Nursingpapers

● Dysmenorrhea

○ painful menstruation

■ attributed to prostaglandin activity

■ increased leukotriene levels

○ one of the most common complaints

○ pain prevents normal activity and requires medication

○ 3 types of dysmenorrhea:

■ primary (no organic cause)

■ secondary (pathologic cause)

● endometriosis, adenomyosis, pelvic inflammatory disease, cervical stenosis, fibroids, and

endometrial polyps

■ membranous (cast of endometrial cavity shed as a single entity

● rare; it causes intense cramping pain due to passage of a cast of the endometrium

through an undilated cervix

○ Clinical Findings

■ almost always is associated with ovulatory cycles, it does not usually occur at menarche but

rather later in adolescence

■ 14–26% of adolescents miss school or work

■ pain occurs on the first day of the menses - about the time the flow begins

● may not be present until the second day.

■ Nausea

■ Vomiting

■ Diarrhea

■ Headache

■ No significant pelvic disease

■ When 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.

○ Treatment

■ continuous heat to the abdomen in addition to NSAIDs decreases pain significantly

● Ibuprofen and Naproxen are prefered - First Line

■ Severe Pain

● Codeine or stronger pain medications

● cyclooxygenase-2 (COX-2)

○ Rofecoxib, valdecoxib, and lumiracoxib are effective for treating primary

dysmenorrhea

■ must be used at the earliest onset of symptoms, usually at the onset of, and sometimes 1–2 days

prior to, bleeding or cramping

■ Cyclic 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 them

● given for 6–12 months. Many women continue to be free of pain after treatment has been

discontinued

● Cystocele aka Anterior Vaginal Prolapse

○ vaginal wall weakens and stretches and allows the bladder to bulge into the vagina

○ Causes-

■ childbirth

■ chronic constipation

■ violent coughing

■ heavy lifting

■ Overweight

■ Age

■ hysterectomy (increased vag weakness)

○ Sx

■ felling of fullness or pressure in vagina

■ increased discomfort when you strain/cough/bear down

■ feeling of incomplete empty

■ repeated bladder infection

■ pain or urinary leak during sex

■ bulge of tissue into vaginal opening

○ Prevention

■ Kegels

■ prevent constipation

■ avoid heavy lifting

■ avoid wt gain

● Rectocele aka Posterior Vaginal Prolapse

○ When thin tissue of vagina separates the vaginal and rectum allowing vaginal wall to bulge

○ Sx

■ soft bulge of tissue in vaginal

■ difficult BM

■ sensation of rectal pressure

■ incomplete emptying after BM

■ sexual concerns-dyspareunia

○ Causes

■ constipation/strain

■ chronic cough

■ heavy lifting

■ Overweight

■ Childbirth

■ age

○ Prevention

■ Kegels

■ prevent constipation

■ avoid heavy lifting

■ Cough

■ avoid wt gain

● Uterine prolapse aka Apical Prolapse

○ pelvic floor muscles and ligaments stretch and weaken and no longer provide support for uterus and

protrude into vagina.

○ Causes

■ Pregnancy

■ large baby delivery

■ lower estrogen level after menopause

■ obesity

■ Common in postmenopausal and one or more childbirth

○ Sx

■ heaviness or pulling into pelvis

■ tissue protruding from vagina

■ urinary probs (leakage, retention)

■ trouble having BM

■ feeling of sitting on small ball

■ sexual concerns

○ Prevention

■ Kegels

■ treat constipation

■ correct lifting

■ avoid wt gain

○ Tx

■ pessary

● STDs

○ Chlamydia Trachomatis

■ Reportable

■ Most infections are asymptomatic

■ 25+ yoa most prevalent

■ Most common STD in USA

■ Annual 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 infection

● Females: Cervicitis, endometritis, salpingitis, PID

● Males: epididymitis, prostatitis

● Both genders: urethritis, pharyngitis, proctitis

■ Complications:

● PID

● tubal scarring

● ectopic pregnancy

● Infertility

● Reiter’s Syndrome

● Fits-Hugh-Curtis Syndrome

■ Labs

● NAATs- gold standard

● negative whiff w/ mucopurulent d/c and + clue cells

■ Treatment:

● Azithromycin 1g PO single dose OR

● Doxycycline 100mg BID PO x 7d

● Treat partner too.

● Abstain from sex for 7 days after tx.

● Can tx partner without seeing partner in most states

● Pregnant women

○ Do test of cure 3 weeks after tx then again within 3 months

○ Azithromycin 1g PO single dose OR

○ Amoxicillin 500mg TID x 7d.

● Complicated Infections (PID)

○ Rocephin 250 mg IM x 1 dose plus Doxycycline PO BID x 14d with or without

Metronidazole PO BID x 14d.

○ Syphilis

■ chronic, systemic disease caused by a sphirochete transmitted via contact with infectious moist

lesion.

■ Sexually acquired or vertically transmitted from infected mom.

■ Reportable disease

■ Prevention

● Condom

● wash w/ soap and water after sex

● screen 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 margins

○ Women can have on cervix or inside vagina.

○ Any mucus membrane

■ Secondary:

● 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 chancre

● Flu-like symptoms

● General diffuse lymphadenopathy

● Patchy alopecia

● Hepatitis

● Nephritis

■ Latent Stage

● Asymptomatic but has positive titers

■ Tertiary (3-10yrs)

● Neurosyphilis

○ Blindness, paralysis, paresthesias, tabes dorsalis, gait abnormalities,

confusion/dementia

● gumma (soft tissue tumors)

● Aneurysms

● valvular damage

■ Labs

● T pallidum spirochetes on dark field exam of cutaneous lesion

○ Not commonly used.

● 2 types of tests needed to dx syphilis

○ Treponemal

○ Nontreponemal

● Step 1: (Nontreponemal) order rapid plasma regain (RPR) or VDRL. If reactive then order

confirmatory test

● Step 2: (Treponemal) fluorescent treponemal antibody absorption (FTA-ABS),

microhemagglutination test for antibodies (MHA-TP), TPPA

● If RPR and FTA-ABS positive then diagnostic for syphilis.

● If RPR used then order additional RPR to document Tx response

○ Use same laboratory to monitor

● If RPR or VDRL shows fourfold or higher (>1:4) decrease in titers, then pt is responding

to tx.

■ Treatment

● Primary Syphilis, Secondary, or Early Latent Syphilis (<1yr)

○ Benzathine PCN G 2.4 million units IM x 1 dose

● Latent Syphilis (>1yr), Latent unknown duration, Late (tertiary)

○ Benzathine PCN G 2.4 million units IM once per wk x 3 wks

○ PCN allergy: Doxycycline, tetracycline, and for neurosyphilis, Rocephin; use

these with close lab f/u; refer to specialist

■ Follow-up

● Recheck RPR or VDRL at 6-12 months after tx

● TX sexual partners from previous 90 days even if partner testing negative

● Test partner and pt for for HIV and other STDs

● Refer to ID for suspected neurosyphilis, poor response to tx, PCN allergy, or if not

familiar with management.

○ HSV-1 & HSV-2

■ Asymptomatic shedding occurs intermittently and pt is still contagious

■ HSV-1: usually oral infection, sometimes genital

■ HSV-2: causes most cases of recurrent genital herpes, can be oral

■ Clinical Manifestations

● May have prodrome (itching, burning, and tingling) on site.

● Sudden onset of small vesicles sitting on erythematous base.

○ Easily ruptures and is painful

○ Vesicle fluid and crusts are contagious

● Primary episode is more severe and can last from 2-4 wks.

● Recurrent breakouts

○ Virus lays dormant and can be reactivated

■ Treatment

● Herpes viral culture or RPR assay for HSV-1 and HSV-2 DNA.

● Tzanck Smear

○ Old test

● First episode

○ Acyclovir 400 mg TID x 7-10d

■ 200mg 5 times/d x 7-10d.

○ Famciclovir 1g BID x 7-10d

○ Valacyclovir (Valtrex) TID x 7-10d

● Flare-up Tx

○ Best if tx srt within 1 d of onset

○ Famciclovir 125 mg BID x 5d

○ Zovirax BID or TID x 5d or Valtrex BID x 5d

● Suppressive Tx

○ Acyclovir 400 mg BID

○ Famciclovir 250 mg PO BID

■ Prevention

● consistent 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 HSV

■ Pregnant women, mechanical methods are used to destroy genital warts

○ Chancroid pg 704

■ Transmitted via sexual contact or on hands that have touched lesion. Caused by Haemophillus

ducreyi

■ Reportable disease

■ Sx

● erythematous papule that evolves into pustule and degenerates into saucer shaped

ragged ulcer that is circumscribed by inflammatory wheal.

● Tender

● heavy foul discharge that is contagious

■ Dx

● culture that grows H ducreyi

■ Tx

● Azithromycin 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 bath

○ Neisseria Gonorrhoeae

■ Reportable

■ Gram negative

■ Can become systemic

■ If positive for gonorrhea, tx for chlamydia too.

■ NO QUINOLONES due to high resistance

■ Labs:

● NAATs

■ Clinical Manifestations

● Purulent green vaginal discharge

● May walk with shuffling gait to avoid pelvic pain

● Speculum exam reveals friable cervix with purulent discharge

● Males will have Penile Discharge with Dysuria

● Vag discharge

● Urinary frequency

● Dysuria

● unilateral swelling of intoitus

● anal itching

● Pain

● Pharyngitis

● Conjunctivitis

● systematic triad (polyarthalgia, tenosynovitis, and dermatitis)

● Usually hx of new partner with in last 3 months or multiple partners

● Inconsistent condom use

● Cervicitis

○ Mucopurulent cervix

○ Pain

○ Bleeding after intercourse

○ Dyspareunia

● Urethritis

○ Scant-copious purulent discharge

○ Dysuria

○ Frequency

○ Urgency

● Proctitis

○ Pruritus

○ Rectal pain

○ Tenesmus

○ Feeling urge to defecate when no stool present

○ Avoidance of defecation due to pain

● Pharyngitis

○ Severe sore throat not responsive to traditional tx

○ Purulent green discharge on posterior pharynx

● Bartholin’s Gland Abscess

○ Cystic lump that is red and warm

■ Located on introitus or vestibule

○ Can have purulent discharge

● Endometritis

○ Menometrorrhagia (heavy prolonged menstrual bleeding)

● Salpingitis and PID

○ One-sided pelvic/lower-abdominal pain

○ Adnexal pain

○ Dyspareunia

○ Cervical motion tenderness

■ Treatment

● Uncomplicated

○ Rocephin 250 mg IM x one dose PLUS

○ Azithromycin 1 g PO once OR

■ Doxycycline 100mg BID x 7d

● Complicated (PID, Salpingitis, Tubo-ovarian abscess, disseminated, asymmetric arthritis

and maculopapular rash

○ Rocephin 250 mg IM once PLUS

○ Doxycycline 100 mg BID x 14d WITH OR WITHOUT

■ Metronidazole 500mg BID x 14d

■ Disseminated Gonococcal infection refer to EMERGENCY DEPARTMENT for ID consult.

● Give rocephin 1g IM or IV q 24hrs

■ Prevention

● Screen all high risk ppl sexually active women age 25 or less

● Use condoms

● Sex partner w/ in 60 days evaluate to tx that sex partner

● > 60 days tx most recent sex partner

● NB receive erythro ointment after delivery

○ Trichomoniasis

■ Caused by flagellated protozoan, mobile

■ Prevention

● Condoms

● decrease # of sex partners

● vulvular hygiene

■ Sx

● purulent malodorous d/c w/ burning itching

● Dysuria

● Frequency

● painful sexl.

● Postcoital bleeding may occur foamy white green d/c

● strawberry appearing cervix

■ Dx

● motile flagellated organisms on saline wet smear, Affirm

■ Tx

● Metronidazole 2g PO single dose OR tinidazole 2 gm in single dose

○ Candidiasis

■ white curd like discharge

■ Common after antibiotic use.

■ Dx

● potassium hydroxide prep---distinct presence of hyphae

■ Tx

● topical azole drugs or PO fluconazole

○ BV

■ most prevalent vaginal infection.

■ * Loss of lactobacilii and increase in vaginal pH

■ fishy odor

■ Risk factors

● multiple sex partner

● Douching

● lack of condom use

● lack of vag lactobacilli

■ Prevention

● condom use

● no douching

■ Sx

● 3 of 4 Amsel criteria

■ Dx

● Gram stain is gold standard

○ saline wet mount with “clue cells”

● Amsel criteria: need 3 of 4 to be dx.

○ thin homogenous white/yellow discharge

○ “clue cells on microscopy

○ fishy odor w/ k hydroxide solution

○ pH of 4.5

■ Tx

● metronidazole 500 mg PO x7 days

● metronidazole gel 0.75 %x5 days

● clinda cream 2% x3 nights OR tinidazole PO x2 days

○ HIV

■ Reportable disease

■ wide 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 infections

■ Transmitted

● sexual contact

● parenteral exposure to blood or body fluid infected woman to fetus.

● Heterosexual

■ Prevention

● condom use

● avoid sharing needles

● universal precautions w/ jobs

● good prenatal care

● Screen high risk populations

■ Sx

● wt loss

● Fever

● night sweats

● Pharyngitis

● Lymphadenopathy

● reddened maculopapular rash

● extragenital lymphadenopathy

■ Dx

● HIV-1 antibody

○ Ppl develop detectable levels after 12 wks of exposure.

● ELISA.

● Viral load/CD4 count is useful in determining activity of disease

■ Tx

● managed by specialist

● Use 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 B

■ Reportable disease

■ caused by Hep B virus

■ transmitted 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 death

■ Risk factors

● unprotected sex w/ infected partner

● hx of STD

● illegal injection drug use.

■ Prevention

● Hep 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 Vaccine

○ contains 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.

■ Sx

● Asymptomatic

● Constitutional @ first

○ Anorexia

○ Nausea

○ Jaundice

○ RUQ pain

■ Dx

● presence of igM antibody is dx

■ Tx

● supportive care.

● No effective antiviral drugs

○ Hepatitis C

■ Caused by Hep C virus through parenteral exposure of contaminated blood

■ Prevention

● no vaccine

● reducing transmission and chronic liver disease.

● + pt do not donate blood

● don’t use razors or toothbrushes

■ Sx

● asymptomatic or mild illness.

■ Dx

● nucleic acid PCR

■ Tx

● interferon and ribavirin

● Vosevi (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 Sclerosus

○ Most common nonneoplastic epithelial vulvar disorder

○ Benign chronic inflammatory process

○ Causes

■ Vit A deficiency

■ Autoimmune

■ excess enzyme elastase

■ decreased activity of 5-alpha reductase

○ Clinical Findings

■ Intense pruritus occurs, usually in women >60

■ Vulvar pain

■ Dyspareunia

■ Can have asymptomatic white lesions

■ Clinical progression

● Erythema and edema of vulvar skin

● White plaques

● Uniting of white plaques

● Intense itching

● Telangiectasias (small broken blood vessels) and subepithelial hemorrhages

● Erosions, fissures, and ulcerations

● Vulvar skin is thin, wrinkled, and white if chronic

■ HIGH rate of SQUAMOUS CELL cancer.

● Biopsy all new lesions

○ Dx

■ Fixed labia

■ Adhesions

■ Vulvar biopsy to confirm.

○ Treatment

■ Medications

● Oral antihistamines

● Clobetasol 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 carcinoma

○ Treat as needed for rest of woman’s life.

● Vulvodynia-Long one...pg 635 got info from FB file

○ persistent pain/burning

○ Sx

■ introital pain on vestibular or vag entry (entry dyspareunia) vestibular tenderness

○ Commonly affects 20-30 yr

○ Tx

■ pelvic floor PT

■ maintain vulvar hygiene

■ avoid constricting clothes and irritating agents.

■ 5% lido cream for pain relief

■ topical estrogen prep

■ after 3 months and no relief tx w/ TCA

● Lichen Simplex Chronicus

○ Clinical Findings

■ Epithelial thickening

■ Hyperkeratosis

■ Usually 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 Sclerosus

○ Treatment

■ Sitz baths

■ Oral antihistamine

■ Lubricants

■ Medium-potency steroids twice daily.

● Betamethasone dipropionate 0.05%

● Betamethasone valerate 0.1%

● Fluocinolone 0.025%

● Triamcinolone Acetonide 0.1%

■ Intractable cases

● Antidepressants

● subQ intralesional injections of steroids considered.

● Amenorrhea pg 889

○ Primary (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 menses

○ Pregnancy is most common cause & must be considered in every pt for eval.

○ Primary

■ No menses by age 13 in absence of normal growth or secondary sexual dev. OR

■ No menses by 15 w/ normal growth & secondary sex dev.

● Usually from chromosomal dx such as Turner syndrome

○ Secondary

■ No menses x6 mo

■ pelvic pathology

■ most common cause=pregnancy

■ eating disorder most frequent etiology

■ no menses for 3 or more cycles OR 6 consecutive months in previous menstruation.

○ Causes

■ pregnancy (most common)

■ hypothalamic amenorrhea

■ pit amenorrhea

■ androgen disorders (PCOS, adult onset adrenal hyperplasia),

■ galactorrhea-amenorrhea syndrome.

■ female athlete triad (anorexia, amenorrhea, osteoporosis)

● ASCUS/HSIL results from paper test report

○ ASCUS

■ < 20 yoa: repeat cytology/Pap in 12 months

■ 21-24: repeat pap in 12 months (ok to reflex HPV test)

■ 25-29: preferred is to reflex to HPV. Acceptable is repeat pap in 12 months

■ 30+: 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.

○ HSIL

■ Suggests 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 biopsy

■ 25+: 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 file

○ post menopausal women, pruitus

○ 4th most common gyn malignancy

○ 90% of tumors are squamous cell carcinoma

○ disease in postmenopausal women 60-70 yrs

○ Sx

■ vulvar itching

■ Mass

■ vulvar bleeding/pain

■ tumor found incidentally during pelvic

○ Dx

■ biopsy

○ Tx

■ surgery, removal of tumor

● Molluscum Contagiosum

○ Benign epithelial poxvirus-induced tumors

○ Transmit

■ direct person-to-person contact, sexual contact w/ affected

○ Sx

■ Dome shaped

■ Up to 1cm (pin size up to eraser size)

■ Multiple contagious lesions

■ Look-a-likes of Chondylomata Acuminata

■ Have inclusion bodies (molluscum) under microscope

■ have small indentation (umbilication)

■ Itchy

■ may be seen on genitals

■ lower abd and inner thighs if was spread sexually

○ Prevent

■ wash hands

■ avoid touching bumps

■ avoid sexual contact

■ cover bumps

○ Treatment

■ Individual lesions

■ Desiccation

■ Freezing

■ Curettage

■ Chemical cauterization

■ Topical imiquimod

○ Scarring is frequent

● Condyloma Acuminate (Genital Warts)

○ Verruciform warts

○ Soft flesh pedunculated, flat, papular growths that are keratinized

○ High-risk oncogenic types

■ 16 & 18

■ Any age

○ Cervical HPV usually asymptomatic and appears normal

○ HPV vaccine given at age 11-12 boys and girls

■ 2 doses 6-12 months apart

■ Recommended for gay men

○ Warts may appear on the vagina, external genitals, urethra, anus, penis, nasal mucosa, oropharynx,

conjunctiva

○ Medications

■ Podofilox 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 Pregnancy

● Apply 3x wk at bedtime for 16 wks

● Leave on skin for 6-10 hrs then wash off

■ Sinecatechins 10% (External Warts only)

● Apply to each wart while wearing glove 3x/d x 16wks

● Wash off for sexual contact or before inserting tampons

● Weakens condoms and diaphragms

○ Other Tx

■ Corry Laser

■ Electrocautery

■ Bichloracetic or Trichloroacetic Acid surgical excision in clinic.

● Condyloma Lata (Secondary Syphilis) see syphilis

○ Generalized maculopapular rash on trunk and proximal extremities and spreads to entire body including

palms, soles and scalp.

● Androgen insensitivity/resistance Syndrome

○ when 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 chromosome

○ Two Types

■ complete AIS

● the 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 AIS

● people have different numbers of male traits.

● Can include other disorders, such as:

● Failure of one or both testes to descend into the scrotum after birth

● Hypospadias, a condition in which the opening of the urethra is on the underside

of the penis, instead of at the tip

● Reifenstein syndrome (also known as Gilbert-Dreyfus syndrome or Lubs

syndrome)

■ Infertile male syndrome is also considered to be part of partial AIS

○ From the book word for word

■ The 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 593

○ Disorder of females by absence of all/part of 2nd sex chromosome. 1 of 2 X chromosomes. Infertile

○ Sx

■ congenital lymphedema

■ short stature

■ gondal dysgenesis

■ broad chest

■ small nipples

■ webbed neck

■ coarctation of aorta

■ renal abdnormalities

■ epicanthal folds

■ Nevi

■ short 4th metacarpal

○ Need gondal hormone therapy for sex dev., enhancement of growth, & maintenance of sex reprod tissue

● CDC Recommendations regarding STDs and PID- think I answered in STI section.

○ From FB file

■ STD screening recommendations--- ● All adults & adol 13-64 @ lease 1x for HIV ● Annual chlamydia & gonorrhea screen for sex active women less than 25 OR older

if multiple sex partner ● Syphillis, HIV, Hep B for all preg women, chlamydia and gonorrhea early in preg ● Yearly for syphilis, gonorrhea, chlamydia for Gay, bisexual, and MSM

● UTI- pg 748 from FB files

○ Can be complicated OR uncomplicated.

○ E.Coli is primary cause

○ Risk factors

■ Preg

■ DM

■ no void after sex

■ Improper toileting hygeine

○ UA dipstick:

■ +WBC

■ Nitrates + 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 longer

■ Cipro 500 mg BID x7-10 days OR

■ Macrobid 7-10 days, if allergy Keflex

● Interstitial Cystitis aka Painful Bladder Syndrome

○ NOT an STD/STI

○ chronic condition causing bladder pressure, pain, and sometimes-pelvic pain

○ Sx

■ pelvic pain

■ persistent urge to urinate

■ Frequency

■ pain as bladder fills

■ pain w/ sex

○ Risk factors

■ female, >30

○ Tx

■ pelvic PT

■ NSAIDs

■ TCA (relax bladder and block pain)

■ Antihistamine

■ pentosan polysulfate sodium

● PID - 721

○ inflamm of upper female genital tract w/ combo of endometritis, salpingitis, tubo-ovarian abscess, and

pelvic peritonitis.

○ Prevention

■ Screening

■ tx sexually active women and sex partners for gonorrhea and chlamydia

○ Sx

■ insidious or acute lower abd/pelvic pain usually bilateral

■ Pelvic pressure/back pain ass w/ purulent vag discharge

■ Nausea

■ HA

■ fever is NOT necessary

■ Abd tenderness

■ may be distended bowel sounds hypo or absent

■ Bimanual= 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.

○ Tx

■ empirically with presumptive dx.

■ Rocephin 250 IM AND doxycycline 100 mg BID x14 PLUS metronidazole 500 mg BID x14

● Pyelonephritis- 484 and 364

○ bacteria in urine culture/ bacterial infection of kidney

○ Sx

■ Fever

■ Shaking

■ Chills

■ CVA tenderness

■ N/V

■ HA

■ increased urinary frequency

■ dysuria

■ –pyuria on UA w/ WBC casts….absence of pyuria should raise suspicion for other dx.

○ Dx

■ UA w/ culture

○ Tx

■ (outpt) Bactrim 14-21 days

■ antipyretics for fever

● Cervical Cancer Screening - 609? Or 819

○ Screening Methods for Average-Risk Asymptomatic Women

■ Age 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 Screen

■ Younger 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 exams

○ Women, Age 50-74 Years

■ The USPSTF recommends biennial screening mammography for women 50-74 years.

○ Women, Before the Age of 50 Years

■ the 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 Older

■ The USPSTF concludes that the current evidence is insufficient to assess the benefits and harms

of screening mammography in women 75 years and older.

○ All Women

■ The USPSTF recommends against teaching breast self-examination (BSE).

● BMI

○ Below 18.5 = Underweight

○ 18.5-24.9 = Normal

○ 25.0-29.9 = Overweight

○ 30.0+ = Obese

● Cervix/Uterus examination

○ Cervix

■ firm structure 3-4 cm diameter

■ projects into vagina.

■ Multiparous may have laceration

■ irregular shape or nodularity may be r/t nabothian cyst

■ Firm may be tumor or cancer

■ Normally mobile can be moved 2-4cm w/o pain

● restricted movement could mean inflammation

○ Friable cervix

■ easily irritated

■ prone to bleeding esp after intercourse

■ suspicious for cervical cancer firm and easily friable

○ Uterus

■ 1/2 size of pt’s fist

■ Pear shaped thick walled organ between base of bladder and rectum.

■ 2 portions

● The body

● smaller cervix below.

● Gravida/Para

○ Gravida = total number of pregnancies, regardless of outcomes

○ Para= number of births

■ Broken down into

● Full-term

● Preterm at or beyond 20 wks

● Abortions pregnancy ending before 20 wks either induced or spontaneous

● Living Children

● Mammogram

○ Breast US & mammo reason

○ screening method for breast ca.

■ Cancer may be id 2 yr before size detected via palpation.

○ US

■ not 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

mass

● Bartholin Glands Abscess and Cysts

○ Enlargement in postmenopausal pt may reflect malignant process.

○ Blockage of main duct of bartholin gland resulting in retention of secretions and cystic dilatation.

■ Infection

■ Congenital narrowing

■ Inspissated mucus

○ Secondary infection may result in recurrent abscess formation

○ Dx by clinical exam

○ Clinical findings

■ Pain

■ Tenderness

■ Dyspareunia

■ Difficulty walking

■ Surrounding tissues may become inflamed and edematous

■ Fluctuant tender mass palpable

○ Treatment

■ Drainage of infected cyst by marsupialization or inserting Word catheter.

■ Incision made by vestibule.

■ May need to remove entire cyst, especially in postmenopausal

■ Abx

■ Sitz Bath

■ Warm Compresses

● Skene’s Glands

○ Large 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 arousal

● Nabothian Gland and Cyst

○ Gland of the cervix that secretes mucus

○ Cysts

■ When a cleft or tunnel of columnar endocervical epithelium becomes covered by squamous

metaplasia.

■ Appear translucent or yellow

■ Carry in diameter up to 3cm.

■ don’t cause pain, discomfort, or other symptoms

■ No treatment unless very large

● Excision

● Electrocautery ablation

● Cryotherapy

● Contraceptives- i’ll do monday

○ IUD

■ Mechanism of action thought to be

● Spermicidal

● interferes w/ normal dev of ova or fertilization

● causes cervical mucus to thicken

■ T shaped frame.

■ Can cause anovulation

■ Contraindications:

● Active PID or hx PID within last yr

● Suspected or confirmed pregnancy or has STD

● Uterine or cervical abnormality

● Undiagnosed vaginal bleeding or uterine/cervical cancer

● History of ectopic pregnancy

■ Increased Risk

● Ectopic pregnancy

● Spontaneous abortion

○ If pregnant with device in place then 50/50 chance of abortion

○ Removal of device while pregnant reduces the spontaneous abortion rate by

50%

● Endometrial and pelvic infections

● Perforation of the uterus

● Heavy or prolonged menstrual periods

■ Education

● Pt to check for missing or shortening of string periodically, esp after each menstrual

period.

● If no string order pelvic ultrasound

■ Good for:

● wanting less menses flow (increased initially, but then decreases by 70%)

● experience dysmenorrhea

● have DUB.

■ Positives

● can be nulliparious,

● inserted same day

● Can start immediately postpartum

○ Implant-[Nexplanon]

■ 3 yr usage, placed in upper arm, contains 68 mg of etonogesterl

■ Can be inserted anytime after pregnancy.

■ Positives

● high efficacy, long term, can use w/ lactation

■ Negatives

● bleeding irregularities

● wt gain

● Emotions

● Acne

● Depression

■ Ovulation may not return for 12 months after removal

○ OCP- estrogen & progestin

■ Positives:

● reduction in ovarian & endometrial cancer risk

● Ectopic

● PID

● menses disorder

● benign breast disease & acne.

■ Negatives:

● Thromboembolism

● Stroke

● AMI

○ Progestin only (mini pill) ME!!!! LOL, I get migraines on estrogen.

■ Safe for breastfeeding mothers

■ MUST take at same time.

● If missed >3hrs then back-up method must be used for 2 days.

● NO PLACEBO PILLS

■ cervical 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 Patch

■ HIGHER risk of VTE; releases higher levels of estrogen

■ Removed after 7 days and new patch applied.

■ 3 wks on, 1 week off

■ Apply anywhere but breasts.

■ Breakthrough bleeding and spotting with transdermal patch use is similar w/ OCP users.

○ Vaginal Ring- Nuvaring

■ Do 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 starting

■ Must be given within 5 days of beginning of cycle

■ IM inject q3 months.

■ Not recommended for women wanting pregnancy within 12 months

■ Suppresses ovulation and causes uterine atrophy

■ BLACK BOX warning:

● Avoid long-term use >2yrs because increases risk of osteopenia/osteoporosis that is not

reversible.

■ Avoid use with HX of Anorexia Nervosa

■ Positives:

● low risk of ectopic

● reduced risk of endometrial ca

● does not increase risk of DVT

■ Negatives

● May reduce bone mineral density

● wt gain

● return to baseline to get fertile may take 12 months.

○ Male/female condom/Diaphragm/Cervical cap

■ mechanical barrier between vagina and cervical canal

■ Inserted 6 hrs before and 6-24 after.

■ Has to be fitted by Dr.

■ Side effects

● vaginal wall irritation

■ Cap

● placed over cervix held in place by suction.

● Leave in place 8-48 hrs after sex

○ Emergency Contraceptive

■ delays ovulation by disrupting function of corpus luteum.

■ Med given twice, 12 hours apart.

■ Administer 1st dose within 72 hours of sex.

■ 89% effective

■ Side effects

● nausea/vomiting

○ If vomits within 1 hr of taking, repeat dose

● If no meses within 3 weeks, must return to r/o pregnancy.

● PCOS aka Stein-Leventhal Syndrome

○ Dx

■ 2 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)

■ Amenorrhea

■ Bad acne

■ Hirsutism

■ Dark thick terminal hair on face, cheek, beard areas

○ Higher risk for

■ DMT2

■ Dyslipidemia

■ Metabolic syndrome

■ Endometrial hyperplasia

■ Obesity

■ OSA

○ Treatment

■ Transvaginal Ultrasound for multiple follicles

■ Labs

● Serum testosterone - elevated

● DHEA - elevated

● Androstenedione – elevated

● FSH – normal to low

● Fasting BG or OGTT abnormal

● Abnormal lipids

● Insulin resistance

■ Medications

● Low-dose OCPs for hirsutism

● Spironolactone

● If 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 levels.

■ Complications

● CAD

● DMT2

● Cancer of breast and endometrium

● Central obesity

● Infertility

● Metronidazole

○ inhibits DNA synthesis and rapidly bactericidal

○ Drug of choice for Gardenerella vaginalis, trich, BV

○ Adverse effects

■ do not take w/ ETOH (antabuse like effects)

■ HA

■ N/V

■ metallic unpleasant taste

■ prolonged use can cause peripheral neuropathy

● Cimetidine

○ H2 receptor agonist

○ acid reducer for heartburn and GERD

○ safe in pregnancy, sit up 30 min after

● ACOG guidelines regarding well woman exam

● American Cancer Society recommendations

● ACOG Pap Smear Guidelines

○ Start @ 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 HPV

■ Rescreen in 5 years

○ Normal Pap and Positive HPV

■ Repeat co-test in 1 yr OR

■ HPV DNA typing now

○ ASCUS Pap, No HPV test

■ Repeat cytology in 1 yr OR

■ Do HPV test now

○ ASCUS/ISIL Pap and Negative HPV

■ Repeat Pap and co-testing every 3 years

○ ASCUS Pap and Positive HPV

■ Colposcopy and/or referral to gynecologist

○ LSIL Pap and Positive or Unknown HPV

■ Colposcopy and/or referral to gynecologist

○ ASC-H Pap

■ Colposcopy and/or referral to gynecologist

○ HSIL Pap

■ Colposcopy and/or referral to gynecologist