diabetes yearly if overweight or over 45 yrs
- DXA scan (for osteoporosis) and Cholesterol based on hx
- STI tests yearly if sexually active and under 24, if new or multiple partners, or pregnant
Perimenopause/ climacteric period (5)
- typically when menopausal signs and symptoms begin
- lasts 4-8 yrs
- Pregnancy possible in this period
- Quality and quantity of ova decline gradually in late thirties leading to decreased estrogen and progesterone
- may have dysfunctional uterine bleeding/endometrial hyperplasia in obese
Menopause (2)
- 12 months after last menstrual period
- natural phase of life
8 Signs and Symptoms of Menopause
- Irregular periods (longer or shorter cycles, change in flow; may be anovulatory)
- Hot flashes and night sweats due to vasomotor response to hormone levels
- Sexual dysfunction (decreased libido, dyspareunia (due to vaginal dryness), vaginal atrophy (thin and dry))
- Weight gain
- Dry skin and nails; loss of skin elasticity
- Food cravings
- irregular heartbeat or palpitations
- Psychological signs: mood swings, anxiety, lethargy, panic attacks, forgetfulness, difficulty coping, depression, irritability
4 Prevention/treatment of Hot flashes in Menopause
- Avoid alcohol, hot or spicy foods, caffeine, or stress
- Dress in layers and use fans
- Avoid wool or synthetic clothing
- Low-dose antidepressants (fluoxetine), antiseizure (gabapentin), antihypertensive (clonidine)
3 Prevention of Night Sweats in menopause
- Sleep in cotton nightwear and on cotton linen
- Sleep in cool room with fan
- Take cool shower prior to bed
6 Prevention of sleep disturbances in menopause
- Regular bedtime (get 8 hrs)
- No TV, cell phone, computer use in bed
- Keep room dark, quiet, and cool
- Wear loose fitting garments
- Eat dinner early (balanced diet and exercise
- No alcohol or caffeine close to bedtime
3 Treatment for sexual dysfunction due to menopause
- Use water-based lubricant (never oil based)
- Vaginal moisturizers and Estrogen vaginal cream
- Flaxseeds and soy flour decrease vaginal dryness
Menopausal Hormone Replacement Therapy (transdermal recommended)
Types (2)
Benefits (3)
Risks (2)
Two types
- Estrogen-only for women w/o uterus
- Estrogen and progesterone for women w/ uterus to reduce risk of endometrial cancer
Benefits
- relieve vasomotor symptoms (night sweats, flushing) and most other symptoms
- osteoporosis prevention
- decrease risk for colon cancer
Risks
- increased breast cancer risk
- increased CVD, DVT risks
Methods of Contraception: Oral Combo Contraceptives and patch
9 Contraindications
- hx of DVT, pulmonary emboli, CAD
- uncontrolled hypertension
- liver disease
- clotting disorders
- active cancer
- smoker (>35 yrs.)
- undiagnosed abnormal bleeding
- migraines with aura
- pregnancy
Methods of Contraception: Oral Combo, vaginal ring, patch
8 common side effects
- nausea, vomiting
- headache
- spotting
- weight gain (edema)
- breast tenderness
- chloasma
- increased risk for clotting, heart disease, stroke
- mood swings (change in libido)
Methods of Contraception: Depo-provera and Progestin
6 side effects
- weight gain
- bleeding abnormalities
- decreased bone density
- headache
- mood changes
- breast tenderness
Best time to start contraception (2)
- when on menses
- if started at any other point, use condom for 2 weeks
Methods of Contraception: Oral Combo Contraceptives and patch
7 serious side effects to report (Achhess)
- Hepatic mass or abdominal RUQ pain
- Severe pains in chest, left arm, neck
- Headache, Unilateral numbness, weakness, tingling
- Hemoptysis
- Eye problems- Loss of vision, proptosis, diplopia, papilledema
- Severe pains, tenderness, swelling, warmth in legs
- Slurring of speech
Methods of Contraception: IUD (copper or hormonal)
Type
Disadvantages (4)
Type: Long-acting reversible contraceptive
Disadvantages
- Low risk for uterine perforation
- Contraindicated w/ pelvic inflammatory disease within 3 months
- preferred for monogamous women
- Increased cramping and bleeding in 1st few cycles
4 Situations of early menopause
- women who smoke
- women w/ shortened cycles (q21 days)
- women who have surgical removal or medical ablation of the ovaries (hysterectomy)
- Premature ovarian failure if menopause prior to age 40
6 Nonmodifiable risk factors for Breast Cancer
- Increasing age (more common around menopause)
- BRCA1 or BRCA 2 defects
- Family hx of breast cancer (1st degree)
- Personal hx of breast cancer in at least one breast
- Dense breasts
- Excess exposure to estrogen through early onset of menarche or late menopause
Diagnostics for Breast Cancer
4 diagnostics for breast cancer
What test is ideal?
- Mammogram(x-ray): give info on size and character of mass
- Ultrasound: determine if area of concern is fluid-filled cyst or solid mass
- MRI: differentiates benign from malignant tissue
- Biopsy: differentiate benign from malignant (ideal test w/ fine-needle aspiration)
Radiation therapy
When done?
Two types
- usually 3 to 4 weeks after surgery
Types
* External radiation: machine aims radiation toward the tumor (5 days a week for 5-6 wks.)
* Internal radiation (mammo site): radioactive substance sealed in needles, seeds, wires, or a catheter placed directly into or near the tumor. (BID for 5 days i.e., 10 sessions)
Chemotherapy (ex. Anthracyclines, taxanes, docetaxel, 5-fluorouracil (5-FU), Cyclophosphamide, Carboplatin)
Indication
Big side effects (8)
Indication: usually used for advanced metastatic cancer or prevention of recurrence of cancer after Oncotype DX test done to determine if likely to benefit
Side effects: NVD, myelosuppression (anemia, thrombocytopenia, neutropenia), loss of appetite, constipation, hair loss, nail changes, mouth sores (mucositis and stomatitis), fatigue
6 Modifiable risk factors for Breast Cancer
- Women who did not breastfeed
- Exposure to head or chest radiation
- Excess weight/ obesity or sedentary lifestyle
- Excess estrogen exposure through use of hormone therapy(including OCs)
- Excessive use of alcohol
- Exposure to diethylstilbestrol (DES)
Diagnostics for Breast Cancer
When is MRI preferred over mammogram? (3)
Best for dense, fibroglandular breast, scar tissue from previous surgery, or new tumors in women w/ previous lumpectomy
8 Risk factors for cervical cancer
- Primary cause is HPV (most common STI)
- Early onset of sexual activity (before age 16)
- Cigarette smoking
- Immunocompromised
- Multiple sex partners
- In utero exposure to DES
- Use of oral contraception for 5 or more years
- Multiparity (3 or more)
Two main diagnostics for Cervical Cancer
- Pap smear for early screening (If abnormal Pap test or HPV screening, further eval done)
- Colposcopy (visual exam w/ biopsy) = definitive diagnosis by APRN or OB-GYN
Progression of Cervical Cancer (3)
- typically, slow growing
- Begins with dysplasia (precancerous condition that is treatable w/ cryotherapy)
- If dysplasia not treated, cervical cancer develops and metastasize
8 Signs and Symptoms of cervical Cancer
- None in early stage
- Vaginal discharge (watery, pink, brown, bloody, or foul-smelling)
- Leaking of urine or feces from the vagina
- Abnormal vaginal or uterine bleeding b/w periods, after intercourse, or after menopause
- Dyspareunia (pain w/ intercourse)
- Loss of appetite or weight
- Fatigue
- Pelvic, back, or leg pain
7 Medical management options for cervical cancer
- LEEP (burn off cervix; may leave scar tissue which can impair fertility)
- Conization (cervical cone biopsy)
- Cryosurgery
- Total or radical hysterectomy
- Radiation
- Chemotherapy (if metastasized or recurrence)
- Targeted therapy (Angiogenesis inhibitors (bevacizumab)) for advanced cervical cancer – adjuvant to chemo)
5 male causes of infertility
- Endocrine (Pituitary diseases or tumors, hypothalamic diseases, Low levels of LH, FSH, testosterone or high levels of estrogen and cortisol decrease sperm production)
- Gonadotoxins (facts that interfere with spermatogenesis)
- Sperm antibodies (produce immune reaction and decrease sperm motility; seen in vasectomy reversal or after testicular trauma)– not common)
- Sperm transport factor (missing or blocked structures in male anatomy that interfere w/ sperm transport, i.e. vasectomy, prostatectomy, inguinal hernia, congenital absence of vas deferens)
- Intercourse disorders i.e., erectile dysfunction, ejaculatory dysfunction (retrograde or premature ejaculation), anatomical abnormalities (hypospadias, varicocle, torsion), or psychosocial reasons
6 Gonadotoxins
- Drugs (chemotherapeutics, CCBs, heroin, alcohol, marijuana, smoking)
- Infections (prostatitis, STIs, mumps after puberty)
- Systemic illness
- Prolonged heat exposure to testes (hot tubs, tight underwear, frequent bike riding)
- Pesticides
- Radiation to pelvic region
3 major factors contributing to female infertility
- Ovulatory dysfunction (anovulation or inconsistent ovulation)
- Tubal and pelvic factors (Damage to fallopian tubes due to previous PID or endometriosis; Uterine fibroids, benign growths of muscular wall of uterus narrow uterine cavity -> spontaneous abortion)
- Cervical mucus factors (interfere w/ ability of sperm to enter or survive in uterus)– Infection; Cervical surgery (cryotherapy- treats cervical dysplasia)
What is infertility?
What is most effective way to get pregnant?
Who diagnoses infertility?
- Infertility: inability to conceive after 12 months (6 months if >35) of unprotected sexual intercourse
- Most effective way to get pregnant: sex every other day after menses OR when you know you’re fertile
- women diagnosed by obgyn or repro endocrinologist; urologist diagnoses men
8 Tests for infertility
- STI screening
- Lab tests for hormonal levels (TSH, FSH, LH, anti-Mullerian hormone (AMH), testosterone)
- Semen analysis and penetration assay (may need multiple; cheap)
- LH surge test (ovulation predictor test b-c LH surges 36 hrs before ovulation)
- Ovarian reserve test
- Sonohysterogram or hysteroscopy evaluates uterus
- Hysterosalpingogram (HST)
- scrotal ultrasound
Ovarian reserve Test
Purpose
Process (2)
Purpose: determine size of remaining egg reserve for Infertility
Process
- On day 3 of menstrual cycle, blood drawn to evaluate levels of FSH, estradiol, and AMH
- On same day, transvaginal ultrasound done to assess ovarian volume and antral follicle count
Hysterosalpingogram
Purpose
What is it useful for?
Purpose: radiological exam with dye to give info on endocervical canal, uterine cavity, and fallopian tubes for infertility analysis
Useful to detects tubal problems such as adhesions, occlusions, or uterine abnormalities (fibroids, bicornate uterus, and uterine fistulas)
Semen analysis (may need multiple; cheap)
Purpose
Procedure (2)
Purpose: analyze volume, sperm concentration, motility, morphology, WBC count, immunobead, and mixed agglutination reaction test to determine fertility
Process
- Man abstains for 2-3 days then masturbates to provide semen sample
- Specimen provided at site of testing or within 1 hr. of collection at home
3 lifestyle modifications for infertility due to anovulation or abnormal sperm count
- stress reduction
- improved health (weight control, daily exercise, proper nutrition)
- Abstinence from alcohol, nicotine, recreational drugs
7 drugs used to stimulate ovulation
- Clomiphene citrate (very high success rate)
- Letrozole-ovulation induction
- Injectable gonadotropins (HCG, FSH)
- Gonadotropin-releasing hormone [GnRH] pump
- Progesterone
- Bromocriptine
- Metformin- restores cyclic ovulation and reduces insulin levels
Clomiphene citrate
Indication
Side effects (8)
Indication: stimulate ovulation; high success rate
Side effects (generally safe): hot flashes, blurry vision, breast discomfort, headaches, insomnia, bloating, nausea, vaginal dryness
4 Treatments for Male Infertility
- Hormonal therapy for endocrine factors
- Corticosteroids to decrease sperm antibodies
- Repair of varicocele or inguinal hernia to facilitate sperm transport
- Transurethral resection of ejaculatory ducts to treat disorders related to intercourse
5 Options for Patients dealing with infertility
- Drug therapy, lifestyle modifications, or surgery to resolve cause (if known)
- Adoption
- Gestational surrogate (another women carries baby)
- cryopreservation (freezing eggs)
- Assisted reproductive technologies (ART): surgical removal of oocytes and combination of them w/ sperm in lab (many ethical questions)
8 Causes of ovulatory dysfunction leading to infertility
- hormonal imbalances
- hyper or hypothyroidism
- high prolactin
- PCOS
- premature ovarian failure (menopause before 40 yrs.)
- Eating disorders
- Chronic conditions (diabetes, obesity, autoimmune)
- excessive exercise
4 reasons to consider prophylactic mastectomy or oophorectomy
- MutatedBRCAgenes found by genetic testing
- Strong family history (such as breast cancer in several close relatives)
- Lobular carcinoma in situ (LCIS) detected on biopsy
- Previous cancer in one breast (especially in someone with a strong family history)
STI: HPV
Risk factor(2)
Symptoms
Prevention (2)
Risk factors
- age 16, 18, 45 (common in sexually active but usually reverts in 6-12 months)
- cigarette smoking
Symptoms: genital wart lesion on skin
Prevention of new disease (not treatment): Gardasil – HPV vaccine – from age 11-26 in US x2 doses if <15, 3 doses if >15; condom use
3 Components needed for Unassisted Human Conception
- sperm and egg for fertilization (hormonal balance, adequate sperm # and motility to travel 12-24 hrs to ova)
- cervix and uterus for housing (cervix that is open enough for sperm to enter; Uterus must be receptive to implantation)
- fallopian tubes for transportation ( must be open and able to allow transfer of the ovum)
Side effects of radiation therapy (10)
Side effects: diarrhea, skin changes (redness or bruising), fatigue, fertility issues, urinary and bladder issues, breast pain, infection, breakdown of fatty tissue in the breast, fracture of the ribs (rare), diarrhea
Stages of the endometrial cycle: menstrual cycle
Sloughing off and expulsion of endometrial tissue if no pregnancy)
Stages of endometrial cycle: secretory phase (4)
- After ovulation until menstruation onset
- Endometrium thickens more (primary hormone is progesterone)
- If pregnancy occurs, endometrium develops more and secretes glycogen (energy source for blastocyst)
- If pregnancy does not occur, corpus luteum degrades and endometrium degenerates
Menstrual Cycle
Length
Duration
Total blood loss
Regularity impacted by (3)
Length: 24-36 days (average is 28; but varies cycle to cycle)
Duration: 3-6 days (average 5 days)
Total Blood loss: 20-80 mL (average 50 mL)
Regularity impacted by stress, exercise, nutrition
Prostaglandins
Action
Effects (7)
Action: oxygenated fatty acids; hormones
Effects
- Ovulation (ovum trapped if prostaglandin does not increase w/ LH surge)
- Fertility
- Changes in cervix and cervical mucus
- Tubal and uterine motility
- Sloughing of endometrium (menstruation)
- Onset of abortion (spontaneous and induced)
- Onset of labor (term and preterm)
Three ovulation indicators
- Basal body temperature: drops 1 day (< 37 C) prior to ovulation then rises 1 degree at ovulation for 10 -12 days
- Spinnbarkeit: Change in cervical mucus (abundant, watery, clear, more alkaline, ferns under microscope)
- Mittleschmerz- localized abdominal pain that coincides with ovulation
Most cost-effective genetic test
Obtaining a family history going back 3 generations on both maternal and paternal sides
(most other genetic tests are not done unless risk factors)
Risk factors for miscarriages (9)
- chromosomal abnormalities (25% of first trimester losses)
- Prior pregnancy loss
- Advanced maternal age (> 35 yrs)
- Endocrine abnormalities (DM, luteal phase defects)
- Drug use or environmental toxins
- Autoimmune disorders (SLE)
- Infections
- Uterine or cervical abnormalities
- black woman
How to obtain karyotype of fetus? (4)
- amniocentesis (cells from amniotic fluid)- risk for miscarriage
- cells from fetal blood
- cells from fetal skin
- CVS-Chorionic Villi sampling (sample from placenta b/w 9-11 weeks)
Autosomal Recessive vs Autosomal Dominant
Autosomal Dominant-If one parent carries the gene, 50% chance of child being affected.
Autosomal Recessive Inheritance - both parents must be carriers and both pass on abnormal gene to child for trait, disorder, or disease to be present (1 in 4 chance each pregnancy)
Risk factors for chromosomal abnormalities (6)
- maternal age > 35 yrs by due date (esp trisomy 21)
- paternal age 50 or older
- History of miscarriage or stillbirth
- Diabetes in mom (not fam hx)
- Family history of birth defects/genetic diseases (Huntington’s, Down Syndrome, Muscular dystrophy, hemophilia, cystic fibrosis, intellectual disability)
- Family history of hypercholesterolemia and PKU
3 Conditions for Fertilization
Ovulation occurs -> mature ovum enters a patent fallopian tube (fimbriae of fallopian tube capture ovum and cilia propel ovum to uterus)
Sperm cells are deposited in vagina & travel to fallopian tube surviving 48 hrs (max 5 days)
One sperm cell must penetrate ovum usually in outer third of fallopian tube (ampulla) within 24 hours of ovulation.
Pre-embryonic fetal development
Zygote (3)
Morula (3)
Zygote
- secretes BhCG to signal pregnancy
- has 46 chromosome
- single fertilized oocyte
Morula
- develops by day 3
- 16-cell sphere
- outer cells secrete fluid creating blastocyst
Embryonic Period (3)
- Week 3 through 8 of pregnancy
- Period of organogenesis - highest risk of structural damage by teratogens (chemicals, drugs, viruses, fever)
- rapid hyperplasia of fetal cells
Pregnancy Lengths
Total Pregnancy
Conception
1st trimester
2nd trimester
3rd trimester
Total Pregnancy: 40 weeks, 280 days
Conception: 2 weeks after 1st day of menstrual cycle
1st trimester: 1st day of LMP through 13 weeks
2nd trimester: Week 14 through 26
3rd trimester: Week 27 through 40+
Membranes: Amniotic fluid
Function (6)
Function
- maintain body temp
- barrier for infection
- musculoskeletal development (freedom for movement and symmetrical growth via prevention of membrane tangling)
- fetal lung development (swallow fluid)
- electrolyte balance (urinates around 11 wks)
- cushion
Fetal Period (3)
- 9 weeks to end of pregnancy
- refinement of structure and function
- viability (ability to live outside uterus, 22-25 weeks based on CNS and lung maturity)
Membranes: Umbilical cord
Function
Composition (2)
Problems (3)
Function: Supplies the embryo with maternal nutrients and oxygen
Composition
- Wharton’s jelly (CT cushions vessels from compression)
-2 arteries (carry deoxygenated blood from embryo to placenta), 1 vein (carry oxygenated blood from placenta to embryo- larger than 2 arteries)
Problems
- thin cord
- short cord
- cord w/ one artery and one vein (risk for cardiac or vascular anomaly)
Membranes: Placenta
Composition (3)
Problems (2)
Composition
- Chorionic villus (contains fetal blood vessels and imbeds in decidua basalis)
- intervillous space (contains maternal blood)
- Cell layer (prevents mixing of maternal and fetal blood)
Problems
- small placenta (poorly nourished and oxygenated child)
- teratogens can cross placenta (C, D, X drugs, live vaccines, viruses (rubella, cytomegalovirus)
Membranes
Yolk Sac
Endometrium (2)
Yolk sac
- Becomes primitive digestive system
Endometrium
- Decidua parietalis (lines uterine cavity)
- Decidua basalis (maternal part of placenta; divided in cotyledons/lobes; hemorrhage here usually for miscarriage)
Hormones in Pregnancy: Follicle Stimulating Hormone (FSH)
Functions (5)
Secreted from the anterior pituitary
Stimulates growth of the ovarian follicles
stimulates the follicles to secrete estrogen.
Stimulates sperm production
Decreases in pregnancy (Amenorrhea)
Hormones in Pregnancy: Estrogen
Functions (6)
- Secreted from the follicle cells,
- promotes the maturation of the ovum
- Stimulates enlargement of breasts and uterus.
- Decreases maternal use of insulin.
- Increases vascularity
- responsible for hyperpigmentation
Hormones in Pregnancy: Luteinizing Hormone (LH)
Functions (2)
Secreted from the pituitary gland
Stimulates testosterone production
Hormones in Pregnancy: Progesterone
Functions (2)
- Facilitates implantation by thickening and making endometrium more vascular
- decreases uterine contractility to maintain pregnancy by relaxing smooth muscles
Hormones in Pregnancy: Human Chorionic Gonadotropin (hCG)
Functions (3)
- produced by fertilized ovum and chorionic villi
- Stimulates corpus luteum so it will secrete estrogen and progesterone until placenta takes over
- Pregnancy tests detect this hormone in 1st trimester
Hormones in Pregnancy: Prolactin
Function
Prepares breast for lactation
Hormones in Pregnancy: Oxytocin
Functions (2)
- Stimulates uterine contractions
- stimulates milk ejection from breasts (milk let-down or ejection reflex)
Fetal Developmental Milestones: 9 weeks (2)
- urine in amniotic fluid
- male/female anatomy (9-12 weeks)
Fetal Developmental Milestones: 12 weeks (5)
- Placenta complete
- organ systems complete
- thumb sucking
- somersaults
- heart tone heard on doppler ( heart forms in week 3 and beats at day 17)
Fetal Developmental Milestones: 16 weeks (3)
- meconium in bowel
- sucking motions
- skin transparent
Fetal Developmental Milestones: 20 weeks (6)
- hearing develops
- quickening
- vernix caseosa and lanugo covers body
- sleep/wake cycles
- insulin produced
- brown fat develops
Fetal Developmental Milestones: 28 weeks (5)
- Lungs allow gas exchange)
- hair on head
- eyes open and close
- senses develop (taste buds, process sounds)
- subQ fat develops
Fetal Developmental Milestones: 24 weeks (4)
- rapid brain growth
- hiccups
- vernix caseosa = thick
- Lecithin (L) present (lungs begin producing surfactant)
Fetal Developmental Milestones: 32 weeks (3)
- bones fully developed
- increased subQ fat
- Lecithin/sphingomyelin (L/S) ratio (1.2:1) - enough surfactant to increase survival
Fetal Developmental Milestones: 36 weeks (3)
- decreased amniotic fluid
- Lanugo disappears
- Lecithin/sphingomyelin (L/S) ratio > 2:1 (lungs mature)
Fetal Circulatory System
Functions
- ductus venosus (2)
- foramen ovale (2)
- ductus arteriosus (3)
Ductus venosus
- Connects umbilical vein to inferior vena cava
- Allows most of oxygenated blood to enter right atrium
Foramen ovale
- may not fully close till 3 months of age
- Opening b/w right and left atria which shunts oxygenated blood right-to-left
Ductus arteriosus
-lungs do not function for gas exchange; ductus arteriosus (b/w aorta and pulmonary artery) used to bypass lungs
- Majority of oxygenated blood shunted from left atria to aorta; small amount to lungs
- Constricts after delivery due to higher blood oxygen levels and prostaglandins
Fetal Developmental Milestones: 40+ weeks (2)
- considered full term at 38 weeks
- Hepatic (enough iron for 5 months post birth)
Teratogenic drugs (5 )
- ionizing radiation (>10 rads) or radioiodine
- Tetracycline
- carbamazepine (NTDs)
- ACE inhibitors (renal tubular dysplasia, IUGR)
- warfarin (spontaneous abortion, hemorrhage)
Prenatal Screening: Fetal Anomalies
Offered to?
Types (2)
Results for quad (2)
- offered to all expectant women
Types
- Multiple Marker Screen (Triple, Quad or Penta Screen)– during 2nd trimester for Trisomy 21, Trisomy 18, NTD
- Cell free DNA (cfDNA) blood test for gender, trisomy 21 and 18 but not NTD
Results (quad screen)
- Alpha-Fetoprotein (AFP) is high = increased risk for NTDs
- Low AFP levels = increased risk for Trisomy 21 (Down Syndrome)
Prenatal Diagnostics: Fetal Anomalies
Offered to? (2)
Types (3)
- offered to high risk OR positive screening
Types
- Chorionic Villi Sampling (CVS) at 11-13 weeks
- Amniocentesis at 14-16 weeks (results in 2 weeks)
- Percutaneous Umbilical Cord Sampling (PUBS)- assess for fetal anemia, isoimmunization; diagnosis genetic disorders
Infections and Fetal Anomalies (11)
- Toxoplasmosis (protozoan)- fetal demise, blindness, mental retardation
- Cytomegalovirus- hydrocephaly, microcephaly, cerebral calcification, mental retardation, hearing loss
- Syphilis (RPR)- skin, bone, or teeth defects; fetal demise
- Varicella- hypoplasia of hands and feet, blindness or cataracts, mental retardation
- Zika - microcephaly, blindness, hearing defects
- HSV
- Influenza
- HIV
- Chlamydia
- HPV
- Rubella
Presumptive Signs of Pregnancy (7)
- any subjective symptoms reported by patient
- Amenorrhea
- Nausea/vomiting (weeks 2-12)
- Breast changes (sore, enlarged) - wks 2-3
- Fatigue (1st trimester)
- Increased Urinary frequency (pressure of enlarged uterus)
- Quickening (sensation of fetal movement around 18-20 wks)
Probable signs of Pregnancy (7)
- Chadwick’s sign (bluish-purple cervix) - 6-8 wks
- Goodell’s sign (cervix softens w/ leukorrhea) - 8 weeks
- Hegar’s sign (softened lower uterine segment) - 6 weeks
- Uterine growth
- Skin hyperpigmentation (chloasma, linea nigra)
- Ballottement (tap of examiner finger causes fetus to bounce in amniotic fluid) - 16-18 wks
- Positive pregnancy test (hCG blood, urine or home test) - detects anywhere from 1 week before missed period to 4 weeks gestation
Positive signs of Pregnancy (3)
- Auscultation of fetal heart (normal: 110-160 bpm) - 10-12 wks
- Observation and palpation of fetal movement by provider - 20 wks
- Sonographic visualization (cardiac movement or gestational sac) - 4-8 wks
Determining Pregnancy Due Date
Naegele’s rule (2)
- 1st day of LMP + 7 days - 3 months = EDD
- inaccurate if irregular cycles or cycles > 28 days
GTPAL
Gravida: total # of times woman has been pregnant (INCLUDES CURRENT PREGNANCY and no regard to # of fetus)
Term: # of births after 37 weeks’ gestation whether live or stillbirths ( twins= 1 delivery)
Preterm: number of Preterm deliveries (b/w 20 weeks & 1 day to 36 weeks & 6 days)
Abortion: number of Abortions (either spontaneous/miscarriage or induced) before 20 weeks’ gestation
Living: number of children currently Living (not including adopted or step children)
Adaptations in Pregnancy: Skin (7)
- striae (thighs, breast, buttocks, abdomen–usually darkish gray)
- chloasma (mask of pregnancy, brownish pigmentation on face)
- linea nigra (dark line on abdomen)
- acne (due to increased estrogen, progesterone, sebaceous glands secretions)
- Angiomas (spider nevi)
- Palmar erythema (pinkish-red mottling over palms of hands; red fingers)
- Vasomotor instability (hot flashes, flushing, alt hot and cold, increased perspiration)
Adaptations in Pregnancy: Breast (3)
- tenderness
- enlarged and darkened areola
- colostrum @ 16 weeks
Adaptations in Pregnancy: Cardiac (10)
- heart shifts up and to the left
- systolic murmur and S3
- 45% increase in blood volume
- anemia (physiologic b-c hemodilution of high volume more than polycythemia AND iron-deficiency from fetal demand)
- high WBC (no infection)
- decreased systemic vascular resistance
- increased circulation (10-20 bpm increase)
- supine hypotension ( enlarged uterus compresses inferior vena cava so reduced blood flow to right atrium; decreased CO, BP, GFR, and urine output
- varicose veins and venous stasis (incl. hemorrhoids
- hypercoagulability (increased fibrin and decreased inhibition of coagulation)- low platelets
Adaptations in Pregnancy: Respiratory (4)
- increased nasal congestion and epistaxis
- upward displacement of diaphragm (dyspnea, decreased capacity)
- increased oxygen needs ( high RR, increased inspiratory capacity and decreased expiratory volume)
- slight hyperventilation (light respiratory alkalosis)
Adaptations in Pregnancy: Renal (4)
- increased UTI risk due to dripping
- delayed emptying times (urinary stasis b-c poor tone)
- Hyperemia (increased renal blood flow b-c increased CO and blood volume)– decreased in 3rd trimester
- glycosuria and proteinuria (b-c exceeds tubal reabsorption threshold)
Adaptations in Pregnancy: Gastrointestinal (8)
- NV due to HcG (better by 16 weeks)
- lost of esophageal tone (heartburn)
- delayed emptying (normal may be BM q3days)
- displaced intestines (bloating, flatulence, cramping, pelvic heaviness, constipation)
- gingivitis/bleeding gums r/t vascular congestion
- change in taste and smell ( Pica, aversions)
- gallstones and cholestasis (b-c bile stasis and elevated LDL, Pruritis is sign)
- profuse salivation (ptyalism)
Adaptations in Pregnancy: Musculoskeletal (5)
- round ligament spasm
- waddle gait (softens ligaments; increases joint mobility)
- lordosis (lumbar curvature to compensate for change in center of gravity)
- widening and increased mobility of pubis
- diastasis recti (separation of rectus abdominis muscles in midline; benign in 3rd trimester)—weakened muscles
Discomforts in Pregnancy: Nausea and Vomiting
Tips (3)
- level blood sugar before getting out of bed (eat crackers)
- scopolamine patch
- biggest concern = dehydration (hyperemesis gravidarum)
Discomforts in Pregnancy: Headaches
Tips (4)
- Tylenol
- hydration
- tap of caffeine
- normal discomfort in 1st trimester; concern in 3rd trimester due to possible hypertension and preeclampsia)
Discomforts in Pregnancy: Indigestion/heartburn
Tips (3)
- antacids (tums)
- stay upright postprandial
- eat smaller meals
Discomforts in Pregnancy: Frequent urination
Tips (5)
- urinate as soon as the urge comes (b-c UTI from stasis possible and can lead to preterm pregnancy or pylonephritis)
- encourage wearing pads for dripples
- do kegel exercises (prevent prolapse as well)
- do not limit fluids
- Prevent UTI (wipe front to back, cotton underwear, voiding after intercourse, and not douching)
Discomforts in Pregnancy: Backache
Tips (4)
- wear good supportive bra b-c heavy breast can impair posture
- maternity belt and clothes to support uterus esp in multigravida or multi-gestation
- use pillow b/w legs
- Tylenol
Discomforts in Pregnancy: Constipation
Tips (6)
- hydration
- increased fiber
- avoid straining
- understand BM q3day (may be impaction if > 5 days)
- never use enema during pregnancy
- stool softeners are okay but risk for rebound constipation
Prenatal Care: Frequency of visits (4)
- monthly until 28 weeks
- Biweekly until 36 weeks
- Weekly until delivery/ 40 weeks
- twice a week over 40 weeks
Initial Prenatal Visit: Assessment (6)
- 1st day of LMP and degree of certainty about the date (Regularity, frequency, and length of menstrual cycles
- hx of current pregnancy (knowledge of conception date, Recent use or cessation of contraception, Signs and symptoms of pregnancy)
- psychosocial concerns (intended or unintended?, woman’s response to being pregnant, familial and partner support)
- Obstetrical history (GTPAL, Type of birth experiences, complications and neonatal outcomes)
- Physical and pelvic exams (bimanual)
- Fetal Heart rate w/ ultrasound doppler around 10-12 wks.
Initial Prenatal Visit: Labs (7)
- ABO and Rh (RhoGAM @26-28 wks if Rh-)
- Hct/Hgb (detect anemia, give iron if low)
- serological (varicella, rubella, syphilis, gonorrhea, chlamydia, HIV)
- Urine culture and protein ( UTI)
- HepB (Hep B vaccine at birth)
- HPV (pap q3 yrs even if pregnant till 30 then q5 yrs)
- TB skin test (if high risk)
First Trimester: Warning Signs (6)
- Vaginal bleeding (postcoital spotting is normal)
- Urinary symptoms (dysuria, frequency, urgency)- (UTIs need antibiotic)
- Abdominal cramping or pain( threatened abortion, UTI, or appendicitis)
- Absence of fetal heart tone (missed abortion)
- Fever or chills (infection)
- Prolonged NV (hyperemesis gravidarum, risk of dehydration)
2nd and 3rd Trimester: Assessments (8)
- BP decreases slightly at end of 2nd trimester
- Urine dipstick for glucose, albumin, ketone (mild proteinuria and glucosuria normal)
- Fetal- quickening (confirms EDD), FHR, kick count
- Leopold’s maneuvers (palpation of abdomen) to identify fetus in utero
- Ultrasound (to confirm EDD
- Fundal height measurement (equal weeks of gestation)
- Edema (slight in lower body is normal, abnormal if upper body esp. face)
- discuss psychosocial (fetal attachment, sexual activity, familial support, body image)
Second Trimester: Labs (3)
- Glucola (1-hr @ 24-28 weeks, earlier if obese; not done if pregestational diabetic)
- ABO and Rh (RhoGAM @26-28 wks if Rh-)
- Hct/Hgb (detect anemia, give iron if low) @ 29-32 weeks
2nd and 3rd Trimester: Warning Signs (5)
- Absence of fetal movements once felt ((fetal hypoxia or death))
- s/s of preeclampsia (swelling in face; new onset heartburn (liver involvement), severe headache, visual changes)
- Rhythmic intermittent Abdominal or pelvic pain ( PTL, UTI, pyelonephritis, or appendicitis)
- Vaginal bleeding (possible infection, friable cervix due to pregnancy changes, placenta previa, abruptio placenta, or PTL)
- Leaking of amniotic fluid (PROM)
Assessments: Fetal Kick Count
Procedure
Reassuring (2)
Procedure: pt. palpates abdomen and tracks fetal movement (kicks, flutters, swishes, rolls) daily for 1-2 hrs while at home
Reassuring:
- at least 10 movements in 2 hrs
- at least 4 movements in 1 hr.
Third Trimester: Labs (3)
- GBS vaginal and rectal swab at 35-37 wks (intrapartal antibiotics if positive)
- repeat STI (gonorrhea, chlamydia, syphilis, HIV, Hep B)
- do glucola, H&H if not done in 2nd
Pregnancy Education: Safety (6)
- avoid chemicals (hair dyes) in first trimester
- avoid piercings and tattoos
- avoid contact w/ cat feces (no cleaning or changing litter box- toxoplasmosis risk)
- cook all EGGS, MEATS,FISH thoroughly
- do not eat food left out for > 2hrs
- rinse all rare fruits and veggies
Pregnancy: Foods to avoid (7)
- sushi or smoked seafood)
- cold deli meats and hot dogs (must be heated) (listeriosis risk)
- unpasteurized products (brie, camembert, feta cheeses; juices, dairy)
- limit caffeine to 200 mg (includes coffee, tea, soft drinks, cocoa butter)
- rare beef or lamb (toxoplasmosis risk)
- Certain fish (king mackerel, orange roughie, marlin, shark, swordfish, tilefish) due to high mercury
- Raw sprouts of any kind
Psychosocial Adaptation in Pregnancy
Changes in Trimesters (2)
Changes with trimester
- Ambivalence in 1st trimester (Concern if ambivalence in 3rd trimester)
- nesting behavior in 3rd trimester
Nutritional Needs for Pregnancy
Calories
Needs (2)
Cravings
Caloric requirements
- at least 300 extra calories
Needs
- Vitamins (folic acid)
- Hydration (8 to 10 glasses)
Cravings
- Pica: nonnutritive cravings (clay, dirt, starch)—can be toxic or lead to malnutrition
