Women's Healthcare Flashcards
Healthy People 2030
* This initiative is an overall goal of healthcare
* CVD, breast cancer, colorectal cancer, and osteoporosis as the 4 major diseases of postmenopausal women
* Reduce proportion of adults with obesity (obesity as a risk factor for CVD and colorectal cancer)
* Reduce female breast cancer deaths from 19.7 per 100,000 to a target of 15.7 per 100,000
* Increase the proportion of women aged 50 to 74 years who received a breast cancer screening based on the most recent guidelines
> Breast and ovarian cancer can occur together
* Increase the number of women aged 21 to 65 years who receive screening for cervical cancer according to current guidelines
* Increase the percentage of adults aged 50 to 75 years who undergo colorectal cancer screening according to current guidelines
* Increase the proportion of at-risk women who receive genetic counseling for breast and/or ovarian cancer
* Reduce the proportion of adults aged 50 and older with osteoporosis and reduce the number of women aged 65 and older hospitalized with hip fractures
* Increase the proportion of sexually active female adolescents and young women enrolled in Medicaid and commercial health plans who are screened for Chlamydia trachomatis
> Increase in chlamydia over past decade as it leads to PID
* Reduce pelvic inflammatory disease (PID) in adolescent and young females (aged 15 to 24 years)
Health Maintenance
- Health maintenance as the prevention or early detection of certain diseases
* Some women will only see their OB-GYN and not a PCP
Health History
- Identify risk factors
- Family history
- Drug use (prescribed, over-the-counter, illicit)
- Complimentary and Alternative Modalities (CAM)
> Many people don’t associate this with being a medical therapy; it can contribute to their overall level of wellness though
> OB-GYN’s ask about personal/menstrual/obstetric/sexual/family/psychosocial histories
Physical Assessment
* The focus of the OB-GYN is honed in on our 4 primary diseases
- Vital signs
- Height/weight
- Cardiac auscultation
- Palpation of the abdomen for tenderness
- Visual inspection and palpation of extremities
Preventative Counseling (by OB-GYN)
* Obesity
* Inactivity
* Smoking
* Sexually Transmitted Infection
* General Health Promotion
Obesity
- A BMI >30 correlates with a higher mortality rate in women
- Also associated with diabetes, hypertension, and breast/endometrial/colorectal cancers
- Can also cause abnormal menses and infertility
Inactivity
- Leads to obesity, osteoporosis, osteoarthritis, dyslipidemia, stroke, and CAD
Smoking
- Smoking and cessation or if they are an active smoker
Sexually Transmitted Infections
- Specifically about ___ and ___ as those have higher risk of developing into PID of creating adhesions which can be at the site of the fallopian tubes, increasing risk of ectopic pregnancy and infertility
chlamydia, gonorrhea
General Health Promotion
- Use of sunscreen, skin screenings, skin care as a whole; alcohol and substance abuse; wearing a seatbelt; domestic violence
Breast Cancer Screenings
* Breast cancers discovered with screenings are more likely to be smaller and still confined to the breast
* Screening leads to better outcomes
* Considered to be at average risk if they don’t have a personal history of breast cancer, if they don’t have a strong family history of breast cancer, and if they don’t have the genetic mutation known to increase the risk of breast cancer such as the BRCA gene
> Also, if they haven’t had any chest radiation therapy before the age of 30
* Breast Self-Examination
* Clinical Breast Examination
* Mammography
Breast Self-Examination
* Perform monthly starting at 20 years old; do 1 week after onset of menses to avoid hormonal influences
* For postmenopausal women, choose a day of the month easy to remember
* Is really only recommended for those women at a higher risk; BUT we recommend really for all women so they are comfortable with and can note any changes to their breasts to inform the provider about
Mammography
* Encourage biannual screenings starting at age 50 until age 74
* Can be done <50 but can lead to over-diagnosis and false-positive results
* We do before 50 if someone is considered a high risk; e.g. mother has breast cancer at age 45; screen the individual <45
* We also do if any mass is palpated or felt during a clinical breast exam
* Mammography allows early diagnosis and treatment which increases the chances of long-term survival
* Women may not have mammograms done due to the expense associated, a fear of x-ray exposure causing cancer, fear of pain associated with procedure, or may be reluctant to hear bad news
* May not have access due to racial disparities and rural locations
Clinical Breast Examination
* Done by the healthcare professional
* Includes inspection and palpation
> Inspection: size, shape, symmetry, color, skin changes of the breast as well as examining the nipple and areola for asymmetry
> Palpation: palpate the axilla for any enlarged or tender lymph nodes; women lie supine; palpate around the breast and into the axilla; normal breast tissue should feel firm, lumpy, nodular, somewhat tender and thickened
* Abnormal breast tissue is typically compared to a raisin, watermelon seed, or grape (follow-up with mammography)
* Nipples are compressed to assess for any discharge; any discharge present is collected and sent for culture
Reproductive Organ and Rectal Screening
* Vulvar Self-Examination
* Pelvic Examination
* Papanicolau (Pap) Test
* Rectal Examination
Pelvic Examination
* Aim to schedule 2 weeks after the menstrual period and avoid anything in the vagina 48 hours prior to the exam
* Empty bladder prior to performing
* Can progress from external inspection to a speculum exam and finish with a bimanual exam [seen in photo]
* A manual exam involves internal and external palpation
* In postmenopausal women you won’t be able to palpate the ovaries because they begin to atrophy
Vulvar Self-Examination
* Done monthly by all women age 18 and older and those younger than 18 who are sexually active
* Start inspection at mons pubis, progress to clitoris, labia minora, labia majora, perineum, and anus
* Palpation to accompany visual inspection
* Lumps or bumps should be reported as well as new moles, warts, growths, ulcers, sores, changes in skin color, or any areas of inflammation
Rectal Examination
* Start with inspection by looking for hemorrhoids, lesions, inflammation
* Provider may insert a lubricated finger to assess the sphincter tone of the anus
* Can also perform fecal occult blood testing [occult = hidden]
* Any blood in the stool?
> Useful in screening for colorectal cancer
* Educate on how to prevent a false-negative or false-positive test
* Avoid any aspirin or NSAIDs within 7 days of exam; no red meat, fruits or vegetables, horseradish, iron, or Vitamin C as these can all lead to inaccurate results
Papanicolau (Pap) Test
* Looks for changes that can occur in the cells of the cervix before cervical cancer develops; detects cancerous and pre-cancerous cells (HPV) of the cervix
Serves as a screening tool because cervical cancer is often asymptomatic
- HPV ___ and HPV ___ are most likely strains to cause cervical cancers; vaccinations are available
- Bethesda system for a statement of specimen adequacy
- Pap tests that are performed with persistent abnormal findings lead to a ___ being performed (an examination of the vaginal and cervical tissue with a tool (___) for cell magnification)
16; 18
colposcopy; colposcope
Breast Disorders
Benign Disorders of the Breast
* Are nonmalignant and noncancerous disorders
- Fibrocystic Breast Changes
- Fibroadenoma
- Ductal Ectasia
- Intraductal Papilloma
?
Is a condition that occurs as a women approaches menopause
- Signs and symptoms are very similar to breast cancer which is what can make it very alarming
- To accurately diagnose this, we will have to do a biopsy
Ductal Ectasia
?
Is the most common benign tumor of the breast
- Typically occur during the teenage years and in the early 20’s
- Are firm, rubbery, freely movable nodules with persistent symptoms; may require a mammogram and/or an ultrasound
- To ensure it’s not breast cancer may need a fine needle aspiration or core biopsy
- Even though this is not cancerous, it increases the risk of breast cancer
- Will place a woman into that high-risk category
- Can be surgically excised if desired
Fibroadenoma
?
Is a condition that occurs just before or even during menopause and causes serous or serosanguineous drainage from the nipple
- Treatment is excision of the mass and the entire ductile area
- These women will need regular follow-up because this is a condition that places them at a higher risk of breast cancer development and malignant changes
Intraductal papilloma
?
These occur during the reproductive years
- Is the thickening of normal breast tissue with cyst development
- Cysts can be smooth, well delineated nodules that are tender but mobile
- Can be pain and tenderness during hormone fluctuation throughout the menstrual cycle and this is common
- Interventions include avoidance of caffeine, wearing a supportive bra, NSAIDs for pain and discomfort, as well as oral contraceptives
Fibrocystic breast changes
Diagnostic Evaluation
* Mammography
* Digital Mammography
* Ultrasound Imaging
* MRI Imaging
* Fine Needle Aspiration
* Core Needle Biopsy
* Surgical Biopsy
?
In this procedure we are obtaining a lump of breast tissue; is a larger area that we’re going to evaluate
Surgical biopsy
Mammography
- Not as effective in very dense breasts
- <50 have higher risk of false positives
Digital Mammography
- Takes mammography up a level to adjust clarity and allows us to see better images
?
Differentiates between fluid-filled cyst versus solid tissue; solid tissue is more likely to be malignant
Ultrasound imaging
?
This also allows for the distinguishing of fluid-filled cysts from solid tissue
MRI imaging
?
This is where we remove fluid or small tissue fragments for evaluation
- Can be done by a core needle biopsy which is a larger needle that is used to obtain fluid or tissue from an area of abnormal breast tissue
Fine needle aspiration
Nursing Considerations
* Avoid providing false reassurance and provide facts and education to our patients
Anxiety and fear
- Most breast disorders are benign
- Even if benign, increases risk of cancer development
- Encourage to express concerns
- Educate on what to expect with diagnostic tests
Malignant Tumors of the Breast
* About 1 in 8 women are likely to develop breast cancer at some point in their lives
* Less than 1% of men develop breast cancer
* Greatest risk occurs with age, non-Hispanic black women
* ___ and ___ genes are often present with familial cancers
* Mutation of ___ gene increases risk in both men and women
* Many times can present without presence of risk factors (you could have no risk factors and still be considered to be at average risk)
* There is no low risk unless you have breast tissue removed via a mastectomy
BRCA 1; BRCA 2
CHEK-2
Pathophysiology and Manifestation
70-80% of breast cancers are ___ (the primary one we will see)
> Grows in irregular patterns
> Invades the lymphatic channels and causes lymphatic edema
> Peau d’orange
> Cancer cells carry to the lymph nodes, causing axillary lymph node involvement (which progresses the stage of cancer we’re seeing)
infiltrating ductal carcinomas
* Uncommon inflammatory cancers (1-3%) grow rapidly and are more difficult to treat
* Signs and Symptoms: palpable breast lump, thickening and/or distortion of breast tissue, dimpling, nipple retraction, changes in the skin or shape of the breast
___ - is edema of the arm that will typically occur unilaterally and you see this swelling of just the arm
___ is essentially when the breast takes on the look of an orange
* Oftentimes when women present, the breast cancer has already spread and become a systemic disease rather than simply confined to the breast (this is why screenings are so important)
* ___ occurs when the cells are spread by the blood and lymph to distant organs
> Is all based on where the cancer originates from; breast cancer can be a migration of another cancer
Lymphatic edema
Peau d’orange
Metastasis
Breast Cancer Staging: Based on Tumor, Node, and Metastasis (TNM)
Stage 1: small invasive tumor without lymphatic involvement
Stage 2: tumor growth with or without local lymph node involvement
Stage 3: lymph node involvement
Stage 4: metastasis has occurred
> Is the most difficult to treat; now in more than 1 site
Therapeutic Management of Breast Cancers
* Primary Treatment: surgical excision and adjuvant therapies
* Radiation Therapy
* Chemotherapy
* Hormonal Therapy
* Immunotherapy
?
Are biologically-based target therapies that target specific cell pathways that promote cancer growth and attack them
> See monoclonal antibodies used here
> Unlike chemotherapy, MaB don’t produce all the negative side effects but are effective in reducing the expression of the cancer-related proteins and thus killing off the cancer
* Are often used in combination with a chemotherapeutic agent
Immunotherapy
Hormonal Therapy
- Can give estrogen-blocking rx’s because many breast tumors are estrogen-receptor positive, meaning that their growth is stimulated by estrogen
- Is a greater risk of osteoporosis for women who take estrogen-blocking rx’s
- Common rx given is ___ (hot flashes, vaginal dryness, nausea, anorexia)
- Also give ___ (given to reduce osteoporosis but has shown evidence in preventing breast and uterine cancers as well as decreasing the risk of blood clot development)
tamoxifen
raloxifene
?
Our cytotoxic agents we administer to kill off cancer cells BUT does not know how to distinguish between cancer cells and normal cells
> Especially affects anything in the body with rapid proliferation like cells along the GI tract; also see alopecia but it’s temporary
> See nausea, vomiting, reduced clotting factors and immunosuppression (the latter 3 because we’re killing the normal body cells, RBC’s, WBC’s, and platelets)
Chemotherapy
* Radiation and chemotherapy following surgical excision increase chance of long-term survival significantly
* Radiation therapy uses high energy rays that are destroying the cancer cells > that surgical excision is complete
> Can cause like a sunburn to the area where it’s applied and if we’re involving the axillary nodes, lymphedema is more likely to develop
> IMRT is a newer form of radiation that’s a more precise form of treatment; is more targeted and lessens effects on surrounding tissues; more targeted to where we want it to be
Surgical Treatments
* Breast Conservation Surgery/Lumpectomy
* Quadrantectomy
* Simple Mastectomy
* Modified Radical Mastectomy
* Sentinel Lymph Node Biopsy
?
Is removal of the entire breast but not all of the axillary lymph nodes; some lymph nodes might get removed for staging; oftentimes they’re going to stay
* Can be done prophylactically for women at high risk
Simple Mastectomy
?
Is removal of the breast tissue, axillary lymph nodes, and even some chest muscle
> Pectoralis major and minor are preserved
* Recommended for a large mass in a small breast; recommended for when radiation is contraindicated or whenever a higher genetic risk for breast cancer exists
Modified Radical Mastectomy
?
We are removing some key lymph nodes but a small amount
Visualize with a contrast dye
Reduces risk of lymphedema; helps us to evaluate any cancer spread
Sentinel Lymph Node Biopsy
?
Removing a more extensive area of the breast because we’re essentially removing a quadrant of tissue; more deformity does present
> Lymph nodes are going to be removed to assess the staging of the disease
Quadrantectomy
?
A wide, local excision of malignant tissue; removing that lump only
> Can be performed without major cosmetic deformities; lymph nodes can also be removed to assess for the extent of the cancer (to ensure it hasn’t spread into the lymph nodes)
Breast Conservation Surgery/Lumpectomy
Tissue expansion method
Tissue flap procedure - removes autologous tissue from the back, abdomen, or buttocks to create a breast mound; requires 2 incisions (at the breast and site of donor tissue); healing of 2 sites simultaneously
> Nipple and areola reconstruction as well as tattooing of those areas to promote a more natural appearance
Nursing Care for the Woman with Breast Cancer
* Emotional support
* Education
* Sexuality counseling
* Preoperative teaching
* Discharge teaching
* Support group materials
Cardiovascular Disease
* Is the leading cause of death for women; causing 1 in 5 female deaths in the US each year
* Includes disorders of the heart and blood vessels, myocardial infarction, congenital abnormalities and stroke
* Will especially look at CAD, or coronary artery disease
Recognizing Coronary Artery Disease
Symptoms in Women
* Fatigue, weakness
* ___ (chest pain with exertion) or pain at rest
* Dyspnea, sometimes paroxysmal noctural dyspnea
* Dizziness, faintness, lightheadedness
* Upper abdominal pain, heartburn, loss of appetite
* Nausea, vomiting, sweating
angina
* Pain in the upper body, other than the chest (arm, neck, upper back, jaw, throat, teeth)
> Important that dentists understand the different presentations that women can have
> Tooth pain with no clear indication may necessitate a referral for a cardiac work-up
> Women can have different symptom presentations from men
CAD: Risk Factors
Unmodifiable
* Aging
* Postmenopausal (because estrogen has been shown to provide a protective effect and delays the onset of CVD)
* Family history of CAD
Modifiable
* Hypertension - look at diet [DASH]; lose weight
* Dyslipidemia - changing diet; HDL more, LDL less
* Inadequate physical activity - increase it!
* Overweight and obesity - dietary changes; exercise plan
* Diet of poor nutritional quality - work with a dietician or nutritionist
* Cigarette smoking - cessation!
CAD: Prevention
Hypertension
* Stage I is defined as ___-___/ ___-___
* Stage II is defined as greater than ___/___
* Lifestyle modifications, DASH diet, medications
130-139 / 80-89
140/90
Smoking Cessation
Diet and Glucose Control
> Diabetic women have an increased risk of CAD development
> At least 2 servings of fatty fish are recommended weekly (if no fish, consider an omega supplement)
> Limit sodium to ___ mg and alcohol to 1 drink per day
1500 mg
Increased Activity
> Aerobic exercise - at least 30 minutes daily
Aspirin
> Daily, low dose (81 mg)
- To help keep things from coagulating
- A regular dose of 325 mg can assist someone having an MI to try to get that blood to thin and the flow to restore
Note:
Estrogen replacement therapy after menopause hasn’t yet proven effective in reducing the risk of CVD
Natural estrogen produced by the woman pre-menopause is effective but supplemental is not
Menstrual Cycle Disorders
* Amenorrhea - Primary vs Secondary
* Abnormal Uterine Bleeding
* Pain Associated with the Menstrual Cycle
> Mittelschmerz
> Primary dysmenorrhea
> Endometriosis
> Premenstrual Syndrome (PMS)
* Are typically benign but do require comprehensive gynecological assessments
?
Is the pain that occurs at the time of ovulation; typically unilateral on the side that is releasing the ova
Mittelschmerz
?
Cramping; menstrual pain without any identified pathological process
> Thought to be caused by prostaglandins that diffuse into the endometrial tissues
! begins with start of menstruation
> Treated with NSAIDs to alleviate discomfort; can also be treated with oral contraceptives as these reduce prostaglandin secretion
Primary dysmenorrhea
Abnormal uterine bleeding
* Occurs with abnormal frequency and it lasts an abnormal length
* Can occur irregularly or in excessive amounts
* Common causes can be pregnancy complications; a spontaneous abortion (this can happen at 5 weeks); anatomic lesions that are either benign or malignant of the vagina can cause AUB; also if they’re in the uterus or cervix; can be medication-induced bleeding or breakthrough bleeding that occurs in women taking hormonal contraceptives; can be systemic disorders like diabetes, uterine myomas, hypothyroidism, or blood coagulation disorders as well as a failure to ovulate
?
Is the absence of menstruation for 3 months or more in a woman who has established a regular pattern of menstruation
> Would be 6 months in women if they had a pattern of irregular menstruation
> Consider the facts of pregnancy, lactation; those do apply as well as the postmenopausal woman
> Can be caused by systemic diseases, diabetes, TB, hypothyroidism, CNS lesions, hormone imbalances, strenuous aerobic exercise, poor nutrition, use of hormonal contraceptives, stress, and ovarian tumors
> PCOS can cause anovulation
* Pregnancy testing will always be done 1st to rule out that they’re not pregnant before moving on to evaluation and treatment of ___
Secondary amenorrhea
secondary amenorrheas
?
Is the absence of menstruation
Is normal before menarche, during pregnancy, during the puerperium, and during lactation as well as after menopause (at any other time it is abnormal)
Amenorrhea
?
Occurs if the menses have not yet begun by the age of 15 in the presence of normal growth and secondary sex characteristics
> Also consider it ___ if it occurs at age 13 in the absence of menses and secondary sex characteristics
* Secondary sex characteristics did not develop and that’s commonly caused by ___, which is where girls only have 1 normal X chromosome
> If the secondary sex characteristics are present, then the most common cause is incomplete development of either the uterus, ovaries, fallopian tubes or all of the above
Primary amenorrhea
primary
Turner syndrome
* This condition can also result from excessive exercise, malnutrition, and eating disorders
?
Occurs when endometrial tissue is present outside of the uterus
* Unknown cause; theory of “retrograde menstruation”
* Common symptoms include:
> Cyclic pain (a constant pain that’s going to occur 36-48 hours before the onset of menses)
> Infertility
> Dyspareunia
> Rectal pain (particularly during defecation)
Endometriosis
* Occurs with approximately 10% of women
“Retrograde menstruation” - where essentially there’s a reflux of the menstrual flow into the fallopian tubes and to the ovaries
> If this is occurring, it also allows it to take and be expressed into the peritoneal cavity which would explain why we see it on the large and small intestines
* Most are diagnosed in their 20’s or 30’s
* Does respond to estrogen and progesterone as it’s endometrial tissue (the same way that uterine tissue will respond); will grow and proliferate during the follicular and luteal phases and slough during menstruation
Treatment
* Hormones
> Oral contraceptives, Depo Provera; as these will inhibit the growth of excess endometrial tissue
* Lysis of adhesions
* Hysterectomy with bilateral salpingo-oopherectomy
> Removing the uterus, the fallopian tubes, and the ovaries
> Primarily done in women who are no longer wanting children
> For some women this can be so severe that they opt to lose the ability to have a child themselves than continue to have a uterus; will result in early menopause when we remove all of these parts
> Until everything is removed, events can still occur in the absence of a uterus, fallopian tubes, or ovaries
> Pain can range from being mild to incapacitating
> Each experience will be unique from woman to woman
Premenstrual Syndrome (PMS)
* Cause is unknown, thought to be triggered by hormone imbalances
* Signs and symptoms are cyclic and occur during the luteal phase of the menstrual cycle (Box 32.4) [before menstruation occurs]
* Symptoms are severe enough to impact the woman’s work, lifestyle, and personal relationships (is a syndrome that can be devastating)
* Treatment is based on the symptom profile of each woman
> Fluoxetine (Prozac) and Sertraline (Zoloft) have been effective (they serve as antidepressants, improve anxiety, and stabilize mood)
> Oral contraceptives help improve physical symptoms like pain
?
Is a worsened, much more severe form of premenstrual syndrome (PMS)
Premenstrual Dysphoric Disorder
Elective Termination of Pregnancy (or abortion)
* Voluntary method of ending pregnancy at the request of the woman, but not for reasons of impaired maternal health or fetal disease
* Medication-based (up to ___ weeks)
> ___ followed by ___
> ___
7
Mifepristone; Misoprostol
Methotrexate
* Surgical techniques (7 weeks and up)
> Vacuum aspiration with curettage
> Dilation and evacuation (D+E) - dilate the cervix and evacuate the fetus and placenta; may have to be done gradually
* Provide physical and emotional support
* Educate on signs and symptoms of complications, and when to return
* Rh negative women should receive RhoGAM following the procedure
?
The end of menstruation; is actually termed the “___” - the change of life
Menopause
climacteric
2 branches from that: pre-menopause and post-menopause
?
Refers to the phase after menstruation has ceased altogether
Post-menopause
?
Refers to the period of symptom onset but before the cessation of menstruation occurs; we start to see the symptoms associated with ___ but are still menstruating
Pre-menopause
menopause
Any unplanned vaginal bleeding post-menopause should be evaluated immediately as it suggests ___
* Some women will still take hormones so it will produce some vaginal bleeding at specific times to help to keep the layers of the uterus thinner
* They may have this planned time that they still see bleeding but it is not menstruation and it’s actually triggered by the medication that they’re taking
endometrial cancer
Onset of Menopause
* Typical onset begins between ___ and ___ years of age
* ___ is sporadic, leading to irregular menstrual periods
* ___ levels decline, affecting the reproductive system
* Labia become thin and pale
* Vaginal mucosa atrophies, decreased vaginal lubrication, dyspareunia; increased risk of vaginal trauma and infections
* ___ become smaller
* Atrophy of the uterus and ovaries; fibroids and endometrial lesions atrophy
* ___ increase while ___ decrease
* Hot flashes occur
45-50
Ovulation
Estrogen
Breasts
LDLs; HDLs
Therapies for Menopause
?
* Estrogen alone can only be used in women without a uterus
* Estrogen plus progesterone is needed if women still have a uterus
* Must weigh risks and benefits (can have an increased risk factor for clot formation)
Menopause Hormone Therapy
Complimentary Therapies
* Water-soluble lubricants to alleviate vaginal dryness; botanical preparations; Kegel exercises to strengthen the pelvic floor; and we encourage drinking 8 glasses of water per day
?
Is the loss of bone density
* The decrease in estrogen at menopause accelerates bone loss and slows bone regeneration
* Remember: bone density peaks at age 25
* Risk for development increases after menopause
* Small-boned, fair skin women are at highest risk, but Black and Hispanic women are also at risk
Osteoporosis
* Risk factors include: family history, late menarche, early menopause, sedentary lifestyle, smoking, alcohol intake, excessive caffeine intake
* Medications such as ___ can decrease bone density
* Signs and symptoms include loss of height, back pain, “dowager’s hump”, abdominal protrusion
* Dual-energy x-ray absorptiometry (DEXA) scan
corticosteroids
Osteoporosis Therapy
Medications
___ - a calcium regulator that is a nasal spray
Biphosphonates: Aldendronate (Fosamax), Ibandronate (Boniva) - these inhibit cells that break down the bones and reduces bone turnover
___ (Evista) - binds to estrogen receptors to reduce bone loss
Calcitonin
Raloxifene
Calcium and Vitamin D
* Women who are older than 50 years should be taking ___ mg of calcium per day and ___ mcg of Vitamin D
Exercise
* Weight-bearing exercises; resistance exercises increase bone density and help to build muscle mass; e.g. walking/hiking/stairclimbing/dancing for 30 minutes/day
1200 mg; 600-800 mcg
Pelvic Floor Dysfunction
Vaginal Wall Prolapse
* Cystocele
* Enterocele
* Rectocele
?
Is the posterior wall of the vagina becomes weakened and thin, and feces push against that thin wall causing further stretching until the rectum protrudes into the vagina
> This can lead to incomplete emptying of the rectum
Rectocele
?
Is a weakened upper anterior wall of the vagina and it is no longer able to support the weight of urine in the bladder
> Bladder begins to protrude downward into the vagina, causing incomplete bladder emptying and it can even result in cystitis (a bladder infection)
> Also increases the risk of stress incontinence
Cystocele
?
Is a prolapse of the upper posterior vaginal wall between the vagina and the rectum
> Part of the peritoneum, which can include loops of bowel, can dip down and this is often associated with uterine prolapse
Enterocele
?
Occurs during childbirth, this overstretching, but the symptoms don’t develop until they’re postmenopausal
* Cardinal ligaments that support the uterus and vagina are stretched during pregnancy and do not return to normal after childbirth
* Symptoms become obvious during the postmenopausal period
> Pelvic fullness, pelvic pressure, fatigue, low backache, feeling of “everything falling out”
Uterine Prolapse
Cervical ulceration and bleeding occur if the cervix protrudes from the vaginal introitus
* Risk for trauma and infection and a risk for bleeding
> This risk for bleeding is not as evident as when we talked about this during pregnancy
* During pregnancy we have a body that has extra blood volume on board specifically to give to the uterus
* Here we aren’t perfusing the uterus nearly as much
* We can have blood loss but not nearly to the extent that we see in post-delivery
Management of Pelvic Floor Disorders
* First-line treatments are conservative: relaxation, stress management, and self-care
* Surgical procedures help with significant discomfort
> Anterior and posterior colporrhaphy [vaginal wall repair] - relieves pressure from the bladder or rectum
> Vaginal hysterectomy
* ___ - is a device used to support the pelvic structures and this gets inserted into the vagina
* Pelvic exercises - e.g. Kegel exercises to help strengthen the pelvic floor
pessary
Urinary Incontinence Refresher
?
Arises from both stress and urge incontinences
Mixed Incontinence
?
Is urine leakage occurring with increased intra-abdominal pressure (coughing, sneezing, laughing, or physical exertion)
Stress Incontinence
?
Is urine leakage that accompanies a strong need to void promptly
Urge Incontinence
Disorders of the Reproductive Tract
?
Most common gynecologic tumors
Estrogen dependent: atrophy with menopause, remain with estrogen therapy
Increased uterine size, pelvic pain, excessive menstrual bleeding
Myomectomy, Hysterectomy,
- Uterine Artery Embolization (UAE) [there is a higher risk of future miscarriages, PPH’s, and C-sections; not recommended for women still planning to have more children]
Uterine Leiomyomas
?
Follicular or luteal (can utilize oral contraceptives to treat)
Laparoscopy, Laparotomy
Ovarian cysts
?
Seen on a speculum exam when visualizing the cervix
Small tumors on a pedicle (stem-like structure)
Cause intermittent vaginal bleeding
Surgically removed in an outpatient setting
Cervical polyps
Signs & Symptoms That Should Always Be Investigated
Malignant Disorders
* Primary cancer sites: ___, ___, and ___
Risk Factors, p. 714, Box 32.5
* Often diagnosed at a more advanced stage due to minimal symptoms
* Screening Tests: pelvic examinations, Pap Tests, and ultrasound
* Serum Tests: tumor marker screening, genetic disposition
* Diagnostic Tests: endometrial sampling, colposcopy
cervix, uterus, ovaries
Referred to as “silent killers” because they progress significantly without producing symptoms or symptoms can be dismissed for something else
* Cervical cancer is a lesion on the cervix; HPV is associated with most cervical cancers
> Treatment of cervical cancer consists of cryosurgery; destruction of the abnormal tissue by laser; can do a loop electrosurgical excision procedure; or surgical conization to remove the central cervix
* Often with cervical cancer, we’ll do adjuvant chemotherapy and radiation
* For ___ and ___ cancers these are the most common cancers in the US
> Present with abnormal vaginal bleeding and this occurs near or after menopause
> Surgery is needed at this point; will have a hysterectomy w/a salpingo-oophorectomy (we’ll remove the uterus, fallopian tubes, and ovaries)
> If woman is a poor surgical candidate, they’ll be treated with chemotherapy and radiation
uterine, endometrial
> For ovarian cancer, an oophorectomy can be curable in the early stages; chemotherapy will be required after surgery
Infectious Disorders of the Reproductive Tract
* Women are twice as likely as men to contract STDs
* Aside from abstinence the use of latex condoms is the best way to protect from STDs
Candidiasis (Yeast Infection)
* Changes in vaginal pH permit the growth of Candida albicans
> Caused by pregnancy, contraceptive use, diabetes, antibiotic therapy
* Recurrent candidiasis can occur in sexually-active women
> Male partners could develop erythema and itching of the glans penis
! Main symptom is vaginal and perineal itching (and may note associated vaginal discharge that’s a thick, cheesy-like substance)
* Treatment consists of nonprescription and/or prescription medications
> [OTC] Miconazole (___), Clotrimazole
* Seek medical attention with first infection, if the infection persists, or it recurs regularly
Monistat
Trichomoniasis
* Caused by ?
Signs and Symptoms
* Purulent vaginal discharge that is thin or frothy, malodorous, and yellow-green or brownish-gray
* Vulvar itching, edema, and erythema
* Vaginal discharge is more ___
Trichomonas vaginalis
alkalinic
Treatment: metronidazole (___) or tinidazole (___)
* Must avoid alcohol while taking these medications and for 24-72 hours after therapy has ended
> Refrain from sexual intercourse until therapy is completed
> Re-infection can result if the partner has not been treated
> Condom worn with any new partners
Flagyl, Tindamax
Bacterial Vaginosis (BV)
* Caused by Gardnerella vaginalis or Mycoplasma hominis
> Lack of vaginal lactobacilli can also be a cause (the good flora of the vagina)
Signs and Symptoms
> Thin, grayish-white vaginal discharge with a “fishy odor”
* Treatment: metronidazole (Flagyl) or clindamycin
> Women should refrain from intercourse until they’re cured or partner should use a condom until they’re cured and with this, treatment of the partner has not been shown to be beneficial
Chlamydia
* Caused by Gram-negative bacterium and Chlamydia trachomatis
* High rates in sexually active teens, young adults, and people with multiple sexual partners
Signs and Symptoms
> Often asymptomatic
> May present with a yellowish vaginal discharge and painful urination
Treatment: antibiotics (azithromycin, doxycycline, ofloxacin, levofloxacin, erythromycin)
! If left untreated it can ascend from the cervix to start to involve the fallopian tubes which can cause scarring, PID, infertility, or ectopic pregnancies
> Use of a condom until cured is essential
> All sexual partners should be treated
Gonorrhea
* Caused by the gonococcus Neisseria gonorrhoeae
Signs and Symptoms
* Often asymptomatic
* May present with purulent discharge, dysuria, and dyspareunia
Treatment: single-dose cephalosporin antibiotics
Because ___ and ___ often occur together, we’ll also treat for ___
Like ___, this can ascend to the uterus to the fallopian tubes and cause scarring, PID, infertility, and ectopic pregnancy
* Intercourse should be avoided or a condom used until cured and all sexual partners treated simultaneously
gonorrhea, chlamydia; chlamydia
chlamydia
___
* Caused by the spirochete Treponema pallidum
* Primary/secondary/tertiary
* Diagnosis: Serology - VDRL, RPR [most common], FTA-ABS
* Treatment: ___, ceftriaxone, doxycycline
Syphilis
parenteral Penicillin G
___ Syphilis
* Enters the latent phase
* Can involve the cervix, the blood vessels, and the central nervous system
* Could even result in general paralysis and psychosis
Tertiary
___ Syphilis
* Is a painless chancre that develops on the genitalia, anus, lips, or in the oral cavity
* Heals in approximately 6 weeks but during this time it’s highly infectious
Primary
___ Syphilis
* Is the enlargement of the spleen and liver
* Headaches present; anorexia; may be a maculopapular rash associated
* Skin eruptions on the vulva occur which is called the ___ ?
* In a period where it’s highly contagious
Secondary
condylomata lata
Herpes Genitalis
* Caused by herpes simplex virus (HSV)
> Type I and Type II
Signs and Symptoms
* Within 2-12 days after initial infection, vesicles appear in a cluster on the vulva, perineum, or perianal area
* With primary infection, may experience flu-like symptoms
Type I is associated with ___ herpes; Type II is associated with ___ herpes
oral; genital
Note: Type I can present in the genital area; Type II can present in the oral region
* Virus remains dormant in the nerve ganglia and periodically reactivates
! No cure
* Acyclovir, famciclovir, and valacyclovir help reduce or suppress symptoms and viral shedding
* Women should be advised to abstain from sexual contact while lesions are present
* If genital lesions are present at the time of labor, women are unable to deliver vaginally due to high risk of transmission to the baby and will have a C-section instead
Human Papillomavirus (HPV)
* ___, also known as genital warts, are caused by HPV
___ is done to evaluate cervical tissue and detect HPV
> Women with HPV are advised to have Pap tests more frequently to detect cervical dysplasia
Condylomata acuminata
Colposcopy
Treatment: Topical agents (podophyllin gel, trichloroacetic acid, or bichloroacetic acid)
> Difficult-to-treat warts may need to be treated with cryotherapy, electrodesiccation, electrocautery, or laser
Vaccination(s): ___ and ___
> All sexual partners should be treated and sexual contact should be avoided until all lesions are healed
> Condom use is recommended to reduce transmission
Cervarix; Gardasil
Cervarix protects against HPV strains ___ and ___ (which covers 70% of the cervical cancer strains)
Gardasil protects against strains ___, ___, ___, and ___ (covers 90% of the strains causing cervical cancer)
* Vaccination is recommended for both males and females ages 9-26 years; is administered over a 3-dose regimen
16, 18
6, 11, 16, 18
Acquired Immunodeficiency Syndrome (AIDS)
* Caused by Human Immunodeficiency Virus (HIV)
* Primary mode of transmission is intimate contact with infected bodily secretions, exposure to infected blood, and perinatal transfer
* No medications cure HIV or AIDS
Pelvic Inflammatory Disease (PID)
* Infection of the upper genital tract
* Most commonly caused by chlamydial and gonorrheal infections
* Complications include chronic pelvic pain, ectopic pregnancies, and infertility
S/S: asymptomatic or very mild; pelvic pain, fever, purulent vaginal discharge, nausea, anorexia, and irregular vaginal bleeding
! Serious infection may require hospitalization
___
* Rare, potentially fatal condition caused by Staphylococcus aureus
* Only about 2% of women carry the strain of S. aureus that produces this
* Factors that increase risk of S. aureus reaching the bloodstream:
> Prolonged use of tampons or barrier contraceptives
> h/o S. aureus wound infections
> h/o nasal surgery
S/S: sudden fever, flu-like symptoms, ___, generalized rash, skin peeling on palms and soles of the feet
Toxic Shock Syndrome (TSS)
hypotension
