Women’s Health Flashcards
Contraceptive Methods
Tier 1 (Most effective): Implant, vasectomy, tubal ligation, IUD
Tier 2: Injectables, hormonal pill, patch or ring.
Tier 3 (Least effective): Condoms, fertility timing, diaphragm, withdrawal, spermicides
Combined Estrogen-Progestin Oral Contraceptives (COCs)
- Suppresses Ovulation by:
- Inhibition of GnRH
- Inhibition of LH and FSH
- Prescribe a COC with 35mcg of ethinyl estradiol or less (start at 20mcg and increase if bleeding is a concern)
- Can be started at any point in a female cycle, of course once pregnancy has been rule out.
- Use back up birth control for 7 days.
- Single pill missed: Take missed pill ASAP, even if it means taking 2 at once.
- More than one pill missed: Resume the one a day scheduling and use a back up form of birth control for one week.
- Can be continued until menopause if no contraindications.
Contraindications to COCs
- Age > 35 years and smoking > 15 cigarettes per day
- Multiple risk factors for CVD
- Hypertension (Systolic >160mmHg or diastolic >100mmHg)
- Venous thromboembolism and not an anti-coagulant
- Ischemic heart diseases or heart valve disease
- History of a stroke
- Current breast cancer
- Severe cirrhosis
- Hepatocellular adenoma or malignant hepatoma
- Migraine with aura
- Diabetes for > 20 years or if nephropathy, retinopathy or neuropathy is present.
Progestin only contraceptive
Available in pills… also known as POPs (Progestin only pill), or as an implant, injections, or an IUD
- Most common POP: Norethindrone
Contraindications:
- Known or suspected breast cancer, undiagnosed AUB, or liver disease
- Caution with: History of bariatric surgery, concurrent use of anticonvulsants
Key points with POPs:
- Must take POPs at the same time every day.
- Back up birth control should be used for at least 2 days if the POP was taken > 3 hours off of schedule
Progestin only Injectable:
- Common injectable progestin only: Depot Medroxyprogesterone acetate
- Give injection every 3 months (2 week grace period)
- Return of fertility is variable (50% will become pregnant within 10 months after discontinuing depot)
Intrauterine Devices (IUD)
- Most commonly used reversible method of birth control
- > 99% efficacy in pregnancy prevention
- However, if pregnancy occurs with IUD in place, evaluate for ectopic pregnancy
- Rapidly reversible
- Reduces the risk for cervical, endometrial and ovarian cancers.
TWO types of IUD:
- Copper IUD
- Non-hormonal
- Approved in the US for 10 years
- Preferred IUD for patients with liver disease
- Levonorgestrel releasing IUDs (progestin only)
Contraindications:
- Deformity of the uterine cavity, active pelvic infection, explained AUB and breast cancer.
Menstrual Cycle
Normal frequency of menstruation is the onset of menstrual bleeding every 24 to 38 days.
Follicular Phase:
- Begins with the onset of menses and ends on the day before ovulation
Midcycle/Ovulation Phase:
- Dominant ovarian follicle released an oocyte and the follicle transitions to become a corpus luteum
- Ovulation occurs approx 36 to 44 hours after the LH surge
Luteal Phase:
- Begins on the day after ovulation and ends at the onset of the next menses
Amenorrhea
- Primary amenorrhea: Absence of menses by 15 years old if individual is otherwise healthy and has developed secondary sexual characteristics
- Secondary amenorrhea: Absence of menses for > 3 consecutive months in individuals who have regular cycles and > 6 months in those with irregular menstrual cycles.
Treatment: Heat, therapy, NSAIDs, hormonal contraceptives.
Dysmenorrhea
- Primary: Begins with onset of menses and dissipates over 12 to 72 hours later
- Secondary: May be caused by other complications such as endometriosis, adenomyosis, fibroids or ovarian cysts.
Treatment: Heat, therapy, NSAIDs, hormonal contraceptives.
Abnormal Uterine Bleeding (AUB)
Bleeding occurs from either structural abnormalities within the uterus or causes outside of the uterus.
Diagnosis:
- Thorough gynecologic, obstetric and medical history
- Rule out pregnancy
- Pelvic exam to assess for potential bleeding sites, volume of bleeding, size and shape of t he uterus and the presence of any masses, lesions and tenderness.
- Labs include TSH, prolactin levels, androgen levels, FSH and estrogen levels.
- Transvaginal ultrasound
Treatment:
- Treat underlying ideology
- Estrogen-progestin contraceptives or an IUD, in AUB with unknown etiology and without contraindications
PALM-COEIN Acronym
- Polyps
- Adenomyosis (Endometrial tissue outside of the uterus)
- Leiomyoma (fibroids)
- Malignancy
- Any bleeding that occurs post menopause must be referred to OBGYN to tule out malignancy
- Coagulopathy
- Example: Von Williebrand disease, Factor V Leiden
- Ovulatory Dysfunction
- Dysfunction in the hypothalamic-pituitary-ovarian axis
- Endometrial dysfunction
- Latrogenic
- Medical devices, medication (estrogen, progestin, IUD, anticoagulants, thyroid meds)
- Not otherwise classified
Polycystic Ovarian Syndrome
Most common cause of infertility in women
Presentation:
- Menstrual dysfunction
- Hyperanrogenism
- Hirsutism, acne, male pattern hair loss
- Overweight or obesity should further raise suspicion for PCOS, however is not always present
Diagnosis:
- Rotterdam criteria (2 out of 3 must be present for diagnosis)
- Oligomenorrhea
- Infrequent menses (<9 periods per year)
- Hyperandrogenism
- Polycystic ovaries on US
Other labs used in diagnosis of oligomenorrhea
- HCG to rule out pregnancy
- TSH and FSH
- Total Testosterone
- >60 indicates PCOS
- >150 indicates possible tumor
Polycystic Ovarian Syndrome (treatment)
NOT trying to get pregnant
- COCs to help prevent endometrial hyperplasia, as a result of irregular shedding of the uterus lining and to minimize the hyperandrogenic symptoms.
- May use adjunct metformin for insulin resistance
- May use spironolactone to decrease hirsutism
TRYING to get pregnancy
- Refer to reproductive endocrinology
Endometriosis
- Endometrium grow outside of the uterus, most commonly the ovaries and fallopian tube.
- Peaks between 25 and 35 years old
Presentation:
- Dysmenorrhea, dyspareunia (difficult or painful intercourse), heavy menstrual bleeding, infertility, ovarian mass.
- Physical exam findings: posterior vaginal fornix tenderness, palpable tender nodules, lateral displacement of the cervix.
Diagnosis:
- Presumptive diagnosis
- Transvaginal ultrasound
- Gold standard is surgical biopsy
Treatment:
- First line treatment includes NSAIDs and hormonal contraceptives
- Alternative treatments
- Gonadotropin-releasing hormone analog (GnRH)
- Surgical resection
Bacterial Vaginosis
Presentation:
- Malodorous, off-white vaginal discharge
- Often described as “fishy” smelling
Diagnosis:
- Presence of at least 3 Amsel criteria
- Characteristics of vagina discharge
- Vaginal pH >4.5
- Clue cells on microscopy
- Positive Whiff test
- NAAT becoming more popular
Treatment:
- Metronidazole and Clindamycin (available orally or intra-vaginally)
- Oral agents preferred for pregnant or lactating patients
Vulvovaginal Candidiasis
Risk factors:
- Diabetes, antibiotic use, elevated estrogen levels, patients who are immunocompromised
Presentation:
- Vaginal pruritus
- Little or no discharge and without odor
Diagnosis:
- Candida on wet mount
Treatment:
- Single dose fluconazole for immunocompetent, non-pregnant patients with infrequent episodes
- TWO doses for severe symptoms or those who are immunocompromised
- Topical Azoles for pregnant patients
- Examples: Clotrimazole, Miconazole
Naegele’s Rule
Estimated delivery date (EDD) is calculated by counting back three months from the LMP and adding seven days…
EXAMPLE:
LMP is MAY 8
3 months before is FEB + 7 days so = FEB 15
Signs of pregnancy
Presumptive:
- Amenorrhea, fatigue, sore breasts, nausea, vomiting, quickening
Probable:
- Positive pregnancy test, softening of the cervix (Goodell’s Sign), Bluish color to cervix due to increased blood flow (Chadwick’s sign), enlarged uterus
Positive:
- Fetal movement felt by practitioner, fetal heart sounds with Doppler, fetus on severed on ultrasound.
Physiologic changes during pregnancy
Increase in plasma volume and RBCs
- Leads to physiologic anemia
- Most apparent at 30 to 34 weeks gestation
Increase in cardiac output
- Resting HR should be >115bpm
Decrease in blood pressure
- Positional hypotension after 20 weeks
Prenatal Care
- Initiate by 10 weeks gestation
First visit is comprehensive:
- A1C
- Hematocrit, Hemoglobin, MCV, and Ferritin
- Urine protein and culture
- Syphillis, chlamydia,
- Hep B & C
- Cervical Cancer
- HIV
- ABO and RhD
- RhD negative mom: Rhogam at 28 weeks and within 72 hours of delivery, miscarriage or termination
Additional points
- Check medications
- Address prenatal vitamins
- Folic Acid
- Without neural tube defect risk: 0.4mg once daily beginning at least 1 month prior to conception and throughout pregnancy
- With neural tube defect risk: 4mg once daily beginning at least 1 month but preferably 3 months prior to conception and through the first trimester.
Folic acid dose is decreased to 0.4mg daily after the first trimester
- Check vaccination status
- No live vaccines during pregnancy
- Tdap between 27 to 36 weeks gestation in each pregnancy
- Completed group B strep rectovaginal culture 35 to 37 weeks gestation
- Intrapartum antibiotics if culture is positive
Preeclampsia
- A serious pregnancy complication characterized by new onset of hypertension and proteinuria.
- Generally presents between 34 weeks gestation and up until 4 weeks after birth.
Risk factors:
- History of preeclampsia, multiple gestation, type one or type two diabetes, chronic hypertension, chronic kidney disease, or certain auto immune diseases.
Presentation:
- Presents after 20 weeks gestation with:
- New onset of hypertension and proteinuria OR
- SBP 140 or greater, DBP 90 or greater
- New onset of hypertension and evidence of end organ damage
- Examples: Include a creatinine greater than 1.1, pulmonary edema, new and persistent headache or visual symptoms.
Diagnosis:
- Diagnosed with two separate readings at least for hours apart
Treatment:
- Delivery of the placenta and fetus
Placenta Previa
Presentation:
- Bright red vaginal bleeding that occurs from the placenta attaching too low covering the cervix
Treatment:
- Pelvic rest (No intercourse, bimanual exam, or intravaginal US)
- Refer to high risk OBGYN
Placenta Abruptio
Presentation:
- Sudden vaginal bleeding (ranging from mild to hemorrhaging)
- Hypertonic (rigid), hard and tender uterus)
- Occurs from the partial or complete detachment of the placenta from the uterus
Treatment:
- Emergent referral to labor & delivery
Ectopic Pregnancy
Extrauterine pregnancy, majority occur within the fallopian tube
Risk factors:
- Current IUD use, or history of pelvic inflammatory disease
Presentation:
- Lower, unilateral, abdominal pain, typically 6 to 8 weeks after LMP
- May have missed period or light spotting, possibly a low grade fever
- Serum hCG that does not rise as expected
- Symptoms of rupture::
- Sudden onset of severe and persistent abdominal pain, symptoms of faintness, or hemodynamic instability
Diagnosis:
- Extrauterine sac or embryo on Transvaginal ultrasound
- Visualization at surgery
Treatment:
- Refer to ER
- Methotrexate, surgery
Menopause
Permanent cessation of menstrual periods
Presentation:
- Hot flashes, mood disturbances, sleep disturbances, genitourinary atrophy symptoms (vaginal dryness, dyspareunia)
Diagnosis:
- Clinical diagnosis based on 12 months of amenorrhea, not attributed to another cause
- Individuals <45 years should have laboratory evaluation to rule out endocrine complications
Breast Mass
Breast cancer risks: Increases with age, obesity, dense breasts, family history, longer estrogen exposure, first pregnancy >30 years old, nulliparous, moderate to high intake of alcohol.
- Malignant mass is typically solid, immovable, irregular borders.
- Advanced symptoms of breast Cancer: Peau d’orange, axillary adenopathy
Presentation:
- Breast mass and <30 years old or if pregnant
- Ultrasound (US): Most benign lesions in young patients are not visualized with mammography
- If mass cannot be visualized on US and clinical suspicion for cancer is low, observation may be appropriate
- If clinical suspicion for cancer is high, mammography and biopsy are indicated
- Breast mass 30 to 39 years old:
- US or Mammography
- US may be preferred (high sensitivity), however if US is negative, mammography is indicated
- US or Mammography
- Breast mass and > 40 years old:
- Mammography; if suspicious abnormality is detected, biopsy is indicated.
Cervical Cancer
- Cervical cancer is the 34d most common cancer in the USA
- HPV 16 and HPV 18 detected in over 70% of cervical cancers
Presentation:
- Often symptomatic
- If symptoms present: Abnormal vaginal bleeding, vaginal discharge
Screening:
- Begins at 12 years of age, regardless of sexual activity and is done every 3 years after
- Decision to discontinue screening is unclear (some practitioners screen until 74 years of age)
