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Dysmenorrheapainful menstruationattributed to prostaglandin activityincreased leukotriene levelsone of the most common complaintspain prevents normal activity and requires medication3 types of dysmenorrhea:primary (no organic cause)secondary (pathologic cause)endometriosis, adenomyosis, pelvic inflammatory disease, cervical stenosis, fibroids, and endometrial polypsmembranous (cast of endometrial cavity shed as a single entityrare; it causes intense cramping pain due to passage of a cast of the endometrium through an undilated cervixClinical Findingsalmost always is associated with ovulatory cycles, it does not usually occur at menarche but rather later in adolescence14–26% of adolescents miss school or workpain occurs on the first day of the menses - about the time the flow beginsmay not be present until the second day.NauseaVomitingDiarrheaHeadacheNo significant pelvic diseaseWhen symptomatic - generalized pelvic tenderness, perhaps more so in the area of the uterus than in the adnexa.Occasionally, ultrasonography or laparoscopy is necessary to rule out pelvic abnormalities such as endometriosis, pelvic inflammatory disease, or an accident in an ovarian cyst.Treatmentcontinuous heat to the abdomen in addition to NSAIDs decreases pain significantlyIbuprofen and Naproxen are prefered - First LineSevere PainCodeine or stronger pain medicationscyclooxygenase-2 (COX-2)Rofecoxib, valdecoxib, and lumiracoxib are effective for treating primary dysmenorrheamust be used at the earliest onset of symptoms, usually at the onset of, and sometimes 1–2 days prior to, bleeding or crampingCyclic administration of oral contraceptives, usually in the lowest dosage but occasionally with increased estrogen, prevents pain in most patients who do not obtain relief from antiprostaglandins or cannot tolerate themgiven for 6–12 months. Many women continue to be free of pain after treatment has been discontinuedCystocele aka Anterior Vaginal Prolapsevaginal wall weakens and stretches and allows the bladder to bulge into the vaginaCauses- childbirth chronic constipationviolent coughingheavy liftingOverweightAgehysterectomy (increased vag weakness)Sxfelling of fullness or pressure in vaginaincreased discomfort when you strain/cough/bear downfeeling of incomplete emptyrepeated bladder infectionpain or urinary leak during sexbulge of tissue into vaginal openingPreventionKegelsprevent constipationavoid heavy liftingavoid wt gain Rectocele aka Posterior Vaginal ProlapseWhen thin tissue of vagina separates the vaginal and rectum allowing vaginal wall to bulgeSxsoft bulge of tissue in vaginaldifficult BMsensation of rectal pressureincomplete emptying after BMsexual concerns-dyspareuniaCausesconstipation/strainchronic coughheavy liftingOverweightChildbirthagePreventionKegelsprevent constipationavoid heavy liftingCoughavoid wt gainUterine prolapse aka Apical Prolapsepelvic floor muscles and ligaments stretch and weaken and no longer provide support for uterus and protrude into vagina.CausesPregnancylarge baby deliverylower estrogen level after menopauseobesity Common in postmenopausal and one or more childbirthSxheaviness or pulling into pelvistissue protruding from vaginaurinary probs (leakage, retention)trouble having BMfeeling of sitting on small ballsexual concernsPreventionKegelstreat constipationcorrect liftingavoid wt gainTxpessarySTDsChlamydia TrachomatisReportable Most infections are asymptomatic25+ yoa most prevalentMost common STD in USAAnnual screening of all sexually active women < 25 as is screening in older women at increased risk for infection (new sexual partner, more than 1 partner, sexual partner with STI)Sites of infectionFemales: Cervicitis, endometritis, salpingitis, PIDMales: epididymitis, prostatitisBoth genders: urethritis, pharyngitis, proctitisComplications:PIDtubal scarringectopic pregnancyInfertilityReiter’s SyndromeFits-Hugh-Curtis SyndromeLabsNAATs- gold standardnegative whiff w/ mucopurulent d/c and + clue cells Treatment:Azithromycin 1g PO single dose ORDoxycycline 100mg BID PO x 7dTreat partner too.Abstain from sex for 7 days after tx.Can tx partner without seeing partner in most statesPregnant womenDo test of cure 3 weeks after tx then again within 3 monthsAzithromycin 1g PO single dose ORAmoxicillin 500mg TID x plicated Infections (PID)Rocephin 250 mg IM x 1 dose plus Doxycycline PO BID x 14d with or without Metronidazole PO BID x 14d.Syphilischronic, systemic disease caused by a sphirochete transmitted via contact with infectious moist lesion. Sexually acquired or vertically transmitted from infected mom.Reportable disease PreventionCondomwash w/ soap and water after sexscreen ppl @ high risk (men that have sex with men, drug trafficers, correctional facilities) Screen for syphilis if HIV infection, MSM, presence of genital ulcer, previous STD, pregnancy, intravenous drug use, or high risk.Primary:Painless chancre (heals in 6-9 wks if not tx)Chancre has clean base, well demarcated with indurated marginsWomen can have on cervix or inside vagina.Any mucus membraneSecondary:Condyloma lata (infectious white papulae in moist areas that look like white warts)Maculopapular rash on palms and soles that is NOT pruritic (may be generalized)Typically 6 wks - 6 months after onset of primary chancreFlu-like symptomsGeneral diffuse lymphadenopathyPatchy alopeciaHepatitisNephritis Latent StageAsymptomatic but has positive titersTertiary (3-10yrs)NeurosyphilisBlindness, paralysis, paresthesias, tabes dorsalis, gait abnormalities, confusion/dementiagumma (soft tissue tumors)Aneurysmsvalvular damageLabsT pallidum spirochetes on dark field exam of cutaneous lesionNot commonly used. 2 types of tests needed to dx syphilisTreponemalNontreponemalStep 1: (Nontreponemal) order rapid plasma regain (RPR) or VDRL. If reactive then order confirmatory testStep 2: (Treponemal) fluorescent treponemal antibody absorption (FTA-ABS), microhemagglutination test for antibodies (MHA-TP), TPPAIf RPR and FTA-ABS positive then diagnostic for syphilis.If RPR used then order additional RPR to document Tx responseUse same laboratory to monitorIf RPR or VDRL shows fourfold or higher (>1:4) decrease in titers, then pt is responding to tx.TreatmentPrimary Syphilis, Secondary, or Early Latent Syphilis (<1yr)Benzathine PCN G 2.4 million units IM x 1 doseLatent Syphilis (>1yr), Latent unknown duration, Late (tertiary)Benzathine PCN G 2.4 million units IM once per wk x 3 wksPCN allergy: Doxycycline, tetracycline, and for neurosyphilis, Rocephin; use these with close lab f/u; refer to specialistFollow-upRecheck RPR or VDRL at 6-12 months after txTX sexual partners from previous 90 days even if partner testing negativeTest partner and pt for for HIV and other STDsRefer to ID for suspected neurosyphilis, poor response to tx, PCN allergy, or if not familiar with management.HSV-1 & HSV-2Asymptomatic shedding occurs intermittently and pt is still contagiousHSV-1: usually oral infection, sometimes genitalHSV-2: causes most cases of recurrent genital herpes, can be oralClinical ManifestationsMay have prodrome (itching, burning, and tingling) on site.Sudden onset of small vesicles sitting on erythematous base. Easily ruptures and is painfulVesicle fluid and crusts are contagiousPrimary episode is more severe and can last from 2-4 wks.Recurrent breakoutsVirus lays dormant and can be reactivatedTreatmentHerpes viral culture or RPR assay for HSV-1 and HSV-2 DNA.Tzanck SmearOld testFirst episodeAcyclovir 400 mg TID x 7-10d200mg 5 times/d x 7-10d.Famciclovir 1g BID x 7-10dValacyclovir (Valtrex) TID x 7-10dFlare-up TxBest if tx srt within 1 d of onsetFamciclovir 125 mg BID x 5dZovirax BID or TID x 5d or Valtrex BID x 5dSuppressive TxAcyclovir 400 mg BIDFamciclovir 250 mg PO BIDPreventionconsistent condom use b/c viral shedding can occur in asymptomatic periods and can lead to transmission. ALL cases of genital ulcers R/O syphilis and HSVPregnant women, mechanical methods are used to destroy genital wartsChancroid pg 704Transmitted via sexual contact or on hands that have touched lesion. Caused by Haemophillus ducreyiReportable diseaseSxerythematous papule that evolves into pustule and degenerates into saucer shaped ragged ulcer that is circumscribed by inflammatory wheal. Tenderheavy foul discharge that is contagiousDxculture that grows H ducreyiTxAzithromycin 1 g PO once, ceftriaxone 250 mg IM once, cipro 500 mg PO BID x3 days, erythromycin 500 mg PO TID x 7d. Personal hygiene, clean w/ soap and water, sitz bathNeisseria GonorrhoeaeReportableGram negativeCan become systemicIf positive for gonorrhea, tx for chlamydia too.NO QUINOLONES due to high resistanceLabs:NAATsClinical ManifestationsPurulent green vaginal dischargeMay walk with shuffling gait to avoid pelvic painSpeculum exam reveals friable cervix with purulent dischargeMales will have Penile Discharge with DysuriaVag dischargeUrinary frequencyDysuriaunilateral swelling of intoitusanal itchingPainPharyngitisConjunctivitissystematic triad (polyarthalgia, tenosynovitis, and dermatitis)Usually hx of new partner with in last 3 months or multiple partnersInconsistent condom useCervicitisMucopurulent cervixPainBleeding after intercourseDyspareuniaUrethritisScant-copious purulent dischargeDysuriaFrequencyUrgencyProctitisPruritusRectal painTenesmusFeeling urge to defecate when no stool presentAvoidance of defecation due to painPharyngitisSevere sore throat not responsive to traditional txPurulent green discharge on posterior pharynxBartholin’s Gland AbscessCystic lump that is red and warmLocated on introitus or vestibuleCan have purulent dischargeEndometritisMenometrorrhagia (heavy prolonged menstrual bleeding)Salpingitis and PIDOne-sided pelvic/lower-abdominal painAdnexal painDyspareunia Cervical motion tendernessTreatmentUncomplicatedRocephin 250 mg IM x one dose PLUSAzithromycin 1 g PO once ORDoxycycline 100mg BID x 7dComplicated (PID, Salpingitis, Tubo-ovarian abscess, disseminated, asymmetric arthritis and maculopapular rashRocephin 250 mg IM once PLUSDoxycycline 100 mg BID x 14d WITH OR WITHOUTMetronidazole 500mg BID x 14dDisseminated Gonococcal infection refer to EMERGENCY DEPARTMENT for ID consult.Give rocephin 1g IM or IV q 24hrsPreventionScreen all high risk ppl sexually active women age 25 or lessUse condomsSex partner w/ in 60 days evaluate to tx that sex partner> 60 days tx most recent sex partnerNB receive erythro ointment after delivery TrichomoniasisCaused by flagellated protozoan, mobilePreventionCondomsdecrease # of sex partnersvulvular hygieneSxpurulent malodorous d/c w/ burning itchingDysuriaFrequencypainful sexl. Postcoital bleeding may occur foamy white green d/cstrawberry appearing cervixDxmotile flagellated organisms on saline wet smear, AffirmTxMetronidazole 2g PO single dose OR tinidazole 2 gm in single doseCandidiasiswhite curd like dischargeCommon after antibiotic use.Dxpotassium hydroxide prep---distinct presence of hyphaeTxtopical azole drugs or PO fluconazoleBVmost prevalent vaginal infection. * Loss of lactobacilii and increase in vaginal pH fishy odorRisk factorsmultiple sex partnerDouchinglack of condom uselack of vag lactobacilliPreventioncondom useno douchingSx3 of 4 Amsel criteriaDxGram stain is gold standardsaline wet mount with “clue cells”Amsel criteria: need 3 of 4 to be dx.thin homogenous white/yellow discharge“clue cells on microscopyfishy odor w/ k hydroxide solutionpH of 4.5Txmetronidazole 500 mg PO x7 daysmetronidazole gel 0.75 %x5 daysclinda cream 2% x3 nights OR tinidazole PO x2 days HIVReportable diseasewide spectrum of disease that begins w/ acute viral illness and transitions to chronic and latent illness. Will progress to AIDS.It depletes CD4 lypmphocyetes which maintains immunity and when falls below 200 pts are @ risk for lifethreatening infectionsTransmittedsexual contactparenteral exposure to blood or body fluid infected woman to fetus.HeterosexualPreventioncondom useavoid sharing needlesuniversal precautions w/ jobsgood prenatal careScreen high risk populationsSxwt lossFevernight sweatsPharyngitisLymphadenopathyreddened maculopapular rashextragenital lymphadenopathyDxHIV-1 antibodyPpl develop detectable levels after 12 wks of exposure. ELISA. Viral load/CD4 count is useful in determining activity of diseaseTxmanaged by specialistUse high active antiretroviral therapy (HAART)maternal transmission of HIV can occur transplacentally before birth, peripartum via blood and bodily fluid exposure or thru BF.Hepatitis BReportable diseasecaused by Hep B virustransmitted via blood with other concentration in wound exudate, semen vag secretions, and saliva. Transmitted via percutaneous or mucous mem w/exposure to blood or body fluid.Can cause liver failure and deathRisk factorsunprotected sex w/ infected partnerhx of STDillegal injection drug use.PreventionHep B immune globulin-provides 3-6 mo protection and used post exposure prophylaxis in adjunct to vaccine or in unvaccinated person and Hep B vaccine. Hep B Vaccinecontains HBsAg provides protection from pre and post exposure, require series. Routinely screen ALL preg women. Unvaccinated or those who do not respond to Hep b vaccine series should be given HBIG and vaccine if exposed.SxAsymptomaticConstitutional @ firstAnorexiaNauseaJaundiceRUQ painDxpresence of igM antibody is dxTxsupportive care. No effective antiviral drugsHepatitis CCaused by Hep C virus through parenteral exposure of contaminated bloodPreventionno vaccinereducing transmission and chronic liver disease. + pt do not donate blooddon’t use razors or toothbrushesSxasymptomatic or mild illness.Dxnucleic acid PCRTxinterferon and ribavirinVosevi (sofosbuvir/ velpatasvir/voxilaprevir; Gilead) and Mavyret (glecaprevir/pibrentasvir; AbbVie) were approved by the US Food and Drug Administration (FDA) for the treatment and cure of HCV.Lichen SclerosusMost common nonneoplastic epithelial vulvar disorderBenign chronic inflammatory processCausesVit A deficiencyAutoimmuneexcess enzyme elastasedecreased activity of 5-alpha reductaseClinical FindingsIntense pruritus occurs, usually in women >60Vulvar painDyspareuniaCan have asymptomatic white lesionsClinical progressionErythema and edema of vulvar skinWhite plaquesUniting of white plaquesIntense itchingTelangiectasias (small broken blood vessels) and subepithelial hemorrhagesErosions, fissures, and ulcerationsVulvar skin is thin, wrinkled, and white if chronicHIGH rate of SQUAMOUS CELL cancer.Biopsy all new lesionsDxFixed labiaAdhesionsVulvar biopsy to confirm.TreatmentMedicationsOral antihistaminesClobetasol dipropionate 0.05% is recommended at the start for immediate relief BID x 2 wks then SID x 2 wks then twice weekly for 2 wks. Decreases incidence of vulvar carcinomaTreat as needed for rest of woman’s life.Vulvodynia-Long one...pg 635 got info from FB filepersistent pain/burningSxintroital pain on vestibular or vag entry (entry dyspareunia) vestibular tendernessCommonly affects 20-30 yrTxpelvic floor PTmaintain vulvar hygieneavoid constricting clothes and irritating agents. 5% lido cream for pain relieftopical estrogen prepafter 3 months and no relief tx w/ TCALichen Simplex ChronicusClinical FindingsEpithelial thickeningHyperkeratosisUsually form chronic irritation from scented pads or chronic vulvovaginal infections.Itching causes the thickening and humid environment causes maceration.Raised white lesion develops and may spread to adjacent thighs, perineum, or perianal skin.Biopsy necessary.Does NOT have inflammatory infiltrate like Lichen SclerosusTreatmentSitz bathsOral antihistamineLubricantsMedium-potency steroids twice daily.Betamethasone dipropionate 0.05%Betamethasone valerate 0.1%Fluocinolone 0.025%Triamcinolone Acetonide 0.1%Intractable casesAntidepressants subQ intralesional injections of steroids considered.Amenorrhea pg 889Primary (no menses by 13 w/o 2ndary sex characteristics OR 15 w/ secondary sex; causes- chromosomal defect, anatomic anomalies, hormone imbalance, tumor, trauma)absence of mensesPregnancy is most common cause & must be considered in every pt for eval.PrimaryNo menses by age 13 in absence of normal growth or secondary sexual dev. ORNo menses by 15 w/ normal growth & secondary sex dev. Usually from chromosomal dx such as Turner syndromeSecondaryNo menses x6 mopelvic pathologymost common cause=pregnancy eating disorder most frequent etiologyno menses for 3 or more cycles OR 6 consecutive months in previous menstruation.Causespregnancy (most common)hypothalamic amenorrheapit amenorrheaandrogen disorders (PCOS, adult onset adrenal hyperplasia),galactorrhea-amenorrhea syndrome.female athlete triad (anorexia, amenorrhea, osteoporosis)ASCUS/HSIL results from paper test reportASCUS< 20 yoa: repeat cytology/Pap in 12 months21-24: repeat pap in 12 months (ok to reflex HPV test)25-29: preferred is to reflex to HPV. Acceptable is repeat pap in 12 months30+: if oncogenic HPV positive (subtypes 16 & 18), refer for colposcopy. If HPV negative, repeat co-testing in 3 years.Per CDC: For non-pregnant women between 25 and 65 years of age with ASCUS cytology who have not had HPV co-testing already, HPV testing is the preferred next step (high-risk HPV testing only).With a negative HPV test (either on co-test or after cytology), repeat co-testing every three years is recommended. HSILSuggests more serious changes in the cervix than ISIL. More likely to be associated with precancer and cancer.Ages 21-24: refer for colposcopy with cervical biopsy25+: refer for immediate excisional treatment.LEEP or cervical conization surgery.Pelvic Mass- not in book wondering if they just want us to know how to work it up.Vulvar Carcinoma pg 796 in book - from fb filepost menopausal women, pruitus4th most common gyn malignancy90% of tumors are squamous cell carcinomadisease in postmenopausal women 60-70 yrsSxvulvar itchingMassvulvar bleeding/paintumor found incidentally during pelvicDxbiopsyTxsurgery, removal of tumorMolluscum ContagiosumBenign epithelial poxvirus-induced tumorsTransmitdirect person-to-person contact, sexual contact w/ affected SxDome shapedUp to 1cm (pin size up to eraser size)Multiple contagious lesionsLook-a-likes of Chondylomata AcuminataHave inclusion bodies (molluscum) under microscopehave small indentation (umbilication)Itchymay be seen on genitalslower abd and inner thighs if was spread sexuallyPreventwash handsavoid touching bumpsavoid sexual contactcover bumpsTreatmentIndividual lesionsDesiccationFreezingCurettageChemical cauterizationTopical imiquimodScarring is frequentCondyloma Acuminate (Genital Warts)Verruciform wartsSoft flesh pedunculated, flat, papular growths that are keratinizedHigh-risk oncogenic types 16 & 18Any ageCervical HPV usually asymptomatic and appears normalHPV vaccine given at age 11-12 boys and girls2 doses 6-12 months apartRecommended for gay menWarts may appear on the vagina, external genitals, urethra, anus, penis, nasal mucosa, oropharynx, conjunctivaMedicationsPodofilox 0.5% gel or cream BID x 3d Hold tx x 4d then repeat up to 4x.NOT in Pregnancy Imiquimod (Aldara) 5% or Zyclara 3.75%NOT in PregnancyApply 3x wk at bedtime for 16 wksLeave on skin for 6-10 hrs then wash offSinecatechins 10% (External Warts only)Apply to each wart while wearing glove 3x/d x 16wksWash off for sexual contact or before inserting tamponsWeakens condoms and diaphragmsOther TxCorry LaserElectrocauteryBichloracetic or Trichloroacetic Acid surgical excision in clinic.Condyloma Lata (Secondary Syphilis) see syphilisGeneralized maculopapular rash on trunk and proximal extremities and spreads to entire body including palms, soles and scalp.Androgen insensitivity/resistance Syndromewhen a person who is genetically male (who has one X and one Y chromosome) is resistant to male hormones (called androgens). As a result, the person has some or all of the physical traits of a woman, but the genetic makeup of a man.caused by genetic defects on the X chromosomeTwo Typescomplete AISthe penis and other male body parts fail to develop.At birth, the child looks like a girl. The complete form of the syndrome occurs in as many as 1 in 20,000 live births.partial AISpeople have different numbers of male traits.Can include other disorders, such as:Failure of one or both testes to descend into the scrotum after birthHypospadias, a condition in which the opening of the urethra is on the underside of the penis, instead of at the tipReifenstein syndrome (also known as Gilbert-Dreyfus syndrome or Lubs syndrome)Infertile male syndrome is also considered to be part of partial AISFrom the book word for wordThe complete forms of androgen insensitivity are also associated with amenorrhea and normal breast development. Affected persons have normal testicular function but are not responsive to testosterone, and the development of breasts is secondary to the small amounts of unopposed estrogens produced by the testis. Pubic and axillary hair is scant or often absent. A short blind vaginal pouch is present. Once pubertal development has been completed, surgical extirpation of the gonads and reconstruction of the vagina are necessary. Recent data suggest that regardless of the technique used, sexual function may be impaired in some of these young women. A study of 66 women with complete forms of androgen insensitivity showed that 90% had sexual difficulties, most commonly sexual infrequency and vaginal penetration difficulty.Turner’s Syndrome aka Gonadal Dysgenesis pg 593Disorder of females by absence of all/part of 2nd sex chromosome. 1 of 2 X chromosomes. InfertileSxcongenital lymphedemashort staturegondal dysgenesisbroad chestsmall nippleswebbed neckcoarctation of aortarenal abdnormalitiesepicanthal foldsNevishort 4th metacarpalNeed gondal hormone therapy for sex dev., enhancement of growth, & maintenance of sex reprod tissueCDC Recommendations regarding STDs and PID- think I answered in STI section.From FB fileSTD screening recommendations---All adults & adol 13-64 @ lease 1x for HIVAnnual chlamydia & gonorrhea screen for sex active women less than 25 OR older if multiple sex partnerSyphillis, HIV, Hep B for all preg women, chlamydia and gonorrhea early in pregYearly for syphilis, gonorrhea, chlamydia for Gay, bisexual, and MSM UTI- pg 748 from FB filesCan be complicated OR uncomplicated.E.Coli is primary causeRisk factorsPregDMno void after sexImproper toileting hygeineUA dipstick:+WBCNitrates + or – (E.coli converts nitrate to nitrite)RBC cast (pylonephritis)WBC cast (glomeruloarnephritis inflamm)*Uncomplicated (healthy 18-65 yr- 3 day tx) not necessary for C&S. Check for previous Abx.Tx w/ Bactrim BID, Macrobid x5 days.If sx persist then do culture. Pyrdium for pain.*Complicated (elderly, recurrent, children) Tx for 7 days or longerCipro 500 mg BID x7-10 days OR Macrobid 7-10 days, if allergy KeflexInterstitial Cystitis aka Painful Bladder SyndromeNOT an STD/STIchronic condition causing bladder pressure, pain, and sometimes-pelvic painSxpelvic painpersistent urge to urinateFrequencypain as bladder fillspain w/ sexRisk factorsfemale, >30Txpelvic PTNSAIDsTCA (relax bladder and block pain)Antihistaminepentosan polysulfate sodiumPID - 721inflamm of upper female genital tract w/ combo of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis.PreventionScreeningtx sexually active women and sex partners for gonorrhea and chlamydiaSxinsidious or acute lower abd/pelvic pain usually bilateralPelvic pressure/back pain ass w/ purulent vag dischargeNauseaHAfever is NOT necessaryAbd tendernessmay be distended bowel sounds hypo or absentBimanual= extreme tenderness or cervix****CDC says empiric tx should be initiated in sex active young women and those @ risk for STD and if 1 or more of following criteria- cervical motion tenderness, uterine tenderness, and adnexal tenderness.DX+endocervical swabs…but all may be normal.Txempirically with presumptive dx. Rocephin 250 IM AND doxycycline 100 mg BID x14 PLUS metronidazole 500 mg BID x14Pyelonephritis- 484 and 364bacteria in urine culture/ bacterial infection of kidneySxFeverShakingChillsCVA tenderness N/VHAincreased urinary frequencydysuria –pyuria on UA w/ WBC casts….absence of pyuria should raise suspicion for other dx.DxUA w/ cultureTx(outpt) Bactrim 14-21 daysantipyretics for feverCervical Cancer Screening - 609? Or 819Screening Methods for Average-Risk Asymptomatic WomenAge 21 to 29: Every 3 years with cytology (Pap testing), regardless of age of onset of sexual activity or other risk factors.Age 30 to 65: Every 5 years with HPV co-test (Pap + HPV test) OR every 3 years with cytology.When NOT to ScreenYounger Than Age 21: Screening is not recommended for women younger than age 21.Older Than Age 65: No screening past age 65 if adequate prior screening can be assessed accurately (three consecutive negative cytology results or two consecutive negative HPV results within 10 years before screening cessation, with the most recent test occurring within 5 years) and not otherwise at high risk for cervical cancer.No Cervix: No screening if the cervix was removed for a benign reason.USPSTF recs regarding breast examsWomen, Age 50-74 YearsThe USPSTF recommends biennial screening mammography for women 50-74 years.Women, Before the Age of 50 Yearsthe decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms.Women, 75 Years and OlderThe USPSTF concludes that the current evidence is insufficient to assess the benefits and harms of screening mammography in women 75 years and older.All WomenThe USPSTF recommends against teaching breast self-examination (BSE).BMIBelow 18.5 = Underweight18.5-24.9 = Normal25.0-29.9 = Overweight30.0+ = ObeseCervix/Uterus examinationCervixfirm structure 3-4 cm diameterprojects into vagina.Multiparous may have lacerationirregular shape or nodularity may be r/t nabothian cystFirm may be tumor or cancerNormally mobile can be moved 2-4cm w/o painrestricted movement could mean inflammationFriable cervixeasily irritatedprone to bleeding esp after intercoursesuspicious for cervical cancer firm and easily friableUterus1/2 size of pt’s fistPear shaped thick walled organ between base of bladder and rectum. 2 portionsThe bodysmaller cervix below.Gravida/ParaGravida = total number of pregnancies, regardless of outcomesPara= number of birthsBroken down into Full-termPreterm at or beyond 20 wksAbortions pregnancy ending before 20 wks either induced or spontaneousLiving ChildrenMammogramBreast US & mammo reasonscreening method for breast ca. Cancer may be id 2 yr before size detected via palpation.USnot recommended for screening in general population.IS AN ADJUNCT TO ABNORMAL MAMMO. May be added to high-risk woman. Can help decrease false-neg rate of mammo and eval mammographically occult palpable breast massBartholin Glands Abscess and CystsEnlargement in postmenopausal pt may reflect malignant process.Blockage of main duct of bartholin gland resulting in retention of secretions and cystic dilatation.InfectionCongenital narrowingInspissated mucusSecondary infection may result in recurrent abscess formationDx by clinical examClinical findingsPainTendernessDyspareuniaDifficulty walkingSurrounding tissues may become inflamed and edematousFluctuant tender mass palpableTreatmentDrainage of infected cyst by marsupialization or inserting Word catheter.Incision made by vestibule.May need to remove entire cyst, especially in postmenopausalAbxSitz BathWarm CompressesSkene’s GlandsLarge paraurethral gland that opens beside the external urethral orifice in the vestibule. located on the anterior wall of the vagina around the lower end of the urethra.secrete a fluid that helps lubricate the urethral opening, and are surrounded with tissue that swell with blood during sexual arousalNabothian Gland and CystGland of the cervix that secretes mucusCystsWhen a cleft or tunnel of columnar endocervical epithelium becomes covered by squamous metaplasia.Appear translucent or yellowCarry in diameter up to 3cm.don’t cause pain, discomfort, or other symptomsNo treatment unless very largeExcisionElectrocautery ablationCryotherapyContraceptives- i’ll do mondayIUDMechanism of action thought to beSpermicidal interferes w/ normal dev of ova or fertilizationcauses cervical mucus to thicken T shaped frame. Can cause anovulationContraindications:Active PID or hx PID within last yrSuspected or confirmed pregnancy or has STDUterine or cervical abnormalityUndiagnosed vaginal bleeding or uterine/cervical cancerHistory of ectopic pregnancyIncreased RiskEctopic pregnancySpontaneous abortionIf pregnant with device in place then 50/50 chance of abortionRemoval of device while pregnant reduces the spontaneous abortion rate by 50%Endometrial and pelvic infectionsPerforation of the uterusHeavy or prolonged menstrual periodsEducationPt to check for missing or shortening of string periodically, esp after each menstrual period.If no string order pelvic ultrasoundGood for: wanting less menses flow (increased initially, but then decreases by 70%)experience dysmenorrheahave DUB.Positivescan be nulliparious, inserted same dayCan start immediately postpartumImplant-[Nexplanon]3 yr usage, placed in upper arm, contains 68 mg of etonogesterlCan be inserted anytime after pregnancy.Positiveshigh efficacy, long term, can use w/ lactationNegativesbleeding irregularitieswt gainEmotionsAcneDepressionOvulation may not return for 12 months after removalOCP- estrogen & progestinPositives: reduction in ovarian & endometrial cancer riskEctopicPIDmenses disorderbenign breast disease & acne.Negatives: ThromboembolismStrokeAMIProgestin only (mini pill) ME!!!! LOL, I get migraines on estrogen.Safe for breastfeeding mothersMUST take at same time.If missed >3hrs then back-up method must be used for 2 days.NO PLACEBO PILLScervical mucus is less permeable to sperms and endometrial activity goes out of [phase. Used for women w/ estrogen contraindication (smoke, older, sickle cell, MR, migraine HA, HTN, SLE, breastfeeding)Transdermal PatchHIGHER risk of VTE; releases higher levels of estrogenRemoved after 7 days and new patch applied. 3 wks on, 1 week offApply anywhere but breasts. Breakthrough bleeding and spotting with transdermal patch use is similar w/ OCP users. Vaginal Ring- NuvaringDo NOT use if >35 and smoker.Flexible unfitted ring placed in vagina that releases ethinyl estradiol etonogestrel.3 wks in/1 wk out. Can still work w/ 3 hours out.Injection/Long acting hormone contraception [Depo medroxyprogesterone acetate]Check for pregnancy before startingMust be given within 5 days of beginning of cycleIM inject q3 months. Not recommended for women wanting pregnancy within 12 monthsSuppresses ovulation and causes uterine atrophyBLACK BOX warning:Avoid long-term use >2yrs because increases risk of osteopenia/osteoporosis that is not reversible.Avoid use with HX of Anorexia NervosaPositives:low risk of ectopicreduced risk of endometrial cadoes not increase risk of DVTNegativesMay reduce bone mineral densitywt gainreturn to baseline to get fertile may take 12 months.Male/female condom/Diaphragm/Cervical capmechanical barrier between vagina and cervical canal Inserted 6 hrs before and 6-24 after. Has to be fitted by Dr. Side effectsvaginal wall irritationCapplaced over cervix held in place by suction. Leave in place 8-48 hrs after sexEmergency Contraceptivedelays ovulation by disrupting function of corpus luteum. Med given twice, 12 hours apart. Administer 1st dose within 72 hours of sex. 89% effectiveSide effectsnausea/vomitingIf vomits within 1 hr of taking, repeat doseIf no meses within 3 weeks, must return to r/o pregnancy.PCOS aka Stein-Leventhal SyndromeDx2 out of 3---oligiomenorrhea/amenorrhea, hyperandrogenism, polycystic ovaries on US Hormonal abnormality marked by anovulation, infertility, excessive androgen production, and insulin resistance.Oligomenorrhea ( infrequent periods)AmenorrheaBad acneHirsutismDark thick terminal hair on face, cheek, beard areasHigher risk forDMT2DyslipidemiaMetabolic syndromeEndometrial hyperplasiaObesityOSATreatmentTransvaginal Ultrasound for multiple folliclesLabsSerum testosterone - elevatedDHEA - elevatedAndrostenedione – elevatedFSH – normal to lowFasting BG or OGTT abnormalAbnormal lipidsInsulin resistanceMedicationsLow-dose OCPs for hirsutism SpironolactoneIf pt does not want OCPs give Provera (medroxyprogesterone) 5-10 mg daily for 10-14 days, repeat every 1-2 months to induce menses.Metformin to induce ovulation if pregnancy desired.Weight loss to reduce androgen and insulin plicationsCADDMT2Cancer of breast and endometriumCentral obesityInfertilityMetronidazoleinhibits DNA synthesis and rapidly bactericidalDrug of choice for Gardenerella vaginalis, trich, BVAdverse effectsdo not take w/ ETOH (antabuse like effects) HAN/Vmetallic unpleasant tasteprolonged use can cause peripheral neuropathyCimetidineH2 receptor agonistacid reducer for heartburn and GERDsafe in pregnancy, sit up 30 min afterACOG guidelines regarding well woman examAmerican Cancer Society recommendationsACOG Pap Smear GuidelinesStart @ 21, every 3 yrs.Age 30+ PAP & HPV repeat every 5 if negative (co-test) or 3 yr no co-test@65 may stop if (-) hx for 10 yrs or hysterectomy w/o hx of cancer Normal Pap and Negative HPVRescreen in 5 yearsNormal Pap and Positive HPVRepeat co-test in 1 yr ORHPV DNA typing nowASCUS Pap, No HPV testRepeat cytology in 1 yr ORDo HPV test nowASCUS/ISIL Pap and Negative HPVRepeat Pap and co-testing every 3 yearsASCUS Pap and Positive HPVColposcopy and/or referral to gynecologist LSIL Pap and Positive or Unknown HPVColposcopy and/or referral to gynecologist ASC-H PapColposcopy and/or referral to gynecologist HSIL PapColposcopy and/or referral to gynecologist ................
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