Test Bank for - Springer Publishing



Case Studies/Education Handouts/Appendices forGuidelines for nurse practitioners in gynecologic settings12th EditionHeidi Collins Fantasia, PhD, RN, WHNP-BCAllyssa L. Harris, PhD, RN, WHNP-BCHolly B. Fontenot, PhD, RN, WHNP-BC, FAAN20383502540Copyright ? 2021 Springer Publishing Company, LLCAll rights reserved.This work is protected by U.S. copyright laws and is provided solely for the use of instructors in teaching their courses and as an aid for student learning. No part of this publication may be sold, reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer Publishing Company, LLC.Springer Publishing Company, LLC11 West 42nd StreetNew York, NY 10036ISBN: 978-0-8261-8918-9The author and the publisher of this Work have made every effort to use sources believed to be reliable to provide information that is accurate and compatible with the standards generally accepted at the time of publication. The author and publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance on, the information contained in this book. The publisher has no responsibility for the persistence or accuracy of URLs for external or third-party Internet websites referred to in this publication and does not guarantee that any content on such websites is, or will remain, accurate or appropriate.ContentsCase Studies TOC \o "1-3" \h \z \t "H1,1,CN,1,A head_Verso,2,A head_Recto,1" Case Study 1: Contraception (Chapter 10) ? PAGEREF _Toc33104329 \h 2Case Study 2: Preconception Care (Chapter 11) ? PAGEREF _Toc33104330 \h 3Case Study 3: Breast Conditions (Chapter 12) ? PAGEREF _Toc33104331 \h 4Case Study 4: HPV and Cervical Abnormalities (Chapter 13) ? PAGEREF _Toc33104332 \h 5Case Study 5: Genitourinary Tract Conditions (Chapter 14) ? PAGEREF _Toc33104333 \h 6Case Study 6: Infertility (Chapter 15) ? PAGEREF _Toc33104334 \h 7Case Study 7: Pelvic Floor Dysfunction (Chapter 16) ? PAGEREF _Toc33104335 \h 8Case Study 8: Medical Abortion (Chapter 17) ? PAGEREF _Toc33104336 \h 9Case Study 9: Menstrual Disorders (Chapter 18) ? PAGEREF _Toc33104337 \h 10Case Study 10: Gynecologic Conditions (Chapter 19) ? PAGEREF _Toc33104338 \h 11Case Study 11: Peri- and Postmenopause (Chapter 20) ? PAGEREF _Toc33104339 \h 12Case Study 12: Polycystic Ovary Syndrome (Chapter 21) ? PAGEREF _Toc33104340 \h 13Case Study 13: Sexual Dysfunction (Chapter 22) ? PAGEREF _Toc33104341 \h 14Case Study 14: Sexually Transmitted Infections (Chapter 23) ? PAGEREF _Toc33104342 \h 15Case Study 15: Vaginitis and Vaginosis (Chapter 24) ? PAGEREF _Toc33104343 \h 16"For Your Information”: Education Templates for Electronic RecordsBacterial Vaginosis ? PAGEREF _Toc33104345 \h 18Candidiasis (Monilia) Yeast Infection ? PAGEREF _Toc33104347 \h 19Care After Abortion ? PAGEREF _Toc33104349 \h 20Cervical Cap (FemCap) ? PAGEREF _Toc33104351 \h 21Chlamydia trachomatis ? PAGEREF _Toc33104353 \h 22Contraceptive Implant ? PAGEREF _Toc33104355 \h 23Contraceptive Patch ? PAGEREF _Toc33104357 \h 24Contraceptive Vaginal Ring ? PAGEREF _Toc33104359 \h 26Cystitis (UTI) ? PAGEREF _Toc33104361 \h 27Diaphragm ? PAGEREF _Toc33104363 \h 28Genital Herpes Simplex ? PAGEREF _Toc33104365 \h 29Genital Warts (Condylomata Acuminata) ? PAGEREF _Toc33104367 \h 31Gonorrhea ? PAGEREF _Toc33104369 \h 32Hormone Therapy ? PAGEREF _Toc33104371 \h 33Intrauterine Device ? PAGEREF _Toc33104373 \h 34Lice (Pediculosis) ? PAGEREF _Toc33104375 \h 36Osteoporosis ? PAGEREF _Toc33104377 \h 38Polycystic Ovary Syndrome ? PAGEREF _Toc33104379 \h 39Preconception Care ? PAGEREF _Toc33104381 \h 40Premenstrual Syndrome ? PAGEREF _Toc33104383 \h 41Scabies ? PAGEREF _Toc33104385 \h 42Smoking Cessation ? PAGEREF _Toc33104387 \h 44Stress or Urge Urinary Incontinence ? PAGEREF _Toc33104389 \h 45Syphilis ? PAGEREF _Toc33104391 \h 46Trichomoniasis ? PAGEREF _Toc33104393 \h 48Vaginal Contraceptive Sponge ? PAGEREF _Toc33104395 \h 49AppendicesA: Abuse Assessment Screen ? PAGEREF _Toc33104396 \h 50B: Danger Assessment: Women With Male or Female Partners ? PAGEREF _Toc33104397 \h 52C: HIV Risk Assessment ? PAGEREF _Toc33104398 \h 56HIV Testing ? PAGEREF _Toc33104399 \h 56HIV Prevention ? PAGEREF _Toc33104400 \h 56D: Women and Heart Disease: Risk Factor Assessment ? PAGEREF _Toc33104401 \h 58E: Endometrial Biopsy ? PAGEREF _Toc33104402 \h 60F: Differential Diagnosis of Vaginitis and Vaginosis ? PAGEREF _Toc33104403 \h 62G: Body Mass Conversion Table ? PAGEREF _Toc33104404 \h 63CASE STUDIESContraception?2Preconception Care?3Breast Conditions?4HPV and Cervical Abnormalities?5Genitourinary Tract Conditions?6Infertility?7Pelvic Floor Dysfunction?8Medical Abortion?9Menstrual Disorders?10Gynecologic Conditions?11Peri- and Postmenopause?12Polycystic Ovary Syndrome?13Sexual Dysfunction?14Sexually Transmitted Infections?15Vaginitis and Vaginosis?16Case Study 1: Contraception (Chapter 10)A 41-year-old woman presents for contraceptive counseling. She has been in a new sexual relationship with a male partner for the past 3 months. She is using condoms for birth control but neither she nor her partner is happy with this method. Her ex-husband had a vasectomy and she has not thought about birth control “for years.”Her past medical history is benign, and her past surgical history includes a primary cesarean section (C/S) for breech and a repeat, elective C/S. Her blood pressure is 122/78 and her body mass index is 27. Family history is notable for hypertension for her parents, both of whom are still living. Her menses are regular, occurring every 26 to 28 days and her last menstrual period was 8 days ago. She has two to three alcoholic drinks per day on weekends only and smokes in social situations, often when with friends. She estimates that she smokes less than one pack of cigarettes per week. She denies recreational drug use. She just had a complete physical exam and Pap smear with her primary care provider and states that all testing was normal. She is seeing you only to establish contraception.How would you approach contraceptive counseling?This woman is over the age of 35 and smokes <15 cigarettes per day, which equates to a level 3 recommendation for estrogen-containing combined hormonal contraception according to the U.S. Medical Eligibility Criteria for Contraceptive Use. Level 3 indicates that theoretical or proven risks usually outweigh the benefits. In this situation, her age, tobacco use, and estrogen would place her at a higher risk for a venous thrombotic event (VTE). Therefore, estrogen-containing contraception should be avoided as there are other safer methods available. As with all women who smoke, she should be assessed for readiness to quit and offered options if she wants to stop using tobacco.All progestin-only methods, including progestin-only pills (POPs), implant, injection, and intrauterine devices (IUDs) are appropriate, as is the copper IUD and all barrier methods. Your contraceptive counseling should focus on these methods and provide an explanation about the risk of VTE with estrogen and smoking. Any method she chooses could be started today. POPs, injection, implant, and hormonal and nonhormonal IUDs would require a backup (barrier) method of contraception for the next 7 days because she is not within the first week of her menstrual cycle. Additionally, it is appropriate to have a discussion about permanent methods. The Essure system is no longer available in the United States so the only permanent female method is laparoscopic tubal ligation.Case Study 2: Preconception Care (Chapter 11)A 26-year-old woman presents for an annual gynecologic exam and IUD check. She had a 52 mg progestin IUD placed last year and other than some mild, irregular bleeding and spotting, she has no complaints and wishes to continue with this method. She has started a new job and is in a committed relationship with a partner of 6 months. She has no desire for a pregnancy in the immediate future.In addition to routine gynecologic care, what elements of preconception care would you include in today’s visit?Promotion of preconception health ideally begins far before pregnancy occurs. Healthy habits that are well-established are more likely to be continued. Because this woman is not planning a pregnancy within the next year, counseling can focus on general health habits such as diet, exercise, weight management, alcohol and drug use, avoidance of tobacco, use of sunscreen, seat belts, and moderate caffeine use. Chronic medical or mental health conditions should be reviewed, as well as any medications. Any changes in family history should be noted. Vaccination status should be reviewed and updated as necessary and follow the guidelines from the Centers for Disease Control and Prevention (CDC), which are updated annually. Vaccines that are contraindicated during pregnancy should be given and this woman can receive the human papillomavirus (HPV) vaccine if she has not been previously vaccinated. Use of multivitamins with folic acid by individuals without nutritional deficiencies has not been shown to improve health but can be used if there is a desire to do so and are important during the 3 months prior to conception. The 52 mg progestin IUDs can be used for 5 to 7 years. As a pregnancy is not imminent, no specific preconception laboratory work is necessary, and a detailed genetic history (beyond family history) is not warranted, although women can be referred for genetic counseling at any time if they express concerns about genetic conditions.Case Study 3: Breast Conditions (Chapter 12)A 25-year-old woman presents for evaluation of right-sided breast pain. She reports the onset suddenly 7 days ago. She has never been pregnant, her menses occur monthly, and she is using combined oral contraceptive pills as her method of contraception. She denies significant medical and surgical history, no change in weight, and has no first degree or family relatives with breast cancer, either maternally or paternally. Her Pap smear 2 years ago was normal, and she is sexually active with one male partner. Her last menstrual period was 3 weeks ago and today is day 22 of her cycle. She denies trauma to the chest area, has no nipple piercings, and no significant breast stimulation during sexual activity. She does not practice monthly breast exams and her last clinical breast exam was 2 years ago. She drinks socially approximately 2 alcoholic beverages per week and does not smoke or use illicit substances.What would this visit involve?A clinical breast exam is performed in all three positions and the breasts are symmetrical bilaterally, no dimpling or retraction, redness, skin rashes/lesions, and no nipple retractions are present. No nodules or masses are noted bilaterally or in axilla, and there is no lymphadenopathy. Based on exam the clinical findings support a diagnosis of mastalgia. The discomfort could be related to the menstrual cycle, her hormonal contraception, or an injury that she does not recall. Given her young age and negative family history, malignancy is highly unlikely.The plan of care at this time is to have her monitor pain in relation to menstrual cycle for next 3 months, noting any times the pain seems better or worse and any factors that exacerbate or relieve the pain. A supportive bra should be encouraged, especially during exercise and she can sleep in a support (sports) bra if this decreases her discomfort. Ibuprofen or acetaminophen can be trialed as needed for pain relief. Consider dietary changes that reduce caffeine and salt. Offer education regarding breast self-exam, breast awareness, and provide reassurance that the pain is most likely not related to a pathologic process. She should be reevaluated in 3 months.Case Study 4: HPV and Cervical Abnormalities (Chapter 13)A 21-year-old woman presents for an annual gynecologic examination. She does not have a sexual partner at this time, has never been pregnant, and has no complaints. She is using the subdermal implant for contraception, which was placed 2 years ago.Her past medical history is benign; she has never had surgery and has never had a sexually transmitted infection. She has had seven lifetime sexual partners, both male and female. She states her vaccines are current but denies ever having the HPV vaccine. Her BMI is 23, and her vital signs are normal. She has not had her menses or any vaginal bleeding for 1 year. She drinks 6 to 12 alcoholic drinks per week, smokes “occasionally” on weekends, and does not use drugs.What would today’s annual exam entail?Based on her age, this woman is due for her first cervical cancer screening. Despite not having any current sexual partners, it would still be important to provide annual screening for gonorrhea and chlamydia that is recommended by the CDC for all women younger than age 25. Assess her happiness with her contraceptive method. Recommend starting the HPV vaccine three-dose series and provide educational material explaining the importance of this cancer prevention vaccine. Because she has passed her 15th birthday, she will need three doses of the HPV vaccine. Consider any other needs related to primary care. Counsel on smoking cessation and risks related to cancer and smoking. Assess alcohol use further, assess for binge drinking, and counsel on risks associated with binge drinking if necessary. Assess pattern of alcohol use in relation to sexual activity and counsel on related behavioral risks. Screening for intimate partner violence (IPV) is important, even in the absence of a current relationship. Return to the office in 2 months for second dose of HPV vaccine, even if her Pap smear result is abnormal. History of a previous or current HPV infection is not a contraindication to initiating or continuing the HPV vaccine series. Follow up on cervical cancer screening per results and American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines.Case Study 5: Genitourinary Tract Conditions (Chapter 14)A 25-year-old woman presents for care and reports a 2-day history of burning with urination, urinary frequency, and feeling as though she is not emptying her bladder completely. She is sexually active with the same male partner for the past 4 months and is using a progesterone IUD for contraception. Her past medical and surgical histories are negative, and she has no known drug allergies (NKDA). She denies fever, chills, vaginal discharge, concerns about the IUD, or previous urinary infections or problems.What would you do for her during today’s visit?She should leave a urine sample for dipstick and culture. Her vital signs are normal, and she is afebrile. Upon exam, she has no costovertebral angle tenderness (CVAT), but mild suprapubic tenderness is present with no evidence of bladder distention. She is declining a pelvic exam. A dipstick of her urine is positive for nitrates, leukocyte esterase, and trace blood.A presumptive diagnosis of acute cystitis can be made based on the woman’s history, exam, and urine dipstick results. Because she has a newer partner and symptoms of a urinary tract infection can mimic some STIs, nucleic acid amplification testing (NAAT) for gonorrhea and chlamydia should be performed using the urine sample provided. You do not need to wait for urine culture results and can begin empiric treatment today. This woman has NKDA. An appropriate first-line antibiotic choice for an uncomplicated urinary tract infection is nitrofurantoin 100 mg orally twice daily for 5 to 7 days. Phenazopyridine hydrochloride 200 mg orally three times per day for 1 to 2 days can be added to decrease bladder discomfort. Other general measures for bladder health include voiding after intercourse, avoiding contamination from the rectal area, and increasing fluid intake to six to eight glasses of water per day. No follow-up is necessary unless her symptoms do not resolve or worsen.Case Study 6: Infertility (Chapter 15)You are seeing a 33-year-old woman who wants to discuss pregnancy planning. She and her 40-year-old husband have been attempting pregnancy for the past 7 months and she is concerned about her fertility. She and her husband both have no significant past medical or surgical history and she has never been pregnant before. She is a third-grade public school teacher and her husband works as an accountant. She reports regular cycles of 30 days and mild dysmenorrhea that responds well to ibuprofen. For the past 10 years, she was using oral contraceptive pills for contraception but stopped them when she began attempting conception 7 months ago. She appears anxious and wants to know what to do next.How would approach this visit?Because this woman is <age 35 and has been attempting pregnancy for <1 year, a formal diagnosis of infertility cannot be established based upon her history. But she made an appointment to specifically talk about pregnancy, so it is important to not dismiss her concerns. Because she is exposed to children in her job, an immunization history is important. If she needs immunizations that contain live viruses such as rubella and varicella, those should be given prior to pregnancy. After a complete history, you should also review coital frequency and timing of intercourse during her menstrual cycle. Laboratory testing for genetic carrier screening and prolactin, thyroid-stimulating hormone (TSH), anti-Mullerian hormone, and STIs can be completed. Follicle-stimulating hormone (FSH) and estradiol should be evaluated on day 2 of the menstrual cycle. If all laboratory values are normal, she should have a hysterosalpingogram during the follicular phase of her menstrual cycle to assess for tubal patency and commercially available ovulatory predictor kits can used to determine if ovulation is occurring. Based on these results and her husband’s testing, a referral to a reproductive endocrinologist is appropriate to pursue assisted reproductive technology.Case Study 7: Pelvic Floor Dysfunction (Chapter 16)A 48-year-old woman is seeing you today because she is concerned about urinary leakage. She reports increasing episodes of urinary incontinence when coughing and sneezing and occasionally with exercise. She denies fecal incontinence or urinary leakage with intercourse, while sleeping, or during activities that do not increase intra-abdominal pressure. She has no past surgical history. Her medical history is significant for mild dyslipidemia for which she takes 10 mg of atorvastatin daily. She has two children aged 18 and 15 who were both born vaginally. Her method of contraception is her husband’s vasectomy. She reports some mild vasomotor symptoms, irregular menses, and occasional vaginal dryness. Her BMI is 29. LMP was 7 weeks ago.What would today’s visit entail?In addition to a complete history, a pelvic exam should be performed to assess vaginal tone, presence of cystocele/rectocele, atrophy, and organ prolapse. Testing for STIs, vaginitis, and vaginosis can be done if warranted based on history and exam. Urine culture is prudent to exclude infection as a cause of incontinence. A bladder diary can be considered if the woman is unsure of timing and amount of leakage, but this is not necessary prior to suggesting treatment.Based on history and exam, a probable diagnosis of stress urinary incontinence can be made. Treatment can include avoiding bladder irritants such as coffee, caffeine, and alcohol. Weight loss can decrease overall abdominal pressure and stress on pelvic floor muscles. If vaginal atrophy is present, use of topical vaginal estrogen cream can be considered. Pelvic floor muscle exercises will improve pelvic tone and a referral can be given for pelvic floor physical therapy. A discussion of all options, including lifestyle changes, physical therapy, and surgical treatment should occur and she can choose the treatment that best addresses her symptoms and needs.Case Study 8: Medical Abortion (Chapter 17)A 19-year-old woman presents to you requesting termination of her pregnancy. She reports that her LMP was 6 weeks ago that she has had three positive home pregnancy tests. She has no significant past medical and surgical history but reports having had chlamydia 2 years ago, which was treated with azithromycin. Her partner was treated at that time also. She uses male condoms for contraception but had a condom failure since her last period. She is currently in an intimate sexual relationship with one male partner and has had three lifetime sexual partners. She is interested in medical abortion.What is your evaluation and considerations for care?In-office urine pregnancy testing is indicated to confirm pregnancy. Options counseling should be conducted to review and confirm pregnancy termination decision-making, including discussion of support of partner/family. Upon confirmation of termination decision-making, she should be educated on the types of termination available (medical or surgical with aspiration/vacuum), what the procedures entail, and risks/benefits. Written information about the procedure and written consent should be obtained as well as distribution of written information/instructions on the medications used in the termination. The choice of medical termination requires an ultrasound to confirm pregnancy dates. Laboratory testing should include urine human chorionic gonadotropin (hCG), blood type and Rh, and hemoglobin and hematocrit. Due to a previous history of chlamydia, testing for chlamydia and gonorrhea is appropriate as well as HIV if she has never been tested. RhoGAM is indicated for all women who are Rh negative.What to expect during the termination should be reviewed, including amount of bleeding (heavier than a menstrual period), passing of products of conception and possible gestational sac, how to manage discomfort, and information on when to call and/or go to the ED if necessary. Mifepristone 200 mg orally is distributed to the woman and taken in the presence of the clinician. The woman is instructed to place misoprostol 800 mcg buccally in 24 to 48 hours; written instructions for medication timing and use are distributed at this time. She should return for a follow-up ultrasound 2 weeks postprocedure. She can continue using condoms for contraception or change to another method. An IUD or subdermal implant can be placed at the follow-up visit.Case Study 9: Menstrual Disorders (Chapter 18)You are seeing a 25-year-old woman who reports irregular menstrual periods with amenorrhea lasting for as long as 4 months. This pattern has occurred since menarche at age 14. Her LMP was 3 months ago. She began taking combined oral contraceptive pills when she was 17 to regulate her cycles and she reports this worked well. She stopped taking the pills 1 year ago “to give her body a break” but the irregular menses resumed shortly thereafter. She has no past medical or surgical history, is taking no medication, and her BMI is 22. She has not been sexually active for the last 8 months. She is frustrated that her irregular periods are an ongoing issue and is asking what her options are.How would you proceed with the visit?Amenorrhea can have multiple causes. Her physical exam should include skin, thyroid, breasts, abdomen, and bimanual exam for uterine and adnexal size and shape. Laboratory assessment should include hCG, prolactin, and TSH. If these values are normal and pregnancy is excluded, a progesterone challenge can be administered such as medroxyprogesterone acetate (MPA) 10 mg orally each day for 10 days. If a withdrawal bleed occurs after the MPA is stopped, this confirms adequate endogenous estrogen, a responsive endometrium, and an unobstructed outflow tract.There are options to regulate menstrual bleeding. Prolonged amenorrhea should be avoided to reduce the risk of endometrial hyperplasia. This woman previously took combined oral contraceptive pills that worked well. The contraceptive patch and vaginal ring could also be used. Cyclic MPA 10 mg orally for 10 days each month would induce bleeding but does not provide contraception. Periodic reevaluation is necessary as monthly menstrual cycles can resume after treatment. If irregular menses and periods of amenorrhea continue, pregnancy may be more difficult and require induction of ovulation.Case Study 10: Gynecologic Conditions (Chapter 19)A 23-year-old woman presents for an annual exam. She is sexually active with the same male partner for the past 2 years. They are using condoms and withdrawal for contraception. She has no complaints other than occasional right lower quadrant (RLQ) abdominal pain. She describes the pain as mostly dull, but sometimes sharp. Review of systems is negative except for the intermittent RLQ pain. She has no past medical or surgical history and her family history is noncontributory. Her LMP was 3 weeks ago and her cycles are regular, occurring approximately every 30 days. Vital signs and BMI are all normal. Bimanual exam reveals a slightly full and tender right adnexa. The remainder of the physical and pelvic exam is normal.How would you proceed?Given the woman’s young age, a benign ovarian condition is likely. Because she is not using contraception that prevents ovulation, a functional ovarian cyst is highly probable. Although she reports her last menses as 3 weeks ago, a urine pregnancy test in the office is an efficient and inexpensive mechanism to help rule out a more serious condition such as a missed ectopic pregnancy. Without fever, chills, and associated signs on physical exam there is a low level of suspicion for an abscessed appendix, but assessing rebound tenderness, Rovsing, psoas, and obturator signs is prudent. Obtaining testing for gonorrhea and chlamydia could be considered if there was a high suspicion of an abscess. Although a urinary tract infection is unlikely, a urine dipstick in the office can help rule this out. A transvaginal ultrasound will assist with distinguishing between a simple ovarian cyst and other conditions such as an endometrioma, dermoid, ovarian torsion, tubo-ovarian abscess, or suspected malignancy. MRI or CT is not appropriate as a first-line diagnostic test.The ultrasound report reveals a 3-cm, fluid filled mass on the right ovary, consistent with a functional cyst. The left ovary and uterus are unremarkable. Options include expectant management with a follow-up ultrasound in 3 to 6 months or medical management with combined hormonal contraception that inhibits ovulation (pills, patch, or ring). Some progestin-only contraception methods do not fully suppress ovulation and can contribute to cyst development. Regardless of option, the woman should be instructed to report worsening of symptoms, especially sudden, sharp abdominal pain that can accompany cyst rupture or ovarian torsion. Follow-up in the office is appropriate in 3 to 6 months.Case Study 11: Peri- and Postmenopause (Chapter 20)A 55-year-old Caucasian woman presents for her annual exam. She lives in Maine with her husband of 30 years and reports being in good health. Her only significant event over the past year was a fall and fracture of her right hip resulting in hip replacement surgery 6 months ago. She has completed her physical therapy. Her past medical history includes postmenopausal status (LMP age 51), dyslipidemia, and hypertension. She had two vaginal births in 1994 and 1996. She has no significant gynecologic history other than childbirth. She is reporting occasional vasomotor symptoms of menopause but reports they do not significantly interfere with her life. Her medications include atorvastatin 20 mg orally daily and hydrochlorothiazide 12.5 mg orally daily. She is a social drinker (approximately two to four drinks per week) and smokes 10 cigarettes daily (1/2 pack per day). Today her vital signs are blood pressure 138/88, pulse 84, respiration rate 20, and BMI 30.In addition to her annual well-woman gynecologic visit, what are considerations for your plan of care?Assessment of risk for other fractures is important. The Fracture Risk Assessment Tool (FRAX) can estimate her 10-year risk for a future fracture. This can be used to determine if she would benefit from osteoporosis pharmacotherapy. Other important information to obtain includes whether she has a family history of fractures, her dietary habits (vitamin deficiency assessment, dietary calcium intake), exercise habits (type, frequency), and circumstances of the fall that led to the fracture. She lives in the northeast that has longer winters and more limited opportunities for sun exposure and natural vitamin D synthesis.Although she is 10 years younger than the recommended age for bone mineral density (BMD) assessment, she has risk factors of a previous fracture and smoking. She would benefit from a duel energy x-ray absorptiometry (DEXA) scan. Assessment 25-hydoxyvitamin D is prudent due to her history of smoking and living in a northern climate. Combined with the results from the FRAX tool, a plan of care can be formulated which can include pharmacotherapy, dietary changes, weight-bearing exercise, and strength training. She should be assessed for readiness to quit smoking and offered options to help quit if she is interested. Her BMI is somewhat protective for osteoporosis, but she has dyslipidemia and hypertension and should be encouraged to maintain a normal BMI to decrease cardiovascular risks.Case Study 12: Polycystic Ovary Syndrome (Chapter 21)A 22-year-old woman is seeing you to discuss her menstrual cycle. She reports heavy bleeding and occasionally missing a period. When she does get her period the bleeding sometimes lasts for 10 days. She is not currently sexually active but uses condoms for contraception when she has a partner. She also reports acne and hair on her chin and neck, which is bothersome. Her BMI is 34. She reports gaining weight steadily as an adolescent and being unable to lose weight despite multiple attempts. What would you do for this woman during today’s visit?The woman’s history is suggestive of polycystic ovary syndrome (PCOS) so the exam should include systems that would be affected by PCOS. A waist-to-hip ratio should be measured to assess abdominal adiposity, and the skin examined for excessive oiliness, extent of acne, excess hair growth, and acanthosis nigricans. A breast exam will reveal whether galactorrhea is present. Ovaries may not be enlarged with PCOS, but a careful bimanual exam is necessary. Initial laboratory work should include FSH, luteinizing hormone (LH), hCG, and TSH. Insulin resistance is common with PCOS so consider a fasting glucose, HgbA1C, or a 2-hour oral glucose tolerance test based on history. Other initial labs can include 17-hydroxyprogesterone (17-OHP), free testosterone, and a lipid panel. However, PCOS can exist in the presence of many normal lab tests and these alone should not be used to establish a diagnosis. A transvaginal ultrasound is the imaging modality of choice to assess ovarian morphology but enlarged, cystic ovaries are not always present with PCOS.First-line treatment is weight loss that will decrease androgen levels, however weight loss is often challenging for women who have PCOS. Dietary and activity modifications can be suggested, and a nutrition consult may be considered if the woman is interested. Some women may achieve desired weight loss with the addition of a pharmacologic agent such as orlistat. Low-androgenic oral contraceptive pills will regulate the menstrual cycle, protect the endometrium from hyperplasia, and most likely improve acne. An antiandrogen such as spironolactone can be added if hirsutism and acne are not well controlled. Oral insulin-sensitizing agents such as metformin should not be used as part of initial treatment but may be more effective for women seeking pregnancy.Case Study 13: Sexual Dysfunction (Chapter 22)Your patient is a 48-year-old perimenopausal woman who presents for her annual exam. Her past medical history and surgical history are notable for hypertension for which she takes hydrochlorothiazide (HCTZ) 25 mg orally each morning. She takes no other medications. Her exercise includes daily walking of 2 miles. She had two previous vaginal deliveries and two live births. Her menses are regular each month and her menstrual pattern is unchanged. Her last Pap and HPV were 2 years ago and were negative. Upon review of systems, she reports that she has concerns about her decreasing ability to achieve an orgasm. She has been married to the same man for the past 25 years and this change in her sexual response is new within the past year.What would your plan of care entail?You should conduct a complete sexual history and use a tool such as the Female Sexual Function Index (FSFI) to assess sexual functioning at present. This can be used again if treatment is initiated to measure any change in functioning. It is important to assess whether orgasm is achieved, delayed, or diminished and whether this has occurred at any other time in her life (e.g., after pregnancy). It is important to ask about general interest in sex, any fantasies, and level of arousal/excitement and how long it takes to achieve arousal, if it occurs at all. Self-esteem should also be assessed. You need to inquire about the relationship with her intimate partner (spouse) and whether she or he have any other partners. It is necessary to ascertain her level of satisfaction with partner/relationship, level of partner awareness or support of current problem, and level of impact the change in her sexual response is having on their intimate relationship and sexual activity. Other factors such as the role of culture/race/ethnicity/religion and life stressors should be explored.A comprehensive physical exam including a vaginal and pelvic exam is warranted. Assess for presence of vaginitis or vaginosis with a wet prep or other testing. Gonorrhea and chlamydia testing can be done based on history and exam. Consider laboratory testing including complete blood count (CBC), HbA1C, metabolic panel, and thyroid tests if you are concerned about an underlying medical condition that is contributing to her decreased sexual response. Hydrochlorothiazide does not typically affect libido but if onset of the sexual dysfunction correlates with beginning the medication a change can be considered.Final management plan will include treatment of any conditions or infections if present. Consider the impact of perimenopausal symptoms (if present), including vulvovaginal atrophy, and prescribe vaginal or systemic hormone therapy if appropriate. She should be offered a referral for cognitive behavioral therapy (CBT), including sex therapy if she is interested. Other behavioral modalities include guided imagery, the use of toys, erotica (movies, books), and sensory therapy. Pharmacologic treatment can be offered although most women have a limited response. Because she has hypertension and bremelanotide injection can raise BP, flibanserin may be a more appropriate initial treatment. Cost can be prohibitive and financial implications explored prior to treatment.Case Study 14: Sexually Transmitted Infections (Chapter 23)A 22-year-old woman is seeing you today because of a painful rash in her genital area and discomfort with urination. She reports shaving her pubic hair and spending a lot of time at the beach in a bathing suit. She thought the rash was from heat, friction, and shaving. She noticed the symptoms 3 to 4 days ago and thought they would resolve but made an appointment because she was not feeling better. She denies having these symptoms before, has no medical or surgical history, and is not taking any medication. She is also complaining of feeling tired and achy but contributes that to a variable work schedule. She is sexually active with two casual partners and uses condoms for contraception.How would you approach this visit?On exam, pubic hair is mostly absent and there is mild folliculitis present. The labia are swollen bilaterally, and multiple shallow ulcers are present in different stages of healing. A speculum exam is not possible due to discomfort. There are palpable inguinal lymph nodes.The exam is suggestive of herpes simplex virus (HSV) infection. A culture can be taken of the lesions, but timing is important and if healing has begun a negative culture is possible. Pain with urination is most likely related to HSV but a urine dipstick can be done if a urinary tract infection is also suspected. Testing for other STIs such as syphilis, HIV, gonorrhea, and chlamydia should be done. Her history is consistent with a primary HSV outbreak and treatment can begin prior to lab results. Valacyclovir 1 g orally twice daily for 7 to 10 days is appropriate (other antiviral medications such acyclovir and famciclovir are alternatives). General comfort measures include tepid baths and loose clothing. She should be encouraged to contact her sexual partners so they can be evaluated and treated as necessary. Consider a follow-up visit in 1 to 2 weeks to assess resolution of symptoms, review lab results, discuss daily suppressive medication, and review safer sexual practices and contraceptive options.Case Study 15: Vaginitis and Vaginosis (Chapter 24)A 28-year-old woman presents with increased vaginal discharge and a foul odor. She has been in a sexual relationship with a male partner for 1 month. She has a 52 mg progestin IUD for contraception and is not using condoms with her partner. Her past medical history is benign, she has never had surgery and has never been pregnant. Her BMI is 25, and her vital signs are all normal. She has not had a menstrual period for 3 years related to the IUD. She does not use drugs, does not smoke, and has two to four alcoholic drinks per week, mostly on the weekends. She is complaining of increased vaginal discharge with a foul odor that is worse after sex. She has mild itching. This started 2 days ago. She reports no burning with urination and no pain with sexual intercourse. She has not self-treated with any over-the-counter (OTC) products.What would today’s visit entail?Based on history, a pelvic exam and microscopic assessment of vaginal discharge are indicated. The pelvic exam should include visualization of the external genitalia as well as the vaginal canal and cervix. A sample of the vaginal discharge should be obtained from the vaginal side wall with two cotton swabs. Use these swabs to assess pH with nitrazine paper and perform a microscopic assessment for differential diagnoses of bacterial vaginosis (BV), candidiasis, or trichomoniasis. Assess for an amine odor with KOH (“whiff test”).The vaginal exam reveals a thin, white malodorous discharge that is coating the vaginal walls, which is suggestive of BV. A diagnosis of BV can be made if 3 out of 4 Amstel’s criteria are met: (a) pH >4.5, (b) positive clue cells, (c) positive amine odor, and (d) thin, homogeneous, white discharge. Other point-of-care tests can also help to make the diagnosis. If BV is confirmed discuss treatment options with the young woman and decide on an appropriate course of therapy. If oral metronidazole or tinidazole are the chosen course of therapy, she should avoid any alcohol consumption while taking these medications and for at least 24 hours after completion of the medication. Secnidazole oral granules can be used for women who have difficulty swallowing pills but want an oral treatment. Vaginal gel and cream preparations containing either metronidazole or clindamycin are also treatment options. No treatment of her male partner is needed. She should be screened for other STIs based on her history and avoid intercourse until symptoms subside. No follow-up is needed unless symptoms persist or recur.“For Your Information”: Education Templates for Electronic RecordsBacterial Vaginosis?18Candidiasis (Monilia) Yeast Infection?19Care After Abortion?20Cervical Cap (FemCap)?21Chlamydia trachomatis?22Contraceptive Implant?23Contraceptive Patch?24Contraceptive Vaginal Ring?26Cystitis (UTI)?27Diaphragm?28Genital Herpes Simplex?29Genital Warts (Condylomata Acuminata)?31Gonorrhea?32Hormone Therapy?33Intrauterine Device?34Lice (Pediculosis)?36Osteoporosis?38Polycystic Ovary Syndrome?39Preconception Care?40Premenstrual Syndrome?41Scabies?42Smoking Cessation?44Stress or Urge Urinary Incontinence?45Syphilis?46Trichomoniasis?48Vaginal Contraceptive Sponge?49EDUCATION HANDOUTBACTERIAL VAGINOSISI. DEFINITIONBacterial vaginosis (BV) is overgrowth of various anaerobic bacteria and other types of bacteria that are in the vagina in small amounts. Sometimes these bacteria overgrow and cause the symptoms of BV.II. TRANSMISSIONBV occurs more commonly among women who are sexually active, although it is not considered to be a sexually transmitted infection (STI) and male partners do not need to be treated. However, it is common for BV to be present for female partners of women.III. SIGNS AND SYMPTOMSWoman may notice1.Fishy, musty odor with a thin, milky white to dull gray vaginal discharge2.Discharge may cause vaginal and vulvar itching and burning3.Burning and irritation of the vagina and vulva after intercourse4.Some women may have no symptomsIV. DIAGNOSISWomen may have1.Vaginal examination to check for BV2.Testing for yeast and STIsV. TREATMENTTreatment may involve taking pills by mouth or the use of an antibiotic vaginal gel or cream.Male partners do not need treatment. Female partners should consider treatment as BV is common among women who have sex with women.Your health care provider will review your allergies, medications, and health conditions before prescribing treatment.If treated with a vaginal gel or cream, you should not have intercourse right after the medication is placed in the vagina.VI. WHAT YOU SHOULD KNOWCommon medications for BV interact with alcohol and can cause intense nausea and vomiting. Avoid alcohol during treatment and for 24 to 72 hours after oral medication.Side effects of oral medication may include nausea, dizziness, and a metallic taste in your mouth.VII. FOLLOW-UPReturn to your clinician if symptoms do not improve or come back after treatment. More information on BV can be found at std/bv/default.htmEDUCATION HANDOUTCANDIDIASIS (MONILIA) YEAST INFECTIONI. DEFINITIONCandidiasis, more commonly referred to as a yeast infection, is an overgrowth of a fungus that is often found in small amounts in the vagina. Sometimes this small amount of yeast overgrows and causes symptoms, including itching and discomfort.II. TRANSMISSIONNot a STI and can occur for women who are not sexually active. Pregnant women and women with diabetes can get yeast infections. Taking antibiotics for another condition can allow yeast to overgrow in the vagina. Many times it is not possible to determine what caused a yeast infection.III. SIGNS AND SYMPTOMSWoman may notice1.Vaginal discharge: thick, white, clumpy, and curd-like2.Vaginal area itch and irritation, swelling, and redness3.Often itching, burning, and swelling around and outside the vaginal opening4.Burning on urination5.Possibly, pain with intercourseMen may notice1.Itch and/or irritation of penis2.Cheesy material under foreskin, underside of penis3.Jock itch, rashIV. DIAGNOSISIf women are unsure if their symptoms are from yeast, a clinician can perform a vaginal examination to check for yeast or other infections.Evaluation of men can include1.Examination of penis and surrounding skin2.Testing for other infectionsV. TREATMENTThere are many medications, including vaginal creams and suppositories that can be obtained in a pharmacy or other stores that treat yeast infections without a prescription. There are also medications that require a prescription from your clinician.VI. WHAT YOU SHOULD KNOWIntercourse is often uncomfortable and should be avoided until symptoms subside.You can treat a yeast infection even if you have your period, but tampons will absorb vaginal medication and should not be used during treatment.Many women choose to try an over-the-counter preparation before seeking an examination. If symptoms do not subside after one course of treatment, you should see your clinician for an exam to see if you need different medication.VII. FOLLOW-UPReturn to the clinician for reevaluation if symptoms persist or new symptoms occur after treatment is completed.More information can be found at fungal/diseases/candidiasis/genital/index.htmlEDUCATION HANDOUTCARE AFTER ABORTION1.It is helpful to have a support person accompany you to the office visit. If you had a surgical abortion and received certain types of anesthesia, you will need a ride home.2.Follow directions from your clinician regarding medication for discomfort. Cramping after an abortion can often be relieved with acetaminophen (Tylenol) or ibuprofen (Motrin).3.If you are prescribed antibiotics, it is important to finish all the medication.4.Call immediately or seek emergency treatment if you are bleeding heavily (soaking through two thick, full-size sanitary pads per hour for more than 2 hours in a row); you have pain that is not controlled with medication; you have a fever higher than 100.4°F that lasts more than 4 hours; weakness; nausea; vomiting; and/or diarrhea for more than 24 hours after taking medication for the abortion.5.If you had a medical abortion, then you will have heavier bleeding and cramping at home as you complete the abortion. You can expect this bleeding to be heavier than a normal menstrual period.6.Normal physical activities may be resumed as soon as you feel ready, usually within 1 to 2 days.7.Because of the risk of infection, it is important not to have vaginal intercourse or to insert anything into the vagina for 2 to 3 weeks or until your health care provider determines it is safe to resume these activities.8.Bleeding will slow down after 3 to 4 days but may last up to 2 to 3 weeks.9.You should get your next period in 4 to 6 weeks.10.You should schedule an appointment with a clinician 2 to 3 weeks after your abortion. Your health care provider will make sure you are healing well and ask how you are doing. You can get pregnant right away after an abortion, so it is important to discuss birth control methods if you are sexually active.EDUCATION HANDOUTCERVICAL CAP (FEMCAP)I. DEFINITION/HOW IT WORKSThe contraceptive cervical cap (FemCap) is a prescription-only contraceptive device that is used to hold spermicide and to provide a partial barrier to sperm when placed over the cervix. It is available in three sizes: 22, 26, and 30 mm. The best size for you will be determined by your clinician based on your pregnancy history and an exam.II. EFFECTIVENESSApproximately 92% effective with perfect use, but can be less effective depending on correct use and fit. It is less effective if you delivered a baby vaginally.III. SIDE EFFECTSMinor side effects can include1.Vaginal irritation from the device2.Vaginal irritation from the spermicide used with the device3.Sensation of something in the vaginaIV. CONTRAINDICATIONSMost women can use the cervical cap. However, it is only available in three sizes and some women may need a size that is not available. Your clinician will be able to determine if the cervical cap is a good choice after your exam.The cervical cap should not be used during your period or immediately after having a baby or an abortion.V. INSTRUCTIONS FOR USE1.Insert spermicide into the device according to directions by the manufacturer and place in the vagina over the cervix before sexual activity. It can be placed up to 40 hours prior to sex and should be placed at least 15 minutes prior to sexual arousal.2.Keep device in place for at least 6 hours after last act of intercourse. It can stay in for 48 hours.3.You do not need to add additional spermicide to the outside of the device if you have sex again while the cap is in place.4.Remove the cap by squatting and bearing down. Slip finger between the dome and the removal strap and pull gently.5.Wash device thoroughly with soap, rinse thoroughly in clear water, and allow to air dry.6.The cervical cap requires correct use with each act of intercourse for it to be effective.More information on the cervical cap can be found at EDUCATION HANDOUTCHLAMYDIA TRACHOMATISI. DEFINITIONChlamydia infection is an STI of the reproductive tract. It is one of the most common STIs in young people and can be treated with antibiotics.II. TRANSMISSIONChlamydia can be transmitted during vaginal, anal, or oral sex with an infected partner.III. SIGNS AND SYMPTOMSWomen may notice1.Often no symptoms2.Possibly increased vaginal discharge, change in menses3.More cramping during your period4.Uncomfortable urination, like a urinary tract infection (UTI)5.Pelvic pain6.Bleeding after intercourse or in between periods7.Chlamydia infections in the throat or rectum may cause sore throat or rectal discomfortMen may notice1.Possibly no symptoms2.Cloudy discharge from the penis3.Pain with urination or with ejaculation4.Chlamydia infections in the throat or rectum may cause sore throat or rectal discomfortIV. DIAGNOSISTesting for chlamydia can be done from a urine sample or swab of the infected area. Testing for other STIs or infections can be done.V. TREATMENTChlamydia infections are treated with antibiotics. Your clinician will ask about allergies to medications and discuss which treatment is best. All sexual partners also need to be treated.VI. WHAT YOU SHOULD KNOWIt is important to finish all medication even if symptoms resolve. If all medication is not finished, the infection will not be treated completely and can come back.Do not have intercourse for 7 days after single-dose treatment or until you and any sex partner(s) have completed treatment. If you have intercourse before this time, you could get the infection back.You need to let all sexual partners know about the infection, so they can get tested and treated if needed.VII. FOLLOW-UPReturn to clinician if symptoms persist or new symptoms occur.More information on chlamydia can be found at std/-chlamydia/default.htmEDUCATION HANDOUTCONTRACEPTIVE IMPLANTI. DEFINITION/HOW IT WORKSThe contraceptive implant (Nexplanon) is a single rod that contains a progestin hormone called etonogestrel. The implant is effective for at least 3 years and is inserted just under the top layer of skin on the upper, inner part of the arm. The insertion is quick and is done during an office visit. The implant works by preventing ovulation and making it harder for sperm to enter the uterus.II. EFFECTIVENESSThe implant is over 99% effective.III. POSSIBLE SIDE EFFECTS1.Pain, bruising and possibly a small scar at the insertion site2.Menstrual cycle changes, including irregular bleeding or no bleeding3.Some women report they gain a small amount of weight while using the implant4.Some women will have changes in their mood or experience depression5.Headaches and acne can happen but often decrease over timeIV. CONTRAINDICATIONSMost women can use the implant. Your clinician will ask about your medical and family history to help decide if the implant is safe for you to use.V. INSERTION AND REMOVAL1.Insertion and removal are both done in the office in a quick procedure. You do not need a pelvic exam before having the implant inserted. Your clinician will check a urine pregnancy test before the procedure.2.You will be given numbing medication prior to the procedure. The insertion site might be tender and bruised for a few days but should heal quickly. You will leave the office with a bandage on your arm, which should stay on for a few days.3.If the implant is inserted during your menstrual period, you are protected against pregnancy immediately. If it is placed at another time during your menstrual cycle, you should use a backup method of contraception (condoms) for 7 days.4.The implant can stay in place for at least 3 years and may even be effective for 4 to 5 years. If you decide you want to change to a different method or become pregnant, the implant can be removed sooner during an office visit. Women can get pregnant quickly after removal.5.When you decide you want the implant removed, you will be given numbing medication and the implant will be taken out through a small incision.VI. WHAT YOU SHOULD KNOW ABOUT THE IMPLANTChanges in the menstrual cycle are common and you may have some irregular bleeding. If it continues, talk with your clinician about what can be done to decrease the bleeding.The implant will not protect against STIs. You should continue to use condoms to reduce your chance of a STI. You should be able to feel the implant in your arm. If you cannot feel it anymore let your clinician know.Let your clinician know about any side effects that are bothering you.You can have the implant removed if you want to become pregnant or are interested in a different method.More information about the contraceptive implant can be found at EDUCATION HANDOUTCONTRACEPTIVE PATCHI. DEFINITION/HOW IT WORKSThe contraceptive patch is a small square patch that sticks to your skin. It has two hormones, estrogen and progesterone, that are absorbed into the body through the skin. The main ways the patch works are by preventing ovulation, changing the cervical mucus so sperm cannot get through, and making the lining of the uterus thin.II. EFFECTIVENESSThe patch is 99% effective when used correctly all the time.It may be less effective for women who weigh 198 pounds (90 kg) or more. If your weight is in this range, talk with your clinician about all your contraceptive choices.III. SIDE EFFECTSMinor side effects, most go away after a few months of use1.Local irritation from patch2.Dislocation of patch3.Breast discomfort, tenderness4.Nausea5.Spotting between periods6.HeadachesMore serious adverse reactions. The patch contains estrogen which can cause1.Blood clots in the body, including in the legs, lungs, or brain2.High blood pressure3.Heart attack and stroke, especially for women who are over 35 and those who smokeIV. CONTRAINDICATIONSMost women can use the contraceptive patch. However, there are some conditions such as a history of blood clots, certain cancers, heart disease, severe headaches, and diabetes that affect circulation in which the patch should not be used.Your clinician will ask you about your medical and family history to determine if the contraceptive patch is a safe choice.Smoking increases the risk of serious events, including blood clots. Women who want to use the contraceptive patch should not smoke. It should not be used by current smokers who are 35 years of age of older.V. INSTRUCTIONS FOR USE1.Apply patch on first day of your menstrual period or at any other time during your menstrual cycle if you are reasonably certain you are not pregnant. Apply to clean, dry, healthy skin on upper buttocks, lower abdomen, upper outer arm, or upper torso. Patch should not be applied to breasts.2.Do not use lotions or other topical products in area where patch will be applied, or it might not stick well. Press down firmly so the edges stick.3.Each patch is used for 1 week. Apply a new patch the same day of the week, 7 days after first patch. Repeat this weekly for 3 weeks. On week 4, no patch is applied. You should get your period during the week you are not wearing a patch.4.If you forget a patch or if a patch falls off, call your clinician and they can let you know what to do.VI. WHEN TO CALL YOUR CLINICIANMost women have no problems when they use the patch. But if you experience any of the following conditions you should call your clinician:1.Trouble with your vision, including seeing spots or flashes2.Chest pain or trouble breathing3.New pain in your lower legs4.Severe headaches or worsening of headaches5.Any other side effects that are concerningYou should plan on seeing your clinician about 3 months after starting the contraceptive patch, so your blood pressure can be checked, and you can discuss any questions or concerns you might have.More information on the contraceptive patch can be found at EDUCATION HANDOUTCONTRACEPTIVE VAGINAL RINGI. DEFINITION/HOW IT WORKSThe contraceptive vaginal ring is a flexible, silicone ring that contains the hormones estrogen and progesterone. The contraceptive ring works by preventing ovulation, thickening mucus in the cervix, and making the lining of the uterus thin.II. EFFECTIVENESSApproximately 99% effective when used correctly all the time.III. SIDE EFFECTSMinor side effects can include1.Vaginal irritation from the ring2.Some women have increased vaginal discharge3.Possible spotting between periods4.Some partners report feeling the ring during sexual activityMore serious adverse reactions. The ring contains estrogen which can cause1.Blood clots in the body, including in the legs, lungs, or brain2.High blood pressure3.Heart attack and stroke, especially for women who are over 35 and those who smokeIV. CONTRAINDICATIONSMost women can use the vaginal ring. However, there are some conditions such as a history of blood clots, certain cancers, heart disease, severe headaches, and diabetes that affect circulation in which the ring should not be used. Your clinician will ask you about your medical and family history to determine if the contraceptive ring is a safe choice.V. INSTRUCTIONS FOR USE1.Insert ring into your vagina during the first 5 days of your menstrual period or at any other time during your menstrual cycle if you are reasonably certain you are not pregnant. The ring stays in for 3 weeks.2.After 3 weeks remove the ring for 1 week. You should get your period during this week the ring is not in your vagina.3.After the ring has been out for 1 week, insert a new ring following the same schedule as earlier.4.You do not need to remove the ring during sex and if you are having any bleeding you can use a tampon.5.If the ring is removed from the vagina and is out for more than 3 hours at any time during the first 3 weeks, you should put the ring back in as soon as you remember and use backup contraception for the next 7 days.VI. WHEN TO CALL YOUR CLINICIANMost women have no problems when they use the contraceptive ring. But if you experience any of the following conditions you should call your clinician:1.Trouble with your vision, including seeing spots or flashes2.Chest pain or trouble breathing3.New pain in your lower legs4.Severe headaches or worsening of headaches5.Any other side effects that are concerningYou should plan on seeing your clinician about 3 months after starting the contraceptive ring, so your blood pressure can be checked, and you can discuss any questions or concerns you might have.More information about the vaginal contraceptive ring can be found at EDUCATION HANDOUTCYSTITIS (UTI)I. DEFINITIONUTIs are caused by bacteria that enter the urinary system. Women are more prone to UTIs because the urethra, which leads to the bladder, is short and the vagina and rectum are close to the opening of the urethra. However, men can also develop UTIs.II. SIGNS AND SYMPTOMS1.Frequent urination of small amounts of urine with the urgent feeling of needing to urinate2.Burning and pain with urination3.Can have blood in the urine4.Lower abdominal pain5.Chills, fever may occurIII. TREATMENTUTIs are treated with antibiotics. Your clinician will ask if you are allergic to any medications and prescribe an antibiotic that is appropriate.You will probably be asked for a urine sample to check for bacteria in the urine and to see what antibiotics will work best.It is important to take the entire prescription medication even if symptoms disappear quickly.UTIs can only be treated with antibiotics. Over-the-counter medications for bladder pain and cranberry drinks or tablets do not cure infections.IV. WHAT YOU SHOULD KNOWAfter going to the bathroom, wipe from front to back so you do not carry bacteria from your rectal area to the vaginal or urethral area.You should empty your bladder before and after sex.Empty your bladder frequently when you feel the urge. This will help prevent bacteria from growing in your bladder.Drink plenty of water, at least six to eight large glasses per day, to help flush out bacteria.If you get UTIs frequently, speak to your clinician about ways to prevent future infections.More information on UTIs can be found at antibiotic-use/community/for-patients/common-illnesses/uti.htmlEDUCATION HANDOUTDIAPHRAGMI. DEFINITION/HOW IT WORKSThe diaphragm is a prescription-only contraceptive device that is used to hold spermicide and to provide a partial barrier to sperm when placed over the cervix. Depending on the type of diaphragm you use, there may be different sizes. Some diaphragms have limited availability. The choice for you will be determined by your clinician and based on your pregnancy history and an exam.II. EFFECTIVENESSApproximately 85% effective with perfect use but can be less effective depending on correct use and fit.III. SIDE EFFECTSMinor side effects can include1.Vaginal irritation from the device2.Vaginal irritation from the spermicide used with the device3.Sensation of something in the vagina4.Some women are more prone to UTIs when they use a diaphragmIV. CONTRAINDICATIONSMost women can use a diaphragm. However, there may be different sizes depending on the specific type of diaphragm. Some women may need a size that isn’t available. Your clinician will be able to determine if the diaphragm is a good choice after your exam and trying different sizes.The diaphragm shouldn’t be used during your period or immediately after having a baby or an abortion.V. INSTRUCTIONS FOR USE1.Insert spermicide into the device according to directions by the manufacturer and place in the vagina over the cervix before sexual activity. It can be placed up to 2 hours prior to sex.2.Keep device in place for at least 6 hours after last act of intercourse. It should not stay in the vagina for more than 24 hours.3.You will need to add additional spermicide to the outside of the device if you have sex again while the diaphragm is in place.4.Remove the diaphragm by squatting and bearing down. Hook your finger under the rim or edge and pull gently.5.Wash device thoroughly with soap, rinse thoroughly in clear water, and allow to air dry.6.The diaphragm requires correct use with each act of intercourse for it to be effective.More information on the Caya diaphragm can be found at caya.EDUCATION HANDOUTGENITAL HERPES SIMPLEXI. DEFINITIONThe herpes simplex virus (HSV) is one of the most common STIs. It is transmitted by direct contact with the virus from the skin of an infected person. The HSV is of two typesA.HSV type 1 (HSV-1): Usually affects body sites such as the mouth or lips, but can also infect the anal/genital regionsB.HSV type 2 (HSV-2): Usually involves the genitalsGenital herpes may be caused by either HSV-1 or HSV-2. HSV-1 lesions on the mouth can be spread to the genital area.II. SYMPTOMSPainful sores like cold sores or fever blisters surrounded by reddened skin that appears around the mouth, buttocks, thighs, or genital areas between 1 and 2 weeks (average) after contact.With the very first outbreak, you can experience symptoms such as1.Fever or flu-like symptoms2.Tenderness or pain in muscles3.Burning sensation during urination4.Swollen lymph nodes in the area of the lesions (neck, underarms, groin)5.Joint pain6.Headache7.Symptoms may last 2 to 3 weeksIII. DIAGNOSISUsually diagnosed based on your symptoms, history, and exam.Culture can be taken from the lesions.Blood test for HSV-1 and HSV-2 antibodies is possible.IV. TREATMENTHSV cannot be cured but it can be managed. Antiviral medication can be taken every day to prevent outbreaks or taken during an outbreak to decrease symptoms.Avoid sex during a HSV outbreak.Wearing loose clothing and soaking in cool or warm water will decrease discomfort.V. COMPLICATIONSThe herpes lesions could become infected.Pain in the genital area that lasts after the lesions have healed.Severe infections for infants born vaginally during an episode of herpes in the mother.VI. RECURRENCESHSV may never recur after the first episode, or there may be occasional outbreaks that are not as painful as the initial infection, lasting up to 7 days. Recurrences are caused by a reactivation of the virus already present in the nerve endings of your body. Recurrences are not associated with body aches, fever, or muscle pain. You may feel some tingling or itching in the genital area right before an outbreak.VII. WHAT YOU SHOULD KNOWAvoid sex during an outbreak. Condoms do not completely prevent transmission to a partner and sex will be uncomfortable.Antiviral medication will decrease outbreaks and reduce the chance of passing HSV to a sexual partner.If you become pregnant, it is important to let your provider know that you have HSV, even if you have not had a recent outbreak. You can take medication to help prevent transmission to the baby.Consider being tested for HIV if you have never been tested or have not been tested recently.More information on herpes can be found at std/herpes/default.htmEDUCATION HANDOUTGENITAL WARTS (CONDYLOMATA ACUMINATA)I. DEFINITIONGenital warts are caused by the human papillomavirus (HPV) and can occur anywhere in the genital area for both women and men. HPV has more than 100 types, some of which cause warts on the genitals (more than 40 types). Some HPV types are associated with cancers of the cervix, penis, mouth, anus, tongue, and throat.II. SIGNS AND SYMPTOMSWarts may not appear until a few months to many months (or even years) after exposure. Depending on the area, it may be difficult to notice the warts when they are small.1.In moist areas, the warts are small, often itchy bumps or lumps, sometimes with a cauliflower-like top, appearing alone or in clusters.2.On dry skin the warts commonly are small and calloused and resemble warts that appear on other parts of the body.3.For women, the warts are commonly found on or around the vaginal opening, around the rectum, and on the cervix. Symptoms can include itching or burning of the genital skin, and feeling a lump in the vulvar area or groin.4.For men, the warts can be found on any part of the penis, scrotum, or rectal area.III. DIAGNOSISThe diagnosis is made based on the appearance of the warts. A biopsy is usually not necessary.There is no lab test for genital warts. Your clinician may recommend testing for other STIs if that has not been done recently.IV. TREATMENTGenital warts can be treated with applications of topical medication that are applied by you or your provider. You and your clinician will decide the best treatment based on your preference, cost, number and location of warts, and whether the warts are in an area you can easily reach.Most treatments are successful but could take repeated applications of medication over the course of many weeks.Warts that are very large or blocking the vagina or cervix may need different treatment from a specialist.V. WHAT YOU SHOULD KNOWSexual partners should be told about the genital warts.Recurrence is possible because treatment eliminates the wart but not the virus in the body.If warts are present on the cervix, women should have Pap smears as recommended by their clinician. If the Pap smear is abnormal, follow-up is based on the result of the test.All men and women should have the HPV vaccine (Gardasil 9) that can be given up to age 45. It protects against nine types of HPV and can be given if you have already been diagnosed with HPV. You should speak with your clinician about getting the vaccine.More information about HPV can be found at std/hpv/EDUCATION HANDOUTGONORRHEAI. DEFINITIONGonorrhea is a STI caused by the bacteria Neisseria gonorrhoeae. It can infect any site of sexual contact, including the cervix, urethra, throat, or rectum.II. IMPORTANT INFORMATIONThe highest incidence of gonorrhea occurs in males and females who are 24 years of age or younger. Men who have sex with other men are also at high risk for gonorrhea. Symptoms of gonorrhea usually occur within a month of getting the infection, but some people do not have symptoms right away.III. USUAL SIGNS AND SYMPTOMSWomen may report1.More than half of women may have no symptoms2.Abnormal, yellow vaginal discharge; change in vaginal discharge3.Frequency, pain with urination4.Pain with sex5.Rectal pain and discharge with rectal infection6.Painful menstrual periods or spotting between periods7.Lower abdominal pain8.Sore throat with throat infectionMen may report1.Most men have symptoms2.Frequency, pain and burning with urination or ejaculation3.White or yellow thick discharge from the penis4.Throat or rectal pain or discharge if infection in these areasIV. DIAGNOSISTesting for gonorrhea taken from infected areas (cervix, urethra, rectum, and/or throat). Urine samples or swabs can be done depending on the site of infection.V. TREATMENTAntibiotics will be prescribed that include pills and a shot that will require you to come back to the office to receive. Gonorrhea is usually cured with the combination of oral antibiotic pills and the antibiotic injection.VI. COMPLICATIONSIf gonorrhea is untreated, women can develop pelvic inflammatory disease (PID) that can cause infertility. Men may also develop scar tissue that causes infertility.Although uncommon, if not treated the infection can spread in the body and cause joint pain and lesions on the skin.VII. WHAT YOU SHOULD KNOWAll medications must be taken as directed. If medications are not finished, the infection will not be treated.Do not have intercourse until treatment of self and partner(s) is completed (no sex for 7 days after treatment).Return to the clinician for reevaluation if symptoms persist or new symptoms occur after treatment is complete.Notify all sexual partners of the infection so they can be tested and treated.Consider testing for HIV or other STIs.More information on gonorrhea can be found at std/gonorrhea/default.htmEDUCATION HANDOUTHORMONE THERAPYI. DEFINITIONHormone therapy (HT) is the use of hormones (estrogen, progesterone) by women around the time of menopause or by women after menopause.II. REASONS FOR HTA woman’s body produces declining amounts of estrogens, progesterones, and androgens during the perimenopausal period and eventually menstrual cycles stop. After 12 months without any bleeding (periods), women are postmenopausal. Some natural estrogen production does continue after menopause but not as much as when women were younger. This decline in estrogen contributes to symptoms such as hot flashes/flushes and night sweats. Less estrogen after menopause can also decrease bone density. Women may also experience vaginal dryness and itching. HT can help reduce these symptoms.III. WHAT YOU SHOULD KNOW WHEN CONSIDERING HTIf you are having any irregular bleeding, speak with your clinician about whether HT is an appropriate choice. Your clinician will want to determine what is causing the bleeding.Pregnant women or perimenopausal women who suspect pregnancy cannot take HT.If you have ever had a stroke, heart attack, or a blood clot in your legs or lungs, or serious liver disease, you may not be a candidate for HT.Women with known or suspected cancer of the breast, ovaries, uterus, or cervix may not be good candidates for HT.Several conditions require special evaluation to determine whether taking HT will be safe. You should let your clinician know about all medications that you take and all medical conditions you have. Considering HT is a decision that is yours to make if you and your clinician decide that you have no contraindications to its use and you want treatment for bothersome menopausal symptoms.HT is generally taken for no longer than 5 years. It is used only to treat symptoms associated with menopause and does not reduce your risk of heart disease or the signs of aging. When used longer than 5 years, your risk of certain conditions such as breast cancer and heart disease increase.IV. TAKING HTHT is available in pills, patches, vaginal preparations (ring, cream, tablets, suppositories), and topical formulations such as creams. Your clinician will discuss all the forms of HT and you can decide which will be the best for your lifestyle.More information about menopause can be found at Patients/FAQs/The-Menopause-Years?IsMobileSet=false for-womenEDUCATION HANDOUTINTRAUTERINE DEVICEI. DEFINITION/HOW IT WORKSIntrauterine devices (IUDs) are small T-shaped devices that are inserted into the uterus to prevent pregnancy. One type of IUD contains no hormones and the other types contain a progestin hormone called levonorgestrel. Depending on the kind of IUD you choose, it can be effective for at least 3 years and up to 12 years. The insertion is quick and is done during an office visit. The IUD works by making it harder for sperm to enter the uterus and changing the lining of the uterus.II. EFFECTIVENESSIUDs are at least 99% effective.III. POSSIBLE SIDE EFFECTS1.Pain and discomfort during insertion2.Menstrual cycle changes, including irregular bleeding or no bleeding. One type of IUD may make your period heavier3.The IUD could move through your uterus during insertion, although this is uncommon4.Some women have the IUD come out of the uterus5.Some women might get an infection in their uterus that could cause infertilityIV. CONTRAINDICATIONSMost women can use an IUD. Your clinician will ask about your medical and family history to help decide if the IUD is safe for you to use. Your clinician will also ask about your sexual history, including past STIs.V. INSERTION AND REMOVAL1.Insertion and removal are both done in the office in a quick procedure. You will need a pelvic exam before having the IUD inserted. Your clinician will check a urine pregnancy test before the procedure.2.You may be given numbing medication on your cervix prior to the procedure. Ask your clinician about taking medication such as ibuprofen before having the IUD put it. It can help with cramping and discomfort.3.Your clinician will measure the size of your uterus and insert the IUD through your cervix. The strings of the device will come through the cervix and remain in the vagina. The strings help with removal.4.If the IUD is inserted during your menstrual period, you are protected against pregnancy immediately. If it is placed at another time during your menstrual cycle, you should use a backup method of contraception (condoms) for 7 days.5.The IUD can stay in place for at least 3 years and other types of IUDs can stay in place for 5 to 7 years. One IUD can be used for 12 years. If you decide you want to change to a different method or become pregnant, the IUD can be removed sooner during an office visit. Women can get pregnant quickly after removal.6.When you decide you want the IUD removed, your clinician will grasp the IUD strings and gently pull the device out. Removal is very quick.VI. WHAT YOU SHOULD KNOW ABOUT AN IUDChanges in the menstrual cycle are common and you may have some irregular bleeding, spotting, or no bleeding at all if you have an IUD that has progesterone in it. The IUD without hormones can make your period heavier. Your clinician will let you know what to expect based on the type of IUD you choose. The IUD will not protect against STIs. You should continue to use condoms to reduce your chance of an STI.You should be able to feel the strings of the IUD in your vagina and should check every month to make sure they are there. If you cannot feel the strings anymore, let your clinician know.Any vaginal infections and STIs should be treated quickly. If you think you might have an infection, make an appointment to get tested.Let your clinician know about any side effects that are bothering you.You can have the IUD removed if you want to become pregnant or are interested in a different method.More information about IUDs can be found at opa/pregnancy-prevention/birth-control-methods/iud/index.htmlEDUCATION HANDOUTLICE (PEDICULOSIS)I. DEFINITIONPediculosis means having the skin infested with lice, particularly on hairy areas such as the scalp and the pubic area. Humans can be infected with head lice, body lice, or pubic lice or “crabs.”II. TRANSMISSIONLice are transmitted by lice-infected shared clothing, bedding, brushes, combs, hats, stuffed animals, car seats, towels, pillows, and upholstered furniture or by close personal contact with an infected person. Head lice move from head to head. Adult pubic lice probably survive no more than 24 hours off their host. In addition to shared clothing and fabrics, lice can also be transmitted through close contact during sexual activity.III. SIGNS AND SYMPTOMS1.Intense itching2.Observing the lice or, more easily, their nits (eggs), which are greenish white ovals attached to hair shafts in eyebrows, eyelashes, scalp hair, pubic hair, and other body hair3.Known exposure to a household member or intimate partner with lice4.Crusts or scabs on body from scratching5.Swollen glands in the neck or groin (for pubic lice), an allergic response to the lice6.Body lice found on clothing, especially in the seams, as lice are rarely found on the body7.Black dots (representing lice feces) on skin and underclothingIV. DIAGNOSISLice can be detected by using a magnifying glass or microscope but are often diagnosed after reviewing symptoms and an exam.V. TREATMENTA.General measures1.Wash clothing, towels, and so forth, with hot water, dry-clean contaminated items, or run them through a dryer on high heat to destroy nits and lice; wash combs and hair brushes in hot, soapy water. Items can also be sealed in a plastic bag for 2 weeks; lice will suffocate. Or items can be put outside in cold weather for 10 days.2.Spray couches, chairs, car seats, and items that cannot be washed or dry-cleaned with over-the-counter products (A-200 Pyrinate, Triplex, RID, or store brand products); an alternative is to vacuum carefully to pick up lice and nits although this is less effective.B.Specific measures1.Head licea.Thoroughly wet hair with permethrin 1% cream or malathion 0.5% lotion applied to affected areas and washed off after appropriate time. Permethrin 1% shampoo is available by many different names over the counter without a prescription. The shampoo should be worked into a lather and left on the head for 5 to 10 minutes and then rinsed off. The directions on the specific product should be followed. Rinse thoroughly, towel dry.b.Remove remaining nits with fine-tooth metal comb or tweezers (use of vinegar solution and hair conditioner or olive oil makes combing easier). Lice combs are available with fine teeth that are designed to remove nits more easily.2.Body licea.Bathe with soap and water if no lice are found.b.Wash with warm water and dry in dryer all clothing, bedclothes, towels, and so forth.c.Dry-clean items that cannot be washed; for items that cannot be washed or dry cleaned, seal in a plastic bag for 1 week: lice will suffocate (in cold climates, put bags outside for 10 days; temperature change kills lice).d.If evidence of lice is found or the first two measures mentioned are not effective, use malathion 0.5% lotion applied for 8 to 12 hours and thoroughly rinse.3.Pubic licea.Permethrin 1% cream rinse applied to affected area and washed off after 10 minutes; orb.Pyrethrins with piperonyl butoxide applied to affected area and washed off after 10 minutes; orc.Malathion 0.5% lotion applied for 8 to 12 hours, and thoroughly rinsed off.d.If pregnant or breastfeeding, use the same products as previously mentioned.rm any sexual partners within past month that they also need to be treated.f.Wash in warm water and thoroughly dry on heat cycle or dry-clean all clothing, bed linen, towels, and so on, or remove from body contact for at least 72 hours.C.Carefully check family and household members and close contacts for evidence of lice contamination and if found, treat as previously mentioned or see your clinician for advice.D.Call your clinician if signs of infection from scratching occur (redness, swelling of skin, discharge that looks like pus, bleeding, fever).E.Stop using the treatment and call your clinician if you or your family members experience sensitivity to the treatment (pain, swelling, rash).F.Consult with your clinician if you have lice on the eyelashes as the treatments cannot be used near the eyes.G.Prescription treatments are available if over-the-counter products are not effective.VI. FOLLOW-UPContact your clinician if itching, redness, or other problems listed previously persist or recur.More information on lice can be found at parasites/lice/index.htmlEDUCATION HANDOUTOSTEOPOROSISI. DEFINITIONOsteoporosis is characterized by decreased bone mass (loss of bone density) and an increase in bone fragility. This can put you at risk for bone fractures (broken bones).II. ETIOLOGYFor bones to develop properly and maintain bone mass, we need adequate calcium and phosphorus and other minerals in our diets. We also need other vitamins and adequate vitamin D for our bodies to absorb calcium from our diets and enable the body to maintain our bones. We reach our peak bone mass at about 35 years of age. Estrogen seems to play a role in allowing women’s bones to retain calcium and the other minerals necessary to build bone and preserve bone mass. After menopause, the loss of bone mass may accelerate. If bone mass loss becomes too great, a woman becomes susceptible to fractures.III. RISK FACTORSThe risk of developing osteoporosis is greater for women than for men (women begin with less bone mass) and increases with age. Other risks for osteoporosis include an earlier menopause (in 40s or earlier), a family history of osteoporosis, being of fair-skinned Caucasian or Asian descent, living in a northern climate, having a small or thin body frame, high alcohol intake, a diet low in calcium and vitamin D, smoking, no weight-bearing exercise, and high caffeine intake.IV. PREVENTIONCertain risks for osteoporosis cannot be changed, such as family history, sex, age, and the transition to menopause. However, dietary and social habits can be modified to eliminate tobacco and excessive alcohol and increase exercise and the intake of calcium and vitamin D. Even with these changes, women can develop osteoporosis. Talk with your clinician about ways you can make changes in your life to reduce your risk.V. TREATMENT FOR OSTEOPOROSISIn addition to the lifestyle modifications discussed earlier, there are many medications that can prevent further bone loss and possibly restore some bone mass. The medications have different side effects, instructions for use, and costs. Some insurance plans only pay for certain types of medications. Your clinician can talk with you about what treatment is most appropriate.More information on osteoporosis can be found at bones.health-info/bone/osteoporosis/overviewEDUCATION HANDOUTPOLYCYSTIC OVARY SYNDROMEI. DEFINITIONPolycystic ovary syndrome (PCOS) is a complex condition of the endocrine system that causes an imbalance in hormones. It is one of the most common hormonal conditions for women of reproductive age. In addition to hormonal imbalance, some women can develop multiple cysts on their ovaries.II. SIGNS AND SYMPTOMSNot all women have symptoms, and often women only have some of the symptoms listed.1.Menstrual cycles without ovulation2.Difficulty becoming pregnant3.No menses (periods) or very scanty menses4.Prolonged menses, sometimes unpredictable or irregular bleeding5.Increase in body and facial hair6.Increase in or appearance of acne7.Loss of hair, especially at the crown of the head8.Nipple discharge9.Change in body shape—increased waist-to-hip ratio (apple shape)10.Increase in skin pigment around the neck, under the arms, and in the groin areaIII. DIAGNOSISThe diagnosis is made based on your history, symptoms, exam, laboratory tests, and maybe an ultrasound of the ovaries. However, it is possible to have PCOS with normal appearing ovaries and normal lab tests. Testing can include measures of male and female hormones, tests for diabetes, and an ultrasound of the ovaries.IV. TREATMENTDietary and physical activity changes that result in weight loss are the first-line treatment.Oral contraceptive pills can help regulate the menstrual cycle and help with abnormal hormone levels.Prescription medications can help reduce excessive hair growth and acne.Medications for type 2 diabetes may be helpful.Electrolysis and/or depilatories for excessive hair.Medications to induce ovulation when pregnancy is desired.V. WHAT YOU SHOULD KNOWEven a small amount of weight loss (5% of your weight) can help. Changing your diet and exercising regularly are very important when managing PCOS. This will also decrease your chance of getting diabetes.Your clinician will talk to you about any prescription drugs that might help with your menstrual cycle and regulating hormones.Women with PCOS often do not ovulate every month. This could make becoming pregnant more difficult. Talk with your clinician if you decide you want to be pregnant in the next year.More information can be found at Patients/FAQs/Polycystic-Ovary-Syndrome-PCOS?IsMobileSet=falseEDUCATION HANDOUTPRECONCEPTION CAREI. DEFINITIONPreconception care involves getting regular health care before you become pregnant. This care will help you to be your healthiest before you are pregnant. Being healthy can help prevent complications for you and your baby. Working with your clinician, you can identify any medical problems or medications you are taking that need to be considered when contemplating a pregnancy. You may also wish to have a genetic consultation if you or your partner has a family history of inherited disorders or birth defects.II. WHAT YOU CAN DOGood health is important for a healthy pregnancy and baby. Preconception care can start well before you are thinking about having a baby. Specific things you can do to be healthy include maintaining a normal body weight, eating well, and getting exercise on most days. It is important to have all your immunizations completed, including a yearly flu vaccine. If you are due to have any specific screening tests such as a Pap smear or testing for STIs those should be done when needed. Smoking (including e-cigarettes), drinking alcohol, and using recreational drugs (including marijuana) should not be done during pregnancy because they can harm the baby. It may take more than one attempt to stop smoking or using drugs. Starting the process of quitting prior to being pregnant allows for a greater chance of not using these substances while pregnant and after the baby is born.III. HEALTHY DIETTaking a multivitamin every day will ensure that you receive the amount of folic acid you need both before and during pregnancy. Prior to being pregnant you can make any dietary changes that will improve your health. A balanced diet includes fresh fruits and vegetables, whole grains, lean protein, and six to eight glasses of water a day. You should try and decrease caffeine, sugary drinks, salt, and large amounts of processed food and fast food. Dietary changes can be challenging. Making small changes over time is often easier than changing many dietary practices all at once.IV. HEALTHY RELATIONSHIPDiscuss with your partner your feelings about parenting, your expectations of him or her, and what parenting means to you. How do you expect your life to change? How will having a child change your relationship, the way your household functions, your work schedule, your expectations and those of your partner? Who will be the primary parent? Will one or both of you have parenting leave? How will your finances be affected by having a child? How do you plan to integrate a new baby into the household with other children, extended family, and other members of the household?Planning for a pregnancy will help you be at your best when you conceive. It will also help you consider the changes that pregnancy and a baby will have on your life and the lives of those close to you.More information can be found at pregnancy/planning-your-pregnancy.aspxEDUCATION HANDOUTPREMENSTRUAL SYNDROMEI. DEFINITIONPremenstrual syndrome (PMS) consists of a group of physical and emotional symptoms that can occur during the last 2 weeks of the menstrual cycle. The symptoms may be bothersome, but they are not harmful.II. SIGNS AND SYMPTOMSSymptoms usually appear 1 week prior to your period but may also appear up to 2 weeks or just several days before your period starts. Women may experience some or all these symptoms.1.Mood fluctuations: anxiety, crying, irritability, depressed mood2.Fatigue3.Weight gain, bloating4.Headache5.Breast tenderness6.Appetite changes, craving for sweets and/or salt7.Acne8.CrampingIII. TREATMENTPMS symptoms can often be managed with changes to diet and lifestyle.Diet recommendations include1.Limit sugar and processed foods that often have high amounts of salt and simple carbohydrates.2.Limit your intake of alcohol.3.Decrease caffeine (e.g., coffee, tea, chocolate, soft drinks).4.Increase your intake of complex carbohydrates (e.g., fresh fruit, vegetables, whole grains).5.Consume moderate protein and fat. Limit your red meat consumption to two times weekly.Exercise recommendations include1.Try to exercise most days—aim for exercise at least 5 days per week for 30 to 45 minutes2.Yoga and stretching may also help with cramping and discomfortMedications1.There are medications that can help if your symptoms are very bothersome. Talk with your clinician about what treatment might be right for you.Consider complementary therapies such as meditation, yoga, mindfulness, and acupuncture. Some women find these therapies to be helpful.More information on PMS can be found at Patients/FAQs/Premenstrual-Syndrome-PMS?IsMobileSet=false menstrual-cycle/premenstrual-syndromeEDUCATION HANDOUTSCABIESI. DEFINITIONScabies is a highly contagious skin rash. The main symptom is itching. Scabies is caused by the scabies mite that burrows into the skin and deposits its eggs. The eggs hatch in 3 to 5 days and gather around hair follicles.II. TRANSMISSIONScabies among adults can be sexually transmitted or acquired in conditions of overcrowding or living closely with many people.Persons living close to each other, in dormitories, and in crowded living spaces are more likely to get scabies if one person among them becomes infested with the mite. Persons sharing clothing or towels are at increased risk.III. SIGNS AND SYMPTOMSMay appear 4 to 6 weeks after contact with scabies from another person because it takes several weeks for sensitization to develop. In persons who are previously infected, symptoms may appear within 24 hours after repeat exposure to the scabies mite.Itching becoming worse at night or at times when the body temperature is raised, such as after exercise or a hot shower. Itching begins first, before other signs and symptoms.Lesions look like burrow lines with raised, red areas and can occur on the webs between fingers, the inner aspects of the wrists and elbows, beltline, lower abdomen, and pubic area. These lesions can become scaly and become crusted over. When scratched, the areas become irritated and uncomfortable.IV. DIAGNOSISYour clinician can make a diagnosis by listening to your symptoms, looking at the lesions, and might be able to see the mite under a microscope.V. TREATMENTThere are medications that either require a prescription from your clinician or can be purchased over the counter in a pharmacy or drug store. The medications can be pills or creams that are used to kill the scabies mites.Your clinician will talk to you about which treatment is best and how to use it. There are also medications such as antihistamines that can help with itching.General measures to decrease the risk of reinfestation include1.Clothing, towels, and bed linens should be laundered (hot cycle) and dried on heat cycle or dry cleaned on day of treatment with medication.2.If clothing items cannot be washed or dry cleaned, separate them from the cleaned clothes and do not wear for at least 72 hours. Mites cannot exist for more than 2 to 3 days away from the body. You can decontaminate mattresses, sofas, and rugs with over-the-counter sprays or powders.3.Sexual partners and close personal or household contacts within the past month should be informed and referred to a clinician for examination and treatment.VI. WHAT YOU SHOULD KNOWFollow the treatment regimen carefully.Itching may persist for several weeks. If you do not respond to therapy and if itching persists after 1 week, contact your clinician to decide whether further therapy is necessary.Call your clinician if the infested areas do not seem to be healing, are swollen or warm to the touch, or look infected.VII. FOLLOW-UPMost infections clear with treatment. There is no specific need to follow-up unless you think the infection is not getting better or you have new symptoms.More information can be found at parasites/scabies/index.htmlEDUCATION HANDOUTSMOKING CESSATIONSmoking is the leading cause of preventable illness and early death in the United States. If you stop, you can expect an increase in your life expectancy and an improvement in your health. Smokers are at risk for many health conditions such as cancers, lung disease, and heart disease. Children who are exposed to secondhand smoke also have more breathing problems and infections.Quitting smoking can be difficult. Often people try to quit many times before they are successful. If you think you are ready and want to quit, the following suggestions may help:1.Make the decision to stop smoking and think about why you want to stop smoking. Let friends and family know you are trying to quit and ask for their support and encouragement.2.Try and identify things such as social situations or people that you associate with smoking. Think about ways you can avoid smoking when these things occur.3.Some people smoke more when they drink alcohol. Try and avoid alcohol if it triggers a craving to smoke.4.Once you have made a decision to quit, remove all smoking materials from your house, car, or any other areas.5.Avoid being around other smokers if possible.6.If possible, establish living space as “no smoking” if you live with other people who smoke.7.Increase exercise. Some people report that exercise helps reduce the urge to smoke.8.Support groups can be helpful. Consider joining one if you would like this kind of support.9.Talk with your clinician about wanting to stop smoking. Your clinician can help you choose the most appropriate method that fits your needs. There are pills that can reduce the urge to smoke and nicotine replacement gum, patches, inhalers, and lozenges that can reduce rmation about quitting smoking can be found at healthy/stay-away-from-tobacco/guide-quitting-smoking.htmlEDUCATION HANDOUTSTRESS OR URGE URINARY INCONTINENCEI. DEFINITIONStress and urge urinary incontinence are caused by relaxation of the muscles and ligaments of the pelvic floor, which support the bladder, uterus, urethra (tube leading from the bladder to the outside), lower bowel, and vagina. Because of this relaxation, which can happen with childbirth and aging, any stress (such as laughing, coughing, or sneezing) can cause involuntary loss of urine or the need to urinate urgently, known as urge incontinence.II. TRACKING SYMPTOMSKeeping a log of when the urine leaking happens and how much urine loss occurs can help your clinician suggest the best options for treatment. The following situations are commonly associated with stress incontinence. Also consider how much urine you lose with each activity (a few drops to a gush).1.Coughing/sneezing2.Laughing/crying3.Blowing nose4.Climbing stairs5.Bending over6.Sitting or resting7.Washing hands or dishes8.Other timesIII. TREATMENTThere are many ways to treat incontinence.Incontinence products are available that can be used while you are determining your options. If you are overweight, weight loss can help decrease pressure on the pelvic area. Excessive caffeine and smoking can be irritating to the bladder. Some women decide to have surgery to improve the incontinence.Pelvic floor physical therapy can help strengthen the muscles that support the bladder. But there are also exercises you can do on your own. Practice contracting, holding, and relaxing each time you urinate until you can stop the flow completely and start and stop at will. Do these exercises periodically throughout the day to help strengthen the muscles around your bladder.Some medications can help with the urge to urinate frequently. Talk with your clinician to see if treatment with medication is appropriate for the type of incontinence you have.More information on urinary incontinence can be found at a-z-topics/urinary-incontinenceEDUCATION HANDOUTSYPHILISI. DEFINITIONSyphilis is an STI caused by the organism Treponema pallidum. It can infect the vagina, rectum, and mouth and if not treated spreads throughout the body. It is spread by sexual contact and can also be passed on from a woman to her unborn baby.II. IMPORTANT INFORMATIONAny sexually active person can become infected with syphilis. An untreated person can spread syphilis for at least 1 year after being infected.Symptoms can occur 10 to 90 days after sexual contact. Most people notice symptoms within a month after being infected.III. USUAL SIGNS AND SYMPTOMS: WHAT YOU MAY EXPERIENCEA.Primary syphilis. The first sign of syphilis is a painless chancre (sore) at the site of entry of the syphilis organism. It usually appears about 3 weeks after infection has occurred. The chancre may occur at any site of sexual activity, including the mouth, vagina, or rectum. The chancre is not painful and sometimes you do not notice it. It eventually heals even if not treated. Without treatment, syphilis progresses to the secondary stage.B.Secondary syphilis. Within a few weeks to a few months after the chancre appears (average 6 weeks), a rash may develop on your body. Your chest, back, abdomen, and palms of your hands or the soles of your feet are common areas for the rash. You may have a low-grade fever, a sore throat, headache, sore joints, and feel tired. This will last about 6 weeks and go away without treatment. If you are not diagnosed and treated, syphilis will continue to progress.C.Latent syphilis. You will have no symptoms but the organism is in your blood. After 12 months from the initial infection, you are probably not contagious anymore. If you are not diagnosed and treated, you may remain in the latent stage for the rest of your life.D.Tertiary syphilis. One third of people infected with syphilis and not treated will go into the tertiary stage. In this stage, your bones, skin, heart, or brain can be affected. People with tertiary syphilis can die from complications of the disease.IV. DIAGNOSISA diagnosis of syphilis is made if there is history of sexual contact with a known infected person and from the results of blood tests.V. TREATMENTThe treatment is the antibiotic penicillin given by a shot (injection). For those allergic to penicillin, other antibiotics can be used but they can be less effective. It might be recommended that your penicillin allergy be treated so you can use that antibiotic. The amount of antibiotics and length of treatment will depend on the stage of the syphilis.VI. COMPLICATIONSProgression of the disease to tertiary stage.Transmission of syphilis from a woman to her unborn baby, causing syphilis in the baby. Syphilis can cause permanent damage to the baby.Transmission of the infection to sexual partners. VII. WHAT YOU SHOULD KNOWYour health care provider will tell you how much medication you need to treat syphilis. You will need to come to the office for your injection.You will need to have your blood tested at least every 6 months for a while to check and see if the infection is going away.You should notify all sexual partners and they should be tested and treated. Do not have any sexual contact until everyone has finished their treatment.There is no immunity to syphilis, so you can be reinfected by another partner. Using condoms will reduce the chance of getting STIs.If you have syphilis, you should be tested for HIV and other STIs.More information can be found at std/syphilis/default.htmEDUCATION HANDOUTTRICHOMONIASISI. DEFINITIONTrichomoniasis is a parasitic infection occurring in the female vagina. It can also infect the urethra and prostate of a male partner. The infection is considered to be sexually transmitted and transmission without sexual activity is rare.II. SIGNS AND SYMPTOMSSymptoms usually appear within a month of getting the infection.Women may have no symptoms or experience1.Foul-smelling, greenish yellow, frothy vaginal discharge (often fishy smelling)2.Discomfort with intercourse or urination3.Irritation, itching, and discomfort inside and outside of the vaginaMale partners often have no symptoms or can have mild discomfort or discharge from the penis.III. DIAGNOSISWomen are often diagnosed after a pelvic exam and examination of the vaginal discharge. This can be done in the office by looking at the discharge under a microscope of by sending a swab to the laboratory.IV. TREATMENTYou will be given antibiotics to treat the infection and all partners should also be treated so you will not be reinfected with the parasite. Your clinician will review your medical history and allergies before choosing an antibiotic that is appropriate.V. WHAT YOU SHOULD KNOWThe types of antibiotics that treat trichomoniasis cannot be taken with alcohol because the combination causes severe vomiting. You need to avoid alcohol during treatment and for 24 to 72 hours after you finish the medication.The antibiotics may cause nausea and a metallic taste in your mouth.You should contact your sexual partner(s) and have them seek treatment. Avoid sex until everyone has completed treatment.Condoms can reduce your risk of STIs such as trichomoniasis.VI. FOLLOW-UPReturn to your clinician if symptoms do not improve or new symptoms occur.More information can be found at std/trichomonas/default.htmEDUCATION HANDOUTVAGINAL CONTRACEPTIVE SPONGEI. DEFINITION/HOW IT WORKSThe vaginal contraceptive sponge is a round polyurethane device with an indentation in the center. The center area fits over the cervix. The sponge has a string loop to provide for easy removal. It contains the spermicide nonoxynol-9 and provides a barrier between the sperm and the cervix, traps sperm within the sponge, and releases spermicide to inactivate sperm over 24 hours.II. EFFECTIVENESS AND INFORMATIONAbout 80% to 90% effective; less effective for women who have had a baby.May be inserted before intercourse and left in place for up to 24 hours.Latex free.Can be purchased without a prescription in pharmacies and stores that sell family planning products.No need to add extra spermicide if you have sex again within 24 hours.III. POSSIBLE SIDE EFFECTSVaginal irritation from the sponge and/or spermicide.Difficulty in inserting or removing the sponge.Concern about sponge use increasing the risk of toxic shock syndrome if not used as directed (left in longer than 30 hours or used with your period).Frequent use of nonoxynol-9 can cause genital irritation and increase the risk of HIV and other sexually transmitted infections.IV. INSTRUCTIONS FOR USEInstructions on how to use, insert, and remove are detailed on the package1.Wet the sponge with water and insert high into the vagina as you would a tampon.2.The sponge can be left in place for up to 30 hours from the time you inserted it and offers protection for each act of intercourse.3.To be effective, it must stay in place for at least 6 hours after intercourse.4.Remove by pulling down on the loop. Squatting down may help you reach the sponge more easily.V. ADDITIONAL INFORMATIONThe sponge can be used during swimming or bathing but cannot be used during your period.The sponge cannot be reused once it is removed.VI. SIGNS OF TOXIC SHOCK SYNDROMEToxic shock syndrome is unlikely if the sponge is used according to the product directions. However, you should let your health care provider know if you develop1.Fever (temperature higher than 101°F)2.Vomiting and diarrhea3.Muscle aches, flu-like symptoms4.Rash that resembles a sunburnVII. FOLLOW-UPNo specific follow-up is required other than routine health care and screening tests based upon your age and history. If you want a different method of birth control, talk with your clinician.More information can be found at APPENDIX AAbuse Assessment Screen1.Have you EVER been emotionally or physically abused by your partner or someone important to you? YES/NO2.WITHIN THE LAST YEAR, have you been hit, slapped, kicked, or otherwise physically hurt by someone? YES/NOIf YES, by whom? _______________Total number of times: _______________3.SINCE YOU HAVE BEEN PREGNANT, have you been hit, slapped, kicked, or otherwise physically hurt by someone? YES/NOIf YES, by whom? _______________Total number of times: _______________Mark the areas of injury on a body map (Figure A.1)Score each incident according to the following scale:1 = Threats of abuse, including use of a weapon2 = Slapping, pushing; no injuries, and/or lasting pain3 = Punching, kicking, bruises, cuts, and/or continuing pain4 = Beating up, severe contusions, burns, broken bones5 = Head injury, internal injury, permanent injury6 = Use of weapon; wound from weaponIf any of the descriptions for the higher number apply, use the higher number.4.WITHIN THE LAST YEAR, has anyone forced you to have sexual activities?YES/NOIf YES, by whom? _______________Total number of times: _______________5.ARE YOU AFRAID of your partner or anyone in your life? YES/NOSource: Used with permission. Developers: Judith McFarlane, Barbara Parker, Karen Soeken, and Linda Bullock.McFarlane, J., Parker, B., Soeken, K., & Bullock, L. (1992). Assessing for abuse during pregnancy: Severity and frequency of injuries and associated entry into prenatal care. Journal of the American Medical Association, 267, 3176–3178; Soeken, K. L., McFarlane, J., Parker, B., & Lominack, M. C. (1998). The abuse assessment screen: A clinical instrument to measure frequency, severity, and perpetrator of abuse against women. In J. C. Campbell (Ed.), Sage series on violence against women. Empowering survivors of abuse: Health care for battered women and their children (pp. 195–203). Thousand Oaks, CA: Sage Publications.Spanish translation available:Pearce, C. W., Hawkins, J. W., Kearney, M., Peyton, C. E., Dwyer, J., Haggerty, L. A., . . . Aber, C. S. (2003). Translation of domestic violence instruments for use in research. Violence Against Women, 9(7), 859–878.FIGURE A.1 Body map.APPENDIX BDanger Assessment: Women With Male or Female PartnersDANGER ASSESSMENTJacquelyn C. Campbell, PhD, RN Copyright ? 1985, 1988, 2001Several risk factors have been associated with homicides (murders) of both batterers and battered women in research conducted after the murders have taken place. We cannot predict what will happen in your case, but we would like you to be aware of the danger of homicide in situations of severe battering and for you to see how many of the risk factors apply to your situation.Using the calendar, please mark the approximate dates during the past year when you were beaten by your husband or partner. Write on that date how bad the incident was according to the following scale:1.Slapping, pushing; no injuries and/or lasting pain2.Punching, kicking; bruises, cuts, and/or lasting pain3.“Beating up”; severe contusions, burns, broken bones4.Threat to use weapon; head injury, internal injury, permanent injury5.Use of weapon; wounds from weapon(If any of the descriptions for the higher number apply, use the higher number.)Mark Yes or No for each of the following. (“He” refers to your husband, partner, ex-husband, ex-partner, or whoever is current physically hurting you.)____1.Has the physical violence increased in severity or frequency over the past year?____2.Has he ever used a weapon against you or threatened you with a weapon?____3.Does he ever try to choke you?____4.Does he own a gun?____5.Has he ever forced you to have sex when you did not wish to do so?____6.Does he use drugs? By drugs, I mean “uppers” or amphetamines, speed, angel dust, cocaine, “crack,” street drugs, or mixtures.____7.Does he threaten to kill you and/or do you believe he is capable of killing you?____8.Is he drunk every day or almost every day? (In terms of quantity of alcohol)____9.Does he control most or all of your daily activities? For instance, does he tell you who you can be friends with, when you can see your family, how much money you can use, or when you can take the car? (If he tries, but you do not let him, check here: ___________ )____10.Have you ever been beaten by him while you were pregnant? (If you have never been pregnant by him, check here: ____________ )____11.Is he violently and constantly jealous of you? (For instance, does he say “If I can’t have you, no one can.”)____12.Have you ever threatened or tried to commit suicide?____13.Has he ever threatened or tried to commit suicide?____14.Does he threaten to harm your children?____15.Do you have a child that is not his?____16.Is he unemployed?____17.Have you left him during the past year? (If you never lived with him, check here: ____________ )____18.Do you currently have another (different) intimate partner?____19.Does he follow or spy on you, leave threatening notes, destroy your property, or call you when you do not want him to?Total “Yes” AnswersThank you. Please talk to your nurse, advocate, or counselor about what the Danger Assessment means in terms of your situation.Source: Used with permission.Campbell, J. C., Webster, D. W., & Glass, N. (2009). The danger assessment: Validation of a lethality risk assessment instrument for intimate partner femicide. Journal of Interpersonal Violence, 24(4), 653–674.ResourcesDA.aspxuploads/permissionword.pdfDANGER ASSESSMENT-RevisedFor Use in Abusive Female Same-Sex RelationshipsNancy Glass, PhD, MPH, RN and Jacquelyn C. Campbell, PhD, RN, FAANCopyright 2007 Johns Hopkins University, School of NursingSeveral risk factors have been associated with increased risk of reassault of women in abusive same-sex relationships. We cannot predict what will happen in your case, but we would like you to be aware of the danger of repeat abuse and for you to see how many of the risk factors apply to your situation.Using the calendar, please mark the approximate dates during the past year when you were abused by your partner or ex-partner. Write on that date how bad the incident was according to the following scale:1.Slapping, pushing; no injuries and/or lasting pain2.Punching, kicking; bruises, cuts, and/or continuing pain3.“Beating up”; severe contusions, burns, broken bones, miscarriage4.Threat to use weapon; head injury, internal injury, permanent injury, miscarriage5.Use of weapon; wounds from weapon(If any of the descriptions for the higher number apply, use the higher number.)Mark Yes or No for each of the following.(“She” refers to your female partner or ex-partner)YesNo________________________________________________________________________________________________________________________1.Is she constantly jealous and/or possessive of you?2.Does she try to isolate you socially?3.Has the physical violence increased in severity or frequency over the past year?4.Has she threatened you with a gun over the past year?5.Have you lived with her in the past year?6.Has she ever abused or threatened to abuse a previous intimate partner, or their family members or friends?7.Does she use illegal drugs (by illegal drugs, I mean “uppers” or amphetamines, “meth,” speed, angel dust, cocaine, “crack,” street drugs, or mixtures) or abuse prescription medication?8.Is she an alcoholic or problem drinker?9.Does she try to control/limit your spirituality?10.Does she constantly blame you and/or put you down?11.Has she destroyed or threatened to destroy things that belong to you?12.Has she threatened to harm a12a.Pet?12b.Elderly family member?12c.Person you care for with a disability?________________________________________________13.Has she ever violated a restraining order?14.Does she stalk you, for example, follow or spy on you, leave threatening notes or messages on answering machine or cell phone, call you when you do not want her to?15.If you were being abused by her and tried to get help, do you think people would not take you seriously?16.If you were being abused by her, would fear of reinforcing negative stereotypes about female same-sex relationships and/or being discriminated against prevent you from seeking help, for example, help from friends, domestic violence advocates, or health care providers?17.If you were having serious difficulties with her, would you keep it a secret out of fear or shame?18.Have you threatened or tried to kill yourself?Total “Yes” AnswersThank you. Please talk to your nurse, advocate, or counselor about what the Danger Assessment-Revised means in terms of your situation.Weighted Score for DA-RYes to Item 1 = 4 points; Yes to Item 2 = 3 points; Yes to Item 3 = 2 points; Yes to Item 4 = 2 points; Yes to Item 5 = 2 points; Yes to Item 6 = 2 points; Yes to Items 7–17 = 1 point eachItem 18 is not scored, assessing her suicide attemptSource: Used with permission.Glass, N., Perrin, N., Hanson, G., Bloom, T., Gardner, E., & Campbell, J. C. (2008). Risk for reassault in abusive female same-sex relationships. American Journal of Public Health, 98(6), 1021–1027.APPENDIX CHIV Risk AssessmentHIV TestingWho should get tested for HIV??Everyone between the ages of 13 and 64 should get tested for HIV at least once.?If you are pregnant or planning to get pregnant, get tested as early as possible to protect yourself and your baby.?You should get tested at least once a year if?You are a sexually active gay or bisexual man. Some sexually active gay and bisexual men may benefit from more frequent testing (every 3 to 6 months).Other people should get tested for HIV if you have?Had sex with an HIV-positive partner.?Had more than one partner since your last HIV test.?Shared needles or works to inject drugs.?Exchanged sex for drugs or money.?Had another sexually transmitted infection, hepatitis, or tuberculosis.?Had sex with anyone who has done anything listed earlier or with someone whose sexual history you do not know.HIV PreventionIn addition to safer sex practices such as limiting partners and using condoms all the time, there are medications that help reduce the risk of HIV infection.■? Postexposure ProphylaxisPostexposure prophylaxis (PEP) involves taking medication after you may have been exposed to HIV to reduce your risk of getting HIV. If you may have been exposed to HIV in the last 72 hours, talk to your health care provider, an ED provider, or your local health department about PEP right away.Who should consider PEP? In the last 72 hours were you?Possibly exposed to HIV during sex—the condom broke or you did not use one?Sharing needles and works to prepare drugs and inject drugs?Sexually assaultedHow do I take PEP??PEP must be started within 72 hours (3 days) after you may have been exposed to HIV. But the sooner you start PEP, the better. Every hour counts!?PEP needs to be taken once or twice daily for 28 days. Your provider will explain how to take the medication. It is very important that you take it as directed for the full 28 days.?PEP is effective in preventing HIV, but not 100%. It should not be used routinely. You should always use condoms with sex partners and use clean needles and safe injection practices if you use drugs.■? PreExposure ProphylaxisPreexposure Prophylaxis (PrEP) is for people who are HIV negative but at very high risk for HIV. PrEP involves taking medication every day to reduce the risk of getting HIV. PrEP can reduce your chance of getting HIV from sex by 90%. If you inject drugs, PrEP can reduce your chance of HIV by 70%. Using condoms all the time decreases your risk even more.How to decide if PrEP is right for you?If you are HIV negative and any of the following conditions apply to you:Gay or Bisexual ManHeterosexualInjection Drug UserHave a HIV+ partnerHave a HIV+ partnerShare needles or equipment to inject drugsHave multiple partners, a partner with multiple partners, or a partner whose HIV status is unknown, and you also have anal sex without a condomorRecently had a sexually transmitted infectionHave multiple partners, a partner with multiple partners, or a partner whose HIV status is unknown, and you also do not always use a condom for sex with people who inject drugsorDo not always use a condom for sex with bisexual menAre at risk for getting HIV from sexWhile taking PrEP, you need to have an HIV test every 3 months. If you do not have a health care provider and need help locating one who will prescribe PrEP, visit Source: Adapted from the Centers for Disease Control and Prevention (CDC): hivAPPENDIX DWomen and Heart Disease: Risk Factor AssessmentI.NONMODIFIABLEA.Age: Heart disease is the leading cause of death for adult women; risks increase with age and after the menopause transitionB.Race or ethnicity: Black women have a higher rate of death than White women. Rates of diabetes and hypertension in Black women are higher than those in White women. Systemic racism is a significant contributing factor for heart disease among women of color.C.Family history of the disease, especially myocardial infarction or stroke at age younger than 50 years oldD.Sex: Attenuating advantage of being a woman, especially premenopausally when women’s risk is lower than men’sII.MODIFIABLEA.Lifestyle1.Exercise: Aerobic physical activity can reduce the risk of atherosclerotic cardiovascular disease (ASCVD). Adults should reduce overall sedentary behavior and engage in at least 150 minutes of accumulated moderate-intensity physical activity or 75 minutes of vigorous-intensity physical activity per week.a.Moderate-intensity activity includes brisk walking (2.4–4 mph), biking (5–9 mph), dancing, active yoga, recreational swimmingb.Vigorous-intensity activity includes jogging, running, swimming laps, biking (≥10 mph), playing tennis, racquetball2.Chronic diseases: Diabetes, obesity, and hypertension increase ASCVD. If present, these conditions should first be managed with lifestyle modification or pharmacologic therapies if lifestyle changes are ineffective.3.Nutritional recommendations:a.Replace saturated fat with monounsaturated and polyunsaturated fatsb.Overall fat intake between 20% and 35% of all calories (20% is best)c.Avoid trans fatsd.Less than 2,000 mg day of sodium (<1,500 mg per day with hypertension)e.Maintain body mass index (BMI) between 18.5 and 24.9 kg/m2f.Diet that emphasizes the intake of fruits, vegetables, legumes, fish, lean protein, nuts, and whole grainsg.Minimize intake of animal fats, red meat, processed foods, sugar, refined, simple carbohydrates, and sugary and sweetened drinksh.Reduce alcohol intake to ≤1 drinks per day4.Cigarette smoking (including use of e-cigarettes)a.Assess all women for tobacco use at every visit for the risk of adverse cardiovascular and thrombotic eventsb.Advise all women of the health risks of tobacco and encourage quittingc.Assess readiness to quit and offer behavioral interventions and/or pharmacotherapy to increase success with tobacco cessationd.Encourage avoidance of secondhand smoke when possiblee.Caution regarding the risks of e-cigarettesf.Smoking and use of combination hormonal contraception increases the risk of adverse cardiovascular and thrombotic eventsB.Internal and external environmental factorsa.Management of comorbid health conditionsb.Psychosocial concerns: chronic stress contributes to comorbid health conditions. Encourage women to manage stress in their livesc.Access to health care: Regular, preventive health care and age-related screening tests are an important component of cardiac risk reduction.d.Encourage all women to explore options for health insurance.e.Socioeconomic status: Inverse association with morbidity and mortalityResourcesdoi/10.1161/CIR.0000000000000678en/health-topics/consumer-healthcare/what-is-cardiovascular-disease/heart-health-risk-assessments-from-the-american-heart-associationAPPENDIX EEndometrial BiopsyI.DEFINITION AND PURPOSEA.Endometrial biopsy is a method of obtaining a sample of the uterine lining from a woman who is not pregnant. Biopsy allows for cytologic and histologic examination. The procedure is quick and can easily be completed during a routine outpatient office visit.B.Endometrial biopsy is an important skill for nurse practitioners to master because it is done frequently and can provide important information regarding the endometrial lining. Biopsy is done when there is unexplained abnormal vaginal bleeding for women of any age, to rule out endometrial pathology for women who are postmenopausal and bleeding (with or without hormone therapy), and to monitor response to drug therapy for women who are taking medications known to cause endometrial hyperplasia, such as tamoxifen.C.Most women tolerate an endometrial biopsy without any adverse effects and no specific preparation is necessary. If the procedure is planned, women can take a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen 600 mg orally prior to leaving for their appointment. The evidence to show this is helpful is lacking, although it can be considered for women who are concerned about discomfort and cramping. The procedure should not be delayed or postponed if women have not premedicated with an NSAID.D.Most practices have their own consent for procedures and the woman should be allowed to ask questions and sign a consent for the endometrial biopsy. A pelvic exam and speculum exam are necessary to determine the uterine and cervical position and uterine size, shape, flexion, and contour. An endometrial biopsy is contraindicated if pregnancy cannot be ruled out or pelvic inflammatory disease (PID) is suspected. A urine human chorionic gonadotropin (hCG) should be obtained prior to the procedure. If acute cervicitis, vaginal or cervical infections are present or strongly suspected, the biopsy should be postponed until the infection is treated.II.BIOPSY TECHNIQUEA.?Cleanse cervix and vagina with antiseptic, considering any sensitivities, allergies.B.Administer local anesthetic agent to the cervix (lidocaine gels, other topical gel or spray products, or paracervical block) if necessary/desired, depending on sampling technique and equipment to be used.C.The cervix is stabilized with a tenaculum. A local anesthetic at the site for tenaculum placement can reduce pain. After the tenaculum has been applied, sound the uterus—average depth is 6 to 10 cm.D.Insert the sampling pipelle in the os, taking care not to force the device through a resistant os. If the os is stenotic, cervical dilators may be used. The pipelle should be inserted gently to the same depth as determined by the sound.1.Pipelle device (flexible sampler with a piston to create suction for sampling): Insert up to the fundus. Pull back completely on the piston to create suction and rotate the pipelle continuously, moving it from the fundus and back again several times to collect the sample completely, filling the plastic tube. Withdraw the pipelle and push in the piston to deposit the sample into the preservative.E.Monitor the woman during and after the procedure to assess for vasovagal response and signs/symptoms of uterine perforation (rare with training and experience).F.Allow the woman to rest briefly before getting off the examination table. Ensure that she is not feeling dizzy and there are no signs of a vasovagal reaction prior to leaving her so she can get dressed.G.Instruct the woman regarding postprocedure care and follow-up1.Signs and symptoms of complications are severe cramping or pelvic pain; bright red bleeding with or without clots; fever, chills, foul-smelling vaginal discharge. These are uncommon but should be reported immediately2.Spotting can occur for 1 to 2 days after the biopsy, but heavy bleeding should be reported3.Vaginal intercourse can resume in 2 to 3 days4.If cramping occurs postprocedure, NSAIDs can be used5.If premenopausal and having menstrual cycles, menses should resume at expected timeIII.Follow-upA.Women should be told when the pathology results will be available and how they will be informed of the results (phone call, patient portal, letter, etc.)B.Treatment is based upon biopsy resultsC.No specific postprocedure visit is necessary, and follow-up is based on underlying reason for the biopsyIV.ReferralA.Some women have significant cervical stenosis that makes it difficult or impossible to pass the sound or pipelle through the cervix. Co-management with physician colleagues is necessary and the woman may need the biopsy performed under general anesthesiaB.Biopsy results that indicate carcinoma or complex hyperplasia require referralC.Consider physician consult for all abnormal results to review plan of careAPPENDIX FDifferential Diagnosis of Vaginitis and VaginosisDiagnostic CriteriaConditionNormalBacterial VaginosisCandida VulvovaginitisTrichomonas VaginitisVaginal pH3.8–4.2>4.5.5 (usually)>4.5DischargeWhite, clearThin, homogeneous, white, gray, adherent, often increasedWhite, curd-like, clumpy; sometimes increasedYellow, green, frothy, adherent, increasedAmine odor (KOH “whiff test”)AbsentPresentAbsentPresent, but not alwaysMicroscopicLactobacilliClue cells, coccoid bacteria, no WBCsBudding yeast, pseudohyphae with KOHTrichomonads, WBCs > 10 HPFCommon complaintsNoneMalodorous discharge (worse after sex), potential itchingItching, burning, stinging, thick discharge; dysuria possibleFrothy malodorous discharge, vulvar pruritus, dysuriaHPF, high-power field; KOH, potassium hydroxide; WBC, white blood cell.APPENDIX GBody Mass Conversion Table-15525751102360Weight(lb)125130135140145150155160165170175180185190195200205210215220225(kg)56.859.161.463.665.968.270.572.775.077.379.581.884.186.488.690.993.295.597.7100.0102.3Height(in)(cm)58147.326272829303132343536373839404142434445464759149.925262728293031323334353637383940414344454660152.424252627282930313233343536373839404142434461154.924252627272829303132333435363738394041424362157.523242526272728293031323334353637383839404163160.022232425262728282930313233343536363738394064162.622222324252627282829303132333434353637383965165.121222323242526272828293031323333343536373866167.620212223232425262727282930313232333435363667170.220202122232424252627272829303131323334353568172.719202121222324242526272728293030313233343469175.318192021212223242425262727282930303132333370177.818191920212222232424252627272829293031323271180.317181920202122222324242526272728292930313172182.917181819202021222223242425262727282929303173185.417171819192020212222232424252626272828293074188.016171718191920212122232324242526262728282975190.516161718181919202121222323242425262627282876193.015161617181819202021212223232424252626272700Weight(lb)125130135140145150155160165170175180185190195200205210215220225(kg)56.859.161.463.665.968.270.572.775.077.379.581.884.186.488.690.993.295.597.7100.0102.3Height(in)(cm)58147.326272829303132343536373839404142434445464759149.925262728293031323334353637383940414344454660152.424252627282930313233343536373839404142434461154.924252627272829303132333435363738394041424362157.523242526272728293031323334353637383839404163160.022232425262728282930313233343536363738394064162.622222324252627282829303132333434353637383965165.121222323242526272828293031323333343536373866167.620212223232425262727282930313232333435363667170.220202122232424252627272829303131323334353568172.719202121222324242526272728293030313233343469175.318192021212223242425262727282930303132333370177.818191920212222232424252627272829293031323271180.317181920202122222324242526272728292930313172182.917181819202021222223242425262727282929303173185.417171819192020212222232424252626272828293074188.016171718191920212122232324242526262728282975190.516161718181919202121222323242425262627282876193.0151616171818192020212122232324242526262727 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download