Week 1: Women in Health

Question 1

How do you start an annual women’s health history?

Answer 1

Ask about last date of pap smear
-Had you had your cervix froze?
-Any surgeries/operations to cervix

Question 2

Are they sexually active yes or no?

Answer 2

If no, then why are they not having sex?

Need for topical estrogens, dilators, counseling

Question 3

Dyspareunia

**Genital pain before, during, or after intercourse

Answer 3

1. pain with 1st insertion?
2. pain with penetration?
3. with deeper penetration?
4. vigorous intercourse
5. specific positions?
6. dryness, atrophy? does it interfere with sex? Or makes you stop sex?

Question 4

Causes of dyspareunia (genital pain)

Answer 4

-atrophy
-prolapse
-size disproportion
-vaginitis
-UTI
-STD

Question 5

post coital bleeding (after sex bleeding)

Causes?

Answer 5

-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

Question 6

Dysmenorrhea

(cramps & pelvic pain with menstruation)

Common causes include:
-heavy flow
-passing clots
-uterine fibroids
-endometriosis

Answer 6

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

Question 7

STD/ Pelvic Inflammatory Disease

Answer 7

-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?

Question 8

Vaginitis Symptoms

Answer 8

-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

Question 9

UTI

Answer 9

dysuria
urgency
frequency
change in urine color
OTC- cranberry meds

h/o interstitial cystitis (UTI BUT w/ negative cultures)

Question 10

Pelvic Relaxation?

Answer 10

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

Question 11

Causes for Pelvic Relaxation?

Answer 11

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

Question 12

Stress urinary incontinence
(leaking urine from bladder)

Answer 12

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)?

Question 13

Detrusor dysfunction (underactive bladder

Answer 13

Urinary urgency, frequency, nocturia, spontaneous leakage, or enuresis.

This is also another reason to do urodynamic studies to document bladder spasms or lack thereof.

Question 14

Detrusor dysfunction

Answer 14

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

Question 15

Detrusor dysfunction meds

Answer 15

toviaz
enablex
detrol LA
vesicare
myrbetric
ditropan

Question 16

Digitalization

Answer 16

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?

Question 17

Chronic pain

Answer 17

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.

Question 18

Endometriosis

Answer 18

-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

Question 19

Endometriosis Treatment?

Answer 19

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.

Question 20

Dysfunctional uterine bleeding

Answer 20

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.

Question 21

Menorrhagia (heavy menstrual bleeding)

Answer 21

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.

Question 22

Menometrorrhagia

Answer 22

Menometrorrhagia-

heavy irregular bleeding all the time. Ultrasound and endometrial biopsy.

Possible sonohysterogram.

Question 23

Menopausal symptoms

Answer 23

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.

Question 24

Postmenopausal bleeding

Answer 24

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.

Question 25

PMS

Answer 25

Moody, grumpy, irritable, hateful, breast tenderness, cravings, overeating-high-dose vitamins,

sometimes vitamin E will help, caffeine use or avoidance could go either way

Question 26

Contraceptive problems

Answer 26

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?

Question 27

Infertility

Answer 27

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).

Question 28

Current method of contraception

Answer 28

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.

Question 29

Screening and Counseling that we can get paid for?

Answer 29

-tobacco usage, alcohol or substance use/abuse, obesity, depression, high risk sexual behavior

Question 30

Self Breast Exam

Answer 30

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

Question 31

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.

Answer 31

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.

Question 32

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.

Answer 32

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.

Question 33

Weight Management-this can be accomplished through Women’s Health and Wellness, LLC using phentermine or Contrave and encouraging nutritional counseling and guidance.

Answer 33

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.

Question 34

Hormone Pellet Therapy

Answer 34

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.

Question 35

Hormone pellet therapy

Answer 35

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).

Question 36

Side effects of hormone therapy

Answer 36

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.

Question 37

Low Vitamin D

Answer 37

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.

Question 38

B12 Deficiency

Answer 38

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.