Well Women Visit - Exam 2 Flashcards
What does FDLMP stand for? PMS? PMDD?
FDLMP - first day of last
menstrual period
PMS - Premenstrual Syndrome
PMDD - Premenstrual
Dysphoric Disorder
_______ few years leading up to menopause - may already have erratic hormones, menses typically regular
premenopause
______menses often irregular and hormones are erratic, but menstruation has not completely ceased
Perimenopause
What is the technical definition for postmenopause? What is dysmenorrhea?
no menstrual flow for 12+ months
painful menstrual flow
What is cryptomenorrhea? Metrorrhagia?
light menstrual flow or spotting only, same thing as hypomenorrhea
menstrual bleeding occurring between cycles, same thing as intermenstrual bleeding
What is considered polymenorrhea? Menometrorrhagia?
periods that occur too frequently , a cycle that is 20 days or less
bleeding at irregular intervals
amount and duration may also vary (often heavy)
What is Oligomenorrhea? Amenorrhea?
periods that occur too rarely, cycle is over 35 days apart
no menstrual period for over 6 months
postcoital bleeding can be a sign of _______. What is another name for it?
cervical cancer
contact bleeding
What is the difference between a subtotal hysterectomy and radial hysterectomy?
Subtotal hysterectomy : uterine corpus only (not cervix)
Radical hysterectomy: uterus, cervix, pericervical tissue, upper vagina
What is a BSO? TAH? TVH?
bilateral salpingo-oophorectomy
TAH - total abdominal hysterectomy
TVH - total vaginal hysterectomy
When should you NOT recommend a laparoscopic hysterectomy for your pt?
if cancerous because they chop up the uterus into little tiny pieces and remove them via the vagina
What does a subtotal hysterectomy remove? Total hysterectomy? Radical?
subtotal: just the body of the uterus but leaves the cervix
total: takes the uterus and the cervix
radical: takes the uterus, cervix and top portion of the vagina PLUS the right and left parametrium
What are the weeks related to term, preterm, abortion, post-term, puerperium. Give the weeks of trimesters
What are the differences between spontaneous, therapeutic and elective abortions?
What is considered a still birth?
Stillbirth - the birth of an infant who has died in the womb
Typically used later in pregnancy (after 20 weeks’ gestation)
What does BTL mean? FHT? EFW? PROM? EGA?
BTL - Bilateral tubal ligation
FHT - fetal heart tones
EFW - estimated fetal weight
PROM - preterm ROM (< 37 wks)
EGA - estimated gestational age
What is considered grand multigravida? Great grand multipara?
pt who has been pregnant 5+ times
delivered 7 + infants of 24+ wks gestational age
What is the GTPAL system
G - Gravida
T - Term
P - Preterm
A - Abortions
L - Living children (30 days)
G4P4-0-0-4 (G4P4)
When is the recommended first reproductive health visit? Do you have to do a pelvic exam? What is the purpose?
between 13 and 15
No pelvic exam unless symptomatic or STI screen needed
to provide age-appropriate reproductive health info
What determines the frequency of subsequent GYN visits in the 13-21 age window?
varies depending on sexual activity, symptoms, patient needs
or if the pt gets pregnant
**What is the recommended age for the pts first pap smear? Do you need a pelvic exam before prescribing birth control?
begin age 21 in healthy pts regardless of sexual activity
NO!! do not need pelvic exam before prescribing birth control
How often should you preform a clinical breast exam on an average risk women?
Clinical breast exam (CBE) - controversial, no longer recommended for average-risk women
If done, every 1-3 years for women 20-39 years old
What is the recommendation for mammograms for the average risk woman?
Yearly CBE and mammograms for women 40+
What are some menstrual history questions you should ask?
Age at menarche and menopause
Length and regularity of cycles
Intermenstrual or contact bleeding
Amount of flow
Pain with menses
Presence of PMS
What are questions you should ask your pt regarding contraceptive/sexual history?
Current birth control method
Patient’s satisfaction with that method
Current sexual activity status
Number and gender/sex of partners
New partner in last 3 months
Condom use
History of abuse
_______ in the medical history would be especially important to realize in the GYN setting
Include in particular hx of blood clots or excessive bleeding/bruising
aka bleeding disorders!!
What is dyspareunia? When should you start asking about perimenopausal symptoms?
pain with sex
around age 45-55 or on MHT
Before performing a pelvic exam, have your patient ______. What should you do with the drape?
empty bladder before exam!!
When doing pelvic exam, try to “press down” drape between patient’s knees to help maintain eye contact and monitor patient’s face
What are the 5 different quadrants of the breast? Where is the tail of spence?
What are the 4 positions you should inspect in for a breast exam?
arms at sides
arms over head
arms pressed against hips
leaning forward
What is the best technique for a breast exam?
Use the pads of the second, third, and fourth fingers, keeping the fingers slightly flexed. It is important to be systematic. Palpate in small, concentric circles applying light, medium, and deep pressure at each examining point.
What is the recommendation for self-breast exams?
no longer recommend!!
In order to check perineal support, what should you have your pt do? What are you checking for?
pt needs to “bear down”
Cystocele, urethrocele, rectocele, uterine prolapse
What is urethral stripping?
applying pressure from proximal to distal urethra to express discharge
What is the traditional method for a pap smear?
Step 1:
Obtain cervical scraping from complete squamocolumnar junction by rotating 360 degrees around the external os.
Smear the material from one end of the slide to the other.
Step 2:
Place a saline-soaked cotton swab or small endocervical brush into the endocervical canal and rotate 360 degrees.
Place this specimen on the same slide and apply fixative solution
What is the ThinPrep Test method of pap smear?
Insert spatula, brush combo into cervical os opening and rotate 360 degrees 5X
then push combo to the bottom of the vial forcefully 10 times and swirl vigorously
What should a normal cervix feel like during a bimanual exam?
3-4 cm diameter and moderately firm, moderately mobile
without undue discomfort
What should a normal uterus feel like during a bimanual exam?
Half the size of the patients’ fist, smooth and regular outline,
not tender, mobile, symmetric
How do you preform a rectovaginal exam?
Insert well-lubricated middle finger of examining hand gently into the rectum and examine
Insert index finger of examining hand into vagina
Raise cervix toward anterior abdominal wall and palpate uterosacral ligaments
May also do fecal occult blood testing
What are the ACS guidelines for a comprehensive skin exam?
periodic (q 3 yrs) for pts 20-40 and yearly 40+
Annually or more often for higher risk patients
Encourage monthly self-examinations
What is the UV ray protection recommendation?
SPF 30 or higher
What are risk factors that would mandate a comprehensive skin exam?
Suspicious moles or lesions
History of skin cancer - personal or family
Atypical moles
History of extensive sun exposure
50+ total moles
Cervical cancer screening should start _____. How often for pts 21-29? 30-65?
age 21
Pap every 3 years
Pap every 3 years OR HPV +/- Pap every 5 years
When is the recommended age to stop doing pap smears? What are the factors?
Age > 65 - Stop screening if:
no history of moderate/severe dysplasia or cancer AND…
3 negative Paps in a row or 2 negative Pap+HPV results in a row in past 10 years (most recent result within last 5 years)
______ is the alternative if a pt will not get a pap smear
self-HPV testing
**What are the 4 criteria that if you meet them the pap smear guidelines do NOT apply?
If hx of cervical cancer, HIV+, immunodeficient or DES exposure
T/F: Only women with a functioning uterus need pap smears
False! May still need yearly Paps even after hysterectomy
they will just brush the cells out of the vaginal cuff instead of the cervix
What are the pregnant women STD screening guidelines?
Hep B, HIV, Syphilis - All pregnant women should be screened
Gonorrhea / Chlamydia - < 25 years or high-risk sexual behavior
Hep C - if high-risk sexual behavior
What are the non-pregnant ALL sexually active STD screening recommendations?
HIV - if they consent; one time if low-risk
Gonorrhea/Chlamydia - if < 25 years, annually
What are the non-pregnant high-risk sexual behavior STD screening recommendations?
HIV
Syphilis
Trichomoniasis
Hepatitis B and C
Gonorrhea/Chlamydia
+/- HSV, Hepatitis C
every year
What is considered the high risk sexual behavior demographics and criminal hx?
Young Age (15-24 years old)
African-American race
Unmarried status
Living in low socioeconomic status area
illicit drug use
admission to correctional facility
What 5 things in a women’s sexual history qualifies them as high risk?
New sexual partner in past 60 days
Multiple sexual partners
History of prior STI
Contact with sex workers
Meeting partners on the internet
What is the conservative approach to breast cancer screenings? When should you stop screening?
yearly screens starting age 40-45
May transition to biennial, esp. at age 55
age 74 but many providers continue screening “as long as a woman is in good health and expected to live 10+ yrs”
What is the colon cancer screening recommendation for your average risk patient? High risk pt? When should you stop screening for colon cancer?
FOBT, FIT, CT colonography, or endoscopy (sigmoid/colon) age 45-75
refer to specialist
75
_____ is the initial screening for bone density. When should you start?
DEXA scan
All women 65+ years old OR Any woman < 65 whose fracture risk ≥ that of a 65 year old white female without additional risk factors
**According to FRAX screening tool, a 65-yr-old white woman with no other risk factors has a ____ chance of 10-yr risk of osteoporotic fracture
9.3%
Under the Bethesda system; what are the different cell types results that could come back for a pap smear?
Atypical Squamous Cells Undetermined significance: ASC-US
Atypical Squamous Cells Cannot exclude high-grade lesion : ASC-H
Low-grade Squamous Intraepithelial Lesion: LGSIL or LSIL
High-grade Squamous Intraepithelial Lesion: HGSIL or HSIL
Atypical glandular cells: AGC
Negative for intraepithelial lesion or malignancy: NILM
What results of a pap smear require no further work up?
Negative for intraepithelial lesion or malignancy: NILM
_______ cells are associated with adenocarcinoma of endocervix or of endometrium
Atypical glandular cells
What is CIN I considered?
mild cervical dysplasia
disordered growth of lower ⅓ of epithelial lining
What is CIN II considered?
moderate cervical dysplasia
disordered growth of lower ⅔ of epithelial linin
What is CIN III considered?
severe cervical dysplasia
disordered growth of over ⅔ of epithelial lining
considered full thickness
What CIN levels ALWAYS require treatment? What are the 2 exceptions?
CIN II and III
Pregnant women (wait until postpartum period)
CIN II in adolescents
Why do you NOT treat CIN II in adolescents?
there is a high chance of spontaneous regression and lower risk of cancer
T/F: Cervical cancer is not considered severe until it invades another nearby structure
FALSE!! once the cancer is seen to be TOUCHING the basement membrane it is considered severe
do not need to wait until it reaches another structure
What are the sexual activity risk factors for cervical dysplasia?
Multiple sexual partners
Early onset of sexual activity
High-risk sexual partner
What are the infection factors for risk factors for cervical dysplasia?
HPV infection
History of sexually transmitted infection
Immunosuppression (including HIV/AIDS)
_____ and _____ also increase risk for cervical dysplasia.
Multiparity
Long term oral contraceptive pill use
HPV strains ____ and _____ are associated with cervical cancer and ____ and ____ are associated with cervical warts
Cancer: 16 and 18
Warts: 9 and 11
Most HPV+ women do NOT develop _____ or _______. ______ have a synergistic effect with HPV
CIN
cervical cancer
cigarettes (increase risk of cervical dysplasia)
_____ is the ONLY cervical cell type that has treatment options. The rest of them (LSIL, HSIL, ASC-H, AGC) require ________
ASC-US
Colposcopy
What are the 3 management options for ASC-US?
- Repeat serial cytology - q 6 mo till 2 consecutive normal
- Test for high-risk HPV (if +, then colposcopy)
- Immediate referral to colposcopy
What do you do if the repeat pap for ASC-US is also abnormal? What should you do BEFORE you do the repeat pap?
then colposcopy
Before repeat smear - treat underlying conditions: Hormones if atrophic vaginitis or
Antimicrobials for infection
How do you perform a colposcopy? _____ is applied
3-5% aqueous acetic acid solution
What are the 5 indications for colposcopy?
Abnormal cervical cytology or HPV testing
Clinically abnormal cervix
Unexplained intermenstrual or postcoital bleeding
Vulvar or vaginal neoplasia
History of in utero DES exposure
What am I?
normal cervix
What am I?
cervical leukoplakia
What am I?
acetowhite lesion
What am I?
mosaicism on cervix
What am I?
atypical vessels on cervix
What is the CIN I expectant management?
What is the tx for CIN II/III?
surgical therapy
Consider looking at this slide again
Draw the summary table of all the different cell types
What are the 3 major estrogens produced by women?
Estrone (E1)
Estradiol (E2)
Estriol (E3)
**______ is the major secretory product of the ovary. What does it do during menses? menopause?
Estradiol (E2)
Fluctuates widely during menses
Drops significantly after menopause
How does estradiol (E2) compare to estrone (E1)?
Up to 4x as common and 5x as potent as estrone
______ is the main estrogen in postmenopausal women who are not on HRT/MHT
estrone (E1)
_____ is the major estrogen in pregnancy
estriol (E3)
______ is the estrogen of choice to check to see if you have any estrogen at all. Often effected in delayed or precocious puberty
estrone (E1)
_____ is used to check monitoring antiestrogen therapy or adjunct assessment of fracture risk
Estrone (E1)
_____ is part of the quad screen and screening for fetal pathology
Estriol (E3)
aka all pregnancy related things
check _____ if concerned about ovarian function or monitoring HRT/MHT
Estradiol (E2)
When can estradiol be elevated?
Can be elevated in hepatic cirrhosis and hyperthyroidism
______ and _____ are used to monitor antiestrogen therapy and disorders of sex steroid metabolism
Estrone (E1) and Estradiol (E2)
Where are 3 places that produce progesterone? What can cause false progesterone readings?
Corpus luteum - significant production after ovulation
Adrenal glands - progesterone converted to other steroids
Placenta - primary secretor in pregnancy by end of 1st trimester
high doses of biotin (>5 mg/d)
progesterone from the adrenal glands does not contribute to serum levels unless ______
a tumor is present
Of the following places, consider if FSH and LH would be high or low:
Ovarian hypofunction/hypogonadism:
Pituitary failure:
Menopause:
Hypothalamic failure:
Castration:
Precocious puberty:
Pregnancy:
Anorexia/malnutrition:
Oral Contraceptives:
Ovarian hypofunction/hypogonadism - high
Pituitary failure - low
Menopause - high
Hypothalamic failure - low
Castration - high
Precocious puberty - high
Pregnancy - low
Anorexia/malnutrition - low
Oral Contraceptives- low
What is the main function of prolactin? What is it inhibited by?
initiation and maintenance of lactation
Inhibited naturally by dopamine
**Most medication-induced rise in prolactin are modest, how do they compare to the ULN?
**2-4x ULN
aka but NOT super super high
What are some s/s of hyperprolactinemia?
loss of libido, galactorrhea, infertility, decreased muscle mass, osteoporosis, impotence in men, oligomenorrhea or amenorrhea in women
