Week 1.docx

Content: - Menarche - Contraception - Unintended pregnancy/pregnancy options - Pap guidelines Readings and PPTs: - **Menarche** pp 94-97 (Chp 6) - **Initiation of menstruation usually happens between 12-15 years old** - The median age of menarche is **12.5 years old, but th...

Content: - Menarche - Contraception - Unintended pregnancy/pregnancy options - Pap guidelines Readings and PPTs: - **Menarche** pp 94-97 (Chp 6) - **Initiation of menstruation usually happens between 12-15 years old** - The median age of menarche is **12.5 years old, but this may occur earlier especially if minimal body fat has been achieved (17%)- think** about this with obese children - The menstrual cycle interval during the first few years of menarche is 21-45 days - Menopause starts between 45-55 years old - Body composition is important in determining the onset of puberty and menstruation in young women (ratio of total body weight to lean body weight) - Think about athletes who may have irregular cycles or late start to their menarche - Must have at **least 17% body fat for menarche** to occur - May take 18-24 months to establish regular ovulatory cycles - More obese ppl tends to have earlier onset of menarche - Menstrual cycles occurring during the first 1-1.5 years after menarche are usually irregular b/c of the immaturity of the hypothalamic-pituitary-ovarian axis 1. Follicular phase: this varies in length, there is an increase in FSH which lead to increase in estrogen levels; overall increase of LH and FSH 2. Ovulation: this happens 10-12 hours after LH peak 3. Luteal phase: usually lasts 14 days; the corpus luteum causes an increase of progesterone and estrogen; the decreased corpus luteum function causes decrease of estrogen and progesterone which causes menses 4. Endometrial cycle: proliferative phase, secretory phase, menstrual phase the prostaglandins cause uterine contractions and sloughing of degraded tissue - The hypothalamus is what controls the anterior pituitary functions via the secretion of releasing and inhibiting factors - The hypothalamus and the pituitary glands manage the production of hormones that serve as chemical messengers for the regulation of the gynecologic system - The release of gonadotropin-releasing hormone (from the hypothalamus) stimulates the pituitary gland to produce follicle- stimulating hormone (FSH) and luteinizing hormone (LH) - Estrogen and progesterone are secreted by the ovaries at the command of FSH and LH - This is an oval-shaped, pea-sized gland that is located in a small depression in the skull - This gland is controlled by the pituitary gland - The anterior pituitary gland synthesizes seven hormones: 1. Growth hormone (GH) 2. Thyroid-stimulating hormone (TSH) 3. Adrenocorticotropin (ACTH) 4. Melanocyte-stimulating hormone (MSH) 5. Prolactin (PRL): responsible for preparing the mammary gland for lactation and brings about the synthesis of milk 6. Follicle-stimulating hormone (FSH): targets the ovaries, where it stimulates the growth and development of the primary follicles and results in the production of estrogen and progesterone 7. Luteinizing hormone (LH): this hormone targets the developing follicle within the ovary, it is responsible for ovulation, corpus luteum formation, and hormone production in the ovaries - Endometrium in the uterus emulates the activities of the ovaries, so whatever happens in the uterus during the menstrual cycle is correlated with whatever occurs in the ovaries - Purpose of the ovarian cycle is to produce an ovum - Purpose of the endometrial cycle is to prepare a site to nourish and maintain the ovum if it becomes fertilized - Ovarian cycle has three phases: 1. Follicular phase- this is the development of ovarian follicles and usually lasts from day 1 to day 14 of the ovarian cycle. As menses progresses, FSH levels decline due to the negative feedback of estrogen and the negative effects of the peptide hormone inhibin. 2. Ovulation- the mature ovum is released from the follicle 3. luteal phase - Endometrial cycle: proliferative phase, secretory phase, and menstruation 1. Proliferative phase: influenced by estrogen and entails the regrowth of endometrium after the menstrual bleed. At the beginning of this phase, the endometrium is relatively thin and the endometrial glands are straight, narrow and short and as the phase progresses, the glands become long and tortuous 2. Secretory phase: begins at ovulation, but this phase does not occur if ovulation has not occurred. 3. Menstrual phase: this phase begins with the initiation of menses and lasts 3-5 days. The initiation of menstruation is due to enzymatic autodigestion of the functional layer of the endometrium. For 3-5 days, an average of 10 to 80 ml of blood loss occurs - Changes in Organs due to cyclic changes: after menstruation the cervical mucus is scant and viscous cervical mucus during the follicular phase is clear and stretchable (has a ferning appearance on the microscope) after ovulation, when the progesterone levels are high, the amount of cervical mucus decreases and becomes thick, viscous, and opaque which makes it super difficult for sperm to travel through The pH of the vagina responds to cyclical changes as estrogen stimulates the growth of lactobacilli Intersex (previously known as hermaphroditism): infants who are born with a genital anatomy that does not appear to fit the standard binary definitions of female or male. - These patients are at higher risk for lifelong pain, scarring, sexual problems, urinary problems, depression and infertility. - As a NP caring for ppl who are intersex it is important to follow these principles: 1. Gender assignment must be avoided until there has been expert evaluation in neonates 2. Evaluation and long-term management must be carried out in a center with an experienced multidisciplinary team 3. All individuals should receive gender assignment 4. Open communication with patients and families is essential, and participation in decision-making is encouraged 5. Patients and family concerns should be respected and addressed in strict confidence - The most effective method is the one that the patient will use - Check your biases - Provide counseling on all options - Reproductive goals/intentions are key - Don't forget patient may not have control - Don't forget historical context - Good medical history, family history, and use the U.S. Medical Elibility Criteria for Contraceptive Use: heart disease, VTE, CVA, liver disease, gallbladder disease, migraines WITH Aura, HTN, clotting disorder, or cancer - Gyn History and Physical pp 99-133 (Chp 7) - As a NP need to be aware of trauma informed care b/c ppl with trauma may experience triggers, including in the healthcare setting - Trauma-informed care applies the assumption that all bodies have, at some point, experienced trauma, and reasonable accommodations that would be made for individuals with a known sexual assault history should be the standard of care for all individuals. - Example of language to use: "in the past, how have these exams been for you? Is there anything I can do today during today's exam to make it more comfortable?" " you are in complete control of this examination" - In history taking try to ask open ended questions for example "tell me more about your sexual partners", " describe your periods" and " how do you feel your overall health is right now" - **General Health History (review)** - Reason for seeking care (cc) - HPI/Concern - General medical history: current health conditions, previous serious illnesses, past hospitalizations, prior surgical procedures, immunization status - Mental health history: current concerns, diagnoses and txt, mood disorder screening, hx of or current concern for self-harm practices, and/or suicidal or homicidal thoughts - Medications and allergies: current medications (including contraceptives), over-the-counter meds, vitamins, supplements. Medication, environmental, food allergies - Substance use: alcohol, tobacco (include vaping), cannabidiol products, marijuana, illegal drugs, misuse of over-the-counter medications - Family health history: physical and mental illnesses and causes of death of first-degree relatives; congenital malformations and unexplained intellectual developmental disabilities - Social history: education, current activities, long-term life plans, partners, living companions, support system - Occupation and finances: current employment, occupational safety, military service and veteran status, financial security - Safety: personal, home, community, sexual - Personal habits: health maintenance including exercise, sleep, nutrition, and hydration. Ongoing health maintenance like dental and eye exams - **History of Present Illness/Concern: OLDCARTS** - ONSET: when did symptoms begin? What were the circumstances at that time? Have you had this before? - LOCATION: where are the symptoms located physically? - DURATION: how long have you had the symptoms? - CHARACTERISTICS: describe the concern or symptoms; if it is pain is it sharp, stabbing, dull, radiating, or burning? - ASSOCIATED Symptoms: what other symptoms happen at the same time as the primary concern? - AGGRAVATING/RELIEVING FACTORS: what makes it better or worse? What have you already tried to change or solve the symptoms? How effective have these strategies been? - TIMING: when do the symptoms happen? Constant, or during certain times? - SEVERITY: how much is the concern affecting daily quality of life; if there is pain rate on a scale of 0 -- 10 - Gynecologic Health History: - Menstrual history: age of menarche date of last normal menstrual period cycle length, duration, and flow any menstrual irregularities or symptoms associated with menses - Sexual health: sexual orientation and gender identity current sexual relationships types of sex (oral, vaginal, anal) safer sex practices sexual satisfaction and orgasm pain with sex sexual concerns - Contraceptive use: - Pregnancy history: gravida and para; GTPAL Gravida or pregnancy: the total number of pregnancies, including current pregnancy if applicable Term: the number of pregnancies that reached 37 weeks gestation or greater Preterm: the number of pregnancies that reached 20-36 weeks gestation regardless of the number of fetuses or outcome Abortions: number of spontaneous and induced abortions prior to 20 weeks gestation Living children: number of living children (usually = total of term and preterm children) course of pregnancies: date, duration, type of birth, complications, newborn's sex and weight, and whether the child is currently alive and well abortions (induced or spontaneous) - History of vaginal and sexually transmitted infections - Genital and breast hygiene: vaginal or rectal douching frequency, medication or solutions used, reasons for douching pubic hair removal piercings other products: creams, lubricants, specialty soaps, scented pads or tampons breast/chest binding - Gynecologic procedures and surgeries: - Urologic and rectal health: occurrence and frequency of infections, urinary or bowel incontinence, any other abnormal symptoms - Cervical cancer screening: date of last testing, history of an abnormal result if any - Abnormal symptoms: pelvic pain, bleeding unrelated to menstruation, and other symptoms Physical Exam for Gynecologic visit: - General physical exam: height, weight, blood pressure, pulse, and temperature, BMI - General appearance: posture, emotional state, appropriateness of dress, speech pattern, social interaction - Eyes, ears, nose, throat - Neck - Thyroid - Chest and lungs - Spine - Kidneys (checking for CVA tenderness) - Reflexes - Peripheral circulation and varicosities (inspect the legs and feet) - At this point have the patient lay down and listen to the heart - Breasts and axillary lymph nodes - Abdomen exam (remember inspect, listen, then palpate and percuss) - Breast exam starts with the patient in a sitting position, usually on the exam table with arms relaxed at their sides - Examiner stands in front to do an inspection of breasts - Important to compare the breasts for size, symmetry, contour, skin color, texture, and venous patterns - Contraception pp 235-266 (Chp 13) **Reproductive Goals/Intentions: PATH Questions** PA: do you think you might like to have (more) children at some point? T: timing, when do you think that might be? H: how important is it to you to prevent pregnancy (until then)? - Progestin hormones: inhibit fertilization, prevents ovulation, and prevents implantation - The progestin hormones inhibit fertilization by thickening cervical mucus and changes tubal motility - Estrogen inhibits follicular growth (prevents ovulation) and maintains endometrium which decreases breakthrough bleeding - Single rod with 68 mg etonogestrol - Effective up to 5 years but FDA approved for 3 years - [Can help with dysmenorrhea and endometriosis symptoms and reduces the risk for PID] - Advantages: highly effective and long-term, fertility returns rapidly after removal, user-friendly ppl can insert and forget, invisible but palpable, can be used while breastfeeding, can help with dysmenorrhea and endometriosis symptoms, reduces risk for PID - Quickly reversible - Adverse effects: bleeding irregularities, local site reaction, weight increase, breast tenderness, ovarian cysts - Bleeding irregularities are most common and worse in the first months to 1^st^ year of use; they get shorter and lighter, longer, infrequent, to no periods - **Key patient education**: the bleeding irregularities are very common and will improve in 3-6 months (there are treatment options available and it is not necessary to remove implant immediately) - **Key patient education**: procedure counseling includes keeping a pressure dressing x 24 hours, band-aid for 3-5 days and then let the steri-strips fall off on its own, signs/symptoms of infection after insertion/removal. Also educate patient to use condoms/barriers to protect against STIs. - Mirena and Lilita: 8 years for contraception and 5 years for heavy menstrual bleeding; can be used as emergency contraceptive if inserted within 5 days - Kyleena: 5 years, smaller device and insertion tube - Skyla: 3 years; smaller device and insertion tube but more irregular bleeding - These work by inhibiting fertilization and preventing implantation - Advantages: can help with **HMB, dysmenorrhea, and endometriosis symptoms** - Inhibits fertilization and prevents implantation - The implant is a foreign body so this causes a local foreign body reaction - Cervical mucous is thickened which inhibits sperm migration - Highly effective and long-term - Fertility returns rapidly after removal - Discrete and private - Few medical contraindications - Can help with heavy menstrual bleeding, dysmenorrhea, and endometriosis symptoms - Reduce endometrial hyperplasia, PID, and cervical cancer - Requires minor procedure by trained provider to insert and remove - Does not protect against STIs, including HIV - ParaGard - Good for up to 12 years; but FDA approved for 10 years - This is the most effective reversible non-hormonal method - Can be used for emergency contraception if inserted within 5 days of having unprotected sex - **But there is an increased risk for PID** - How does this work? Copper is poison to sperm; inhibits fertilization and prevents implantation - Adverse effects: bleeding irregularities/change in menses (heavier and longer, up to 50% increase in blood loss) - Highly effective and long-term - Fertility returns rapidly after removal - Discrete and private - Few medical contraindications - Can be used while breastfeeding - No hormones - Can be used as emergency contraceptive if used within 5 days of unprotected sex - Decreases risk for cervical cancer - Requires minor procedure by trained provider to insert and remove - Increased risk for PID - Does not protect against STI's including HIV - The hormonal ones the bleeding is worse in the first 3-6 months of use and is dependent on levonorgestrel dose and duration of use - The copper IUD the bleeding is worse in the first 6 months of use, heavier and longer, up to 50% increase in blood loss, dysmenorrhea is possible - Expulsion (3-6% in the first year of use) - Uterine perforation during insertion is 1 in 1000 (this risk is higher in postpartum and breastfeeding women) - Lower abdominal pain/cramping - Others (for the hormonal IUDs): back pain, breast tenderness, headaches, acne, mood changes, ovarian cysts - Expect spotting for 4-6 weeks after insertion - Check strings monthly (if you don't feel a string ensure to use a backup method) - Timing: the back-up method for 7 days; the Copper IUD and 52 LNg IUD are effective immediately - Discomfort with procedure similar to menstrual cramps - Pain management: NSAIDs (ibuprofen 800 mg or Naproxen 550 mg), lidocaine- prilocaine cream, paracervical block, conscious sedation - Risk of procedure: uterine perforation, expulsion, infection - Nothing in the vagina for 24 hours - Cramping will likely last for 24-48 hrs - Continue NSAIDs for cramping - Red flags: heavy bleeding (soaking through a pad or tampon in an hour), severe pain (worse than the procedure), foul smelling discharge from the vagina, fever - Use condoms/barriers to protect against STIs - **Given every 12-14 weeks** - Rapid and highly effective - Advantages: decreases dysmenorrhea and endometriosis symptoms reduces risk of PID and ectopic pregnancy decreases sickle cell crisis possible decrease in seizures - **Disadvantages**: **decreases bone density** increase risk of diabetes and insulin resistance delays return of fertility of 6-18 months increased risk of HIV acquisition does not protect against STIs including HIV - CAN use in patient with HTN - Adverse effects: mainly weight gain (about 5 lbs per year) - Bleeding irregularities are the most common - The first 3 months: irregular bleeding, prolonged bleeding - At 1 year: no monthly bleeding, infrequent bleeding, irregular bleeding - Weight changes (increase 5 lbs per year) - Headaches - Mood changes - Bleeding irregularities: irregular bleeding common after the first injection, amenorrhea is common after the second injection, if there is a gap in between injections then bleeding irregularities may occur again - Fertility return may take 6-9 months - **Adequate calcium and vitamin D in diet** - Use condoms/barriers to protect against STIs - Multiple formulations: monophasic, biphasic, triphasic, quadphasic - Estrogens: ethinyl estradiol, mestranol, or estradiol valerate - Multiple different progestins: levonorgestrel, norgestimate, ethynodiol - Different cycles: 21/7, 24/4, 84/7, 365 - Now there is a plant-based estrogen and drospirenone - So which one do we use? - Monophasic: consistent hormone dose, can be used continuously or extended-cycle - **Estrogen dose: recommended less than 35 mcg** - 21/7 vs 24/4 (this one is increased efficacy especially in obese women and decreased hormone withdrawal adverse effects) - Individualizedpatient's experience and/or preference, clinical characteristics, insurances coverage, and cost - Generic is more affordable and more likely covered - Monophasic is a consistent hormone dose and can be used continuously or extended-cycle there's a lower risk of exacerbating mood symptoms - Cyclic vs. extended-cycle vs. continuous use will be patient dependent like how many withdrawal bleeds they desire and the risk for breakthrough bleeding - Estrogen dose: recommend less than 35 mcg - Progestin type doesn't matter - 21/7 vs 24/4 : **the 24/4 has increased efficacy especially in obese women and decreased hormone withdrawal adverse** effects - Norethindrone - Derived from testosterone - Lowest potency - Levonorgestrel, norgestrel - Derived from norethindrone - More androgenic than 1^st^ generation - Norgestinate, desogestrol, - Less androgenic - Drospirenone - Derived from spironolactone - Minimal antiandrogenic and diuretic properties - **Patch**: this is contraindicated in patients with **BMI greater than 30 b/c** increase risk of VTE and decreased efficacy - Ring: new ring every month or use the same ring for 12 cycles; want to avoid oil or silicone-based vaginal products, can use both continuously (approved for 21/7) - Improve acne - Improve hirsutism - Protect bone mineral density for high-risk patients - Decrease symptoms of endometriosis - Treat hot flashes and other perimenopausal symptoms - Increases risk of vte - Increased risk of MI and stroke - Several drug interactions - **Can increase blood pressure and decrease HDL cholesterol** - Does not protect against STIs, including HIV - Changes in bleeding pattern: usually shorter and lighter, may cause amenorrhea, spotting is common in the first 3 months of use of if using continuously - Other potential, but no difference: nausea, breast tenderness, bloating, headaches, mood change, decreased libido - Skin irritation (patch) - Vaginitis, vaginal wetness, leukorrhea (ring) - Spotting is normal in the first 1-3 months it will go away - Should take pill everyday at the same time (3 hour window) - Use condoms/barriers to prevent STIs - Missed pills, if miss 1 then take as soon as remember no back-up needed - Missed pills, if missed 2 or more in week 1-3 ensure to use back up method (may need if missed week 1 but will need for sure if missed week 2-3) - Apply one patch per week for 3 weeks, followed by 1 patch- free week - Use a different site with each new patch - Apply to skin that is clean and dry without powders, lotions etc - Wash hands after applying patch bc there are hormone in the adhesive - Still need condoms/barriers to prevent STIs - If the patch falls off, put on anew patch and this becomes the patch change day - Insert ring into vagina as high as possible - Put ring in for 3 weeks and take out for 1 week - To use continuously: change ring every 4 weeks or change ring every 13 cycles - May take ring out for up to 3 hrs - Discard the ring in the package - Use condoms/barriers to prevent STD - 4 weeks of hormone pills, no reminder pills - Need to take daily at the same time b/c it inhibits fertilization for only 20 hours - Drosperinone 4 mg has 24 hormone pills and 4 reminder pills - Advantages: can be used while breastfeeding, easily and immediately reversible - Disadvantages: need to take at same time daily - The Opill is the first OTC non-emergency contraceptive - 24/4 cycle: 24 hormone pills with 4 reminder pills - Suppresses ovulation unlike norethindrone - Likely more effective than norethindrone POPs - Check potassium during 1^st^ cycle in those with disease or medication that may cause hyperkalemia. - Can be used while breastfeeding - Easily and immediately reversible - Decreases menstrual flow and cramps - Protects against endometrial cancer - Decreased risk of ectopic pregnancy - Need to take daily at the same time every day - Several drug interactions - Does not provide protection against stds - Changes in bleeding pattern- frequent bleeding, amenorrhea or irregular bleeding - Others: ovarian cysts, acne, mood changes - Must be taken same time every day - Take missed pill as soon as you remember - Use a back-up method for 7 days - For Drosperinone: need to take the same time every day; missed pill up to 24 hours late, no back-up method needed unless missed more than 1 pill - Bleeding irregularities are common - Use condoms still - Diabetes- no CHC or DMPA (depo) - Hypertension- no CHC - Elevated BP- no CHC, no CHC or depo - DVT- no CHC - Migraine WITH Aura- no CHC - History of bariatric surgery- no orals (COCs or POPs) - Postpartum- no CHC - Unexplained vaginal bleeding- no IUD, implant or Depo - Smoking- no CHC - Drug interactions- anticonvulsants, lamotrigine, rifampin or rifabutin - **Effective up to 72 hours after unprotected sex (maybe 120 hrs)** - **Less effective for BMI \>25**, may not be effective at all for BMI \>30 - [This works by preventing ovulation by blocking LH surge]; 96% effective if taken before LH surge, 14% effective if taken after LH surge - Adverse effects: changes in menses, nausea/vomiting, breast tenderness, headache, mood changes - Can start hormonal contraceptives immediately - **Educate patient that if they do not have menstruation in 3 weeks after taking they need a urine pregnancy test** - **Less effective for BMI \>35** - Selective progestin receptor modulator - Effective up to 120 hrs after UPIC - This is a selective receptor modulator - T**his works by delaying ovulation both pre-ovulatory and after LH surge** - 100% effective if taken before LH surge, 79% effective if taken after onset of LH surge - Adverse effects: headache, dysmenorrhea, nausea, and abdominal pain - Interacts with progestin-containing contraceptives so delay start by 5 days, back-up method for 7 days after starting - If breastfeeding need to pump and dump for 24 hrs after taking - If no menses within 3 weeks need to do a urine pregnancy test - Insert within 5 days of unprotected sex - Best choice for obese ppl - If no menses in 3 weeks, take a pregnancy test, if using the copper IUD - LNg52 IUD, take a pregnancy test 2-4 weeks after insertion and with any pregnancy symptoms Special populations: - Adolescents: AAP and ACOG recommend LARC (like IUD) for first-line contraceptive - Transgender male or non-binary individuals: testosterone will cause cessation of menses, typically within 6 months, but ovulation can still occur. Can use all methods but may not like estrogen containing regimens. IUD insertion may be more uncomfortable if on T. - Perimenopause: CHC can be used if there are no other risk factors. Can use the Ring but avoid the patch. POPs and copper iUD are acceptable without medical contraindications. Must stop contraceptives at 55 or menopause - Immigrants: types of contraceptives are different overseas Managing Adverse Effects: - Unscheduled bleeding (after ruling out other causes including pregnancy) 1. Combined hormonal contraceptives: reassurance that because it typically takes 3 months; if using continuously then need to take a hormone break for 3 days; if cyclic use then increase estrogen dose (remember max 35 mcg). Encourage smoking cessation 2. Depo and Implants: reassurance (typically takes 3-6 months), NSAIDs Ibuprofen 400-800 mg TID x 5-10 days; COCs: monophasic with less than 35 mcg estrogen for 3-6 months 3. POPs: take at same time every day 4. IUDs: for heavy and/or prolonged bleeding need to exclude pregnancy, expulsion, infection, and malposition; take NSAIDs, COCs, tranexamic acid, POPs, and refer - Unintended pregnancy CHCs and POPs: stop using immediately Depo: reassure that there is no evidence Depo is teratogenic Implant: remove immediately if desiring to continue pregnancy IUDs: visible strings and 1^st^ trimester can remove, do an U/S to r/o ectopic pregnancy and prescribe azithromycin 500 mg PO once IUDs: strings not visible can do an U/S to confirm Prescence and location of IUD and then refer to OBGYN. **Unintended pregnancy pp 367-377 (Chp 19**) **Unintended pregnancy in the US:** - 41.6% of pregnancies are unintended (2019 data) - 36.6% of unintended pregnancies ended in abortion (2017 data) - Pregnancy-related deaths are more likely in states with abortion bans - Abortion mortality rate: 0.45 per 100,000 ppl **All Options Counseling:** - Options: end the pregnancy via medication abortion or procedural abortion - Continue the pregnancy: parenthood or adoption Adoption: 1. Open 2. Semi-open: contact between birthing parents and family is through an agency or agent 3. Familial/kinship: placing child with relative until that family member can adopt 4. Closed: there is no contact between families **Medication Abortion:** - **Up to 77 days from LMP 95% effective** - Can be done without delay - Less invasive and more natural - Disadvantages: takes 1-2 days to complete, baseline ultrasound or quantitative hcg is recommended to know how far along the patient is - Two meds used: mifepristone (Mifeprex) and misoprostol (Cytotec) - Mifepristone 200 mg is administered first - Misoprostol 800 mcg is given after mifepristone (24-48 hours after mifepristone-bucally) - **For pregnancies 9-11 weeks Mifepristone given 3-6 hours after 1^st^** - Cramping and bleeding within 4-24 hrs of misoprostol placement - Provide pain medications (NSAIDs or opiates as needed) - Mifepristone is what causes the progesterone blockade leading to decidual necrosis and cervical ripening, then the misoprostol leads to uterine cramping, contractions and expulsion. - Important to confirm positive urine pregnancy test - The estimated gestation age should be less than 77 days - Rule out contraindications: IUD in place, allergy to meds, ectopic pregnancy, anemia, concurrent anticoagulant therapy, chronic adrenal failure, long-term systemic corticosteroid use Medication Abortion Process Cont. - **Labs to do H and H** (greater than 10 weeks or history of anemia), Rh status, and quantitative Beta hcg - Determine if ultrasound is required: concern for ectopic, uncertain LMP, irregular menses, vaginal bleeding, size/date discrepancy (if exam is done), LMP estimates gestation age is 77 days (11 weeks) **Initiating contraception:** - Implant can be put in at the time of mifepristone - Pills/patch/ring and depo can be done the day after mifepristone - IUD can be put in at the follow-up visit after confirming completion Assess Completion of Abortion: - Could do in-office visit or phone visit within 1-2 weeks - Hx of abortion completion: appropriate bleeding after misoprostol and no further pregnancy symptoms; if continued heavy bleeding and is symptomatic thinking continued pregnancy vs retained POC need to do aspiration - Declining quantitative beta hcg; will see 80% decline in beta hcg after 1 week - Ultrasound: verify prior gestation sac is no longer present - Negative home UPT: 4 weeks after mifepristone; if positive UPT need evaluation for ongoing pregnancy and possible aspiration abortion **Aspiration Abortion:** - Takes minutes, no follow-up needed - Can perform up to 14 weeks safely - Multiple anesthesia options - Shorter bleeding period - Disadvantages: requires pelvic instrumentation, less patient control, potential medication adverse effects - Analgesia and anxiolytic options: NSAIDs, local, moderate or deep sedation - Additional comfort measures: heat packs, music, patient-centered language vs triggering language - Procedure lasts about 5-10 min - After procedure IUD can be inserted immediately after **Cervical Cancer Screening Guidelines:** - HPV and Cervical Cancer: High-risk HPV is necessary, but not sufficient for the development of squamous cervical neoplasia - HPV infectiontransient or persistent infection - HPV 16 and 18 are responsible for most types of HPV - Factors in persistence: genotype of HPV: HPV 16 accounts for 60% of cases, HPV 18 accounts for 15%, twelve other types responsible for the rest cigarette smoking compromised immune system HIV age \> 30 years at time of infection: most young AFAB effectively clear infection in 8-24 months Risk Factors for cervical CA: - Age: coitarche \ 25 years old OR conventional (slide based) which does not do HPV. Reflex HPV will test for hrHPV if the cytology is ASCUS (but only order this hrHPV in women \>25 yrs old). The conventional (slide based) you cannot order HPV testing. 2. Cotest Pap: only liquid based; does cytology and HPV high risk are both performed. Reflex to 16, 18/45 will test for genotypes if hrHPV is positive Primary hrHPV test: only 2 FDA approved primary tests same collection procedure as liquid pap tests for genotypes 16 and 18 and twelve other hrHPV types if positive, reflex to cytology is preferred if 16/18 positive and unable to reflex from same sample, colposcopy plus cytology are acceptable **Cervical CA Screening Guidelines:** ACS- start at 25 years old, 25-65 years old and do the primary HPV test alone every 5 years; co-test every 5 years or cytology only every 3 years USPSTF- start at 21 years old; 21-29 cytology alone every 3 years; 30-65 years do cytology alone every 3 years or primary hrHPV testing every 5 years or cotest every 5 years If there is an ASCUS pap result in 21-24 year-olds no need to reflex to HPV. Screening Special Populations: - HIV-infected and immunocompromised: start cytology alone within 1 yr of onset of sexual activity or within 1^st^ year of HIV diagnosis, no later than 21 - Under 30 years old need to repeat cytology in 1 yr after normal pap; after 3 consecutive normal annual paps then can screen every 3 years - Over 30 years old need to do cytology alone or contesting, contesting can go to every 3 years after 1 negative cotest Colposcopy: - Use of a colposcope to provide an illuminated, magnified view - The goal is to identify precancerous and cancerous lesions - Acetic acid is used to improve visualization of abnormal areas, the areas will appear white - Should biopsy abnormal areas Is the high risk HPV transient or chronic? This is why you're doing re-check yearly Remember under 29 we do not routinely check for HPV Remember to use the algorithm from the age of the original abnormal PAP If hrHPV positive do a reflex to 16/18 test, if the reflex test is positive then do a colposcopy