Unit 4 Health Promotion and Gynecological Exam PDF

**Unit 4 Health Promotion and Gynecological Exam** **Clinical Guidelines in Primary Care Hollier** - Chapter 1: \"Cardiovascular Disorders\"-page 46 to 60 congenital heart disease in children, heart murmurs page 79 - Chapter 3: \"Dermatologic Disorders\"-acne vulgaris page 167, 5th di...

**Unit 4 Health Promotion and Gynecological Exam** **Clinical Guidelines in Primary Care Hollier** - Chapter 1: \"Cardiovascular Disorders\"-page 46 to 60 congenital heart disease in children, heart murmurs page 79 - Chapter 3: \"Dermatologic Disorders\"-acne vulgaris page 167, 5th disease page 201 hand foot and mouth disease 2O2 herpes zoster p 206 impetigo p 210 rubeola and rubella p 228 varicella p 253 - Chapter 4: \"Endocrine Disorders\"- Gynecomastia page 348, hypothyroidism P356 - Chapter 13: Psychiatric & Mental Health Disorders - Chapter 15: Reproductive Health - Chapter 16: \"Sexually Transmitted Diseases\" - Chapter 17 Urological Disorders p 961, 963 - Chapter 18 Women's Health Disorders Clinical breast exam- see standford25video Genitourinary exam Menstrual Cycle/Menses **Abnormal Uterine Bleeding** - About [14%-40% of patients of childbearing age](https://www.dynamed.com/approach-to/abnormal-uterine-bleeding#INCIDENCE_PREVALENCE) are reported to have abnormal uterine bleeding. [Causes](https://www.dynamed.com/approach-to/abnormal-uterine-bleeding#CAUSES) include: - structural uterine abnormalities, such as, endometrial polyps, uterine fibroids, adenomyosis, or malignancy - early pregnancy-related complications, including spontaneous abortion, septic abortion, or ectopic pregnancy - coagulopathies or bleeding disorders - ovulatory dysfunction, including polycystic ovarian syndrome or other causes of oligoovulation, such as eating disorders or physical or psychological stress - smoking - iatrogenic sources, such as, medications or breakthrough bleeding with use of intrauterine device or noncompliance with hormonal contraceptives - sexually transmitted infection - sexual trauma +-----------+-----------+-----------+-----------+-----------+-----------+ | - **Str | **Nonstru | | | | | | uctural** | ctural ** | | | | | +===========+===========+===========+===========+===========+===========+ | **P** | Polyps | AUB-P | **C** | Coagulopa | AUB-C | | | | | | thy | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **A** | Adenomyos | AUB-A | **O** | Ovulatory | AUB-O | | | is | | | Disorders | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **L** | Leiomyoma | AUB-L~SM~ | **E** | Endometri | AUB-E | | | (submucos | | | al | | | | al | AUB-L~O~ | | | | | | or other) | | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | | | | **I** | Iatrogeni | AUB-I | | | | | | c | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **M** | Malignanc | AUB-M | **N** | Not | AUB-N | | | y | | | Classifie | | | | | | | d | | +-----------+-----------+-----------+-----------+-----------+-----------+   - **Laboratory Testing:** - Beta hCG: any person in whom pregnancy is possible - Evaluate hemodynamic stability: CBC with platelets, iron studies - Coagulation studies (PTT/PT/fibrinogen, thrombin time, von Willebrand panel) - STD testing, wet prep - Cervical cytology - Other considerations as clinically indicated (TSH, LFTs, renal panel, screening for PCOS) - Consider ovulatory function: prolactin, estrogen, testosterone, FSH, LH - Endometrial biopsy (older than 45: first-line test) - **Imaging:** - TV-USS (transvaginal sonography): first line if imaging needed - Saline infusion sonohysterography: helpful for leiomyoma - Hysteroscopy: for guided endometrial biopsy - MRI **Amenorrhea- always rule out pregnancy** - **Primary amenorrhea**: no menses by age 13 in the absence of secondary sex characteristics **OR **absence of menses by age 15 regardless of the development of secondary sex characteristics - **Secondary amenorrhea**: cessation of menstruation for three normal cycles or for 6 months in a woman who previously experienced menstrual bleeding - **Primary amenorrhea** - Chromosome mutations - Outflow tract disorders - Ovarian disorders - Hypopituitarism - CNS disorders - Extreme weight loss/anorexia nervosa - **Secondary amenorrhea** - Pregnancy - Polycystic ovarian syndrome (PCOS; accounts for 90% of oligomenorrhea) - Endocrine disorder - Anatomical causes - Premature ovarian failure - Stress - Malnutrition **Menopause- 1 year without a cycle** - **Vasomotor Symptoms** - Hormone therapy is gold standard for VMS - Estrogen-alone therapy for symptomatic women after hysterectomy - In symptomatic women with uterus, combination therapy protects against endometrial neoplasia: progestogen or conjugated equine estrogen plus bazedoxifene - Prescribe lowest dose 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 - Selective serotonin reuptake inhibitors (SSRIs) serotonin-norepinephrine reuptake inhibitors (SNRIs), clonidine (Catapres) and gabapentin (Neurontin) are nonhormonal treatments that have effectiveness for VMS (off label) - **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 not required - Ospemifene is only nonhormonal therapy with an FDA indication for VVA (intravaginal DHEA used off label) - OTC vaginal moisturizers effective for mild vaginal dryness and dyspareunia - **Urinary Tract Systems and Pelvic Floor Disorders** - Low-dose vaginal ET may provide benefit for urinary systems, 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 of the 3 | | | 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. Oxytocin causes smooth muscle contractions in the uterus during labor and then postpartum, preventing hemorrhage. The release of oxytocin is stimulated by visual, olfactory and auditory stimulation. Oxytocin creates a warming effect via vasodilation of peripheral blood vessels, enhancing skin-to-skin contact. It calms, reduces stress and promotes bonding for mother and infant - **Prolactin **plays a major role in milk synthesis. It peaks 45 minutes after breastfeeding. Infant suckling (hand expression or using a breast pump) can release prolactin. Prolactin also promotes appetite and stress reduction during pregnancy. It 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. It is rich in immunoglobulins, vitamin E, and leukocytes. The color of colostrum ranges from clear to a deep yellow - Production begins midpregnancy; secretion occurs within 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. Mature milk is 87.5% water - Milk composition changes only slightly with maternal diet changes - Color of mature milk can vary from a white/cream to a light green color - Foremilk is the milk at the beginning of the feed and is higher in lactose - Hindmilk is the milk at the end of the feed and is higher in fat - **Extra 300-400 kcal while breast feeding** **Bacterial Vaginosis** **DIAGNOSTIC STUDIES** - Amsel's criteria specify that diagnosis of BV requires three or more of the following clinical signs and symptoms: - Homogenous, thin, gray-white discharge coating the vaginal wall - Vaginal pH \>4.5 - Positive whiff test: amine (fishy) odor after application of 10% KOH on vaginal discharge sample - Presence of more than 20% epithelial cells (clue cells) on saline microscopy: microscopic evaluation of vaginal discharge on glass slide with normal saline shows few WBCs, and epithelial cells are obscured with coccobacilli. Presence of clue cells identified by an experienced microscopist is the single most reliable predictor of BV - Gram stain: microscopic evaluation of vaginal smears for bacterial morphology (*Lactobacilli* sp.) using Nugent scoring criteria - Vaginal culture is not diagnostic because G. vaginalis can be present in healthy asymptomatic women - Commercial tests for diagnosis of BV if microscopy is not available include: - **Affirm VP III:** an automated DNA probe assay for detecting *G. vaginalis*. A concentration of *G. vaginalis* ≥2 times 107 CFU/mL on the DNA probe and vaginal pH \>4.5 has a sensitivity of 95% and specificity of 99%. Results can be ready in 45 minutes if onsite testing available - **OSOM BVBLUE system:** a chromogenic diagnostic test based on the presence of sialidase enzyme produced by anaerobes associated with BV. Elevations in sialidase enzyme activity in vaginal fluid samples is indicative of BV. The test can be performed at the point of care and results are available in 10 minutes - **Fem Exam test**: a two-card system that detects vaginal pH and trimethylamine on one card and a chemical produced by G. vaginalis (prolineaminopeptide) on the other. Results are available in 5 minutes. This test has low specificity and sensitivity and is not recommended by the CDC A picture containing text Description automatically generated Contraception- see CDC pdf Cancer  Osteoporosis **Cervical cytology interpretation** +-----------------+-----------------+-----------------+-----------------+ | **Cervical | | | | | Cancer | | | | | Screening | | | | | Recommendations | | | | | : | | | | | General | | | | | Population** | | | | +=================+=================+=================+=================+ | **Age** | **ASCCP/ACS/ASC | **USPSTF 2018** | **ACOG 2016** | | | P | | | | | 2020** | | | +-----------------+-----------------+-----------------+-----------------+ | **Younger than | Recommends | Recommends | Recommends | | 21** | against | against | against | | | screening this | screening | screening | | | age group. If | | | | | screening is | | | | | done and is | | | | | abnormal, | | | | | follow | | | | | guidelines for | | | | | ages 21-24 | | | +-----------------+-----------------+-----------------+-----------------+ | **Ages 21-29** | - Cytology | Cytology every | - Cytology | | | every 3 | 3 years | every 3 | | | years **OR* | | years | | | * | | | | | | | - hrHPV | | | - hrHPV | | primary | | | primary | | screening | | | screening | | (starting | | | may start | | at age 25) | | | at age 25 | | every 3 | | | and | | years | | | continue | | | | | every 5 | | | | | years | | | +-----------------+-----------------+-----------------+-----------------+ | **Ages 30-65** | - Cotest | - Cotesting | - Cotesting | | | every 5 | every 5 | every 5 | | | years | years **OR* | years **OR* | | | | * | * | | | - If hx of | | | | | CIN 2 or | - hrHPV only | - hrHPV only | | | higher, | every 5 | every 3 | | | cotest | years **OR* | years **OR* | | | every 3 | * | * | | | years for | | | | | at least 25 | - Cytology | - Cytology | | | years **OR* | alone every | alone every | | | * | 3 years | 3 years | | | | | | | | - hrHPV | | | | | primary | | | | | screening | | | | | every 3-5 | | | | | years **OR* | | | | | * | | | | | | | | | | - Cytology | | | | | every 3 | | | | | years | | | +-----------------+-----------------+-----------------+-----------------+ | **Posthysterect | - Women who | Recommends | Women who have | | omy** | have had | against | had total | | | total | screening in | hysterectomy | | | hysterectom | women who have | including | | | y | had a | cervix should | | | including | hysterectomy | stop screening | | | cervix, and | with removal of | and not restart | | | have no | cervix and do | for any reason | | | history of | not have a | | | | CIN 2 or | history of | | | | higher, | CIN2, CIN 3,or | | | | should stop | cervical cancer | | | | screening | | | | | | | | | | -  Women with | | | | | a | | | | | hysterectom | | | | | y | | | | | for | | | | | treatment | | | | | of CIN 2 or | | | | | higher | | | | | should have | | | | | 3 | | | | | consecutive | | | | | annual | | | | | HPV-based | | | | | tests. | | | | | Then, | | | | | HPV-based | | | | | test every | | | | | 3 years for | | | | | at least 25 | | | | | years | | | | | | | | | | - Women who | | | | | have a | | | | | supracervic | | | | | al | | | | | hysterectom | | | | | y | | | | | should | | | | | continue | | | | | with | | | | | routine | | | | | screening | | | | | according | | | | | to | | | | | guidelines | | | +-----------------+-----------------+-----------------+-----------------+ | **When to | - In women | For women who | Women with | | screen after | with | have inadequate | history of CIN2 | | age 65** | history of | screening | or higher | | | CIN2, CIN3, | history or lack | should continue | | | adenocarcin | documentation | aged-based | | | oma | of adequate | screening for | | | in situ or | screening, | at least 20 | | | cervical | routine | years | | | cancer, | screening | | | | screening | should continue | | | | should | for at least 20 | | | | continue | years after | | | | every 3 | spontaneous | | | | years for | regression or | | | | at least 25 | treatment for | | | | years | high-grade | | | | | lesion, even if | | | | - Discontinua | it extends past | | | | tion | age 65 | | | | of | | | | | surveillanc | | | | | e | | | | | is | | | | | recommended | | | | | for | | | | | patients | | | | | with a | | | | | limited | | | | | life | | | | | expectancy | | | +-----------------+-----------------+-----------------+-----------------+ | **When to | - Age \>65 | Recommends | Age \>65 with | | stop** | with | screening in | adequate | | | adequate | women who have | negative prior | | | negative | adequate prior | screening and | | | prior | screening and | no history of | | | screening | are not | CIN2 or hi | | | and no | otherwise at | | | | history of | high risk for | | | | CIN2 or | cervical cancer | | | | higher | | | | | within the | | | | | last 25 | | | | | years | | | | | | | | | | - Adequate | | | | | negative | | | | | screening = | | | | | 3 negative | | | | | Pap or 2 | | | | | negative | | | | | Pap and HPV | | | | | in previous | | | | | 10 years | | | | | AND no | | | | | abnormal | | | | | results | | | +-----------------+-----------------+-----------------+-----------------+ - Nearly 100% of cervical cancers test positive for high-risk human papillomavirus (hrHPV) - HPV type 16 accounts for 55-60% of all cervical cancer and causes a greater proportion of squamous cell carcinoma - HPV type 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 ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- **Five hrHPV assays have been cleared by the FDA: Hybrid Capture 2, Cervista HPV HR, cobas HPV Test, Aptima HPV Assay, and Onclarity HPV Assay. Two of these are FDA-cleared for primary HPV (standalone) screening in women 25 years and older: cobas HPV test and Onclarity HPV assay. These two tests report initial genotyping for HPV types 16 and 18 on every test.** ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - Sometimes cytology or pathology are not conclusive. Consider management according to the highest-grade abnormality found when histology or cytology is inconclusive such as a result of 'LSIL cannot rule out HSIL'. - Note that a negative past history should be entered only when documented in the medical record and performed on time: - Negative HPV test or cotest within 5 years - Colposcopic examination confirming CIN1 or less within 1 year.  Diagram Description automatically generated Diagnostic studies (ordering and interpreting) Sexually Transmitted Infections- please see STI insert **Osteoporosis** **\ Guidelines for pharmacologic** intervention in **postmenopausal women** and **men ≥ 50 years of age** - - - **Nonpharmacologic therapy** **Diet**---adequate calorie intake, avoid malnutrition **Supplemental elemental calcium (1,200 mg/day)** - - **Vitamin D supplementation** is recommended with **800 to 1000 IU/day** - - - **Exercise, smoking cessation, **and** alcohol** - - - **Pharmacologic therapy** **Bisphosphonates **are** first-line drug therapy.** By inhibiting bone resorption, bisphosphonates preserve bone mass and can **decrease vertebral and hip fractures by 50%.** They can be given orally or IV - - - - **Teriparatide** (recombinant PTH) - considered first-line in patients with a **very high risk of fracture** (T-score of -3.5 or below even in the absence of fractures, or T-score of -2.5 or below plus a fragility fracture) - **Urinary Incontinence** **ETIOLOGY** - **Urge Incontinence (detrusor instability):** - Urinary tract infection - Chronic cystitis - Dementia - Parkinson's disease - Aging - Stroke - Irradiation of bladder +-----------------------------------------------------------------------+ | Conditions That Mimic Urge Incontinence (DIAPPERS) | +=======================================================================+ | - **D**ementia/delirium | | | | - **I**nfection | | | | - **A**trophic vaginitis | | | | - **P**harmaceuticals (retention) | | | | - **P**sychological conditions | | | | - **E**xcess urinary output | | | | - **R**estricted mobility | | | | - **S**tool impaction | +-----------------------------------------------------------------------+   - **Stress Incontinence (sphincter incompetence):** - Aging - Pelvic floor muscle weakness - Estrogen deficiency - Perineal trauma - Prostatic/pelvic surgery - Sneezing - Coughing - Laughing - Exertion or effort - **Overflow Incontinence (term not widely used):** - Urinary leakage from overdistended bladder - Incomplete emptying - Impaired detrusor contractility - Bladder outlet obstruction - Prostatic enlargement - **Functional Incontinence:** - Severe mental illness - Sedating medications - Physical or mental disability A diagram of a pelvic muscles Description automatically generated with low confidence