Week 1: Women in Health Flashcards
How do you start an annual women’s health history?
Ask about last date of pap smear
-Had you had your cervix froze?
-Any surgeries/operations to cervix
Are they sexually active yes or no?
If no, then why are they not having sex?
Need for topical estrogens, dilators, counseling
Dyspareunia
**Genital pain before, during, or after intercourse
- pain with 1st insertion?
- pain with penetration?
- with deeper penetration?
- vigorous intercourse
- specific positions?
- dryness, atrophy? does it interfere with sex? Or makes you stop sex?
Causes of dyspareunia (genital pain)
-atrophy
-prolapse
-size disproportion
-vaginitis
-UTI
-STD
post coital bleeding (after sex bleeding)
Causes?
-peri-menopausal (hormones) changes in estrogen
-menopausal
**both peri & menopausal requires a utrasound and biopsy because can be something else
-mid cycle (evulation can cause bleeding)
-cervicitis (cervical inflammation)
-vaginitis (vag inflammation)
-STD
Dysmenorrhea
(cramps & pelvic pain with menstruation)
Common causes include:
-heavy flow
-passing clots
-uterine fibroids
-endometriosis
Is the pain mild, moderate or severe
severe= endometriosis (tissue grows outside of uterus causing pain) (tissue thickens, breaks down & bleeds) usually
Does it interfere with quality of life?
Does anything cause relief? tylenol, heating pad, goodys (pamprin), nsaids, narcotics
OR
GI issue that causes cramps during this time
STD/ Pelvic Inflammatory Disease
-gonorrhea
-chlamydia
-herpes
-syphillis
-condyloma
-hepatitis
-TB
-mono
-mono- when did it happen? What was the treatment plan? Was there treatment? Was there follow up?
Vaginitis Symptoms
-discharge
-external or internal burning
-external or internal burning
-external or internal itching
-external or internal bleeding
-external or internal pain
-genital fissures
are the genital fissures causing causing (genital pain)? or disruption of sex?
any h/o antibiotic use that may have caused a yeast infection
New sexual partners
UTI
dysuria
urgency
frequency
change in urine color
OTC- cranberry meds
h/o interstitial cystitis (UTI BUT w/ negative cultures)
Pelvic Relaxation?
Do you feel pressure?
Fullness?
Feeling like your internal lady parts are falling out from below?
Feel like a bulge? Does it feel like bladder is falling out
Or bulge is posterior (rectocele)
Feels like vaginal penetration?
Or feeling like a sex toy is hitting her pelvic floor/bladder?
Or does it feel like your cervix is at the beginning (opening) of vag & that some times it has to be pushed back inside
Causes for Pelvic Relaxation?
Cystocele (bulge of bladder into the vag)
Uterine prolapse (herniation of the uterus into the vaginal canal) . . . the support structures weaken
Urethrocele- (urethral prolapse . . . the urethra moves from its normal position & presses against the front wall of the vagina
Rectocele-tissue between the rectum & vag weakens
Enterocele- small bowel prolapse ( the small bowel descends into the lower part of the pelvic cavity
Stress urinary incontinence
(leaking urine from bladder)
When you cough, sneeze, laugh run, jump exercise, does this leakage interfere with quality of life and if so how much so?
Urodynamic studies can and should be done in the office to determine post void residual, and any leakage that may occur can be evaluated this way.
Has this ever been surgically corrected?
Has she seen a urologist for this?
Has she ever been diagnosed with interstitial cystitis (chronic painful bladder)?
Detrusor dysfunction (underactive bladder
Urinary urgency, frequency, nocturia, spontaneous leakage, or enuresis.
This is also another reason to do urodynamic studies to document bladder spasms or lack thereof.
Detrusor dysfunction
We have medication that will help treat these issues and frequently I will give 2 weeks of multiple medications and follow-up at the end of the samples to see which drug worked best.
I tell them to do a diary of the good, the bad, and the ugly of each of the drug so that we can make an optimal choice
Detrusor dysfunction meds
toviaz
enablex
detrol LA
vesicare
myrbetric
ditropan
Digitalization
Does she need to insert her finger in her vagina to push posteriorly towards her rectum in order to express stool from the rectum and help her have a bowel movement?
Chronic pain
Any generalized or specific pelvic or abdominal pain that interferes with normal general physical activity?
Musculoskeletal, genital, urinary, abdominal wall pain, mesenteric pain, endometriosis, irritable bowel syndrome.
Endometriosis
-pain occurs in the perimenstrual time frame. There is generalized pelvic pain, sometimes focal/localized to one area.
Dysmenorrhea is usually pretty severe!
The best treatment would be a progestin contraceptive
About any hormonal contraceptive, Depo-Provera or progestin will work. In theory a Mirena IUD and other progestin IUDs are helpful
BUT what they really do is to reduce dysmenorrhea type pain and don’t really arrest the disease process
Endometriosis Treatment?
Treatment can be
- nonsteroidals
-hormonal contraceptives
Lupron, and if this is due to irritable bowel syndrome
amatiza, Bentyl, Levsin, Levsinex are helpful.
From a constipation side-fluid, fiber, milk of magnesia mixed with Orange juice daily, and Linzess are helpful.
Dysfunctional uterine bleeding
This is bleeding that is out of the characteristic regular monthly predictable cycles.
If they are on hormonal contraceptives this would be “breakthrough bleeding”.
Anybody over 35 generally gets ultrasound and endometrial biopsy. Possible sonohysterogram.
Menorrhagia (heavy menstrual bleeding)
Heavy menstrual bleeding, not only in volume of flow, but in days of flow as well.
Ask:
how many days that they bleed?
how many pads/tampons or boxes of each that are used per cycle?
Sometimes fatigue, dizziness, lightheaded low energy will be associated with heavy cycles.
Premenstrual and postmenstrual CBCs are frequently helpful. A low MCV is indicative of iron deficiency and an elevated MCV is usually B12 or folic acid deficiency.
Ultrasound and endometrial biopsy is usually warranted if over 35.
If they are less than 35 and their lining is significantly thick by ultrasound then sonohysterogram followed by biopsy (or the reverse) is indicated.
Menometrorrhagia
Menometrorrhagia-
heavy irregular bleeding all the time. Ultrasound and endometrial biopsy.
Possible sonohysterogram.
Menopausal symptoms
hot flashes, night sweats, mood swings, irritability, vaginal dryness, insomnia, depression. Oral, transdermal, or pellet HRT is usually beneficial. Brisdelle (low dose Paxil) and other antidepressants may be helpful as well.
Postmenopausal bleeding
a good menstrual and menopausal history is required.
Ultrasound, sonohysterogram, endometrial biopsy may be warranted.
Rule out cervicitis, cervical lesions, abnormal Pap smear, vaginal lesions, vulvar lesions as well.
PMS
Moody, grumpy, irritable, hateful, breast tenderness, cravings, overeating-high-dose vitamins,
sometimes vitamin E will help, caffeine use or avoidance could go either way
Contraceptive problems
bloating
irritability
breast tenderness
vaginal discharge
menstrual dysfunction
headaches
hypertension.
Which specific contraceptive has been used in the past?
IUD-copper or progestin.
Nexplanon usage-Did they like or not like this?
Infertility
do they desire children in the immediate future or in the distant future?
Have there been any fertility issues in her family? How long has she had infertility?
Has she had a hysterosalpingogram?
Has she documented ovulation with basal body temperature chart, ovulation indicators, or ultrasound?
Has he had a semen analysis to prove and that he is adequate?
Has she had children in the past or has he has children in the past?
(Just because he claims to have fathered children doesn’t mean that he was actually the biologic parent).
Current method of contraception
Hormonal contraceptives-this would be pill, patch, ring, Nexplanon, Depo-Provera.
IUD-copper containing or progestin-if so is this a 3, 4 or 5 year IUD?
Date of insertion is nice to have so that we can predict date of removal for the patient.
Screening and Counseling that we can get paid for?
-tobacco usage, alcohol or substance use/abuse, obesity, depression, high risk sexual behavior
Self Breast Exam
This should be done about 3-4 days after the onset of menses and on a monthly basis.
Cyclic findings are most likely hormonal.
Breast lumps/masses that are reported by the patient should be examined and treatment based upon this exam.
Mammogram or ultrasound is easy to schedule ASAP for them.
If a cyst is present then needle aspiration may be attempted using an 18 guage needle (smaller may not aspirate the fluid). Base futher treatment upon radiographic studies
like having mammograms on an annual basis beginning at age 40 unless somebody’s insurance mandates that it has to be a different schedule.
I start doing rectal exams at age 40 on an annual basis with Hemoccults.
If they Hemoccults are positive then I send them home with Hemoccult cards to mail back in.
Urinalysis and urine drug screens are done on all annual exams unless the patient tells us not to.
I do gonorrhea and chlamydia testing on every annual exam because I never know who’s sleeping with who and everybody lies about who they might be sleeping with or who they’re not sleeping with and how many different people are actually sleeping with.
For depression, anxiety, insomnia, I will start out with a 1 month prescription and usually see them back at 1 month to make sure we have an adequate response.
Thereafter, for these medications they require an every 3 month evaluation so that we can check their controlled substance history via CSMDTN.gov and have appropriate follow-up since these are controlled substances.
If they claim they have an allergy to something I want to know what kind of allergic reaction that they had and who told them they had an allergy to a specific medication so that it can be documented that it’s a real allergy and not just a side effect.
Weight Management-this can be accomplished through Women’s Health and Wellness, LLC using phentermine or Contrave and encouraging nutritional counseling and guidance.
Frequently, I will tell them to look at the American Diabetes Association website and consider Weight Watchers to learn about portion control and balance of caloric intake.
Phentermine is usually given for 30 days taken first thing in the morning with a 1 month follow-up and a weight loss goal in pounds is established.
At 1 month, side effects and compliance with diet, exercise, and success need to be evaluated.
Exercise in a regimented fashion 3-4 times a week for 30-45 minutes is encouraged.
Hormone Pellet Therapy
For issues like fatigue, malaise, arthralgias, myalgias, vasomotor symptoms, loss of libido.
Look at the women’s health and wellness hormone pellet sheet and you can see where the testosterone improves certain symptoms and where the estradiol will improve certain symptoms.
There is no PROGESTERONE pellet available.
Hormone pellet therapy
Any woman who is non-menopausal on hormones does not have to take a progestin.
Any woman with a progestin IUD does not have to take an oral progestin.
Any woman with a uterus who is menopausal and who is receiving testosterone and/or estradiol must take a progestin in one way or another-IUD, Depo-Provera, oral Provera, Progesterone, Norethindrone (Camilla).
Any woman non-menopausal receiving testosterone Must Have an Absolute and Perfect Method of Contraception
(testosterone will masculinize a fetus causing a congenital abnormality).
Side effects of hormone therapy
these will usually be some mood volatility, excessive hair growth like hirsutism, maybe some hair falling out on top of the head, and complexion issues.
Spironolactone 50 mg in the morning up to 150 mg in the morning works well for most of these issues. It is a potassium sparing diuretic so potassium levels need to be checked in 4 weeks after starting and then about every 3 months after that.
Low Vitamin D
we do a high-dose D protocol so at about 3-3-1/2 months (12-14 weeks) rechecking her vitamin D level and assessing for side effects is mandatory.
Vitamin D is a fat soluble vitamin so toxicity is always a possibility.
B12 Deficiency
frequently I will recommend weekly injections of 1000 µg per injection x 6 weeks and at the same time start oral vitamin B12 supplements.
This can be rechecked in 6 weeks or at their post-pellet visit usually 12-14 weeks after starting.
