Women’s Issues Flashcards
Premenstrual syndrome
- Experienced by 70-90% of women, severe in 5 %
- begins 3-10 days before menstruation
- most common symptoms (more physical than mood) include:
- abdominal pain/ discomfort 95%
- fatigue 75%
- mood swings 35%
- anxiety 25%
- insomnia 20%
- affect daily life 25%
Premenstrual syndrome link to hormone levels
- when estrogen is high (near ovulation) it creates a positive mood, higher self esteem, confidence and alertness
- in 4 days prior to this anxiety, depression, irritability, hostility and feeling of helplessness
- when estrogen is low- enhanced spatial skills, poorer sense of smell, complex motor skills and verbal fluency
What is the cause of PMS
- unknown
- may be related to abnormal/withdrawal of steroid hormone levels (drop in progesterone nearing end of luteal phase)
- different responses may be related to individual differences in neurological responses to these changes rather than absolute concentrations
PMS possible treatments
Pharmaceutical/ hormonal
- progesterone (not effective) or birth control pill
- GnRH agonists (not pulsatile.. so downregulate) to reduce LH, FSH and ovarian steroids (side effects: hot flashes, headache, dryness, decreased bone mineral density)
- antidepressants or anti anxiety meds effective for some
PMS possible treatments
Lifestyle changes
- exercise
- sexual activity (blood to uterus reduces cramps)
- reduce caffeine and refined cards prior to menses
- balanced diet
- reduce alcohol intake
- keep a log of symptoms
Premenstrual Dysphoric Disorder
More severe form of PMS
- diagnosis must include these three factors
1. At least 5 symptoms of the following (mood>physical) - sadness, anxiety, extreme moodiness, marked irrationality, overwhelmed
- increased increased appetite
- insomnia
- physical symptoms (breast tenderness, headache, bloating
2. Significantly disrupt daily life and relationships
3. Not related to another medical issue
Treatment for premenstrual Dyspjoric Disorder
- serotonin reuptake inhibitors
- birthday control pills: no, or shortened, pill free interval
- calcium supplements
- exercise
- diet: reduce caffeine, alcohol and smoking
Dysmennorrhea
- cramps and pain during menstrual period
- 16 to 91% overall, with 2 to 29% severe
- negative association with age, parity, and oral contraceptives, stress and family history are positively associated
Dysmenorrhea causes and symptoms
- strong contractions of uterine smooth muscle due to reduced blood supply
- prostaglandins in menstrual fluid causing contractions to evacuate the uterus
- IUD, pelvic inflammatory disease, endometriosis
Lower abdominal cramps, back pain, nausea, fatigue and headache
Dysmenorrhea treatments
- NSAIDS: aspirin, ibuprofen, naproxen (inhibits prostaglandins) or acetaminophen
- exercise (increase uterine flow)
- quit smoking
What medication is most effective to reduce menstrual pain
Naproxen
Menorrhagia
Prolonged, or heavy menstrual bleeding
- average is 5 days and 30 ml
- prolonged is >7 days
- heavy is >80ml with large clots
Menorrhagia
- causes
- diagnosis
- cancerous/ non cancerous uterine growths, bleeding disorders or other
- IUD, miscarriage, or periodic pregnancy
- survey regarding symptoms
- address cause (test for anemia, Pap test, endometrial biopsy, ultrasound
Menorrhagia treatments
- iron, iuboprofen
- hormonal (CBCP, hormonal IUD), antifibrinolytic or clotting factors, surgery if required
Amenorrhea
An absence of menstruation-split into two types
- primary if does not occur in female before 16: caused my anorexia or low body fat
- secondary if no menstruation for at least 6 months
Both reversible or non reversible
Amenorrhea causes
- pregnancy, lactation, extended-cycle birth control pills
- menopause, low body fat (11% +-4%)
- extreme exercise
- obesity, tumours of pituitary or ovaries
Oligomennorrhea
In frequent/ skilled menstrual periods
-causes can be PCOS, psychological or physical stress, chronic illness, poor nutrition, intense exercise, menopausal, young women
mTSS
Incidence
Cause
Menstrual toxic shock syndrome
- not caused by menstruation but related to tampon use
- 0.03-50/100000 and can be fatal 8%
Caused by staphylococcus aureus infection
- must be negative for Rocky Mountain fever, leptospirosis, and measles
- staph is found in about >10% of women
- anaerobic and other conditions lead to rapid growth of these bacteria
Symptoms and treatment of mTSS
- fever
- rash, then progression to desquamation of skin
- hypotension
- multi-organ deterioration
-IV fluids and antibiotics
Why did hunter gatherer women have 3x less ovulation than women today
- later age of menarche
- breastfeed longer
- more children
- menopause earlier
Cystic follicles
(Benign) and can be functional
- Un ovulated: fluid filled sacs from continual growth of the follicle
- luteinized: solid mass filled with luteal cells from the corpus luteum
Both kinds are coming and often resolve on their own
Sometimes persist, secrete hormones, disrupt fertility and need to be surgically removed.
PCOS
Polycystic Ovarian syndrome
- common 5-10% of women
- infrequent, irregular or prolonged menstruated periods
Related to high levels of androgens
-elevated LH and low FSH
Growth of body hair on face/chest, lack of ovulation, acne, infertility, sun infertility, risk of diabetes, insulin resistance, obesity, cardiovascular disease
Cause is not well known
PCOS diagnosis
- pelvic exam (imaging such as ultrasound or palpation)
- blood test for diagnosis (androgens like testosterone and estrogen elevated)
- blood test for secondary effects (glucose, insulin, cholesterol, triglyceride
PCOS treatment
- can be management of symptoms and preventing other diseases
- exercise and diet
- combination BCP
- comiphene (anti estrogen), gonadotropins
PCOS risk factors for other diseases
- infertility or sub infertility
- endometrial cancer
- diabetes
- lipid abnormalities (increased total cholesterol, low density lipoprotein cholesterol (LDL) and triglycerides, decreased high density lipoprotein cholesterol (HDL-C)
- cardiovascular risks like hypertension
- obstructive sleep apnea
Ovarian cancer
Growth of cancerous cells in ovaries
-90% form in surface epithelium layer
1% of women will get ovarian cancer in their lifetime
US 22000 cases and >15000 deaths
CA 3000 cases and 2000 deaths
Why does ovarian cancer have a high mortality rate
Often asymptomatic until metastasized, few methods for screening early
Ovarian cancer risk factors
- family history (10% inherited)
- BRCA2 mutation (15%), BRCA1 (40%) likelihood of lifetime
- increased number of ovulation= greater the risk. This multiple pregnancies, breast feeding and oral contraceptives can reduce risk
Ovarian cancer diagnosis
- physical exam (palpation), imaging CT or trans vagina ultrasound
- blood tests (cancer antigen 125)
- biopsy and histology
Ovarian cancer treatment
- ovariectomy
- chemotherapy (including taxol)
- radiation
Ectopic pregnancy
An outside pregnancy where the fertilized egg implants outside the uterus and in the Fallopian tube
- 1% of pregnancies
- rate has increased In last 50 years
- cannot develop normally and will lead to no birth
What percent of ectopic pregnancies are in the Fallopian tube and where in the Fallopian tube?
90%
Ampulla>isthmus>fimbriae
Risk factors of ectopic pregnancy
- previous tubal ligation or surgery
- anatomical abnormalities
- current smoker
- age>35 years
- progestin only contraceptive
- impaired estrogenic response of Fallopian tube
If left untreated what happened to an ectopic pregnancy?
The follicle will grow and can damage the organ/ tissue it is in, thus leading to severe bleeding and infection.
-10% of pregnancy mortality
Symptoms and diagnosis of ectopic pregnancy
Symptoms not always present, and often look like normal pregnancy, but can cause vaginal bleeding, pelvic pain, cramps, pain on one side, dizziness and abnormal B-hCG levels
Pregnancy test and ultrasound
Treatment of ectopic pregnancy
AN EMERGENCY
- methotrexate sodium
- surgery
- not a “watch and wait” scenario
During an ectopic pregnancy, B-hCG levels differ in a normal pregnancy how?
Normal: increase substantially in first trimester
Abnormal: rise slowly, reach a plateau or decline
Methotrexate sodium
Intramuscular injection that inhibits folic acid dihydrofolate reductase (DHFR) which is also an anti cancer or anti viral and is involved in follicular growth.
-dose doses more effective than 1 dose
Pelvic inflammatory disease
-infection to the organs of the reproductive system
/can be caused by bacterial STD’s, or infection from bacterial vaginosis
-can enter via the vagina and then spread
Salpingitis
- inflammatory of oviducts, which can lead to blockage of tube by scar tissue
- symptoms can be present as in pain, discharge/ odour, spotting
- can lead to infertility
- inflammation can be treated with antibiotics and blockage may be repaired by microsurgery
Total Hysterectomy
The uterus and cervix are removed.
Total hysterectomy with salpingo-oophorectomy
Uterus+ cervix+ and/ or one ovary and Fallopian tube are removed or both ovaries and Fallopian tubes are removed
Radical hysterectomy
Uterus+cervix+both ovaries+both Fallopian tubes and nearby tissue are removed
Cervical cancer
Cancer cells grown in or on cervix
- 8th most on in cancer fatality
- 0.6% of women in their lifetime
- higher rates in developing countries
Pap test
A test that recognizes changes in cervical cells before they become malignant.
-removed a small amount of cells from the cervix using a small round brush and fine wooden spatula-examined microscopically
If positive= get a second test or colposcopy
Can prevent 80% of cervical cancers
Cervical cancer signs and symptoms
- Vaginal bleeding or unusual discharge
- pelvic pain or pain during sex
Risk factors and prevention or cervical cancer
- Gardasil vaccine (most are caused by particular strains of HPV
- BRCA2 mutation (4x greater risk), BRCA1 mutation (2x greater risk)
- diethylstilbestrol (DES): synthetic estrogen prescribed to pregnant women with complications known to increase risk of offspring cervical cancer by 2
Cervical cancer treatment
Surgery ( hysterectomy)
Chemotherapy
Radiation
Immunotherapy
Cervical cysts
- Benign growths as a result of past infection or irritation
- cysts look like pea-sized whitish pimples
- can be removed by burning (heat cauterization) or freezing (cryosurgery) or laser
Cervical polyps
- Tear shaped growth extending into the cervical canal
- benign, but can interfere with fertility or vaginal coitus
- can be removed by burning, freezing or laser
Endometrial cancer
- growth of cancer cells in the endometrium layer of uterus
- most coming gynaecological cancer in North America
- increasing incidence over the last 20 years
- usually diagnosed after menopause
Endometrial cancer symptoms
- vaginal bleeding or abnormal discharge (post menopause)
- abnormal menstrual bleeding prior to menopause
- anemia (due to blood loss)
- lower abdominal pain
Diagnosis and treatment of endometrial cancer
- detected by Pap smear 50% of time
- ultrasound or other imaging
- biopsy and histology to confirm
Hysterectomy, radiation, chemo
If caught early, diseased tissue may be removed by cryosurgery
Risk factors of endometrial cancer
- age (post menopause)
- previous diagnosis of endometrial hyperplasia
- use of estrogen replacement therapy or other high estrogen exposure (no link to pill yet)
- obesity (40% of new cases)
- diabetes
- nulliparous
- Caucasian
- use of tamoxifen to prevent breast cancer
- BRCA1 mutation (3x), BRCA2 (1.5x)
- colorectal cancer
Endometriosis
- a condition when the endometrial tissue dislodges from the uterus to implant/ grow in other regions of the body
- ovaries, oviducts, uterine ligaments, urinary bladder, and even intestines and lungs
- these explants respond to hormonal cycles and bled monthly thus it can be painful
Affects 10% of women and more common in younger age
Likely caused by retrograde menstruation
Symptoms of endometriosis
- painful menstrual periods (dysmenorrhea) or chronic pelvic pain
- back pain, pain during sex, pain during voiding
- infertility/ interfere with ovulation (30-40%) scarring of oviduct
Endometriosis diagnosis
- no bio markers
- laparoscopy and biopsy + histology
Endometriosis treatment
- hormonal approaches: extended use of combined or preordering only BCP to stop menstrual cycle and relieve symptoms, GnRH agonists to Dow regulate
- surgery (hysterectomy, or laser)
- pregnancy may cause temporary remission of symptoms and symptoms may be terminated with menopause
Risk factors of endometriosis
- heritable however low risk
- diethylstilbestrol, sun sensitivity, low wait-hip ratio, short duration lactation, and trans fats
Endometrial polyps
Endometrial hyperplasia
Endometrial fibroids
- mushroom like growth that extended into the uterine cavity
- excessive proliferation of endometrial cells, so this layer becomes thicker
- non-cancerous growths of the smooth muscle layer of the uterus which are coming in older women prior to menopause
Cause, symptoms and treatment of endometrial polyps, hyperplasia and fibroids
- imbalance of hormone levels (chronic estrogen without menstruation)
- all are benign but can cause irregular menstrual bleeding
- address hormone Imbalance
- surgery to remove, via endometrial ablation and heat cauterization, cryosurgery or laser
Tipped uterus
- normally the uterus is anteverted, it a tipped uterus is retroverted (facing back) or retroflexed (facing back and bent towards rectum)
- 20% common
Causes pain during menstruation and intercourse, constipation/ bowel pain, may be asymptomatic
Usually does not hamper fertility and it may reposition itself after pregnancy
Prolapsed uterus
Uterus slips down into vaginal opening
Occurs to 50% of older women but only 20% are symptomatic
Grades of prolapsed uterus
1st-uterus descended into upper vaginal
2nd- descended into introitus
3rd-cervix outside of introitus
4th-cervix and uterus outside introitus= surgery
Risk factors and symptoms of prolapsed uterus
- Parity, age, overweight/ obese
- excess strain of… vaginal delivery, bowel movements, heavy lifting, coughing
- difficulties with coitus, pelvic heaviness/pulling, sensation of protrusion
- increased vagina bleeding/discharge, I continence, bladder infections, constipation, lower back pain
Underlying issues of prolapsed uterus
- relaxed/stretched ligaments that hold the uterus in place
- weak pubococcygeus muscles (a sling of myself es sling the pelvic floor connects pubic and tail bone)
Treatments for prolapsed uterus
- kegel exercises
- weight reduction
- vagina pessary to support protruding organs
- surgery (repair of weakened muscles/ ligaments) or hysterectomy
Mastitis
- infection/ inflammation of the mammary glands/ ducts due to blockage or bacteria entering
- occurs most often during lactation
- symptoms are pain, swelling, heat
- treat with antibiotics
- prevent via fully draining breasts during feeding and ensure proper latch
Fibrocystic breast changes
- cysts (fluid filled) and fibroadenomas (solid benign lumps)
- feels lumpy or rope like, with potential for tenderness
- coming in women 25-55 years old as part of menstrual cycle
- cysts result from fluid accumulation in ducts that become walled off whereas fibroadenomas are due to connective tissue build up in ducts
- not a risk for breast cancer
Breast cancer
Cancer of the cells of the breasts
- most coming form of cancer in women (excluding skin)
- 25% of cancers and 13% of cancer deaths in women
- 1/8 women
- 80% diagnosed in women 50+ old
- death rate decreasing
- survival at 5 years is 90%
Risk factors of breast cancer
Family history:
- 5-10% Inherited
- risk is greater the more family members had it
- 7x greater with BRCA1 or 2
Chemicals, plastics, pesticides, cosmetics, cigarettes, manufacturing and more!
Breast cancer signs, symptoms and diagnosis
- breast self examination and clinical examinations: look for changes in breast from month to month that persist such as lumps, seedlings, thickening a, puckering of skin, irritation, inverted nipple, nipple discharge, pain or tenderness that persists through whole cycle
- mammography
- thermography
- Ultrasound
- blood bio markers
- biopsy of breast tissue and histology
Mammography
- low dose x ray of breast
- most beneficial for women at risk and those over 50 years old in cancer
Thermography
Not approved in cancer
Classification of breast cancer
Classified based on location
- Ductal carcinoma
- lobular carcinoma
- sarcomas
A link to hormones in breast cancer classification
Hormone receptor positive (65+%)
-the cancer cells have receptors for hormones, including estrogen (ER+) and progesterone (PR+)
Hormonal receptor negative (20%)
- the cancer cells do not have receptors for hormones
- the cells have over-expression of human epidermal growth factor receptor 2 (HER2)
Triple negative (15%)
- the cancer cells do not have receptors for estrogen, progesterone or over-expression of HER2
- BRCA mutation related cancers are often in this category and grow/ spread more rapidly
Breast cancer stages
TNM (tumour, lymph nodes and metastasis)
- 0 abnormal cells, but not spread outside of breast
- 1 less than 2 cm but not spread outside of breast
- 2 size now 2-5 cm, mag be spread to lymph nodes
- 3 size now >5 cm and spread to lymph nodes and maybe other organs
- 4 cancer now spread outside of breast and to other organs
Breast cancer surgical treatment
Mastectomy
- partial: removal of lump
- simple: removal of breast only
- modified radical: removal of breast and surrounding lymph nodes
- radical: removal of breast, pectoralis muscle, and surrounding lymph nodes
Radiation treatment for breast cancer
Chemotherapy and radiation
Pharmacological treatment of breast cancer
- anti estrogen therapy (tamoxifen or aromatase inhibitors) or removal of the ovaries if estrogen sensitive
- herceptin: binds to HER2 receptors and blocks the signalling pathways, so effective in HER2+ cancers
- targeted immunotherapy (poly ADP ribose polyamorase, PARP enzyme inhibitors) for triple negative breast cancer
Breast cancer prevention
- eat a balanced diet: low in saturated and trans fats, high in mono and poly saturated fats, increase intake of fibre and vitamin d, limit alcohol and red meat
- reduce exposure to natural or synthetic estrogens
- exercise
- more children and extended lactation
- early detection is vital!
FGM prevalence
Female genital mutilation
- estimated that 200 million girls and women have undergone FGM worldwide
- yearly this is expected to be 3 million globally
The prevalence of FGM has____ over the last 30 years
Declined
- But still unequal in country distribution
- legally, FGM is internationally recognized as a violation of the humans rights of girls and women and reflects deep rooted inequality between the sexes
In Canada, FGM is a ______
Criminal offence since 1997
4 types of FGM
- Clitoridectomy (removal of prepuce or removal of clitoris and prepuce
- Excision (a. Removal of labia minora b. Partial/ total removal of clitoris and labia minora c. Partial/ total removal of clitoris, labia minora and labia majora
- Infibulation or pharaonic circumcision
- removal of all external genitalia, then suturing/ fusing the tissues
- leaves only a small opening for urine/ menstrual flow. Often involves binding the child from hip to ankle for a number of weeks - All other harmful procedures- pricking, piercing, cutting, burning or scarring
Type 3 of FGM is often very difficult/ impossible for male to penetrate so…
May need to cut open for intercourse
Differences in the types of procedures of FGM
- 80-85% in types 1 and 2 with about 15% type 3
- some countries such as Sudan, Somalia and Djibouti virtually all type 3
Potential reasons for FGM and potential risk increases
- cultural beliefs, family tradition, preserved a girl for marriage, and more
- can increase risk of HIV and STDS
- no health benefits
- it is not required as part of religion
Complication of FGM
-pain, bleeding, infection, infertility, physical and psychological dysfunction, death
-effect future pregnancies (type 2 increases infant/ neonatal mortality by 30-35%, type 3 increases infant and neonatal mortality by 55%
( deinfibulation needed to open for childbirth)
