Week 1 pt 1 Flashcards
1) Define Obstetrics
2) Define gynecology
1) Care of the woman during pregnancy, labor, & postpartum period
2) Comprehensive women’s healthcare
-Pre-pubescent to post-menopausal
True or false: more women see a family medicine doc for checkups and well-woman visits, but a larger share of younger women see an obgyn
True
Women’s demographics in the U.S.: Are there beginning to be more or less women in their menopause/post-menopause years?
More
4 basic principles of women’s health practice are what?
1) Safety of patients
2) Ethical practices: Nonmaleficence, beneficence, autonomy, justice
3) Value-based healthcare
4) Prevention & early mitigation of disease
“Life-course” perspective of women’s health involves what? (3 things)
1) Starts with preconception health
2) Continues throughout pregnancy + during postpartum period
3) Provides a perspective for healthy living
What are the three concepts describing origin of disease?
1) Barker hypothesis
2) Adaptive developmental plasticity
3) Allostasis
Origin of Disease:
1) What is the Barker hypothesis?
2) Explain
1) Developmental origins of adult disease
2) Perturbations or conditions during pregnancy that account for epigenetic changes may lead to future CVD, obesity, DM, stroke
-A normal pregnancy may be protective of disease later in life
-Harmful behaviors & environment (obesity & smoking; exposures; may account for up to 40% of all premature deaths in the US)
Define primary and secondary prevention and give examples
1) Primary prevention: Goal to eliminate or decrease risk factors for disease
-Ex: Immunizations, fitness & nutrition, hygiene, smoking cessation, personal safety, safe sex
2) Secondary prevention: Screening tests for disease in asymptomatic patients
Ex: Annual exam
-Evaluate and counsel based on age & risk factors
1) Define adaptive developmental plasticity
2) Define allostasis
1) Short-term fetal protective modifications may become permanent
2) Ability to maintain stability during physiologic change (ie. stress response)
True or false: poor nutritional health [during pregnancy] can be correlated with poor adult health
True
What are the recommendations for vaccination on women?
1) Prevention of cervical neoplasia & cancer with HPV vaccine (11-26yo)
2) CDC recommended adult immunization schedule (updated 2024)
*Review this (on next slide too)
3) Annual flu shot; pertussis during pregnancy (Tdap)
1) What do screenings depend on in women’s preventative care?
2) What do these include?
1) Vary by age groups & risk factors
2) Screenings for cancers, metabolic disorders, & STIs
What is the goal of screening for cancer?
Detect preclinical disease in healthy, asymptomatic patients to:
a) Prevent adverse outcomes
b) Improve survival
c) Avoid the need for more intensive treatments
1) Most commonly-diagnosed cancer in women (U.S.) is what? What is the lifetime risk?
2) What is the 2nd leading cause of cancer-related death in women (#1 lung)?
1) Breast cancer; ~12%
2) Breast cancer
Breast cancer publishers of clinical screening guidelines include who? (3 groups)
1) American College of Obstetricians & Gynecologists (ACOG)*
2) American Cancer Society (ACS)
3) United States Preventive Services Task Force (USPSTF)
List risk factors for cervical cancer
1) HPV
2) sexual hx (young age, multiple partners, high risk partner)
3) Smoking
4) HIV
5) Immunosuppression
6) Chlamydia
7) long-term OCP use
8) multiple full-term pregnancies (> 3)
9) young at 1st full-term pregnancy (< 20 y/o)
10) low income
11) diet low in fruits & vegetables
What 2 things may provide early diagnosis for cervical cancer?
Exfoliative cytology (Pap test) + high-risk HPV strain test
ACOG & 2 other organizations endorse ___________ cervical cancer screening recommendations (hint: update in progress)
USPSTF
For routine cervical cancer screening (USPSTF):
1) What should <21 year old’s do?
2) What abt 21-29 year olds?
3) What abt ages 30-65 yrs?
4) What abt >65?
5) What abt hysterectomy with cervix removal?
1) No screening
2) Cytology every 3 yrs
3) Either: a) Cytology every 3 yrs b) Approved hrHPV testing every 5 yrs c) Cotesting (hrHPV + cytology) every 5 yrs
4) No screening if prior negatives
5) No screening if no Hx of HSIL or cervical CA
Colorectal cancer risk factors include what?
Increasing age
Inflammatory bowel disease (IBD)
Personal or family history of colon cancer
Genetic syndromes (ie. familial adenomatous polyposis, Lynch syndrome)
Lack of physical activity
Diet low in fruits & vegetables
Low fiber & high fat diet; diet high in processed meats
Overweight & obesity
Alcohol consumption
Tobacco use
Colorectal cancer screening (average risk): Preferred method is colonoscopy every 10 years starting at age ________.
45yo
STD screening (non-pregnant) depends on what 2 factors?
Age + risk factors
1) Screen for _______ in all females ages 13-64 at least once then annually based on risk factors
2) When should you screen for chlamydia and gonorrhea?
3) What should be screened for annually for women at increased risk?
1) HIV
2) Annually in sexually active women age < 25 & asymptomatic women age > 25 at high risk
3) Syphilis
Describe DEXA scores
DEXA (hip, Lspine) is done for osteoporosis:
1) T-score: SD from the mean peak BMD of a normal, young adult population
2) Z-score: SD from the mean BMD of a population of the same sex, race, age
-Normal BMD T-score as ≥−1 (-1 to -2.5 = osteopenia; <-2.5 = osteoporosis)
Regarding younger postmenopausal women, what are the risk factors for osteoporosis or fracture? (>/= 1 to screen)
1) Medical Hx of fragility Fx
2) Weight <127 lbs
3) Medical bone loss
4) Hx of hip Fx
5) Current smoker
6) Alcohol abuse
7) RA
Metabolic screening: Screening for DM should be done when?
1) Fasting blood glucose starting at age 40yo to 70yo in overweight/obese patients (USPSTF)
2) Also considered in patients with
-physical inactivity
-see chart on slide 32
1) When should thyroid disease be screened for?
2) What are examples of cardiovascular disease screening?
1) Hypothyroidism may present in older women as dementia
TSH levels every 5 years starting at age 35 in women
2) BP, lipids, body wt., blood glucose, smoking, physical activity, diet.
When should the following screenings occur?
1) HTN
2) Lipid disorders
3) Obesity
1) HTN: annually for women & girls age 13 and older
2) Lipid profile starting at age 45, then every 5 years for women without risk factors
3) Height & weight measurements with BMI calculation as part of periodic health assessment
What can help when it comes to an ethical dilemma in choosing and/or implementing management decision?
(ethical, moral, economic, religious, law conflicts, medical liability)
Principle-based ethics (autonomy, beneficence, nonmaleficence, and justice)
chart slide 36
Define each of the following ethical principles and give an ethical concern for each:
1) Autonomy
2) Beneficence
3) Nonmaleficence
4) Justice
1) Respect for the pts right to self-determination
-Knowing what the pt wants + right to refuse care
2) The duty to promote the good of the pt
-Evidence-based Dx and management
3) Duty to not inflict harm or injury
-Impact of management on pts life
4) Assuring the pt is given what is “due”
-The preferences of the pt, the needs of the society, and the boundaries upon management as given by law
7 steps in decision-making process when it comes to ethics are what?
1) Identify the decision makers (capacity vs competence)
-Surrogate decision making
2) Collect data
3) Identify & evaluate all medically appropriate management options
4) Systematically evaluate the options
5) Identify ethical conflicts & set priorities
-Right to refuse care
6) Select the option that can best be justified
7) Re-evaluate decision based on clinical outcomes
A pregnant woman rejects your medical recommendations or engages in actions that put the fetus at risk.
Based on the principle-based approach, how might you address interventions for fetal well-being?
-Ask what she is willing to do
-Give her information and support to make those decisions
Informed consent involves what?
1) Derived from autonomy
2) Responsibility of performing physician (clinician) & cannot be delegated
3) Must be voluntary
4) Document everything
What is a cornerstone of the relationship between patient and provider that involves respect for autonomy & promotion of beneficence (HIPAA)?
Confidentiality
1) What is specific to pregnant women in women’s health?
2) What should you avoid?
1) Advance directives
2) Pt abandonment
List 2 legal obligations
1) Preventing Fraud
2) Know local reporting laws
Regarding patient healthcare enrichment & decreasing potential for litigation, how can you improve each of the following?
1) Pt safety
2) Ethical practice
3) Value
1) Avoiding medical errors
2) Good decision-making, avoiding malpractice
3) Use of “best practices” tools, informed consent, & high-reliability medical teams
There are societal, economic, health, and mental health implications of care of what group of female patients?
Terminally ill
Define the importance of sexuality
1) An important quality-of-life issue for many women (and med)
a) Fundamental to self-identification
b) Strong cultural, biologic, and psychological components
1) Estimated _______% women perceive sexual problem (usually ____ desire)
2) Is there only one factor?
1) 35-45%; low
2) Multiple contributing factors
1) Sexual function & dysfunction a combination of what 2 things?
2) What is the traditional model of sexual function/ dysfunction in women?
1) Mind & body
2) Linear sequence of events; often differs in women and men
Female sexual response:
1) tachycardia, skin flushing, vaginal lubrication are mediated by what?
2) Norepinephrine, dopamine, oxytocin, & serotonin (via 5-HT 1A & 2C) are what kind of NTs?
3) What type of NTs are serotonin, prolactin, & GABA?
1) ANS
2) Positive
3) Negative
What are the 4 stages of female sexual response
1) Excitement stage
2) Plateau stage
3) Orgasm stage
4) Resolution stage
What are the phases of the male sexual response?
A – excitement
B – plateau
C – orgasmic
D – resolution
E – refractory (*only in men; not shown)
What is the definition of female sexual dysfunction?
No universal definition:
“The various ways in which an individual is unable to participate in a sexual relationship the way he or she would wish.” - WHO
slide 57
What are some medications commonly affecting sexual response?
1) Codeine-containing analgesics
2) Alcohol (chronic abuse)
3) SSRIs
4) Cyproterone acetate
5) Some beta blockers
6) OCPs
7) Anticonvulsants
List 4 main factors affecting female sexuality
1) Depression
2) Medications
3) Medical conditions
4) Psychological factors
Give the DSM definitions of:
1) Female sexual interest/ arousal disorder
2) Female orgasmic disorder
3) Genitopelvic pain/ penetration disorder
1) Reduced or absent interest in sexual activity including lack of erotic thoughts or cues. No interest in initiating sexual activity or lack of response. Absent or reduced sensations. Causes distress or interpersonal difficulty.
2) Delay, infrequency of, or absence of orgasm, or reduced intensity of orgasm. Causes distress or interpersonal difficulty.
3) Recurrent or persistent genital pain assoc. with sexual intercourse (dysparenuria). Causes distress or interpersonal difficulty.
OR
Recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse (vaginismus)
Describe how to screen for sexual dysfunction
Respectful & nonjudgmental approach
Broad, open-ended questions
“Are you sexually active?”
“Do you have any sexual concerns (problems, troubles)?”
“Do you have any pain associated with sex?”
Don’t make assumptions about partner(s)
Use “partner” instead of “husband”
Use “sexual activity” instead of “intercourse”
An understanding of non-heterosexual sexuality
Give examples of medical conditions affecting female sexual response
1) Chronic renal failure
2) Diabetes mellitus
3) Spinal cord injury
4) Hypothyroidism
Psychological factors commonly affecting sexual response include what?
1) Past negative sexual experiences
2) Knowledge of a likely unsatisfactory or painful outcome
3) Decreasing self-image (ex: from infertility)
4) Potent nonsexual distractions
5) Lack of physical privacy
6) Fear of physical safety
7) Feelings of shame, embarrassment, or naivety
Additional history (depending on concern) for sexual dysfunction can include what?
1) Duration & evolution
2) Psychological assessment may be needed
3) Context of when dysfunction began
4) Medical history & past sexual experiences
Meds, substance abuse
5) Developmental history may be needed
6) Quality of interpersonal relationship
What do you need to establish regarding female sexual dysfunction?
If the dysfunction is lifelong or acquired and situational or global/generalized.
What are some primary care treatments for sexual dysfunction?
1) Giving info
2) Normalizing nonpenetrative sex to both partners
3) Screening for depression and effects of antidepressants
4) Screening for med-assoc. effects
5) Replacing estrogen locally or systemically
6) Replacing testosterone
7) Rx flibanserin, a multifunctional serotonin agonist-antagonist approved by the FDA for use in premenopausal women
8) Tx hyperprolactinemia, hypothyroidism, or hyperthyroidism
9) Vasoactive drugs for genital arousal
What factors should be considered when deciding if to refer a pt with sexual dysfunction?
1) Expertise of the OBGYN
2) Complexity of dysfunction
3) Presence or absence of partner sexual dysfunction
4) Availability of psychologist, psychiatrist, or sex therapist
5) Motivation of the pt and partner to undergo more detailed assessment for therapeutic interventions
What is an overlooked tool for female sexual dysfunction?
Support groups
A 23-year-old G5P5 women presents because she has lost interest in intercourse with her husband. Review of her past history reveals she was married at an early age, conceiving her first child shortly after. Her last 2 pregnancies were “difficult” and she was unable to get a tubal ligation after her last pregnancy. Her last pregnancy ended about 6 months ago. She reports trouble losing her pregnancy-related weight gain despite reporting little appetite.
What should you consider doing?
Most common cause of reduced libido is depression.
Social stresses, household demands with multiple small children, & possible fears about future pregnancy suggest depression in this patient.
Screening questionnaire can confirm.
Treatment may include medication, social support, & counseling.
Antidepressants may also decrease her libido (side effect).
Ongoing follow up with provider is important.
