unit4review

Cardiovascular Disorders

• Congenital heart disease in children and heart murmurs are discussed in Chapter 1 of the text.

Dermatologic Disorders

• Acne vulgaris is discussed in Chapter 3.
• Fifth disease, hand foot and mouth disease, herpes zoster, impetigo, rubeola, rubella and varicella are also discussed in Chapter 3.

Endocrine Disorders

• Gynecomastia and hypothyroidism are discussed in Chapter 4.

Abnormal Uterine Bleeding

• 14%-40% of childbearing women experience abnormal uterine bleeding.
• Potential causes include structural uterine abnormalities, early pregnancy complications, coagulopathies, ovulatory dysfunction, smoking, iatrogenic sources, sexually transmitted infections, and sexual trauma.
• A table is provided with categories of AUB (Abnormal Uterine Bleeding) including Polyps (AUB-P), Adenomyosis (AUB-A), Leiomyoma (AUB-L), Malignancy (AUB-M), Coagulopathy (AUB-C), Ovulatory Disorders (AUB-O), Iatrogenic (AUB-I), and Not Classified (AUB-N).
• Laboratory testing for AUB includes:
  • Beta hCG
  • CBC with platelets, iron studies
  • Coagulation studies
  • STD testing
  • Cervical cytology
  • Other considerations as clinically indicated (TSH, LFTs, renal panel, screening for PCOS)
  • Prolactin, estrogen, testosterone, FSH, LH
  • Endometrial biopsy (first-line test for women over 45)
• Imaging for AUB includes:
  • TV-USS (transvaginal sonography)
  • Saline infusion sonohysterography
  • Hysteroscopy
  • MRI

Amenorrhea

• Always rule out pregnancy before diagnosing amenorrhea.
• Primary amenorrhea is defined as no menses by age 13 in the absence of secondary sex characteristics or absence of menses by age 15 regardless of secondary sex characteristics.
• Secondary amenorrhea is defined as cessation of menstruation for three normal cycles or for 6 months in a woman who previously experienced menstrual bleeding.
• Primary amenorrhea can be caused by:
  • Chromosome mutations
  • Outflow tract disorders
  • Ovarian disorders
  • Hypopituitarism
  • CNS disorders
  • Extreme weight loss/anorexia nervosa
• Secondary amenorrhea can be caused by:
  • Pregnancy
  • PCOS (accounts for 90% of oligomenorrhea)
  • Endocrine disorder
  • Anatomical causes
  • Premature ovarian failure
  • Stress
  • Malnutrition

Menopause

• Menopause is defined as 1 year without a cycle.
• Vasomotor Symptoms
  • Hormone therapy is the gold standard for vasomotor symptoms (VMS).
  • Estrogen-alone therapy is used for symptomatic women after hysterectomy.
  • Combination therapy (progestogen or conjugated equine estrogen plus bazedoxifene) protects against endometrial neoplasia in symptomatic women with a uterus.
  • Prescribe the lowest dose of hormone therapy that provides symptom relief for the shortest period of time. Periodically assess dosing and need for therapy.
  • Micronized progesterone 300 mg HS decreases VMS.
  • Hormone therapy improves sleep by reducing nighttime awakenings.
  • Paroxetine (Brisdelle) is the only nonhormonal medication with an FDA-approved indication for VMS.
  • Off-label nonhormonal treatments for VMS include SSRIs, SNRIs, clonidine (Catapres) and gabapentin (Neurontin).
• Genitourinary Syndrome of Menopause
  • Low-dose vaginal estrogen preparations are effective and safe for vulvovaginal atrophy (VVA) and preferred over systemic therapies.
  • Vaginal ET lacks data for use > 1 year; evaluate any bleeding; progesterone therapy is not required.
  • Ospemifene is the only nonhormonal therapy with an FDA indication for VVA (intravaginal DHEA used off label).
  • OTC vaginal moisturizers are effective for mild vaginal dryness and dyspareunia.
• Urinary Tract Systems and Pelvic Floor Disorders
  • Low-dose vaginal ET may provide benefit for the urinary system, prevention of recurrent UTI, overactive bladder and urge incontinence.
  • HT does not have FDA indications for any urinary health indication.
  • Systemic HT does not improve urinary incontinence and may increase stress urinary incontinence.
• Sexual Function
  • Systemic HT and low-dose vaginal estrogen increase lubrication, blood flow and sensation in vaginal tissues.
  • Low-dose vaginal ET improves sexual function in postmenopausal women with VVA.
  • Systemic HT does not improve sexual function, sexual interest, arousal or orgasmic response in women without menopause symptoms.
  • Non-estrogen alternatives with FDA indications for dyspareunia: ospemifene and intravaginal DHEA.
• Hormone Therapy
  • Risk Factors for HT use:
    • Age > 60 years or > 10 years past menopause
    • BMI > 30
    • Insulin resistance
    • Hypertension
    • Smoking
    • Dyslipidemia
    • Venous thromboembolism: personal or familial
  • Contradictions to HT:
    • Unexplained vaginal bleeding
    • Known or suspected breast cancer
    • Acute liver disease
    • Active thromboembolic diagnosis
    • Acute cardiovascular disease
    • Recent cerebrovascular accident
    • Pregnancy

PCOS

• Diagnostic Criteria
  • Diagnosis in Adults: Rotterdam Consensus Criteria
    • Evidence of 2 out of 3 of the following must be present:
      • Hyperandrogenism
      • Oligo-ovulation or anovulation
      • Polycystic ovaries on ultrasound
    • Exclusion of alternative etiologies
  • Diagnosis in Adolescents: All 3 of the following (Rotterdam Criteria):
    • Oligomenorrhea or amenorrhea present 2 years after menarche
    • Polycystic ovaries with increased ovarian size (ultrasound)
    • Hyperandrogenemia diagnosed via laboratory analysis

Lactation

• Lactogenesis is initiated by the decline of estrogen and progesterone after delivery of the placenta.
• Oxytocin and prolactin are released by the pituitary gland in response to labor and stimulation of the nerve endings in the breasts.
  • Oxytocin plays a major role in milk ejection/release of milk. Stimulates uterine contractions during labor and postpartum, preventing hemorrhage. Release is stimulated by visual, olfactory and auditory stimulation. Oxytocin creates a warming effect via vasodilation, enhancing skin-to-skin contact. It calms, reduces stress and promotes bonding for mother and infant.
  • Prolactin plays a major role in milk synthesis. Peaks 45 minutes after breastfeeding. Infant suckling (hand expression or using a breast pump) can release prolactin. Promotes appetite and stress reduction during pregnancy. Regulates volume and production of breast milk and fosters maternal adaptation.
• The mammary gland uses 30% of total energy expended by the mother.
• Colostrum is the thick, sticky, fluid discharged from the breasts after delivery. Rich in immunoglobulins, vitamin E, and leukocytes.
  • Production begins midpregnancy; secretion occurs within the first 5 days after birth.
  • Higher protein than mature milk and lower in fat and lactose.
  • Low volume matches small gastric capacity of newborn (about 5-7 mL).
  • Has a laxative effect on newborns to assist in expelling meconium.
• Transitional milk is produced between 2-5 days after delivery and 10-14 days after delivery. It is thinner, more plentiful breast milk with increased lactose, fat, calories, and water-soluble vitamin content.
• Mature milk contains the highest caloric content, fat content, lactose and protein.

Contraception

• See the CDC PDF for information on contraception.

Cancer

• Refer to the text for information on cancer.

Osteoporosis

• Refer to the text for information on osteoporosis.

Cervical Cytology Interpretation

• Cervical Cancer Screening Recommendations
  • General Population
    • Age | ASCCP/ACS/ASCP 2020 | USPSTF 2018 | ACOG 2016
    • Younger than 21 | Recommends against screening this age. | Recommends against screening. | Recommends against screening.

Cervical Cancer Screening

• Women should get regular screening for cervical cancer.
• Nearly 100% of cervical cancers test positive for high-risk human papillomavirus (hrHPV).
• HPV 16 and 18 are most common types associated with cervical cancer.
• HPV 16 accounts for 55-60% of all cervical cancers and causes a greater proportion of squamous cell carcinoma.
• HPV 18 accounts for 10-15% of all cervical cancers and causes a greater proportion of glandular cancer, adenocarcinoma and adenosquamous carcinoma.
• 12 other hrHPV subtypes account for 25-35% of cervical cancers.
• Women aged 25 years and older should have HPV-based testing every 3 years.
• Women with a supracervical hysterectomy should continue with routine screening.
• Women with history of CIN2 or higher should continue screening every 3 years for 20 years after diagnosis.
• Women aged 65 years or older with adequate negative prior screening and no history of CIN2 or higher should discontinue screening.
• For women with history of CIN2, CIN3, adenocarcinoma in situ or cervical cancer, screening should continue every 3 years for 25 years after diagnosis even after age 65.
• Women with inadequate screening history or lack of documentation of adequate screening should continue screening every 3 years for 20 years.
• Discontinuation of screening is recommended for patients with a limited life expectancy.
• A negative history should be based on:
  • Negative HPV test or co-test within 5 years
  • Colposcopic examination confirming CIN1 or less within 1 year
• Two primary HPV tests are cleared by FDA for women 25 years and older:
  • cobas HPV test
  • Onclarity HPV assay
• Both tests report initial genotyping for HPV types 16 and 18 on every test.

Osteoporosis

• Bisphosphonates are first-line drug therapy for osteoporosis.
• Bisphosphonates decrease vertebral and hip fractures by 50% and can be given orally or intravenously.
• Teriparatide is considered first-line therapy for patients with a very high risk of fracture.
• Very high risk factors include T-score of -3.5 or below with no fractures, or T-score of -2.5 or below with a fragility fracture.
• Nonpharmacologic therapy:
  • Adequate calorie intake
  • Avoid malnutrition
  • Supplemental elemental calcium (1,200 mg/day)
  • Vitamin D supplementation (800 to 1000 IU/day)
  • Exercise
  • Smoking cessation
  • Alcohol moderation

Urinary Incontinence

• Urge Incontinence (detrusor instability):
  • Causes:
    • Urinary tract infection
    • Chronic cystitis
    • Dementia
    • Parkinson's disease
    • Aging
    • Stroke
    • Irradiation of bladder
• Stress Incontinence (sphincter incompetence):
  • Causes:
    • Aging
    • Pelvic floor muscle weakness
    • Estrogen deficiency
    • Perineal trauma
    • Prostatic/pelvic surgery
    • Sneezing
    • Coughing
    • Laughing
    • Exertion or effort
• Overflow Incontinence (term not widely used):
  • Causes:
    • Leaking from overdistended bladder
    • Incomplete emptying
    • Impaired detrusor contractility
    • Bladder outlet obstruction
    • Prostatic enlargement
• Functional Incontinence:
  • Causes:
    • Severe mental illness
    • Sedating medications
    • Physical or mental disability