Women's Health Flashcards
Breast CA mass presentation
- hard
- irregular
- attached to skin, immobile
- most common in upper outer quadrants (tail of Spence)
- Peau d’orange
- dimpling
- retraction
- nipple discharge
Breast mass treatment plan
- mammogram
- referral to breast surgeon
Paget’s disease of the breast presentation
- history of chronic scaly red-colored rash like eczema
- starts on nipple and spreads to areola
- itching, burning
Paget’s disease aka
ductal carcinoma in situ
Higher risk for BRCA
- fam hx breast CA before age 50
- male breast CA
- breast CA that is triple-negative (before age 60)
- ovarian and other types of gynecological cancers
Treatment plan for any patient reporting positive BRCA mutation
-refer to breast specialists
What to do with family history of breast CA
- Ask when the family member had it and screen 10 years earlier
- Refer high risk for genetic counseling and testing
ovarian cancer presentation
- middle aged or older
- vague symptoms
- abdominal bloating
- discomfort
- low-back pain
- changes in bowel habits
Risk factors for ectopic pregnancy
- PID
- tubal ligation
- previous ectopic pregnnacy
Estrogen exposure and menarche and breast CA risk
- early menarche <12
- late menopause >55
Diagnostic study for breast CA in <30 year old
US
-assess identified mass with mammogram
Diagnostic study for breast CA in >30
- any woman/man with breast complaint
- mammogram
- f/u with tomosynthesis if dense breasts on mammogram
Diagnostic test for any breast mass
biopsy
Cervical ectropion
- normal finding
- bright-red bumpy tissue with irregular surface on cervical tissue
What can cervical ectropion be caused by
- birth control
- pregnancy
- due to high levels of estrogen
Follicular phase days
1-14
Follicular phase aka
proliferative phase
FSH is released from where
anterior pituitary
Which hormone is dominant in follicular phase
-estrogen
Day for ovulatory phase
day 14
Which hormone induces ovulation
luteinizing hormone
Days for luteal phase
-14-28
Predominant hormone during luteal phase
progesterone
Where is progesterone produced
-corpus luteum
Purpose of progesteron
-stabilize endometrial lining
What happens to menstrual cycle of not pregnant
- estrogen and progesterone levels fall
- induce menses
- low hormones stimulate hypothalamus, then anterior pituitary and release FSH
Fertile time period
-1-2 days before ovulation is best chance for pregnancy
Can you do a pap during menses
no
When is the best time to perform a pap
10-20 days after last menses
OTC ovulation tests detect what in urine
hCG
What age to stop pap smears
> 65
Do women with hysterectomy with cervix removal need pap smear
no
21-24 with LSIL
pap in 12 months
25-20 with LSIL
colposcopy and cervical biopsy
Plan if endometrial cells are seen in pap test
refer for endometrial biopsy
Which age group has large ectropion
girls and teenagers
Extended cycle pills
Seasonale
3 months consecutive
only 4 periods a year
Lab monitoring with ethinyl estradiol and drospirenone
High risk of DVT and hyperkalemia
-check K if on ACE, ARB, or K sparing diuretic
Who should Yaz be considered for
- acne
- PCOS
- hirsutism
- PMDD
Example of ethinyl estradiol and drospirenone
Yaz
Yasmin
Which pill is safe for breastfeeding women
progestin only
Contraindications to oral contraceptives
- increased risk of blood clotting
- > 35 with smoking
- any increased risk of stroke
- inflammation or acute conditions of liver
- CVD; uncontrolled HTN
- some reproductive conditions
Mneumonic for absolute contraindications for OCP
My CUPLETS My: migraines with focal aura C: CAD or CVD U: undiagnosed genital bleeding P: pregnancy L: liver tumor or active liver disease E: Estrogen-dependent tumor T: thrombus or emboli S: smoker >35
Advantage of using pill >5 years
- decreased ovarian and endometrial CA risk
- decreased dysmenorrhea
- decreased endometriosis symptoms
- decreased acne and hirsutism
- decreased ovarian cysts
- decreased irregularity
When to follow up with new start of OCP
within 2-3 months
NSAIDS for menstrual cramps
- mefenamic acid (Ponstel)
- Naproxen (Aleve)
- Ibuprofen (Advil)
missed 1 day
take two pills now and continue
missed 2 days
take two pills the next 2 days to catch up
continue
-use condoms
Drug interactions with OCP
- anticonvulsants
- antifungals
- ampicillin, tetracyclines, rifampin
- St.John’s wort
Pill danger signs mneumonic
ACHES
- abdominal pain
- chest pain
- headaches
- eye problems
- severe leg pain
Which BC products contain both estrogen and progesterone
- COC
- patch
- NuvaRing
What can be elevated with COC
Blood pressure
-check in 3-4 weeks
Paragaurd effectiveness
copper IUD
10 years
Mirena effectiveness
5 years
contains levonorgestrel
IUD patient education
- check occasionally for string
- if not felt, order pelvic US
Depo-Provera lasts…
3 months per injection
Depo-Provera should not be recommended to..
- women who want to become pregnant in 12 months
- avoid long-term use >2 years
- risk of osteoporosis
Anorexia and Depo-Provera
- test for osteoporosis with DXA
- avoid Depo-provera –> increase risk of osteoporosis
- Recommend calcium and vitamin D
How long to leave diaphragm inside vagina after sex
6-8 hours
Diapghram must be used with what
spermicide
How long can cervical cap be worn
up to 72 hours –> may cause abnormal cervical cell change
Cervical ring usage
- place in for 3 weeks
- remove for 1 week
- should fit around cervix
Which contraceptive has a higher risk of VTE than OCP
ortho evra transdermal contraceptive patch
When is the morning after pill most effective
within 72 hours
If patient does not have period within ___ of taking EC, they return to rule out pregnancy.
3 weeks.
Estrogen dose of low-dose BC
20-25 mcg
Yaz or Yasmin has higher risk for what
- blood clots
- stroke
- heart attacks
- hyperkalemia
Which contraceptive has broadest usage
copper IUD
Safe progestin with less BTB
Levonorgestrel
Safe progestin with more BTB
norethindrone
Estrogen dose for heavy periods
30-35 mcg
Estrogen dose for normal periods
20-25 mcg
How does cervical cancer occur
from persistent HPV infection over many eyars
When should Gardasil be given
PRIOR to sexual activity, more effective
21-29 pap frequency
pap every 3 years
ASC-US in >24 year old plan
Reflex HPV
-colposcopy if positive
ASCUS in 21-24 plan
repeat pap in 12 months
- if negative, continue routine
- if positive, colposcopy
ASC-H plan
colposcopy and endocervical sampling
LSIL 21-24 plan
observe, repeat in 1 year
LSIL in >25
colposcopy
HSIL for any age
colposcopy
AGC for any age
colposcopy
Treatment for fibrocystic breasts
- stop caffeine intake
- take vitamin E and evening primrose capsules daily
- wear bra with good support
Fibrocystic breast presentation
- bilateral breast pain around menses
- rubbery, tender, mobile nodes
What is PCOS
- anovulation
- infertility
- excessive androgen production
- insulin resistance
PCOS presentation
- hirsutism
- acne
- amenorrhea
- infrequent periods
- terminal hair on face
- usually obese
PCOS treatment plan
- transvaginal US
- serum testosterone, DHEA, androstenedione elevated
- FSH levels normal or low
- fasting blood glucose abnormal
PCOS medications
- low dose oral contraceptives to suppress ovaries
- Spironolactone to decrease and control hirsutism
- Metformin if pregnancy is desired
- weight loss reduces androgen and insulin levels
PCOS complications
- CHD
- T2DM
- Metabolic syndrome
- Breast and endometrial cancer
- central obesity
- infertility
Rotterdam criteria
- for PCOS
- need 2/3
- irregular cycles
- hyperandrogenism (acne, hair growth)
- cystic ovaries
Total testosterone in PCOS may be elevated at…
> 60
How long after start of menses is AUB okay
2 years
Classification of AUB
Polyps
Adenoids
Leiomyoma/fibroids
Malignancy
Coagulopathy Ovulatory dysfunction Endometrial disorders Iatrogenic Not classified
Caus eof primary dysmenorrhea
excessive prostaglandins
When to take NSAIDs for dysmenorrhea
- start of onset for 1-2 days
- or 1-2 days before
Who is osteoporosis common in
white or asian who are thin with small body frames
Which osteoporosis patients to treat
-postmenopausal women men >50 -history of hip or vertebral fracture -patients on chronic steroids -anorexia and bulimia -long term PPI use -gastric bypass, celiac, hyperthyroidism, anklyosing spondylitis, RA, etc.
Osteoporosis T-score
Osteopenia t score
-1.5–2.4
Osteoporosis treatment
- weight bearing exercises
- calcium with vitamin D2 and D3
- Bisphosphonates
Bisphosponate adverse effects
- esophageal irritant
- osteonecrosis of jaw, more likely on IV or IM bisphosphonates
Bisphosphonate examples
- Fosamax (alendronate)
- Actonel (risedronate)
- Zoledronic acid
Patient teaching with bisphosphonates
- take upon awakening with full glass of water
- sit up for at least 30 minutes
- never take with anything other than water
Repeat DXA how long after starting bisphosphonate
2 years
Contraindications to bisphosphonates
- inability to sit up right
- esophageal motility disorders
- history of PUD
- history of GI bleed
SERM is indicated for who
- postemenopausal women with osteoporosis who also need breast CA prophylaxis
- not to treat menopausal symptoms
- does not stimulate endometrium or breast tissue
SERM BBW
increased risk of DVT and PE
increased risk of death from stroke
Osteoporosis and SERMs
option for patients who cannot tolerate or have contraindications to bisphosphonates
What is tamoxifen used for
-breast CA that is hormone-receptor positive
Side effects of SERM
- hot flashes
- white or brown vaginal discharge
- weight gain or loss
WHI results
- combined estrogen-progestin replacement therapy increased risk of stroke, heart disease, VTE, breast CA, PE
- NOT recommended to prevent chronic conditions
- Use less than 5 years if for menopausal symptoms
- Safe for healthy women to use within 10 years of menopause
- unopposed estrogen for women without uterus
- estrogen/prog needed for women with uterus
Ovarian cancer is often caught early
false
-symptoms arise typically with metastasis
Serum tumor marker for ovarian CA
CA-125
FRAX-calculator
- estimates 10-year risk for fracture
- determine if treatment of osteoporosis is needed
Vulvovaginal atrophy symptoms
- vaginal irritation, dryness, or burning,
- dyspareunia
- UTI
- loss of rugae
- discharge
- vaginal pH >5
VVA treatment
-estrogen vaginal
VV candidiasis differential
- itching, burning, dysuria
- pH 4-4.6
- whiff test negative
- buds and psudohyphae
BV differential
- malodorous discharge
- pH >4.6
- positive whiff test
- clue cells
Trich differential
- malodorous discharge, dysuria
- pH 5-6
- /+ whiff test
- trichomonads on vaginal microscopy
VVC management
- Fluconazole (Diflucan)
- single dose has 72 hours duration
- avoid in pregnancy
- avoid sex until resolved
- topical agents: Monistat, Gyne-Lotrimin, etc.
BV treatment
- Metronidazole x 7 days
- Metronidazole vaginal gel alternative
- watch for disulfuram like reaction with alcohol
- no sex until resolved
What kind of organism is trichomoniasis
-protozoan parasite with flagella
Trichomoniasis presentation
-copious grayish green discharge
-bubbly vaginal discharge
-strawberry cervix
-swollen and reddened vulvar region
dysuria
Trichomoniasis treatment
- Metronidazole 2 g PO
- treat sexual partner
Medroxyprogesterone
Depo-Provera
Women with COPD are at highest risk for what diseases
- heart disease
- endometrial cancer
- chronic anovulation results in high levels of estrogen and androgens
- high risk for HTN, high LDL, low HDL
- > 50% have diabetes
- without progesterone, endometrium becomes thick and can cause heavy or irregular bleeding –> endometrial hyperplasia to cancer
What to do if patient forgot to take BC 2 consecutive days
- take two today and two tomorrow
- use condoms for rest of cycle
Hormone responsible for dysmenorrhea
prostaglandins
-causes contractions for endometrial shedding
Kegel exercise instruction
- pelvic floor muscles are the muscles she holds/stops flow of urine
- anal sphincter will also tighten
- relax abdomen and thighs
- tighten muscles for 10 seconds and relax for 10 seconds
- perform 10 exercises each time three times a day
Criteria for PID
at least one
- cervical motion tenderness
- adnexal tenderness
- uterine tenderness
What to do with women who are at risk for breast ca
refer to breast specialist
mammogram and MRI of breast
genetic counseling and BRCA testing
What does KOH do to vaginal secretions
-kills epithelial cells to better visualize pseudohyphae
Best test to visualize vaginal trichomonas
wet smear with microscopy
KOH will kill the organisms
