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Women's Health EOR > Other > Flashcards

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1
Q

What is endometriosis?

A

a condition in which ectopic endometrial tissue implants are found in extrauterine sites

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2
Q

Where is endometriosis most commonly?

A

the ovaries, Fallopian tubes, cul-de-sac, and uterosacral ligaments

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3
Q

What are the “THREE D’S” of endometriosis?

A

dyspareunia, dyschezia (difficulty in defecting) and dysmenorrhea

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4
Q

What are the signs and symptoms of endometriosis?

A
  • history of infertility is also common (30-45%)
  • pelvic pain just before or during menses
  • 20% of women with chronic pelvic pain will have endometriosis
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5
Q

How is endometriosis dx

A

definitive diagnosis is made by laparoscopy (definitive study) and confirmed by biopsy

  • imaging tests (eg ultrasonography, barium enema, IV urography, CT, MRI) are not specific or adequate for diagnosis
  • however, they sometimes shoe the extend of endometriosis and thus can be used to monitor the disorder once it is diagnosed
  • the uterus is fixed and retroflexed on pe
  • tender modulatory of cult de sac and uterine ligaments
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6
Q

What is the tx of endometriosis?

A

treatments include NSAIDs, OCPs, danazol, depo provera, GnRH agonists, surgical

  • oral contraceptives are first-line medications used in treating endometriosis
  • estrogen-progesterone OCP - ovarian suppression
  • progesterone analogs (eg medroxyprogesterone and levonorgestrel) - inhibit the growth of the endometrium
  • gonadotropin-hormone releasing (gnRH) antagonists
  • pituitary gonadotropin hormones suppressed = decrease estrogen
  • danazol (steroid) - inhibits mid-cycle surges of FSH and LH
  • pain management :nonsterodial anti-inflammatory drugs (NSAIDs)
  • surgery options include laparoscopic ectopic endometrial tissue removal and hysterectomy
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7
Q

What is a leiomyoma?

A

aka uterine fibroids are being smooth muscle cell tumors

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8
Q

What are the symptoms of leiomyoma?

A

polymenorrhea, menorrhagia, intermenstrual bleeding and/or menorrhagia
-pelvic pressure and increased abdominal girth, uterine mass

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9
Q

What population has leiomyomas?

A

black women, family history

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10
Q

How are leiomyoma described?

A

may be single of multiple, described by location, most myxomas involve more than one layer of the uterus

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11
Q

What is a subserosal leiomyoma?

A

projects into the pelvis, may be pedunculated

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12
Q

What is a intramural leiomyoma?

A

within the uterine wall (most common)

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13
Q

What is a submucosal leiomyoma?

A

projects into the uterine cavity

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14
Q

How is a leiomyoma dx?

A

diagnose with ultrasound and/or MRI = uterine mass

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15
Q

What is the tx of leiomyoma?

A

treatment is medical or surgical

  • symptomatic medical treatment: NSAIDs, OCPs, Danazol, Leuprolide (also used to shrink fibroids pre-operatively)
  • definitive: myomectomy, endometrial ablation, hysterectomy (most common surgical tx)
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16
Q

What are the characteristics of barrier methods?

A
  • failure rates are as high as 40%, offer STI protection, safe for patients with contraindications to hormones
  • male condoms:20% failure rate, offer STI protection
  • female condoms:21% failure rate, offers STI protection
  • diaphragm: 15% failure rate, must remain in place 6-24 hours after intercourse, requires pelvic exam and fitting
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17
Q

What are the characteristics of spermicides nontoxynol-9?

A

destroys sperm - often used with other forms of BCP such as condoms

  • 27% failure rate
  • sightly increased risk for HIV
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18
Q

What are the characteristics of OCP’s?

A

prevents ovulation by inhibiting mid-cycle LH surge, thickens cervical mucus, thins the endometrium

  • 9% failure rate, 0.3% failure rate when used correctly
  • improves dysmenorrhea and controls the menstrual cycle
  • protects against ovarian cysts, ovarian and endometrial cancer and improves acne
  • there is no convincing evidence that OCP’s increase the risk of breast, cervical, or liver cancer, potential complications include thromboembolic events, hypertension, hepatic adenoma
  • breakthrough bleeding, nausea and breast tenderness usually resolve within the first three cycles
  • combined estrogen and progesterone - not used in women >35 years of age that are smokers, patients with a history of blood clots, breast cancer, or migraines with aura
  • 35 and younger who smoke OK
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19
Q

What are the characteristics of transdermal patch?

A

this method is very effective

  • the contraceptive efficacy of the transdermal patch is comparable to that of combined OCP’s
  • the failure rate is 0.3 percent with perfect use and 9% with typical use
  • some evidence suggest the efficacy is slightly decreased in women who weight more than 198 pounds, however, the patch is still a very effective method for these women
  • the overall risk of VTE is small, approximately 100 cases per 100,000 per year, for women 25 to 35 years old, the incidence is only 30 cases per 100,000 er year
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20
Q

What are the patient instructions for a transdermal patch?

A
  • the patch should be applied to clean, dry skin on the abdomen, buttock, upper outer arm, or upper torso (excluding breasts)
  • it should not be placed in areas that receive a lot of friction, such as under bra straps
  • the patch must be changed weekly
  • when the patch is removed, it should be folded closed to reduce the release of hormones and should be disposed of in the garbage
  • to avoid the release of hormones into the soil and water supply, a used patch should not be flushed down the toilet
  • non-hormonal back-up contraception is needed for the first 7 days if the patch is started any day other than day 1 of menstrual cycle
  • if patch falls off, a new patch should be applied immediately
  • if the patch was off for more than 24 hours, 7 days of backup contraception is requires
  • this method does not protect again STIs
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21
Q

What are the characteristics of the NuvaRing?

A

a flexible plastic vaginal ring

  • 7% failure rate
  • 1 ring intravaginally for 3 weeks each month
  • insert on day 5 of the cycle within 7 days of last oral contraceptive pill
  • the ring must remain in place continuously for 3 weeks, including intercourse
  • remove for 1 week, then insert a new ring
  • may be used continuously for 4 weeks and replaced immediately to skip a withdrawal week
  • may experience withdrawal bleeding
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22
Q

What are the characteristics of the progestin-only mini pill?

A

failure rates similar to combined OCP’s - 9% failure rate, 0.3% failure rate when used correctly

  • safe in lactation - can be used in a breast-feeding woman
  • no estrogenic side effects (headache, nausea, HTN)
  • decreased ovarian and endometrial cancer risk
  • may cause menstrual irregularities
  • sightly less effective than combined OCP’s
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23
Q

What are the characteristics of an IUD?

A

the most effective form of birth control

  • reversible
  • coper IUD (paragard) - 0.8% failure rate, women who cannot have hormones that want children later in life (replayed every 10 years)
  • progestin-only IUD (Mirena) - 0.2% failure rate, replaced every 3-5 years
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24
Q

What are the characteristics of emergency contraceptive?

A

recommend a levonorgestrel emergency contraceptive (Plan B one-step, etc.) within 3 days of unprotected sex or prescribe Ella (ulipristal) within 5 days

  • up to 25% failure rate
  • levonorgestrel works for up to 5 days after sex…but labeling doesn’t recommend it, and efficacy decreased the longer the patient waits
  • consider a copper IUD within 5 days if the women also wants long-lasting contraception, it is the most effective emergency contraceptive
  • you may also see drug interaction alerts pop up with CYP3A4 inducers (carbamazepine, topiramate, St. John’s worst, etc.)
  • theses may possibly decreased the efficacy of levonorgestrel or Ella
  • but don’t shy away from these emergency contraceptives in women on an interacting med
  • or if it’s practical go with a copper IUD instead
  • for women on an oral contraceptive, tell them to resume or start a pack as soon as possible after levonorgestrel
  • but advise waiting 5 days after Ella…OCs and Ella may decrease the effectiveness of one another
  • also, recommend backup for 7 days after levonorgestrel…and for 14 days or until the next period after Ella, whichever comes first
  • watch for women using emergency contraception as their primary birth control form
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25
Q

What are the characteristics of Depo-Provera?

A

long-acting progesterone injection

  • 5% failure rate
  • lasts 3 months
  • may cause menstrual irregularities
26
Q

What are the characteristics of nexplanon?

A

long-acting progesterone implanted in the upper arm

  • 0.5% failure rate
  • lasts 3 years
  • may cause menstrual irregularities
27
Q

What are the characteristics of sterilization?

A
  • tubal ligation - 0.5% failure rate, permanent
  • essure - chemicals or coils to scar Fallopian tubes - - 0.5% failure rate, can be done in the office
  • vasectomy - 0.15% failure rate - vas deferent from each testicle is clamped, cut, or otherwise sealed
  • this prevents sperm from mixing with the semen that is ejaculated from the penis
28
Q

What is infertility?

A

described as an inability to conceive within 12 months of unprotected intercourse

29
Q

What is primary infertility?

A

infertility in an absence of previous pregnancy

30
Q

What is secondary infertility?

A

infertility after a previous pregnancy

31
Q

What are the causes of infertility?

A

65% female, 20-40% male, 15% unknown

  • anovulation is the most common cause - amenorrhea and abnormal periods
  • tubal disease
  • male factor
  • unexplained/multifactorial
32
Q

How is infertility dx?

A

diagnosis is based on PAP, hormone levels, ultrasound, hysterosalpingogram, semen analysis, ovulation check

  • start with more basic tests
  • take a detailed history first: type of coitus - when, where, how often
  • ovulation tracking:
  • menstrual diary
  • luteal phase (day 21) progesterone level - if the progesterone level is less than 3 ng/ml on day 21 then you know that the patient did not ovulate
  • basal body temperature: no- mid-cycle basal
  • body temperature increases
  • male factor is diagnoses by semen analysis
  • labs: TSH, prolactin, LH and FSH in women over 35

if no diagnosis then proceed with more invasive and expensive tests:

  • hysterosalpingogram (to evaluate for tubal factors)
  • laparoscopy
33
Q

What is the tx of infertility?

A

treatment is based on the underlying cause

  • may require medication such as clomiphene citrate to hyper stimulate ovulation, surgery (lysis of adhesions in tubal disease) or assisted reproductive technologies (i.e vitro fertilization)
  • metformin increases ovulation and pregnancy rates when PCOS is the cause
  • bromocriptine to treat hyperprolactinemia
34
Q

What is an ovarian cyst?

A

a fluid-filled sac within the ovary

35
Q

What are the characteristics of ovarian cyst?

A
  • the majority of cysts are harmless and cause no symptoms
  • occasionally they may produce bloating, lower abdominal pain, dyspareunia, or lower back pain
  • ovarian cysts may be classified according to whether they are a variant of the normal menstrual cycle (functional) or non-functional
36
Q

What is the most common ovarian cyst?

A

follicular cysts

37
Q

What are functional ovarian cyst?

A

(3 types)
-normal physiological functioning of ovaries = follicular (MC) and corpus luteum; 2-3 cm can get as big as 10 cm, clear serous liquid, smooth internal lining

38
Q

What are the three types of functional ovarian cyst?

A
  • follicular cyst (the most common type)
  • corpus luteum
  • theca lutein cysts
39
Q

What is a follicular cyst?

A

most common type

-a dominant follicle fails to rupture

40
Q

What is a corpus luteum ovarian cyst?

A

dominant follicle ruptures but closes again and doesn’t dissolve

41
Q

What is a theca lutein cysts?

A

overstimulation of HCG production by placenta so only seen in pregnancy

42
Q

What is non-functional/neoplastic cysts?

A

PCOS (amenorrhea, hirsutism), endometriosis (chocolate cysts), dermoid cysts (teratomas), ovarian serous and mutinous cyst adenoma, etc.
->10 cm, irregular borders, internal septations

43
Q

What are the three main complications of ovarian cysts?

A
  • hemorrhagic: more common with follicular and corpus luteal cysts
  • rupture: release contents into peritoneal cavity, frequently after sexual intercourse
  • torsion: ovary twists around suspensory ligament, cuts of blood supply to the ovary (risk if the cyst is >5 cm)
44
Q

What is the hx with ovarian cysts?

A

follicular tend to be asymptomatic, larger = pelvic pain; corpus luteum = local pelvic pain, amenorrhea, or delayed menses

45
Q

What is the pe of ovarian cysts?

A

ruptured = pain, low blood pressure, abdominal or shoulder pain, tachycardia, ovarian torsion = waxing and waining pain, n/v, low-grade fever

  • abdominal and pelvic ultrasound is the first imaging study of choice for suspected ovarian torsion because it is less expensive than and has similar diagnostic performance as computed tomography (CT) and magnetic resonance imaging (MRI)
  • definitive diagnosis is direct visualization of a tossed ovary during surgery and prompt operative evaluation is the mainstay of treatment to preserve ovarian function
46
Q

How is ovarian cysts dx?

A

transvaginal ultrasound/abdominal

  • MRI: if ultrasound indeterminate for surgical resection evaluation
  • Labs: serum CA-125 (in menopausal, postmenopausal individuals) = assists in ruling out ovarian cancer
  • histologic analysis via ultrasound-guided aspiration (definitive)
47
Q

What is the tx of ovarian cyst?

A
  • most resolve in one month
  • follow-up imaging in women of reproductive age for incidentally discovered simple cysts on ultrasound is not needed until 5 cm, as these are usually normal ovarian follicles
  • for simple cysts greater than 5 cm but less than 7 cam in premenopausal females, cysts should be followed yearly
  • for simple cysts greater than 7 cm further imaging with MRI or surgical assessment is mandated due to their large size, these cysts cannot be reliably assessed by ultrasound alone
  • cysts that persist beyond two or three menstrual cycles or occur in postmenopausal women should be investigated through ultrasonography and laparoscopy, especially in cases where family members have had ovarian cancer
  • such cysts may require surgical biopsy
48
Q

What is sexual assault?

A

any involuntary sexual act in which a person is coerced or physically forced to engage against their will or any non-consensual sexual touching of a person

  • physical contact need to not occur to be considered assault (eg. forced to watch a sexual act)
  • 1 in 3 women will be sexually assaulted in her lifetime
  • because of stigmata associated with sexual assault, only 1 in 10 victims seek help
  • sexual assault hotline, 800-656-4673
49
Q

How is sexual assault dx?

A

rape constitutes both a psychiatric emergency and a legal situation; all procedures should be documented, clothing saved, and samples are taken

  • explain to the patient the purpose of all procedures, and inform him or her of what is being done before doing it.
  • this provides the patient with a feeling of some control
  • a rape kit, which has instructions regarding questions to include in the history, how specimen samples are to be collected and under what conditions, and how samples should be handled after collection, is valuable and ensures that the proper evidence is secured
  • cultures from the vagina, the anus, and usually, the pharynx for gonorrhea and chlamydia, RPR for syphilis, hepatitis antigens, HIV, urinalysis, pregnancy test for menstrual-aged women (regardless of contraceptive status)
50
Q

What is the tx of sexual assault?

A

prophylactic antibiotic therapy should be initiated

  • rocephin 250 mg followed by oral doxycycline twice daily x 7 days
  • tetanus toxoid if indicated
  • the patient should be given the option of emergency contraception
  • counseling: as soon as possible after the event, and preferably before leaving the emergency department, the patient should talk to a mental health professional and follow-up counseling should be scheduled
51
Q

What is the follow-up for sexual assault?

A

within 24-48 hours after discharge, all victims should be contacted by phone

  • one-week visit - a general review of patient’s progress
  • six-week visit - repeat cultures for STIs and repeat RPR
  • 12-18 week visit may be indicated for repeat HIV titers
52
Q

What are the characteristics of spouse or partner violence, physical?

A
  • this category should be used when non accidental acts of physical force that results, or have reasonable potential to result, in physical harm to an intimate partner or that evoke significant fear in the partner have occurred during the past year
  • nonaccidental acts of physical force including shoving, slapping, hair pulling, pinching, restraining, shaking, throwing, biting, kicking, hitting with the fist or an object, burning, poisoning, applying force to the throat, cutting off the air supply, holding head under water, and using a weapon
  • acts for the purpose of physically protecting oneself or one’s partner are excluded
53
Q

What are the characteristics of spouse or partner violence, sexual?

A
  • this category should be used when forced or coerced sexual acts with an intimate partner have occurred during the past year
  • sexual violence may involve the use of physical force or psychological coercion to compel the partner to engage in sexual act against his or her will, whether or not the act is completed
  • also included in this category are sexual acts with an intimate parter who is unable to consent
54
Q

What are the characteristics of spouse or partner neglect?

A
  • partner neglect is any egregious act or omission in the past year by one partner that deprives a dependent partner of basic needs and thereby results, or has reasonable potential to result, in physical or psychological harm to the dependent partner
  • this category is used in the context of relationships in which one partner is extremely dependent on the other partner for care or for assistance in navigating ordinary daily activities - for example, a partner who is incapable of self-care owing to substantial physical, psychological/intellectual, or cultural limitations (e.g. inability to communicate with others and manage everyday activities due to living in a foreign culture)
55
Q

What are the five major types of incontinence?

A

urge, stress, overflow, functional, and mixed

56
Q

What are the characteristics of urge incontinence (detrusor overactivity)?

A

frequent small amounts of urine

  • most common in elderly and nursing home patients
  • may be associated with UTI
  • occurs at night and disrupts sleep
  • treated with bladder-training exercises
  • if this is unsuccessful, medications include anticholinergics (oxybutynin) and TCAs (imipramine)
57
Q

What are the characteristics of stress incontinence?

A

(weakness of pelvic floor)

  • urine leakage due to abrupt increases in intra-abdominal pressure (eg. with coughing, sneezing, laughing, bending, or lifting)
  • women after multiple deliveries
  • no urine loss at night
  • treated with Kegel exercises to strengthen pelvic floor musculature
  • vaginal estrogens
  • use of a pessary
  • surgery (there are various options, and a popular option is a mid-urethral sling)
58
Q

What are the characteristics of overflow incontinence?

A

(impaired detrusor contractility)

  • occurs when urinary retention leads to bladder dysfunction and overflow of urine through the urethra
  • common in diabetic patients and patients with neurologic disorders
  • elevated postvoid residual volume
  • treated with intermittent self-catheterization is the best management
  • cholinergic agents (bethanechol) to increase bladder contractions
  • alpha-blockers (terzosin, doxaosin) to decrease sphincter release
59
Q

What are the characteristics of functional incontinence?

A

occurs in patients who have normal voiding system, but who have difficulty reaching the toilet because of physical or mental disabilities

  • symptoms include increased urinary volume and the inability to timely urinate
  • treatment includes scheduled voiding times
60
Q

What is mixed incontinence?

A

(combo of stress and urge) most common

  • lifestyle modifications and pelvic floor exercises are first-line
  • if unresponsive to first-line treatments then therapy is based on the predominant symptoms

Women's Health EOR (10 decks)

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