OB + Gynecology Flashcards
Time from sperm emission into vagina to cervical canal:
FIVE seconds
No time to wash them out afterwards
Cervical Cap
Fit like diaphragm but smaller
Refit with childbirth or wt gain/loss of 10 lbs
Must stay in place 24-48 hrs, does result in odor
Must be used with spermicide
Diaphragm
Bigger than Cap
Also refit w/children + wt change of 10 lbs
Only has to stay in place 6 hrs post coitus
ORTHO ALL-FLEX is Deb’s Favorite
Must use spermacidal Jelly on inside when placing and insert with more for each act
Natural/Calendar Method
Count backward 14 days from anticipated first day of menstruation to pinpoint ovulation, add 5 days either side.
No Sex from day 10-20
Thermo Method
Chart waking temp BEFORE getting out of bed daily for a few months to pinpoint ovulation then no sex 5 days prior or after.
Better for getting pregnant as this is rather a hassle and you need to stay motivated!
Temperature DROPS during ovulation, then spikes higher than before and stays higher right through menstruation.
Egg White Mucus
Is Fertile
This method can be thrown off by vaginitis, STDs and candidiasis as these make discharge creamy.
Drugs that undermine effectiveness of hormonal birth control
-Dilantin
Anticonvulsants in General (can use Depo, prog only and Gabapentin and Lamotragine are not affected)
- Tetracyclines (This is contested by why risk it?)
- Rifampin (for Tb + Meningitis prophylaxis)
- St John’s Wort
BCP
Take Pill #1 on Sunday after pd begins, this puts you on a nice weekly schedule. No worries about being pregnant during menstruation.
Take pills in the am, after breakfast if they cause nausea. DON’T take at night, you’ll forget more.
Never if Hx of DVT
Never if HX of Factor 5 Leidenfrost
Strong caution in Smokers over 35, notation of risk conversation. Depo Provera (progestin only inj or pills) is safer than estradiol containing BCPs for older smokers. Mirena is prog only or use the copper IUD
Control HTN on meds/lifestyle BEFORE beginning BCP
Not good for DM (esp progesterone only formulas…)
Does a nice job of preventing ovarian cysts as it prevents follicle ripening.
Not for Migraines with neurological sxs
MOST common side effect of hormonal BCP
Break Thru Bleeding
Usually resolves within 3 months
Common NuvaRing side effect
Watery discharge, non-purulent
No ring during menstruation
This functions as does low dose BCP
Hormonal BC that nursing mothers can use
Progesterone Only pills
Depo injections may be approved soon
Depo implantables may be approved soon
Nexplanon
Implantable Progestagin tagged with Barium so you can find it to remove.
Monophasic bcps:
constant dose of hormone(s) throughout cycle. Can be combo or progesterone only
Lo-Ovral Alesse Nordette Ortho-Novo Portia Yasmine Yaz Zovia
There is no evidence that Bi or Triphasics are safer or more effective than are Monos and Monos are much cheaper.
Biphasics
Have two peaks, estradiol early and progestagin late to mimic normal cycle more closely, peaks are just higher than normal so ovulation stays suppressed. Thought is that it does not expose tissue to constant high levels of both hormones during parts of cycle when they are normally decreased.
Aranelle Jenest Mircette Nelova Nircon Ortho - Novum
Tri-phasics
Early estrogen rise, then progestegin, then late estrogen rise most closely mimics natural cycle
Thought to be best for acne control
Anything with Tri in the name
Enpresse
Velivet
Estrostep FE (has iron during menstrual phase)
Natazia
Estradiol Valerate + Dienogest
Quadraphasic BCP
FDA Approved for relief of heavy menstrual periods in addition to bc.
Side Effects of Progestegin BC
Weight Gain Bloating Hirsuitism Moodiness Amenorrhea (more with shot than pills) Breast Tenderness Dizziness Headache
Before giving the IM or Implantable, try the progesterone only pills for a few cycles, to ensure the side effects are manageable to your pt as IM and implantable are more difficult to undo.
Trying to get pregnant after stopping BCP
May happen immediately but…
Higher risk of miscarriage
Safer to use backup during a 3 month washout period, then try.
May be anovulatory after Depo Provera for up to TWO years. Not a good choice for women heading into family situations.
Which cancer do oral bcps reduce if taken more than 10 yrs
Ovarian Cancer
Which Cancer is caused by estrogen only pills
Endometrial cancer is a risk when there is no progestagin to balance the estradiol, at least during the luteal phase, doesn’t have to be present throughout the cycle.
Increase which hormone if you are having breakthrough bleeding
Progestagin
Though break thru may self resolve if it is occurring in the first 3 months. Warn it may occur so as to calm pt when it does.
Mirena + Skyla
Levongestrel Impregnated IUDs
Mirena - 5 years $500
Skyla - 3 years $650
Scant or absent periods are a plus but online it seems like there is a substantial outcry about joint pain, breast tenderness, mood disorders that require SSRIs, lethargy, disinterest in sex, hair loss and WEIGHT GAIN WEIGHT GAIN WEIGHT GAIN
it is a progestagin after all
IUD Basics
PARAGARD: Copper Wrapped - no hormones, Does NOT stop ovulation - works by irritating the uterus so it may cause cramping and heavier periods, Costs about $300.
MiRENA/SKyLA: Progestagin implants, expensive, cause amenorrhea
Inserting is easier in post-gravid females.
Recheck in 1 month to ensure you can find strings. You can trim the strings if the male complains he feels them.
Removal with Sponge Forceps - don’t tug if discomfort, these things implant in the endometrium and may need to be surgically removed. Do a sono if discomfort on tugging or if you cannot find the strings.
Risk of:
PID
Uterine Perforation
Ectopic Pregnancy
Epulsion of IUD
Never insert if Hx of PID, Malignancy, Copper Allergy, Unexplained Vaginal Bleeding (track this down first)
ORTHO-ERVA
PATCH
Monophasic combo
1 Patch /week 3 weeks on/no patch during pd
Always prescribe an emergency patch for pt to keep on file at pharmacy for the inevitable tear off or loss during swimming
Not a good option for swimmers…
Patch on torso, buttocks, arms NOT ON BREAST
Plan B
ELLA
Levongestril
Take w/in 72 hrs of unprotected sex
OTC
or take 1 Lo-Ovral mono phasic STAT then another in 24 hrs
ELLA is prescription and you can take it up to 120 hours post coitus (5 days)
ESSURE
Spring implanted into fallopian Tube to irritate it into scarring shut
Recheck in 3 mo with post-procedure Salpingogram.
Can be undone but thereafter a high ectopic risk
Pharma Abortion
Methotrexate - 90% effective (2 doses) also used for ectopic pregnancy termination. Must have surgical abortion if fails d/t teratogenic effect of methotrexate.
Mifepristone (RU 486) + Prostaglandin E1 (Misoprostol)
A partial progesterone receptor agonist and glucocorticoid antagonist also used experimentally to treat cushigs dz.
-MOST EFFECTIVE Abortion method less
than 7 weeks, use up to 9 weeks in US
Better than aspiration under 7 weeks.
- 600 mg dose in office followed by a
400 mg dose of Misoprostol at home to
encourage contractions.
Can’t give these in primary care, refer to Planned Parenthood or Gyne
Primary Dysmenorrhea vs Secondary
Primary starts soon after Menarche. It’s caused mainly by E2 cutting off the blood supply to the endometrium which causes CRAMPING, necessary to dislodge the sloughing tissue and propel it out through the cervix.
NSAIDS (with proper education as to use) and caffeine are Rx mainstays. Midol contains Tylenol, which doesn’t have any effect on E2 but it does relieve pain - Deb says its not her favorite but I’m not sure we want to interfere with E2’s job, just make it so the resultant pain is more manageable.
Secondary usually affects women over age 25 and is usually caused by Endometriosis.
Role of Prostaglandin E2 in Dysmenorrhea
E2 is released in response to the breakdown of endometrial tissue at the end of the Luteal phase, when the corpus runs of of progesterone to support it and a placenta has not formed to take over progesterone production.
E2 constricts the blood supply to the endometrium, worsening the situation there and killing off more cells. As they die of hypoxia, they are sloughed from the mesometrium and the irritable, hypoxic uterus cramps, propelling the slough out the cervix.
Ischemia Hurts. It hurts in the heart, it hurts in the muscles after a work out and it hurts in the uterus. We call it Cramps.
Leiomyoma
Fibroids
Noncancerous MYOMETRIAL (muscle) growths that often appear during middle to late child bearing years causing either no symptoms or painful protracted menses and low back ache. Fibroids are a main reason for hysterectomy in this age group. They “retreat” after Menopause.
They are round and can grow as large as a grapefruit - these can be felt through the abdominal wall, of course.
Unfortunately, they do not stay IN the uterus and can grow outside it (subserosal), into its muscular walls (submucosal + intramural) and even in the broad ligament between the uterus and ovaries. It can also pedunculate from the cervix into the vagina (in statu nascendi)
They do not become malignant. There ARE malignant fibroid like tumors of the uterus but they do not develop FROM the benign fibroids and having benign fibroids is not a risk for malignancy. Malignant tumors are present AFTER menopause.
They do, however become life threats when they grow elsewhere in the gut, strangling the intestines. This used to be rare but is seen with increasing frequency and is thought to arise from a laparoscopic hysterectomy technique employing a MORCELLATOR which chops the uterus up into bits inside the abdominal cavity then extracts the bits (obviously not ALL of them) out through the small incision. It may not be a good idea to liberate this uterine tissue into the abdominal cavity like that when it clearly has the ability to colonize other tissues.
African American decent is the biggest fibroid risk in the US with an estimated 80% of women developing fibroids by their 40s - not all are problematic. OBESITY, its related comorbidities and diet high in red meat (hormones or fat?)
Endometriosis
Growth of endometrial tissue outside the uterus, usually on the outside of the uterus, the ovaries or tubes but it can migrate far. It is thought to escape the uterus during menstruation via the fallopian tubes (retrograde menstruation). There are more developmental theories though.
The immune system ought to snap these bits up and dispose of them but if it is compromised, it may not. Also, there has been a huge reduction in “menstrual rest” since women no longer spend decades pregnant and that is thought to have increased the incidence of escaped endometrial tissue.
The problem is that, wherever it is, endometrial tissue behaves as if its in the uterus and it BLEEDS/sloughs in response to the monthly cycle.
Blood is an irritant whenever its is outside its vessels and this causes inflammation, E2 is released to deal with it all and severe cramping results
Cramping can involve the low back and often radiates to the legs.
Endometriosis is associated with Ovarian Cancer, Brain Cancer and Non-Hodgkins Lymphoma. Interestingly, it is NOT associated with endometrial cancer.
Family Hx is the main risk but Dioxin exposure has also been implicated
YOU CANNOT SEE ENDOMETRIOSIS ON SONOGRAM. YOU MUST DO A LAPAROSCOPIC INVESTIGATION AND BIOPSY THE TISSUE.
PROGESTERONE inhibits endometrial growth and so progestagin therapy is an option for management. Other Estrogen Blockers are employed.
This is an old disorder, not new. Hippocrates was prescribing early marriage and child bearing to women ages ago so as to resolve maladies of the uterus. Indeed VAGINAL (not c-section) Childbirth reduces recurrence (perhaps by widening the cervical opening and making it the easier way out?)
Unfortunately, infertility does result from endometriosis.
Adenomyosis
Endometrial growth INTO the Myometrium
Imaging of choice in the pelvis?
Sonogram
Sonos for all dysmenorrhea in sexually active females. You can ID:
Pregnancy Ectopic Ovarian Cyst Torsion Fibroids
You CANNOT see ENDOMETRIOSIS on Sono
Dysmenorrhea?
Pelvic Exam
Tender? RX for PID
Didn’t resolve pain?
Sono
Find something on Sono?
Laparoscopy + Biopsy to ID tissue
