Women's Health Flashcards
What is the most common location for breast cancer
Upper outer quadrant
Tail of spence
What are symptoms of breast cancer
- dominant painless breast mass
- mass feels hard, irregular is non mobile
- skin changes (peau d’orange, dimpling, retractions)
- serous or bloody discharge from the nipple
What are the most common sites for metastatic disease
- bone
- liver
- lungs
- brain
What is the presentation of paget’s disease of the breast?
- history of a red-colored rash that is scaly and starts on the nipple spreading to the areola of 1 breast
- itching
- pain
- burning sensation
- crusting
- ulcer
- bleeding of the nipple
What is the presentation of inflammatory breast cancer
- acute onset of red, swollen warm area of the breast that is rapidly growing
- pitting of breast tissues
Women who have a high lifetime risk of breast cancer should undergo
- annual mammogram
- annual breast MRI
- Clinical breast exam q6-12 months
Beginning 10 years prior to age at which youngest affected family member was diagnosed
What is the typical sx of ovarian cancer
- abdominal pain
- low back pain
- pelvic pain
- dyspareunia
- changes in bowel habits
- unusual fatigue
Presentation of ectopic pregnancy
- pelvic pain that may be diffuse or localized to 1 side
- vaginal bleeding
- reports amenorrhea or light menses in preceeding weeks
What are risk factors for ectopic pregnancy
- IUD use
- tubal ligation
- in vitro
How is an ectopic pregnancy diagnosed?
- Beta HCG
- Transvaginal ultrasound
Risk factors for breast cancer in men are
- cryptochidism
- positive family history
- BRCA 1/2 gene
The diagnostic test for breast CA is
Tissue biopsy
A palpable ovary in a menopausal women is always
-abnormal
If you find a palpable ovary in a postmenopausal woman you should
- order a pelvic ultrasound
- refer
For women 21-29 USPSTF recommends cervical cancer screening by ____ every ____ years
and recommends against _____ if <30
- Liquid based cytology or pap test
- every 3 years
- HPV cotesting if <30
For women 30-65 USPSTF recommends cervical cancer screening by ____ every ____ years
- Liquid based cytology or pap test or liquid based cytology plus cotesting
- every 3 years or every 5 years if cotesting
For women 65+ USPSTF recommends cervical cancer screening
can be stopped if not otherwise high risk
If you have a result of atypical squamous cells of undetermined significance what is the recommendations
- Age 21-24: Repeat pap in 12 months
- 25-29: reflex HPV test, repeat pap in 12 months
- 30+: Cotest for HPV if + refer to colposcopy
If you have a result of Atypical squamous cells and cannot exclude high grade squamous intraepithelial lesion (ASC-H)
Refer to colposcopy regardless of age
If you have a result of LSIL what is the recommendations
- age 21-24: Repeat pap in 12 months
- Age 25-29: Repeat for colposcopy
- Age 30: Repeat pat in 12 months
If you have a result of HSIL what is the recommendations
Refer for colposcopy regardles of age
If a dose of Gardasil is given at age 15 or older how many doses are required
3
When is gardisil given?
between 11-12 years but can be given as young as 9 or as old as 26
What HPV strains are most likely to cause cervical cancer?
16 and 18
What can interfere with pap tests results and how long before a pap should you refrain from the activities
- sex
- douching
- tampon use
- lubricants
- vaginal foams/medications
Refrain for approximately 2-3 days before
If gardisil schedule is interrupted does the dose have to repeated
No
A _______ is used to evaluate herpetic infections and a positive smear will show large abnormal nuclei in squamous epithelial cells
Tzanck
A _____ test is for BV. How is the result +
Whiff test
- when a strong fish like odor is released after 1-2 drops of KOH
Postmenopausal breast will feel
softer with less volume and may be pendulous
According to the CDC you can be reasonably certain a woman is not pregnant if she has no symptoms or signs of pregnancy and meets the following:
- at least 7 days or less after start of normal menses
- has had no sexual intercourse since the start of last normal menses
- has been correctly and consistently using a reliable method of contraception
- is 4 days postpartum
- exclusively breastfeeding and is <6 months postpartum
Combined hormonal contraception work by
-stopping ovulation and thickening the cervical mucus plug
What are absolute contraindications to hormonal contraceptive use
- any condition (past or present) that increases risk of blood clotting (hx of thrombophlebitis or thromboembolitic event)
- smoker >35, >15 cigs/day
- conditions that increase risk for stroke (migraine with aura, or migraine without aura >35, hx of TIA/CVA, HTN >160/100)
- inflammation +/- acute infection of the liver
- known or suspected cardiovascular disease
- known or suspected pregnancy
- undiagnosed vaginal bleeding
- breast/endometrial or ovarial cancer
- <21 days post partum
What are contraindications for dropirenon (Yaz, Yasmin, Synd)
- Hyperkalemia
- Kidney disease
- Renal failure
- Adrenal insufficiency
My CUPLETS (mnemonic for absolute CI to hormonal birth control)
My- Migraines with focal neurological aura C- CAD or CVA U- Undiagnosed bleeding P- Pregnancy L- Liver disease E- estrogen dependent tumor T- Thrombus or emboli S- Smoker >35
What are relative CI to hormonal birth control
- Migraines
- Smoker <35
- Fracture or cast on lower extremity
- adequate controlled HTN
What are advantages of hormonal birth control after 5+ years of use
- Decreases risk of endometrial and ovarian cancer
- decreased incidence of dysmenorrhea, pelvic pain, acne, hirstutism, ovarian cysts, heavy or irregular periods
What is required to be done in order to rx contraception
-health history, rule out pregnancy, check BP
All patients starting a new method of contraception should be instructed to use a back up option for ___ days
7
It is normal to experience spotting for ____ months after initiation and therefore patients should be discouraged from switching in this time frame because it should resolve
3 months
Patients on lower doses of estrogen have _____ rates of spotting
Increased
If your pt misses 1 day for an OCP what should you tell the pt
take 2 now and continue as normal
If your pt misses 2 consecutive days (or >48 hrs since last pill was taken)
- take most recent pill ASAP
- use back up contraception until 7 days of consecutive hormonal pills
Drugs that interact with OCP
- Anticonvulsants
- Antifungals
- Antibiotcs: Ampicillin, tetracyclines, rifampin, clarithromycin
The patch has ____ rate of estrogen which ____ risk for DVT
higher; increases
Do not recommend Depo provera to women who may want to become pregnant within ___ months as it can take up to ____ year for ovulation to occur
12 months; 1 year
What disease process would you want to avoid the use of depo-provera and why
- anorexia nervosa/bulimeia
- increased risk of osteoprosis
When using the progestin only pills if a dose is >3hours late you should advise that the patient
uses a back up method of birth control
The emergency contraception pill works best if taken within ____ hours of intercourse
72
What are contraindications to IUD
- Active or history of PID within the past year
- Suspected or confirmed pregnancy or STI
- Uterine or cervical abnormality
- Undiagnosed vaginal bleeding
- uterine or cervical cancer
- hx of ectopic pregnancy
After intercourse if using a diaphragm it must be left in for at least ______ and up to _____ days
6-8 hours and up to 2 days
The diaphragm must be used with _____ before each intercourse
Spermacide
Woman taking seasonale (84/7) will have ___ cycles/year
4
Copper IUD lasts ____ years; Mirena lasts ___ years
10-12 years; 5
Desogen, Ortho-tricyclen and Yaz are all indicated for what skin condition
Acne
What is primary dysmenorrhea
crampy pelvic pain caused by menstruation not by a disease process
Secondary dysmenorrhea is
crampy pelvic pain caused by a secondary disease process such as endometriosis
What are treatment options for dysmenorrhea
- Mefeamic acid
- NSAIDs
- Tylenol
- Extended cycle OCPs
Primary amenorrhea is the absence of menarche by ____ years or older
15
Secondary amenorrhea is the absence of menses for more than ____ months in a pt that has had regular menstrual cycles or if irregular it has been missing for ____ months
3; 6
What are fibrocystic breast changes?
- non-malignant breast lesions which are either non proliferative or proliferative
- proliferative type increases risk for breast cancer
What is classic presentation of fibrocystic breast changes
- bilateral breast tenderness
- breast lumps that start from a few days up to 2 weeks pre menstrual cycle for many years
- once cycle ends then the lumps decrease and no tenderness
_____ is the most common cancer in women
Breast
What are non modifiable risk factors for breast cancer
- age >50
- BRCA 1/2
- early menarche (<12 years)
- Late menopause (>55)
- dense breasts
- personal or family hx of breast ca
- radiation to chest or breast before age 30
- mother took diethylstillbestrol
Modifiable risk factors for breast cancer
- Sedentary lifestule
- overweight/obese postmenopausal
- hormones post menopause >5 years
- pregnancy at age 30 or greater
- no breastfeeding
- nulliparity
- moderate ETOH intake
USPSTF recommends biennial screening mammography for women (every 2 years)
50-74
What are females with PCOS at increased risk for?
- T2DM
- Dyslipidemia
- Metabolic syndrome
- Endometrial hyperplasia
- Breast cancer
- Obesity
- NAFLD
- Depression
- OSA
- infertility
What is a classic presentation of PCOS
- excessive facial and body hair (hirsutism)
- acne
- amenorrhea or irregular menstruation
What diagnostic imaging test is indicated in PCOS
-Transvaginal ultrasound (enlarged ovaries with multiple small follicles)
What labs are indicated in PCOS
Serum testosterone, DHEA, androgen levels, FSH, LH, TSH, FBG, 2hr OGTT
What are first line treatment for PCOS
OCP
This medication can help induce ovulation in PCOS
Metformin
USPSTF recommends Osteoporosis screening in women ____ years and older
65
At risk groups for osteoprosis include
- older woment
- thin or small body frames
- postmenopausal
- chronic steroid use
- anorexia or bulimia
- Long term PPI use
- Gastric bypass
- celiac
- ankylosing spondylitis
- RA
- Hyperthyroid
- Female Athlete triad
- low calcium intake
- low physical activity
- high caffeine, high ETOH
What do you use to measure the bone mineral density and what is the testing interval
DEXA scan; baseline then q2 years
When do you treat for osteoprosis
- T score (-2.5) or less
- postmenopausal with hx of hip or vertebral fracture
Osteopenia is defined as a T score between
-1.5 and -2.4
What is indicated to minimize risk of osteoporosis
- weight bearing exercise 3x/week >30 minutes
- calcium with vitamin D 1,2000mg/day and vit D 800 IU
- smoking cessation
What is the 1st treatment pharmacotherapy for osteoporosis?
-Bisphosphonates (Fosamax- alendronate) or Actonel (risedronate)
What education should you provide regarding the use of bisphosphonates
- take upon awakening with full glass 6-8oz of plainw after
- remain upright for 30 minutes after
- don’t take with any other meds, juice, coffee, antacids or vitamins
What are CI to bisphosphonates
-inability to sit upright, esophageal motility issues, history of PUD, hx of GI bleeds, CKD, certain bariatric surgeries
Average age of menopause is
51
If ovarian cancer screening is done for a high risk individual then a ____ is ordered with _____
Transvaginal US
CA-125
*starts at age 30 or 5-10 years before first relative was dx’d
What are risk factors for BV
- sex
- new or multiple sex partners
- douching
Should you treat BV in pregnancy and why
Yes because they have higher risk of preterm labor or LBW baby
What is the classic presenation of BV
- unpleasant fishlike odor that is worse after intercourse
- milk like grey discharge
- no vulvar or vaginal redness or irritation
What are the tests for BV and findings
Wet smear: Clue cells (squamous epithelial cells with large amount of bacteria coating the surface that obliterates the edges)
and very few WBCs
Whiff test: 1 drop of KOH produces a strong fishy smell
Vaginal PH >4.5
What is the treatment for BV
Flagyl BID x 7 days
What education should you provide a patient with BV
- abstain from sex or use condoms until treatment is complete
- partner does not need treatment as it is not an STI
What are risk factors for vulvovaginal candidiasis
- DM
- HIV
- Antibiotic use
- Immunosupression
What are symptoms of a yeast infection
-white cheese like vaginal discharge accompanied by pruritis, swelling, redness
What Labs are used vulvovaginal candidiasis and what are the findings
- wet smear microscopy
- findings: pseudohyphae and spores with large # of WBCs
What is the treatment of vulvovaginal candidiasis
Miconazole, clotrimazole x 7 days or Rx Fluconazole 1 dose
What is the presentation of trichomoniasis
- Inflammation (pruritis, burning, irritation) of vagina/urethra
- dysuria
- grayish green frothy discharge
- strawberry cervix
What is the Dx test for trichomoniasis
NAAT for T- vaginalis
What is the treatment for trichomoniasis
Flagyl 2g PO x 1 dose or 500mg BID x 7 days
In a patient with trichomoniasis do you treat their partner?
Yes it is considered a STI
What is the most effective treatment to moderate to severe vaginal atrophy
Estrogen (low dose topical because of decreased systemic absorption)
What is the classic presentation of atrophic vaginitis
- vaginal dryness
- itching
- pain with sex (dyspareunia)
- vulvar or vaginal bleeding with intercourse
- decreased rugae
- dry pale pink color to vaginal
What is the presentation of lichen sclerosis
-Flat topped slightly scaly hypopigmented, white or mildly red polygonal papules that may coalese to form larger plaques with peripheral erythema
What is the classic case of endometriosis
-hx of mod to severe pelvic pain with menses heavy cramping, dyspareunia
What is the management of endometriosis
Estrogen/progesterone contraceptives
- NSAIDs
- GnRH analogues
Post-menopausal is defined as
-any bleeding beyond 12 months since LMP
What are causes of abnormal uterine bleeding
PALM-COEIN Polys (>30) Adenomyosis (>30) Leiomyoma (>30) Malignancy (>40; obesity PCOS, DM)
Coagulopathy Ovulatory dysfunction Endometrial Disorders Iatrogenic; Meds Not yet classified
What are symptoms of PCOS
- oligomenorrhea
- amenorrhea
- AUB
- hyperandrogenism
- cystic ovaries
- infertility
- mood/mental health problems
The pathophysiology of PCOS is associated with
Insulin resistance
The rotterdam criteria is diganostic for ____ ensuring 2 of 3 of the following
PCOS
- Oligomenorrhea
- Hyperandrogenism
- Cystic ovaries
2012 Cervical guidelines
- ages: 21-29 Pap q3 years
- ages >30: Pap and HPV; repeat q5 years; if only pap only q 3 years
- age 65 may stop
What are risk factors for bacterial vaginosis
- new sexual partner
- no condom us
- douching
- Copper IUD
