NSG 6430/NSG6430 Women's Health Final Review LATEST
1. Primary Amenorrhea
Absence of menses: by age 15 years
Often secondary to: dysfunction in the
... [Show More] hypothalamus, pituitary, ovaries (HPO
axis), uterus, or vagina
2. DYSMENORRHEA
Painful cramping: associated with menstruation caused by spasmodic uterine
contractions
Most common GYN problem: in adolescents & adult females
HISTORY: is KEY!!!
Primary versus Secondary
3. Primary Dysmenorrhea: Absence of pelvic pathology
CAUSE: Excessive Prostaglandins
ONSET: in adolescence
PAIN: starts 1-2 days prior to onset of menses or with menses, resolving over
12-72 hours
ASSOCIATED: with nausea, diarrhea, dizziness, fatigue, HA, back pain
IMPROVES: with NSAIDs, hormonal contraceptives, AGE & PARITY
4. Secondary Dysmenorrhea: Presence of Pelvic Pathology
ONSET: Usually after age 25 years
Abnormal uterine bleeding (AUB)
Variable SX: N, V, D, back pain
Dyspareunia: (esp. w/Endometriosis)
Symptoms: OFTEN worsen over time
Causes: Endometriosis, fibroids, infection/PID, adenomyosis, etc.
5. Dysmenorrhea Management
Get a good history: (medical & menstrual)
Physical exam: to identify a cause
Pelvic exam: may defer if young, non-sexually active adolescents with mild
symptoms
Consider pelvic US: to look for adnexal masses, fibroids, other pelvic
pathology
If secondary, address underlying cause.
6. Dysmenorrhea Non-Pharm Management
HEAT: to lower abdomen = Oral Analgesics
EXERCISE: improves symptoms
7. Dysmenorrhea Pharm Management
NSAIDs: 80-86% efficacy
o Start at onset of menses for x 1-2+ days
o If no relief, consider starting 1-2+ days before
Combination Hormonal Contraceptives (CHC)
Consider BOTH, if no relief with NSAIDs
Intrauterine Contraceptive (IUC): Hormonal
o Mirena or Skyla (smaller) with Levonorgestrel
If NO relief, consider SECONDARY CAUSE
8. ABNORMAL UTERINE BLEEDING (AUB)
Comprehensive, focused history
Many causes: PALM-COEIN classification
Consider DIFFERENTIAL by AGE & HISTORY
Post-menopausal:
o Any bleeding beyond 12 months since LMP o Even "1 drop of blood" is concerning
o Must REFER to OBGYN to R/o cancer
9. Classification/Differential: PALM-COEIN
Structural
P
Polyps:
> 30 years
A
Adenomyosis:
> 30
L
Leiomyoma/Fibroids:
> 30
M
Malignancy/Hyperplasia:
> 40 (Obesity, DM, PCOS, > 50 yr)
Non Structural
C
Coagulopathy:
Any age
O
Ovulatory Dysfunction:
Any age
E
Endometrial Disorders:
Any age
I
Iatrogenic, Medications:
Any age
N
Not Classified
10. POLYCYSTIC OVARIAN SYNDROME (PCOS): ANDROGEN EXCESS
Common, complex GYN endocrinopathy
Affects 6-20% of women
S/S: oligomenorrhea, amenorrhea, AUB hyperandrogenism, (acne, hirsutism),
cystic ovaries, infertility, mood/mental health problems
Pathophysiology: Insulin resistance (50-70%)
Associated with Risks, Complications
Diagnosis: Rotterdam Criteria (2 of 3 criteria):
o Oligomenorrhea
o Hyperandrogenism o Cystic ovaries
11. (PCOS): Risks & Complications
Endometrial cancer
Infertility
Diabetes
Metabolic Syndrome
Obesity (independent risk factor)
Cardiovascular disease
Hyperlipidemia
12. PCOS Diagnostic Work-up & Differential: Individualize
Body weight, BMI (> 30), Waist (> 35 inches)
BP
Ultrasound: Ovaries/Uterus-hyperplasia > 10 mm
CBC, Lipids q 2y (Low HDL, High trigs/LDL), LFTs, TSH
Oral GTT (Most sensitive/specific)
Hgb-A1c: DM = > 6.4, At risk = ≥ 5.6-6.4!!!!
Total Testosterone: PCOS = > 60, Tumor > 150-200
o Free T: PCOS = 2-3%
Pregnancy test (hCG)
Prolactin 3-27 ng/ml, consider DHEA-S?
LH/FSH Ratio > 3, BUT may be normal in PCOS
17-hydroxyprogesterone (am, early follicular) < 200 ng/dl rules out NCAH =
Non-classical adrenal hyperplasia
13. PCOS Management: Contraception or Conception?
o Discuss fertility planning
» Fast tract fertility: DO NOT wait to age 35 yr
» Letrozole preferred (NOT Clomiphene)
o Problems:
» Infertility: 40% female associated w/ PCOS
» Spontaneous Abortion (SAB): 25-73% risk
» Gestational diabetes: 3 x increased risk
» Preeclampsia/Hypertension
14. PCOS Management: Life Style Approaches - For All
o Weight loss (> 5%)
Improves insulin sensitivity, acne, hirsutism, ovulation/return of fertility, menses, improves labs, reduces risk of Uterine CA, etc.!!!
o Exercise & Stress Reduction
15. Management: Not Desiring Pregnancy
o Combination Hormonal Contraceptives (CHC)
» New -> Low-Androgen progestins - SAFER:
Levonorgestrel (LNG), Norethindrone (NE),
Norgestimate (NGM)
» Helps androgen sx, prevents Uterine CA
o Insulin sensitizer (Metformin): NOT for ALL
» 30% reduction in IR
o Combination therapy: Metformin & CHCs
16. CERVICAL CANCER
o Caused by HR-HPV
» High-risk subtypes: 16, 18, 45, 31, 33, 52, 58, 35
» Cervical cancer is caused by HPV = STI
» Males AND females infected
» Ubiquitous exposure
» Most clear virus within 1 year
o For most women...
» HPV clears spontaneously w/in 8-24 months
especially if < 24 yrs old
» Cervical CA develops from "persistent HPV
infection" over many years
17. HPV Vaccination*
Give prior to onset of sexual activity "Coitarche" naïve vs non-naïve
Give routinely at 9-12 years for girls (up to 26 yrs.), & boys (21yrs.)
NEW: 9-14 y/o 2 doses 6 months apart
NEW: 9vGardasil (3 doses if ≥ 15 yr)
If series incomplete, finish w/ new vaccine
May benefit if > 26 years, but NO recommendations yet
18. 2019 Screening GuideLines*
https://www.acog.org/About-ACOG/ACOG-Departments/Annual-Womens-Health-Care/FOR-PATIENTS/Pt-Exams-and-Screening-Tests-Age-19-39-Years
o Ages 21-29 years:
» 1st Pap at age 21
» Repeat every 3 years
o Age 21-29 years:
» Pap test alone every 3 years
o Age > 30 years:
» Pap & HPV = Primary screening
» Repeat every 5 years (if both negative)
» Pap ONLY = every 3 years
o Age 65 years:
» MAY STOP (if negative history x 10 years)
* If Low Risk = NO hx of CIN2, CIN3, HIV+, immunocompromised, DES
19. 2019 Screening Guidelines: After Hysterectomy
o For Benign Disease: discontinue
o NOT BENIGN: 3 annual negative tests, then discontinue (ACS); ongoing
screening for 20 yrs (ACOG) even if ≥ 65 yrs old
o USPSTF recommends against screening for Cervical CA in women s/p Hysterectomy w/cervix removal & do NOT have a hx of a high-grade precancerous lesion (cervical intraepithelial neoplasia [CIN] grade 2 or 3) or Cervical CA.
20. Use of the Spatula
Used to collect cells from the EctoCervix
o Usually done 1st to minimize bleeding
o Plastic spatula for liquid-based samples
o Wooden or plastic for conventional
o Spatula: 1 full rotation
o Broom: 3-5 rotations Samples endo/ectocervix
21. Use of the CytoBrush
Used to collect cells from the endocervix
Insert into os
Rotate 1⁄4 - 1⁄2 turn
22. Atypical Squamous Cells (ASC): by Age
o ASC-US (undetermined significance): 21-24 years
» Repeat PAP at 12 months (no HPV or HPV+)
» If NEGATIVE = Routine screening
» If POSITIVE = Colposcopy
o ASC-US: > 24 years
» Reflex HPV, if POSITIVE = Colposcopy
o ASC-H: Colposcopy & Endocervical Sampling
23. Follow-up: Colposcopy Indications
o ASC-H: COLPO FOR ALL
o LSIL (low grade squamous intraepithelial lesion)
» If < 24 years - OBSERVE, REPEAT 1 year
» If > 24 years - COLPO
o HSIL (high grade squamous intraepithelial lesion)
» Mod or Severe dysplasia, CIN 2 or 3 & carcinoma in situ: COLPO FOR ALL
o Atypical glandular cells (AGC): Favor Neoplasia
» COLPO FOR ALL
24. VULVOVAGINITIS
o Bacterial vaginosis (BV): Most common
o Vulvovaginal candidiasis (VVC): 95% Candida Albicans
o Trichomoniasis: common in teens & older women
o Self-diagnosis: OFTEN inaccurate!
25. Vulvovaginitis Assessment:Normal:
-S/S-->Clear, White, odorless
-PH--> 4.0-4.6
-"whiff" test-negative
-vaginal microscopy-->negative
26. Vulvovaginitis Assessment: VV Candidiasis
-s/s-->itching, burning, dysuria
-PH-->4.0-4.6
-"Whiff" test-negative
-Vaginal microscopy-->buds & pseudohyphae
27. Vulvovaginitis Assessment: BV
-s/s--> malodorous discharge
-PH-->greater than 4.6
-"whiff" test-positive
-vaginal microscopy-->clue cells
28. Vulvovaginitis Assessment: trich
-s/s --> Malodorous discharge, dysuria
-PH-->5.0-6.0
-"whiff" test-+/- positive
-vaginal microscopy-->trich
29. Diagnostic Studies: Recurrent yeast infections
Screen for diabetes if suspected
Pregnancy test
HIV
Other tests as indicated
30. Management of yeast infections: Oral Agents
Fluconazole (Diflucan®) orally x1
o 72 hours duration
o Most cost effective = $4
o BUT delayed symptom relief x 24 hours! o Narrow spectrum coverage (C. albicans)
DELAY sexual intercourse until symptoms improve!
31. Management of yeast infections: Topical Agents
Butoconazole (Gynazole) Single Dose vaginally
o Bioadhesive, time-released, broad spectrum!!!!
Miconazole nitrate (Monistat®) vaginal suppository or cream
Clotrimazole (Gyne-Lotrimin 3, 7) cream OR
Terconazole (Terazol®) suppository or cream
DELAY sexual intercourse until symptoms improve!
32. ATROPHIC VAGINITIS
Post-menopausal women
Non-specific sign/symptoms: watery, yellow or white, malodorous vaginal
discharge
33. Clues: Atrophic Vaginitis
Genitourinary Syndrome of Menopause (GSM)
-symptoms
o Vaginal irritation or burning
o Dyspareunia
o Urinary tract symptoms
34. Clues: Atrophic Vaginitis
Genitourinary Syndrome of Menopause (GSM)
-exam
o Thinning of vaginal epithelium, loss of elasticity, loss of rugae
o Vaginal pH ≥ 5
35. Clues: Atrophic Vaginitis
Genitourinary Syndrome of Menopause (GSM)
-RX
Estrogen PV, Osphena PO, DHEA PV
36. Osteoporosis Risk Factors
Caucasian, Asian
Advanced age, previous fracture
Long-term glucocorticoid therapy
Low body weight (< 127 lbs.)
Cigarette Smoking
Excess alcohol intake
37. Osteoporosis Screening
DXA scan: dual x-ray absorptiometry
Screening NOT recommended pre-menopause unless risk factors present
38. Osteoporosis Management
Weight bearing exercise
Stop cigarette smoking, excess alcohol
Avoid corticosteroids, anticonvulsants when possible
Calcium: Daily intake of 1200 mg/day
Plus:
o If Vitamin D deficient: replace with Vitamin D3
o Vitamin D3: 1000-2000 IU/day varies according to reference o Preferred calcium source: FOOD!!!
39. Oral Bisphosphonates: Considered first line for most patients
Inhibits bone resorption: Osteoclasts remains active in bone for weeks, months, maybe years!!!
Increase bone mass: Osteoblasts
Reduce risk of fracture:
o Alendronate (Fosamax®) weekly
o Risedronate (Actonel®) weekly
o Ibandronate (Boniva®) monthly (does NOT reduce hip Fx risk)
40. Breast Masses
Most common: Fibroadenomas, Cysts
Benign complaints: CAN mimic breast cancer
41. Breast masses: Diagnostic Studies
US:
o For any female/male < 30 years, with focal mass, or symptom o First line in pregnancy, or < 30 years
o To assess mass identified on mammography
Mammography:
o For any female/male > 30 years with a breast complaint
Value of Breast Ultrasound???
Differentiates fluid-filled cyst from solid mass!
42. BREAST CANCER Risk Factors
Gender & age: especially > 65 years
Genetic predisposition: BRCA 1, 2 genetic mutations
Family history
Reproductive history (low parity)
Estrogen exposure:
o Early menarche < 12 years
o Late menopause > 55 years o Estrogen medications
43. Breast Cancer: Screening: Average Risk
o Mammogram:
-> ACS: Start 45yrs, (may begin 40-44); then yearly
-> Age 55+ every 2 years*
-> Yearly screening may be offered
-> USPSTF: Start age 50, then every 2 years
o Clinical Breast Exam & Self-breast Exam:
-> ACS: Not recmnd if life expectancy <10 yrs
44. Contraception: Overview
Long acting reversible contraceptives (LARC): o Copper IUC (Paragard),
o LNG IUC (Mirena, Skyla)
o Great option, all ages
o Few contraindications
Combination Hormonal Contraceptives (CHC):
o Pills, Patch, Ring: contain estrogen, progestin
Contraception: Initial Selection
45. Progestin only: Good for Higher risk women
Oral Contraceptives: Initial Selection
Estrogen: cycle control primarily
o Heavy periods: Higher estrogen 30-35 mcg
o "Normal" menses: Lower estrogen 20-25 mcg
Progestin: contraceptive effects primarily
o Levonorgestrel: Safe, less BTB*
o Norethindrone: Safe, more BTB
o Drospirenone: Avoid if unknown family history, family history of clots, or
coagulopathies
46. Headache Red flags in History:
o Sudden onset in seconds or mins (thunderclap HA): SAH
o "First or worst" HA: Hemorrhage, infection
o Focal neuro symptoms: Mass, AVM
o Fever: Infection
o Change in personality, mental status, LOC
47. Headache Red Flags on Exam
o Age (new onset > 35 or 40 years old)
o Neck stiffness
o Neuro deficits
o Papilledema
48. Papilledema
Swelling of the optic disc due to increased ICP
Almost always bilateral
49. Headache Notable Fundoscopic Findings
Absent red reflex: cataract
Swelling of optic disc (papilledema): increased intracranial pressure (ICP)
Abnormal cup disc ratio (>0.5): glaucoma
Absent venous pulsations: papilledema
Blood in center of disc: SAH
50. When to Image a Patient with Headache:
"Red Flag" headache
Change in pattern, frequency or severity of HA
Worsening of HA despite therapy
Unexplained neuro symptoms (abnormal exam)
Onset of HA with exertion, cough, intercourse
New onset > 50 years
HA associated with fever, stiff neck, papilledema, cognitive impairment, or
personality change
51. Diagnosis - Migraine Without aura
Headache lasts 4-72 hours
Has 2 of these characteristics: unilateral, pulsating quality, mod to severe
intensity, aggravated by routine activity
During headache: N & /or V, photophobia OR phonophobia (at least 1)
5 or more attacks have occurred with these characteristics
No other reason for the headache's occurrence
52. Diagnosis - Migraine With aura
2 attacks of migraine with aura
Visual, sensory, motor, brainstem, retinal, or speech changes fully reversible
Develops over 5-20 minutes; headache develops within 60 minutes
53. Headache Common Triggers
Stress
Menses
Skipping meals (fasting)
Changes in weather
Sleep disturbances
Odors
Bright light, EtOH, Smoking
Foods
54. Migraine Health Promotion
Prophylactic treatment for > 2 per month
Avoid triggers
Early treatment & diagnosis
Limit use of triptans (overuse leads to rebound headaches unresponsive to
triptans)
55. Migraine Headache Location
Unilateral 60-70%; bi-frontal or global 30%
56. Migraine Headache Characteristics
Crescendo
57. Migraine Headache Patient Appearance
Patient desires a cool, quiet, dark room
58. Migraine headache Duration
4-72 hours
59. Migraine headache Associated Symptoms
N, V, photophobia, ? aura
60. Tension Headache Location
Bilateral
61. Tension Headache Characteristics
Pressure, tightness bandlike, waxes &nwanes
62. Tension headache Patient Appearance
May continue day's activities or not
63. Tension headache duration
varies
64. Tension headaches Associated Symptoms
None
65. Cluster Headache location
Always unilateral; begins around temple or eye
66. Cluster headache characteristic
Pain peaks within minutes; excruciating, explosive
67. Cluster headache patient appearance
varies
68. Cluster headache duration
30-90 minutes usually (up to 180 minutes)
69. Cluster headache Associated Symptoms
Eye becomes red, tears, rhinorrhea, EtOH can trigger
70. UTI
WBCs, Pyuria = Infection
Most reliable indicator of infection
95% sensitive
> 10 WBC per HPF*/spun sample
USUALLY indicates UTI
71. Paget's disease of the breast (Ductal carcinoma in Situ)
-common in older females
-present with chronic scaly red-colored rash resembling eczema on the nipple that does not heal
-lesion slowly enlarges & evolves to include cresting, ulceration &/or bleeding on the nipple
72. Follicular phase
-AKA proliferative phase
-days 1-14
-estrogen is predominant hormone
-stimulates development/growth of endometrial lining
-FSH stimulates follicles into producing estrogen
73. Midcycle: ovulatory phase
-day 14
-LH is secreted by anterior pituitary gland & induces ovulation of dominant follicle
74. Luteal phase
-days 14-28
-progesterone is predominant hormone
-produced by corpus luteum
-helps stabilize endometrial lining [Show Less]