Women's Health Final Review, Exams of Obstetrics

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1. Primary Amenorrhea: Absence of menses: by age 15 years Often secondary to: dysfunction in the hypothalamus, pituitary, ovaries (HPO axis), uterus, or vagina
2. DYSMENORRHEA: Painful cramping: associated with menstruation caused by spasmodic uterine contractions Most common GYN problem: in adolescents & adult females HISTORY: is KEY!!! Primary versus Secondary
3. Primary Dysmenorrhea: Absence of pelvic pathology: CAUSE: Excessive Prostaglandins ONSET: in adolescence PAIN: starts 1-2 days prior to onset of menses or with menses, resolving over 12-72 hours ASSOCIATED: with nausea, diarrhea, dizziness, fatigue, HA, back pain IMPROVES: with NSAIDs, hormonal contraceptives, AGE & PARITY
4. Secondary Dysmenorrhea: Presence of Pelvic Pathology: ONSET: Usually after age 25 years Abnormal uterine bleeding (AUB) Variable SX: N, V, D, back pain Dyspareunia: (esp. w/Endometriosis) Symptoms: OFTEN worsen over time Causes: Endometriosis, fibroids, infection/PID, adenomyosis, etc.
5. Dysmenorrhea Management: Get a good history: (medical & menstrual) Physical exam: to identify a cause Pelvic exam: may defer if young, non-sexually active adolescents with mild symptoms Consider pelvic US: to look for adnexal masses, fibroids, other pelvic pathology If secondary, address underlying cause.
6. Dysmenorrhea Non-Pharm Management: HEAT: to lower abdomen = Oral Analgesics EXERCISE: improves symptoms
7. Dysmenorrhea Pharm Management: NSAIDs: 80-86% efficacy o Start at onset of menses for x 1-2+ days o If no relief, consider starting 1-2+ days before Combination Hormonal

2 / 20 Contraceptives (CHC) Consider BOTH, if no relief with NSAIDs Intrauterine Contraceptive (IUC): Hormonal

3 / 20 o Mirena or Skyla (smaller) with Levonorgestrel If NO relief, consider SECONDARY CAUSE

8. ABNORMAL UTERINE BLEEDING (AUB): Comprehensive, focused history Many causes: PALM-COEIN classification Consider DIFFERENTIAL by AGE & HISTORY Post-menopausal: o Any bleeding beyond 12 months since LMP o Even "1 drop of blood" is concerning o Must REFER to OBGYN to R/o cancer
9. Classification/Differential: PALM-COEIN: Structural P Polyps:

30 years A Adenomyosis: 30 L Leiomyoma/Fibroids: 30 M Malignancy/Hyperplasia: 40 (Obesity, DM, PCOS, > 50 yr) Non Structural C Coagulopathy: Any age O Ovulatory Dysfunction: Any age E

4 / 20 Endometrial Disorders: Any age

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I

Iatrogenic, Medications: Any age N Not Classified

10. POLYCYSTIC OVARIAN SYNDROME (PCOS): ANDROGEN EXCESS: Com- mon, complex GYN endocrinopathy Affects 6-20% of women S/S: oligomenorrhea, amenorrhea, AUB hyperandrogenism, (acne, hirsutism), cystic ovaries, infertility, mood/mental health problems Pathophysiology: Insulin resistance (50- 70%) Associated with Risks, Complications Diagnosis: Rotterdam Criteria (2 of 3 criteria): o Oligomenorrhea o Hyperandrogenism o Cystic ovaries
11. (PCOS): Risks & Complications: Endometrial cancer Infertility Diabetes Metabolic Syndrome Obesity (independent risk factor) Cardiovascular disease Hyperlipidemia
12. PCOS Diagnostic Work-up & Differential: Individualize: Body weight, BMI (> 30), Waist (> 35 inches) BP Ultrasound: Ovaries/Uterus-hyperplasia > 10 mm CBC, Lipids q 2y (Low HDL, High trigs/LDL), LFTs, TSH Oral GTT (Most sensitive/specific) Hgb-A1c: DM = > 6.4, At risk = e 5.6-6.4!!!! Total Testosterone: PCOS = > 60, Tumor > 150- 200 o Free T: PCOS = 2-3% Pregnancy test (hCG) Prolactin 3-27 ng/ml, consider DHEA-S? LH/FSH Ratio > 3, BUT may be normal in PCOS

6 / 20 17-hydroxyprogesterone (am, early follicular) < 200 ng/dl rules out NCAH = Non-classical adrenal hyperplasia

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13. PCOS Management: Contraception or Conception?: o Discuss fertility plan- ning » Fast tract fertility: DO NOT wait to age 35 yr » Letrozole preferred (NOT Clomiphene) o Problems: » Infertility: 40% female associated w/ PCOS » Spontaneous Abortion (SAB): 25-73% risk » Gestational diabetes: 3 x increased risk » Preeclampsia/Hypertension
14. PCOS Management: Life Style Approaches - For All: o Weight loss (> 5%) Improves insulin sensitivity, acne, hirsutism, ovulation/return of fertility, menses, improves labs, reduces risk of Uterine CA, etc.!!! o Exercise & Stress Reduction
15. Management: Not Desiring Pregnancy: o Combination Hormonal Contracep- tives (CHC) » New -> Low-Androgen progestins - SAFER: Levonorgestrel (LNG), Norethindrone (NE), Norgestimate (NGM) » Helps androgen sx, prevents Uterine CA o Insulin sensitizer (Metformin): NOT for ALL » 30% reduction in IR o Combination therapy: Metformin & CHCs
16. CERVICAL CANCER: o Caused by HR-HPV » High-risk subtypes: 16, 18, 45, 31, 33, 52, 58, 35 » Cervical cancer is caused by HPV = STI » Males AND females infected » Ubiquitous exposure » Most clear virus within 1 year o For most women... » HPV clears spontaneously w/in 8- months especially if < 24 yrs old » Cervical CA develops from "persistent HPV infection" over many years
17. HPV Vaccination:* Give prior to onset of sexual activity "Coitarche" naive vs non-nai ve Give routinely at 9-12 years for girls (up to 26 yrs.), & boys (21yrs.) NEW: 9-14 y/o 2 doses 6 months apart NEW: 9vGardasil (3 doses if e 15 yr)

8 / 20 If series incomplete, finish w/ new vaccine May benefit if > 26 years, but NO recommendations yet

18. 2019 Screening GuideLines https://www.acog.org/About-ACOG/ACOG-Departments/Annual-Wom- ens-Health-Care/FOR-PATIENTS/Pt-Exams-and-Screen- ing-Tests-Age-19-39-Years:* o Ages 21-29 years: » 1st Pap at age 21 » Repeat every 3 years o Age 21-29 years: » Pap test alone every 3 years o Age > 30 years: » Pap & HPV = Primary screening » Repeat every 5 years (if both negative) » Pap ONLY = every 3 years o Age 65 years: » MAY STOP (if negative history x 10 years)

• If Low Risk = NO hx of CIN2, CIN3, HIV+, immunocompromised, DES

19. 2019 Screening Guidelines: After Hysterectomy: o For Benign Disease: dis- continue o NOT BENIGN: 3 annual negative tests, then discontinue (ACS); ongoing screening for 20 yrs (ACOG) even if e 65 yrs old o USPSTF recommends against screening for Cervical CA in women s/p Hysterec- tomy w/cervix removal & do NOT have a hx of a high-grade precancerous lesion (cervical intraepithelial neoplasia [CIN] grade 2 or

3. or Cervical CA.

20. Use of the Spatula: Used to collect cells from the EctoCervix o Usually done 1st to minimize bleeding o Plastic spatula for liquid-based samples o Wooden or plastic for conventional o Spatula: 1 full rotation o Broom: 3-5 rotations Samples endo/ectocervix
21. Use of the CytoBrush: Used to collect cells from the endocervix Insert into os Rotate 1D4 - 1D2 turn
22. Atypical Squamous Cells (ASC): by Age: o ASC-US (undetermined signifi- cance): 21-24 years

9 / 20 » Repeat PAP at 12 months (no HPV or HPV+)

10 / 20 » If NEGATIVE = Routine screening » If POSITIVE = Colposcopy o ASC-US: > 24 years » Reflex HPV, if POSITIVE = Colposcopy o ASC-H: Colposcopy & Endocervical Sampling

23. Follow-up: Colposcopy Indications: o ASC-H: COLPO FOR ALL o LSIL (low grade squamous intraepithelial lesion) » If < 24 years - OBSERVE, REPEAT 1 year » If > 24 years - COLPO o HSIL (high grade squamous intraepithelial lesion) » Mod or Severe dysplasia, CIN 2 or 3 & carcinoma in situ: COLPO FOR ALL o Atypical glandular cells (AGC): Favor Neoplasia » COLPO FOR ALL
24. VULVOVAGINITIS: o Bacterial vaginosis (BV): Most common o Vulvovaginal candidiasis (VVC): 95% Candida Albicans o Trichomoniasis: common in teens & older women o Self-diagnosis: OFTEN inaccurate!
25. Vulvovaginitis Assessment:Normal:: -S/S-->Clear, White, odorless -PH--> 4.0-4. -"whiff" test-negative -vaginal microscopy-->negative
26. Vulvovaginitis Assessment: VV Candidiasis: -s/s-->itching, burning, dysuria -PH-->4.0-4. -"Whiff" test-negative -Vaginal microscopy-->buds & pseudohyphae
27. Vulvovaginitis Assessment: BV: -s/s--> malodorous discharge -PH-->greater than 4. -"whiff" test-positive -vaginal microscopy-->clue cells
28. Vulvovaginitis Assessment: trich: -s/s --> Malodorous discharge, dysuria -PH-->5.0-6.

11 / 20 -"whiff" test-+/- positive -vaginal microscopy-->trich

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29. Diagnostic Studies: Recurrent yeast infections: Screen for diabetes if sus- pected Pregnancy test HIV Other tests as indicated
30. Management of yeast infections: Oral Agents: Fluconazole (Diflucan) orally x o 72 hours duration o Most cost effective = $ o BUT delayed symptom relief x 24 hours! o Narrow spectrum coverage (C. albicans) DELAY sexual intercourse until symptoms improve!
31. Management of yeast infections: Topical Agents: Butoconazole (Gynazole) Single Dose vaginally o Bioadhesive, time-released, broad spectrum!!!! Miconazole nitrate (Monistat) vaginal suppository or cream Clotrimazole (Gyne-Lotrimin 3, 7) cream OR Terconazole (Terazol) suppository or cream DELAY sexual intercourse until symptoms improve!
32. ATROPHIC VAGINITIS: Post-menopausal women Non-specific sign/symptoms: watery, yellow or white, malodorous vaginal discharge
33. Clues: Atrophic Vaginitis Genitourinary Syndrome of Menopause (GSM) -symptoms: o Vaginal irritation or burning o Dyspareunia o Urinary tract symptoms
34. Clues: Atrophic Vaginitis Genitourinary Syndrome of Menopause (GSM) -exam: o Thinning of vaginal epithelium, loss of elasticity, loss of rugae o Vaginal pH e 5
35. Clues: Atrophic Vaginitis Genitourinary Syndrome of Menopause (GSM) -RX: Estrogen PV, Osphena PO, DHEA PV
36. Osteoporosis Risk Factors: Caucasian, Asian Advanced age, previous fracture Long-term glucocorticoid

13 / 20 therapy Low body weight (< 127 lbs.) Cigarette Smoking Excess alcohol intake

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37. Osteoporosis Screening: DXA scan: dual x-ray absorptiometry Screening NOT recommended pre-menopause unless risk factors present
38. Osteoporosis Management: Weight bearing exercise Stop cigarette smoking, excess alcohol Avoid corticosteroids, anticonvulsants when possible Calcium: Daily intake of 1200 mg/day Plus: o If Vitamin D deficient: replace with Vitamin D o Vitamin D3: 1000-2000 IU/day varies according to reference o Preferred calcium source: FOOD!!!
39. Oral Bisphosphonates: Considered first line for most patients: Inhibits bone resorption: Osteoclasts remains active in bone for weeks, months, maybe years!!! Increase bone mass: Osteoblasts Reduce risk of fracture: o Alendronate (Fosamax) weekly o Risedronate (Actonel) weekly o Ibandronate (Boniva) monthly (does NOT reduce hip Fx risk)
40. Breast Masses: Most common: Fibroadenomas, Cysts Benign complaints: CAN mimic breast cancer
41. Breast masses: Diagnostic Studies: US: o For any female/male < 30 years, with focal mass, or symptom o First line in pregnancy, or < 30 years o To assess mass identified on mammography Mammography: o For any female/male > 30 years with a breast complaint Value of Breast Ultrasound??? Differentiates fluid-filled cyst from solid mass!
42. BREAST CANCER Risk Factors: Gender & age: especially > 65 years Genetic predisposition: BRCA 1, 2 genetic mutations Family history Reproductive history (low parity) Estrogen exposure: o Early menarche < 12 years o Late menopause > 55 years o Estrogen medications
43. Breast Cancer: Screening: Average Risk: o Mammogram: -> ACS: Start 45yrs, (may begin 40-44); then yearly -> Age 55+ every 2 years* -> Yearly screening may be offered

15 / 20 -> USPSTF: Start age 50, then every 2 years

16 / 20 o Clinical Breast Exam & Self-breast Exam: -> ACS: Not recmnd if life expectancy <10 yrs

44. Contraception: Overview: Long acting reversible contraceptives (LARC): o Copper IUC (Paragard), o LNG IUC (Mirena, Skyla) o Great option, all ages o Few contraindications Combination Hormonal Contraceptives (CHC): o Pills, Patch, Ring: contain estrogen, progestin
45. Contraception: Initial Selection: Progestin only: Good for Higher risk women
46. Oral Contraceptives: Initial Selection: Estrogen: cycle control primarily o Heavy periods: Higher estrogen 30-35 mcg o "Normal" menses: Lower estrogen 20- 25 mcg Progestin: contraceptive effects primarily o Levonorgestrel: Safe, less BTB* o Norethindrone: Safe, more BTB o Drospirenone: Avoid if unknown family history, family history of clots, or coagulopathies
47. Headache Red flags in History:: o Sudden onset in seconds or mins (thunder- clap HA): SAH o "First or worst" HA: Hemorrhage, infection o Focal neuro symptoms: Mass, AVM o Fever: Infection o Change in personality, mental status, LOC
48. Headache Red Flags on Exam: o Age (new onset > 35 or 40 years old) o Neck stiffness o Neuro deficits o Papilledema
49. Papilledema: Swelling of the optic disc due to increased ICP Almost always bilateral
50. Headache Notable Fundoscopic Findings: Absent red reflex: cataract Swelling of optic disc (papilledema): increased intracranial pressure (ICP) Abnormal cup disc ratio (>0.5): glaucoma Absent venous pulsations: papilledema Blood in center of disc: SAH

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51. When to Image a Patient with Headache:: "Red Flag" headache Change in pattern, frequency or severity of HA Worsening of HA despite therapy Unexplained neuro symptoms (abnormal exam)

18 / 20 Onset of HA with exertion, cough, intercourse New onset > 50 years HA associated with fever, stiff neck, papilledema, cognitive impairment, or personality change

52. Diagnosis - Migraine Without aura: Headache lasts 4-72 hours Has 2 of these characteristics: unilateral, pulsating quality, mod to severe intensity, aggravated by routine activity During headache: N & /or V, photophobia OR phonophobia (at least 1) 5 or more attacks have occurred with these characteristics No other reason for the headache's occurrence
53. Diagnosis - Migraine With aura: 2 attacks of migraine with aura Visual, sensory, motor, brainstem, retinal, or speech changes fully reversible Develops over 5-20 minutes; headache develops within 60 minutes
54. Headache Common Triggers: Stress Menses Skipping meals (fasting) Changes in weather Sleep disturbances Odors Bright light, EtOH, Smoking Foods
55. Migraine Health Promotion: Prophylactic treatment for > 2 per month Avoid triggers Early treatment & diagnosis Limit use of triptans (overuse leads to rebound headaches unresponsive to triptans)
56. Migraine Headache Location: Unilateral 60-70%; bi-frontal or global 30%
57. Migraine Headache Characteristics: Crescendo
58. Migraine Headache Patient Appearance: Patient desires a cool, quiet, dark room
59. Migraine headache Duration: 4-72 hours
60. Migraine headache Associated Symptoms: N, V, photophobia,? aura
61. Tension Headache Location: Bilateral
62. Tension Headache Characteristics: Pressure, tightness bandlike, waxes &nwanes
63. Tension headache Patient Appearance: May continue day's activities or

19 / 20 not

64. Tension headache duration: varies
65. Tension headaches Associated Symptoms: None
66. Cluster Headache location: Always unilateral; begins around temple or eye

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67. Cluster headache characteristic: Pain peaks within minutes; excruciating, ex- plosive
68. Cluster headache patient appearance: varies
69. Cluster headache duration: 30-90 minutes usually (up to 180 minutes)
70. Cluster headache Associated Symptoms: Eye becomes red, tears, rhinor- rhea, EtOH can trigger
71. UTI: WBCs, Pyuria = Infection Most reliable indicator of infection 95% sensitive

10 WBC per HPF*/spun

sample USUALLY indicates UTI

72. Paget's disease of the breast (Ductal carcinoma in Situ): -common in older females -present with chronic scaly red-colored rash resembling eczema on the nipple that does not heal -lesion slowly enlarges & evolves to include cresting, ulceration &/or bleeding on the nipple
73. Follicular phase: -AKA proliferative phase -days 1- 14 -estrogen is predominant hormone -stimulates development/growth of endometrial lining -FSH stimulates follicles into producing estrogen
74. Midcycle: ovulatory phase: -day 14 -LH is secreted by anterior pituitary gland & induces ovulation of dominant follicle
75. Luteal phase: -days 14- 28 -progesterone is predominant hormone -produced by corpus luteum -helps stabilize endometrial lining