Gynecology: Well-Woman Exam & Labs

Gynecology - Well-Woman Exam History Components

• Important to review menstrual cycle details such as LMP, menarche, interval, duration, flow, changes, pain, and any inter-cycle bleeding or clots
• Inquire about past and present contraception methods, safe sex practices, and family planning goals
• Includes a review of L&D history, anesthesia use, and any complications
• Includes STD history, last Pap smear results, HPV vaccine status, and any abnormal Pap smear results
• Exploring sexual orientation, number of partners, length of current relationships, age at first intercourse, and current sexual activity
• During a physical assessment, externally examine genitalia, vagina, cervix, uterus, and adnexa; also perform rectal and breast exams

Gynecology - Labs and Pap Smears

• Lab tests include urine analysis (if indicated), pap smear, STI testing (if indicated), hematologic screening, mammogram, and bone density assessment
• STI and urine tests are highly recommended for patients who have had unprotected sex
• Women aged 21-29 should have a Pap smear every 3 years; if sexually active, include HPV testing
• Women aged 30-65 should have HPV co-testing every 5 years as the preferred method, or cytology (Pap smear) alone every 3 years
• Annual screening should be performed in patients at increased risk
• Women over 65 with 3 normal consecutive Paps do not need Pap or HPV screening
• Continue screening past age 65 for women with a history of CIN II or greater, for a minimum of 20 years

Gynecology - Pap Smear Techniques and Results

• Evaluation of specimens is based on specimen adequacy, either satisfactory or unsatisfactory
• If the specimen is unsatisfactory, repeat the pap smear in 2-4 months
• General results are categorized as negative for intraepithelial lesion or malignancy
• Epithelial cell abnormality results include: ASC-US, ASC-H, LSIL, HSIL, ACIS, AGC
  • ASC-US should be repeated in 1 year
  • Note, screening for pregnant women is the same as for the general population

Gynecology - Cancer Screening Recommendations

• Includes other malignancies, CIN 1 (mild dysplasia), CIN 2 (moderate dysplasia), and CIN 3 (severe dysplasia)
• Breast cancer screening:
  • ACS: women aged 40-44 can choose to start annual screening
  • Women aged 45-54 should be screened annually
  • Women 55 and older: screen every other year (QOY) or yearly (QY); continue screening if in good health and expected to live at least 10 more years
  • USPSTF: screen every 2 years for women aged 40-74
• Cervical cancer screening:
  • ACS: begin testing at age 25
  • For women aged 25-65: primary HPV test every 5 years, or HPV & Pap co-testing every 5 years, or Pap alone every 3 years
  • ACS: for women aged 65 and over with regular past screening and normal results in the last 10 years, screening can be stopped if no abnormal history in the last 25 years; it doesn't need to be restarted
  • Screening after total hysterectomy is unnecessary unless the cervix is still present
  • USPSTF: screen every 3 years for women aged 21-29
  • Screen every 3 years or every 5 years with co-testing for women aged 30-65
• Ovarian cancer screening:
  • USPSTF: screening not recommended if asymptomatic

Gynecology - Bethesda Terminology

• Necessary to review Bethesda terminology and its interpretation for Pap smear results and treatment plans

Contraception - Assessment

• Start with patient’s baseline knowledge
• Must consider personal, religious, and cultural beliefs
• Review past contraceptive use
• Note any contraindications for contraceptive use, especially combined hormonal methods containing estrogen and progestin (estrogen is the reason for the contraindication)
• Determine the 5 P's: practices, pregnancy, prevention, partners, past STI history, and protection

Contraception - Implications and Planning

• Assess financial implications, with the IUD requiring a large upfront payment
• Discuss future pregnancy plans
• Provide evaluation, treatment, and education on contraception, including contraindications, financial implications, and future pregnancy plans

Contraception - Methods Overview

• Natural family planning: track menstruation, ovulation

Contraception - Tier 1 Methods

• Long-acting reversible contraceptives (LARCs) such as IUDs and Nexplanon (3-year subdermal implant) are highly effective (over 99%)

Contraception - Tier 2 Methods

• Includes refillable options such as oral contraceptives (OCs), progestin-only pills, vaginal rings, and injectables, with 91-93% effectiveness
  • Depo-Provera injections should only be used for 2 years

Contraception - Tier 3 and Barrier Methods

• Tier 3 methods include condoms, diaphragms, cervical caps/sponges, and spermicides, which have a higher failure rate (up to 18%)
• Barrier methods: spermicides, condoms, diaphragms
  • Leave in place >6 hours
  • If having another intercourse, insert more cream into the vagina
  • Shouldn't stay in for >24 hrs
  • If pt gains/loses 15 lbs, come back for resizing
  • Don't use in patient with a history of chronic UTI and TSS
  • A prescription is needed for a diaphragm and cervical cap
  • Leave sponge in place for 6 hours and no longer than 30 hours

Hormonal Contraceptives

• Combined hormonal contraceptives:
  • Contraindicated for smokers over 35, those with hypertension, DVT/PE, stroke, breast cancer, or cirrhosis
  • Common side effects: nausea/vomiting, breast tenderness, irregular bleeding
  • Alert the patient to severe adverse effects requiring immediate attention like abdominal pain, chest pain, leg pain, eye problems, jaundice, or stroke Start methods:
  • First-day start: start on the first day of menstruation, no backup needed
  • Sunday start: start on the first Sunday after the period starts, use backup for 7 days
  • Quick start: begin immediately, use backup for 7 days only if the patient is not pregnant Important considerations:
    • Missed 1 pill: take it ASAP; if recognized next day, take 2
    • Missed 3 pills: take normal amount
    • Missed 2-4 pills for 2-3 days; consider a new pack; if 5 or more, start a new pack

Hormonal Contraceptives - Progestin-Only Pills

• Progestin-only pills (mini-pills):
  • Side effects: irregular bleeding, breast tenderness, and edema
  • Progestin-only pills must be taken at the same time each day
  • Can be started anytime
  • Used when estrogen is contraindicated

Contraception - Transdermal Patch

• Transdermal patch (Ortho Evra):
  • Contraindications: same as combined oral contraceptives
  • Side effects: same as combined oral contraceptives, plus skin irritation
  • Adverse effects: same as combined oral contraceptives
  • Applied weekly for 3 weeks
  • Decreased effectiveness if over 198 lbs
  • If BMI is over 30, black box warning for VTE
  • Serious cardiovascular risks if over 35 and smoke

Contraception - Vaginal Ring

• Vaginal ring:
  • Contraindications: similar to combined oral contraceptives, but slightly less
  • Side effects: similar to combined oral contraceptives
  • Adverse effects: similar to combined oral contraceptives
  • Leave in place for 3 weeks

Contraception - Injection

• Injection (Depo-Provera), which contains only progestin:
  • Contraindications: low bone density and severe depression
  • Side effects: irregular bleeding and weight gain
  • Adverse effects: decreased bone density
  • Requires return every 12 weeks for injection
  • Use should not exceed 2 years
  • Encourage calcium intake and smoking cessation
  • Fertility may be delayed after stopping, lasting up to 3 years

Contraception - Devices and Methods

• Intrauterine devices: no hormones
  • Paragard (copper IUD) is effective for 10 years
  • Contraindications: distorted uterus or use of CYP3A inhibiting medications
  • Side effects: irregular bleeding and cramping
  • Education: avoid exposure to infections and check strings
• IUDs with hormones
• Surgical methods: vasectomy requires use of protection until semen count confirms sterility

Contraception - Emergency

• Emergency contraception:
  • Side effects: irregular bleeding, breast tenderness, nausea/vomiting
  • Education: Available OTC, use 1 pill or 2 (1 now, 2 12 hours later)
  • Effective up to 5 days
  • Report if no period in 4 weeks
  • IUD can be used as emergency contraception up to 5 days
• Necessitates assessment, evaluation, and education for patients seeking assistance with infertility

Gynecology - Infections

• Includes the diagnosis and treament of the following:
  • Vaginitis Candidiasis and Bacterial Vaginosis
  • STIs: gonorrhea, chlamydia, trichomoniasis, syphilis, herpes simplex virus, human papillomavirus
  • Pelvic Inflammatory Disease
  • Dyspareunia

Gynecology - Disorders

• Includes the diagnosis and treament of the following:
  • Amenorrhea (primary and secondary)
  • Dysmenorrhea
  • Endometriosis
  • Abnormal Uterine Bleeding
  • Chronic Pelvic Pain