Female Reproductive Flashcards

Question

Follicular Phase Day 1-14 * Each month (1) hormone is produced by anterior pituitary * FSH function = * (1) is produced by the developing follicles ("eggs), there is the predominant hormone during the first 2 weeks of menstrual cycle * Estrogen function = (1) known as the *\_\_\_\_\_ phase*

Answer 1

* Each month FSH hormone is produced by anterior pituitary * FSH function = maturation of follicles in woman's ovary * Estrogen is produced by the developing follicles ("eggs), there is the predominant hormone during the first 2 weeks of menstrual cycle * Estrogen function = stimulate development and growth of endometrial lining known as the *proliferative phase*

Answer 2

* Luteinizing hormone (LH) secreted by anterior pituitary, which induces ovulation and maturation of dominant follicle on day 14 * The follicle migrates to the fimbriae of the fallopian tube * It takes about 5 days for the egg to move through the fallopian tube, where conception can take place

Answer 3

**Progesterone** = predominant hormone during last 2 weeks of cycle It is produced by corpus luteum and helps stabilize the endometrial lining

Answer 4

Estrogen and progesterone fall drastically during menstruation This then stimulates the hypothalamus → anterior pituitary (FSH) and the cycle starts again

Answer 5

**Sexual intercourse 1-2 days before ovulation offers highest chance of pregnancy** * Copious amounts of clear mucus that feels thin and elastic in vagina → cervical mucus method of birth control to indicate fertile period of cycle * Ovulation kits detect urinary LH - false positives in women with PCOS, ovarian insufficiency, and menopause *LH in urine appears 12 hours after it is in serum (released by anterior pituitary)*

Answer 6

Conception occurs when sperm fertilizes the egg * As the fertilized egg travels down the fallopian tube into the uterus it continues to divide until it becomes a blastocyst * The blastocyst implants into the endometrium where it becomes an embryo * It can take 3-4 days for the fertilized egg to fully implant in the uterus * The placenta is fully formed by 18-20 weeks * Estrogen and progesterone levels increase, along with **human chorionic gonadotropin (HCG)** which is produced by the placenta * Pregnancy lasts 280 days or 40 weeks

Answer 7

**Pap Test =** liquid-based cervical cytology is used to screen for cervical cancer * High false-negative rate 20-45% * The test is called Thinprep, which is read by a computer, is now more popular in US than conventional pap smear kit * If cervix bleeds easily when brush is inserted to obtain the sample, may be a sign of inflammation. Rule out cervicitis * Some females have slight spotting after a pap test

Answer 8

* DO NOT perform pap test or liquid based cytology during menstrual period * Best time to perform Pap test is at least 5 days after period stops * 2-3 days before pap, patient should avoid douching, vaginal foams/medicines, tampon use, and vaginal intercourse

Answer 9

_\<_ 20 yo = DO NOT screen 21-29yo = liquid based cytology or pap test Q3 years 30-65yo = liquid based cytology or pap test Q3 years or cotesting with HPV every 5 years

Answer 10

\>65 yo = Can stop screening if not high risk\* Hysterectomy = Can stop screening if not high risk\*

Answer 11

* HIV positive women * history of cervical cancer * DES exposure

Answer 12

* Insert the broom-shaped plastic brush into the cervical os and rotate in the same direction for five turns. * If a transformative zone is present, make sure that it is included. Place the brush in the liquid medium and swish gently. * Remove brush and cover with the plastic cap. * The cervical cytology test is read by a computer, and abnormal results are reviewed by a cytologist and/or pathologist.

Answer 13

* Use wooden spatula to scrape cervical surface (ectocervix). * Then insert the brush into the cervical os (endocervix) and twist gently in a circle. * Smear the glass slide with both samples. Spray the liquid fixative on the glass slide and label. * By sampling the ectocervix first, the chances of bleeding are minimized.

Answer 14

The Bethesda System * Satisfactory specimen has both squamous epithelial cells and endocervical cells but the absence of endocervical cells is not unusual * If woman is being treated by pelvic radiation or is pregnant, make sure this info is included in the cytology requisition * Lubricants or excessive blood can interfere with results

Answer 15

*Atypical Squamous Cells of Undetermined Significance (ASCUS)*

Answer 16

* Age 20 years or younger:* Do not perform Pap if younger than 21 years. * Age 21 to 24 years:* Preferred is repeat Pap test in 12 months (acceptable is reflex HPV test). * Age 25 to 29 years:* Preferred is reflex HPV test. Acceptable is repeat Pap test in 12 months. * Age 30 years or older:* Cotesting for high-risk HPV. If HPV positive, refer for colposcopy.

Answer 17

*Atypical Squamous Cells and Cannot Exclude a High-Grade Squamous Intraepithelial Lesion*

Answer 18

* Age 21 to 24 years:* Refer for colposcopy. * Age 25 to 29 years:* Refer for colposcopy. * Age 30 years or older:* Refer for colposcopy.

Answer 19

Associated with premalignancy or malignancy in 30% of cases * More common in older women (ages 40–69 years). Risk of cancer goes up with age. * There are several subcategories. Follow-up test depends on atypical glandular cell (AGC) subcategory. * Follow-up tests include colposcopy, endocervical sampling, and endometrial sampling.

Answer 20

***Low-Grade Squamous Intraepithelial Lesions*** ## Footnote * Age 21 to 24 years:* Repeat Pap test in 12 months. * Age 25 to 29 years:* Refer for colposcopy. * Age 30 years or older:* Preferred is repeat Pap test in 12 months; acceptable to refer for colposcopy.

Answer 21

***High-Grade Squamous Intraepithelial Lesions*** ## Footnote * Age 21 to 24 years:* Refer for colposcopy. * Age 25 years or older:* Refer for immediate excisional treatment or colposcopy. It can be done by LEEP (loop electrosurgical excision procedure) with cervical conization or surgery of the cervix.

Answer 22

HPV types 16 and 18 cause nearly all cases of cervical cancer. Women are exposed to high-risk HPV through sexual intercourse. Gardasil (males or females) is given at age 11 or 12 years (or as young as ages 9 through 26 years). If given before age 15 years, a two-dose series is required. The second dose should be given 6 to 12 months after the first dose (0, 6–12). If first dose of Gardasil given at age 15 years or older, a three-dose schedule is recommended (0, 1–2, 6). If the vaccine schedule is interrupted, vaccine doses do not have to be repeated (no maximum interval). Gardasil is not recommended for those older than 26 years, but some adults aged 27 years or older may benefit from HPV immunization (Centers for Disease Control and Prevention [CDC], 2019).

Answer 23

Colposcopy A specialized “microscope” used to visualize the cervix, obtain cervical biopsies, and gain access to the cervix during cryotherapy or laser ablative therapy. The diagnostic test for cervical cancer is a biopsy of the cervix, which is obtained during a colposcopy.

Answer 24

A vaginal speculum is used to expose the cervix. After the cervix is studied, it is washed with acetic acid 3% to 5% (vinegar), which helps remove mucus and causes the abnormal areas of the cervix to turn a bright-white color that resembles leukoplakia (acetowhitening). Biopsy samples are obtained from the acetowhitened areas on the cervix, cervical os (glandular cells), and squamocolumnar junction. After a colposcopy, a small amount of cramping and bloody spotting is normal (red, brown, black) in the next few days after the procedure. Nonsteroidal anti-inflammatory drugs (NSAIDs) or analgesics can be used for the pain as needed.

Answer 25

Ablative Treatment Cryotherapy, Laser Therapy Treatment for abnormal superficial cervical cells.

Answer 26

Loop Electrosurgical Excision Procedure

Answer 27

Potassium Hydroxide Slide (KOH slide) **hyphae and spores** Vaginal specimens do not require KOH to visualize *Candida*.

Answer 28

**Whiff Test** A positive result occurs when a **strong, fish-like odor** is released after one or two drops of KOH are added to the slide (or a cotton swab soaked with discharge).

Answer 29

Tzanck Smear A positive smear will show large abnormal nuclei in squamous epithelial cells. Not commonly used.

Answer 30

Recognize menopausal female body changes. If palpable ovary (abnormal), rule out ovarian cancer and order an intravaginal ultrasound. Palpation of postmenopausal women’s breasts will feel softer with less volume and may be pendulous. *(hanging loosely)* Be familiar with physical breast exam findings (hard irregular mass that is not mobile) and follow-up of breast cancer.

Answer 31

Pap/cytology and HPV testing are not recommended before age 21 years, even if sexually active, or if the person has an STD or sexually transmitted infection (STI) or has multiple sex partners. Can perform bimanual gynecologic exam to check for pelvic inflammatory disease (PID) and test for chlamydia/gonorrhea. Do not confuse endometrial biopsy with colposcopy, a test used to visualize the cervix and obtain cervical biopsy.

Answer 32

Using a small amount of K-Y Jelly to lubricate the tips of the speculum (in patients with atrophic vaginitis to reduce pain and vaginal bleeding) will not affect the Pap test results. In reproductive-aged females who present with acute abdominal or pelvic pain, always perform a pregnancy test (use good-quality urine human chorionic gonadotropin strips). Girls and teenagers have larger ectropions. Some adult women on birth control pills may develop ectropion. *Cervical cancer 5-year survival rates:* Localized, 92%; regional spread, 56%; distant metastasis, 17%.

Answer 33

**Infertility** **is defined as having unprotected sex for 1 year with failure to achieve pregnancy.** There is up to an 85% chance of becoming pregnant within 1 year of unprotected sexual intercourse. In the United States, approximately 50% of pregnancies are unplanned. Women seeking to prevent pregnancy can choose from several options with varying degrees of reported effectiveness

Answer 34

Most Effective Options = **Implant, IUD, Sterilization** Less Effective Options = **Injectable, Pills, Patch, Ring, Diaphragm** Least Effective Options = **Condoms, Withdrawal, Sponge, Fertility Awareness monthy tracker, Spermicide**

Answer 35

**Vasectomy or Hysteroscopic sterilization** = use another method for first 3 months **Injectable** = get repeat injections on time **Pills** = take a pill each day **Patch, Ring** = Keep in place, change on time **Diaphragm** = use correctly every time you have sex **Condoms, Sponge, Withdrawal, Spermicides** = use correctly everytime you have sex **Fertility awareness based methods =** abstain or use condoms on fertile days. Newest methods (standard days method and two day method) may be the easiest to use and consequently more effective, what are these methods? * The Standard Days Method (SDM) is a fertility awareness-based family planning method that identifies a 12-day fertile window during which women with regular menstrual cycles (26–32 days long) should abstain from sex or use a barrier method to prevent pregnancy* * The TwoDay method is* ***a variation of the cervical mucous method****.*

Answer 36

According to the Guttmacher Institute (2020), there are 23 states and the District of Columbia that explicitly allow all individuals to consent to contraceptive services. Some states require a specified age (e.g., age 14 or older) to consent to such care. Approximately 24 states permit minors to consent to contraceptive services in certain circumstances. Married minors or emancipated minors do not need parental consent. *A list of state requirements in regard to minors obtaining contraceptive services with/without parental consent is available at* [***https://www.guttmacher.org/state-policy/explore/ minors-access-contraceptive-services***](https://www.guttmacher.org/state-policy/explore/%20minors-access-contraceptive-services)*.*

Answer 37

* At least 7 days or less after start of normal menses (or after an induced or spontaneous abortion) * Has had no sexual intercourse since the start of last normal menses * Has been correctly and consistently using a reliable method of contraception * Is within 4 days postpartum * Exclusively breastfeeding or for the vast majority of the time breastfeeds (\>85%) and is amenorrhoeic and \<6 months postpartum * Check if pregnant with urine pregnancy test before starting hormonal and IUD contraception

Answer 38

Estrogen and Progesterone **Works in a synergistic manner by stopping ovulation (inhibits LH surge) and thickening mucus plug** There are several types of oral contraceptives, transdermal patch, and vaginal ring

Answer 39

**Monophasic Pill** = Loestrin FE 1/ 20 **Biphasic Pill** = Ortho-Novum 10/11, Mircette, Jenest **Triphasic Pill** = Ortho Tri-Cyclen, Cyclessa, Tri-Norinyl, Tri-Levlen, and Triphasil **Ethinyl Estradiol and Drospirenone** = Yaz/Yasmin **Extended Cycle Oral Contraceptive** = Seasonale

Answer 40

Loestrin FE 1/20 | (Monophasic Pill)

Answer 41

Ortho Novum 10/11, Mirette, Jenest Biphasic Pills

Answer 42

Ortho Tri-Cyclen, Cyclessa, Tri-Norinyl, Tri-Levlen, Triphasil Contains 21 days of active pills and 7 days of placebo pills. The dose of hormones varies weekly for 3 weeks (“triphasic”). Progestin used is norgestimate. Indicated for acne.

Answer 43

Yaz 28, Yasmin * Uses drospirenone (a spironolactone analog) as the progestin component * Results in lighter menses and lower rates of unscheduled bleeding * Consider for women with acne, PCOS, hirsutism, or premenstrual dysphoric disorder disorder (PMDD) * Higher risk of DVT and hyperkalemia

Answer 44

Labs: Check the potassium level if patient is on an angiotensin-converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), or potassium-sparing diuretic or has kidney disease.

Answer 45

Seasonale ***Extended-Cycle Oral Contraceptive Pills*** 84 days hormones (3 months) of estrogen/progesterone with 7 days placebo pills This method typically results in four periods per year, although breakthrough bleeding is not uncommon during the first few months. *Literally 1 period per season*

Answer 46

***Cervical Ring*** ***Ortho Evra Transdermal Contraceptive Patch*** ***Both have 7% Typical Use Failure Rate***

Answer 47

NuvaRing Plastic cervical ring that contains EE = Etonogestrel and Ethinyl Estradiol It is left inside the vagina for 3 weeks (21 days), then removed for 1 week (when woman has her period). Educate patient on how to apply = Fold in half and insert into vagina The ring should fit snugly around cervix. Do not use NuvaRing if cigarette smoker aged _\>_ 35 years

Answer 48

Wear a new patch 1 week at a time for 3 weeks in a row. During the fourth week, do not wear a patch. Higher risk of **VTE** bc releases higher levels of estrogen compared with oral contraceptives Absolute and relative contraindications for combined estrogen-progesterone method of contraception are the same as oral contraceptives Patch can be worn on back, chest (except breast), upper back, arm, abdomen

Answer 49

**My** Migraines with focal neurological aura **C** CAD or CVA **U** Undiagnosed genital bleeding **P** Pregnant or suspect pregnancy **L** Liver tumor or active liver disease **E** Estrogen-dependent tumor **T** Thrombus or emboli **S** Smoker aged 35 or older

Answer 50

* Migraine headaches * Migraines and \>35 years * Migraines with focal neurological findings are an absolute contraindication because of increased risk of stroke * Smoker \<35 years * Fracture or cast on lower extremities * Adequately controlled hypertension

Answer 51

Any condition (past or present) that increases the risk of blood clotting * History of thrombophlebitis or thromboembolic disorders (e.g., DVT) * Genetic coagulation defects, such as factor V Leiden disease * Major surgery with prolonged immobilization Smoker older than the age of 35, \>15 cigarettes per day * Also considered a relative contraindication because women \<35 years who smoke can take the pill (if no other contraindications exist)

Answer 52

Any condition that increases the risk of strokes * Migraine with aura or focal neurological symptoms or migraine without aura at age 35 years or older * History of cerebrovascular accidents (CVAs) and transient ischemic attacks (TIAs) * Hypertension (if systolic blood pressure [SBP] \>160 mmHg or diastolic BP [DBP] \>100 mmHg) Inflammation and/or acute infections of the liver with elevated liver function tests (LFTs) * In acute infection or inflammation of the liver (e.g., mononucleosis) with elevated LFTs, estrogen is contraindicated * When LFTs are back to normal, can go back on birth control pills * Hepatocellular adenomas or malignant (hepatoma) * Cholestatic jaundice of pregnancy

Answer 53

Known or suspected cardiovascular disease * Moderately to severely impaired cardiac function * Complicated valvular heart disease (risk atrial fibrillation, history of subacute bacterial endocarditis) * Coronary artery disease (CAD) * Diabetes with vascular component * Systemic lupus erythematosus * Hypertension if SBP is ≥160 or DBP 100 mmHg * Two or more risk factors for arterial cardiovascular disease (such as older age, smoking, diabetes, hypertension)

Answer 54

Some reproductive system conditions or cancers * Known or suspected pregnancy * Undiagnosed genital bleeding or breast mass * Breast, endometrial, or ovarian cancer (or any estrogen-dependent cancer) \<21 days postpartum Contraindications for drospirenone (Yaz, Yasmin, Slynd): Hyperkalemia, kidney disease or kidney failure, adrenal insufficiency

Answer 55

**Ovarian cancer and endometrial cancers (decreased by 40%–50%)** Decreased incidence of: * Dysmenorrhea and cramps (decrease in prostaglandins) * Decreased pelvic pain for patients with endometriosis * Acne and hirsutism (lower levels of androgenic hormones) * Ovarian cysts (due to suppression of ovulation) * Heavy and/or irregular periods (due to suppression of ovaries)

Answer 56

Perform thorough health history to find out if patient has a contraindication. Rule out pregnancy. Check BP (rule out hypertension). According to the CDC (2016), a physical examination, Pap smear, gynecologic exam, STD/STI testing, and/or laboratory blood testing is **not required** for initiating contraception in most healthy patients. Exception is **pelvic exam** before insertion of **IUD** (to rule out an abnormal uterus or cervicitis) and when fitting a patient for a diaphragm. Oral contraceptives can be started **anytime** in the menstrual cycle (rule out pregnancy first)

Answer 57

All patients should be instructed to use “backup” (condoms) in the first week (7 days) during the first pill pack. * *Quick start:* Start taking the pill on the day prescribed (give samples or prescription). Rule out pregnancy first. * *Day one start:* Take the first pill during the first day of the menstrual period. Provides the best protection. * *Sunday start:* Take first pill on the first Sunday after the menstrual period starts. Will avoid having a period on a weekend. Higher chance of ovulation happening. Follow-up visit needed within 2 to 3 months to check BP or any side effects and answer patient’s questions. Can prescribe up to 12 to 13 months of refills for oral contraceptives.

Answer 58

***Unscheduled Bleeding (Spotting)*** **Term used for menstrual bleeding that occurs outside of usual cycle.** Educate patient that she may have spotting/light bleeding during the first few weeks after starting birth control pills, transdermal patch, or vaginal ring. For most, it will decrease to 10% or less by the third month. Discourage patient from switching to another pill brand during the first 3 months because of spotting. Advise patient that most cases resolve spontaneously within a few weeks.

Answer 59

Patients on oral contraceptives with lower estrogen dose (20 mcg EE) have higher rates of unscheduled bleeding, compared with those on OCs with higher dose of 30 to 35 mcg of EE. If patient still has bleeding after a few weeks, an option is to switch to an OC with 30 mcg of EE (Lo/Ovral, Desogen, Loestrin 2, Nordette). Check if patient is taking pills daily. It takes approximately 3 months for the body to adjust to hormones. Early symptoms can include nausea and breast tenderness a few days after starting hormones. Symptoms usually resolve in 1 month.

Answer 60

*Missed 1 Day* Take **two pills now** and **continue with same pill pack** (“doubling up”). Continue taking remaining pills at the usual time. *Missed 2 Consecutive Days (or \>48 Hours Since Last Pill Should Have Been Taken)* **Take the most recent missed pill as soon as possible** (even if it means taking two pills the same day). **Discard any leftover missed** **pills**. **Continue taking remaining pills at the usual time.** Use **backup contraception (e.g., condoms)** or **avoid sex** **until hormonal pills have been taken for 7 consecutive days.**

Answer 61

Omit hormone-free pills (or placebo pills) by finishing the hormonal pills in the current pack and starting a new pill pack the next day. Use backup contraception until hormonal pills have been taken for 7 consecutive days. Consider emergency contraception if unprotected sexual intercourse occurred in the previous 5 days.

Answer 62

* Anticonvulsants:* Phenobarbital, phenytoin * Antifungals (strong CYP3A4 inhibitors):* Griseofulvin (Fulvicin), itraconazole (Sporanox), ketoconazole (Nizoral) * HIV/hepatitis C virus (HCV) protease inhibitors:* Indinavir, boceprevir * Certain antibiotics:* Ampicillin, tetracyclines, rifampin, clarithromycin * St. John’s wort:* May cause breakthrough bleeding

Answer 63

**Thromboembolic events** can happen in any organ of the body. These signs indicate a possible thromboembolic event. Advise patient to report these or call 911 if symptoms of ACHES: ## Footnote **A** Abdominal pain **C** Chest pain **H** Headaches **E** Eye problems; change in vision **S** Severe leg pain

Answer 64

Typical use failure rate is 9%. Traditional oral contraceptive pills have 21 days of “active” pills and 7 days of placebo pills. The last 7 days are the “hormone-free” days. The menstrual period usually starts within 2 to 3 days after the last active pill was taken (from very low levels of estrogen/progesterone). Some brands of birth control pills (e.g., Loestrin FE) contain iron in the pills taken during the last 7 days of the pill cycle (instead of a placebo pill). The last 7 days (hormone-free) of the pill cycle are there to reinforce the habit of daily pill taking.

Answer 65

For the *first* pill cycle, advise patient to use “backup” (an alternative form of birth control) for 7 consecutive days. The extended-cycle OCs are another option to consider. All the combined oral contraceptives (COCs), the patch, and the NuvaRing contain both estrogen (e.g., EE) and progesterone (e.g., levonorgestrel, norethindrone, desogestrel).

Answer 66

The contraceptive patch (e.g., Ortho Evra) results in higher levels of estrogen exposure compared with COCs (higher risk of blood clots, DVT). The estrogen in COCs can elevate BP. Patients’ BP should be checked within 4 to 8 weeks. Breastfeeding women can use the progestin-only pill (POP; “minipill”; e.g., Micronor, Nor-QD) or other progestin-only contraceptives. Barrier methods such as condoms can also be used.

Answer 67

Depo-Provera (4% Typical Use Failure Rate) Etonogestrel Contraceptive Implant (0.1% Typical Use Failure Rate) Progestin-Only Pills (7% Typical Use Failure Rate) Emergency Contraception (“Morning-After Pill”)

Answer 68

Also known as *depot medroxyprogesterone acetate (DMPA)*. Each dose by injection lasts 3 months. Highly effective. Check for pregnancy before starting dose. Start within first 5 days of cycle (days 1–5) because females are less likely to ovulate at these times. Women on Depo-Provera for at least 1 year (or longer) have amenorrhea because of severe uterine atrophy from lack of estrogen

Answer 69

Do not recommend to women who want to become pregnant in 12 months. Causes delayed return of fertility. It takes up to 1 year for most women to start ovulating. ***Black box warning**:* Avoid long-term use (more than 2 years). Increases risk of osteopenia or osteoporosis that may not be fully reversible. Using Depo-Provera for more than 2 years is discouraged.

Answer 70

**Avoid** using Depo-Provera in this population, because it will further increase their risk of **osteopenia**/**osteoporosis**. Consider testing for osteopenia/osteoporosis (dual-energy x-ray absorptiometry [**DEXA**] scan). Recommend calcium with vitamin D and weight-bearing exercises for patients who are on this medicine.

Answer 71

The contraceptive implant contains a long-acting form of progestin (etonogestrel). Initially, unscheduled bleeding is common, but when the endometrial lining atrophies, amenorrhea results. Ovulation may not occur for a few weeks to 12 months after removal.

Answer 72

Thin plastic rods are inserted on the inner aspect of the upper arm subdermally (nondominant arm). If keloid or heavy scarring occurs, may have problem with removal. Special procedures, including surgery in a hospital, may be needed to remove the implant. Norplant II (two rods) is effective up to 5 years. Nexplanon (one rod) is effective for up to 3 years. One out of ten women stop using the implant because of unfavorable changes in menstrual bleeding.

Answer 73

Safe for breastfeeding women, and most effective if woman is exclusively breastfeeding. Also known as the “minipill.” Obese women can take POPs. It is very important to take the pill at the same time each day. If dose is late (≥3 hours) or a day is missed, the woman should use condoms (backup contraception) or abstain from sexual intercourse for 2 days. There is no placebo week with POPs.

Answer 74

* Vomiting or severe diarrhea that occurs within 3 hours after taking a dose:* Take another pill as soon as possible. Continue taking pills daily at the same time each day. Use backup contraception. Consider use of emergency contraception if unprotected sex. * Micronor (Norethindrone 0.35 mg):* Take one pill daily at about the same time each day (each pack contains 28 pills). Start taking pill on day 1 of menstrual cycle. POPs are slightly **less effective** than oral contraceptive pills. An alternative for **women who cannot take estrogen**, such as breastfeeding mothers, older smokers, and diabetics with microvascular disease.

Answer 75

Works best if taken within 72 hours after unprotected sexual intercourse or if 2 consecutive days of birth control pills are skipped. Women and men of all ages can get emergency contraceptive pills (except ulipristal acetate) without a prescription in the United States. 89% effective Advise patient that if she does not have a normal period in next 3 weeks, she should return for follow-up to rule out pregnancy.

Answer 76

* Ulipristal acetate (Ella):* Take one pill within 5 days (120 hours) of unprotected sex. Needs prescription. * Levonorgestrel:* Plan B One-Step My Way, After Pill, or Next Choice One Dose * A few birth control pills that contain levonorgestrel (e.g., Triphasil) may be used as morning-after pills but are more likely to cause nausea (because of the estrogen). * Take first dose as soon as possible (up to 72 hours after). * Take second dose in 12 hours. * If patient vomits tablet within 1 hour (or less), may need to repeat dose; OTC antiemetics (antihistamine drug class) are dimenhydrinate (Dramamine) and meclizine (Dramamine Less Drowsy).

Answer 77

Intrauterine Device (LNG 0.1%–0.4%/Copper 0.8% Typical Use Failure Rate) Barrier Methods (condoms) Diaphragm With Contraceptive Gel and Cervical Cap (17% Typical Use Failure Rate) Sponge (Nulliparous 14%/Multiparous 27% Typical Use Failure Rate)

Answer 78

The IUD is the second most commonly used method of contraception in the world (female sterilization is the first). 1. **Paragard** is copper bearing (effective up to 10 years) * Copper IUD can cause heavy menstrual bleeding and cramping the first few months of use. 1. **Mirena** contains the hormone levonorgestrel (LNG), which decreases vaginal bleeding. * Mirena IUD is effective for up to 5 years and is slightly more effective than copper-bearing IUDs (Cu-IUDs). IUD can be removed if patient desires pregnancy. Not for women who plan on having a baby within 1 to 2 years. Must be inserted by trained health provider. Rule out pregnancy.

Answer 79

Active PID or history of PID within the past year Suspected or confirmed pregnancy or has STD Uterine or cervical abnormality (e.g., bicornuate uterus) Undiagnosed vaginal bleeding or uterine/cervical cancer History of ectopic pregnancy

Answer 80

*_Increased Risk_* Endometrial and pelvic infections (first few months after insertion only) Perforation of the uterus Heavy or prolonged menstrual periods (Cu-IUDs) *_Education_* Mirena IUD: Approximately 20% of patients will have amenorrhea in 1 year. Some have lighter periods. Educate patients to periodically check for missing or shortened string, especially after each menstrual period. If the patient or clinician does not feel the string, order a pelvic ultrasound.

Answer 81

Male condoms more effective than female (18% vs. 21% failure rate) Do not use with any oil-based or silicone oil based lubricants , creams, and so forth

Answer 82

Not as effective as hormonal forms of contraception. The cervical cap is less effective than a diaphragm. After vaginal birth, the failure rate of the cervical cap increases to 29%. The diaphragm must be used with spermicidal gel with every act of intercourse. Apply the spermicidal foam/gel inside the vagina without removing the diaphragm. After intercourse, leave diaphragm inside vagina for at least 6 to 8 hours (can remain inside vagina up to 24 hours). The cervical cap can be left in the vagina up to 2 days. The cervical cap (Prentif cap) can be worn up to 48 hours. Compared with the diaphragm, the Prentif cap may cause abnormal cervical cellular change (abnormal Pap).

Answer 83

Spermicidal gel (nonoxynol-9, or N-9) increases risk of infection with STD, including HIV. It is thought to cause irritation of the cervical surface (breakdown of the skin barrier) after multiple uses. Both diaphragm and cervical cap require a prescription and must be fitted. Avoid lubricants that contain silicone oil; they can cause deterioration of the silicone diaphragm or cap. After each pregnancy by vaginal birth or weight gain (or loss) of 20%, they need to be refitted. The cervical cap and diaphragm cannot be used during menstruation.

Answer 84

Vaginal and cervical irritation (N-9) increases risk of HIV, UTIs, and toxic shock syndrome (rare).

Answer 85

**OTC. Made out of soft foam that contains spermicide. It is inserted inside the vagina so that it covers the cervix.** ## Footnote It can be inserted up to 24 hours before sex, and it should be left in place at least 6 hours after sexual intercourse. The sponge should not be worn for more than 30 total hours. **Spermicide use (nonoxynol-9)** increases **risk of HIV infection** (see section on diaphragm for rationale).

Answer 86

Vaginal and cervical irritation (nonoxynol-9) increases risk of HIV infection. TSS is rare.

Answer 87

Low-dose birth control pills contain 20 mcg to 35 mcg of EE. **Desogen, Ortho-TriCyclen, and Yaz/Yasmin** are all indicated for treatment of acne. Know what to do if 2 consecutive days of the pill are missed. = take most recently missed pill (even if taking two pills on same day), discard any leftover missed pills - and continue taking remaining pills at the usual time Avoid using **Depo-Provera** in anorexic and/or bulimic patients (very high risk of osteoporosis). - *is progesterone only* Women taking Seasonale (84 days hormones/7 days placebo pill) will have only **four** periods per year.

Answer 88

Mefenamic acid (Ponstel) is an NSAID that is very effective for menstrual pain. Know how to use Plan B (emergency contraception) = can take within 72 hours or if skilled 2 consecutive days of birth controll pills, does not need prescription, take as soon as possible and second dose 12 hours later, use antiemetic if pill causes nausea, follow up to RO pregnancy if no period in next 3 weeks Cu-IUD lasts 10 to 12 years. Mirena (progesterone IUD) lasts 5 years. Some questions will ask for the best birth control method for a case scenario. Remember the contraindications or adverse effects of each method (e.g., Depo-Provera).

Answer 89

**Yaz or Yasmin** contain estrogen and drospirenone. Has a higher risk of blood clots, stroke, heart attacks, and hyperkalemia. **Do not recommend Depo-Provera or IUD** for women who want to become pregnant in 12 to 18 months because it may cause delayed return of fertility. It can take up to 1 year for some women to start ovulating. **Cu-IUD probably has the broadest indication** for use as a contraceptive for women with medical conditions (e.g., diabetics, smoker for more than 35 years, on anticonvulsant or antiretroviral therapy, ovarian cancer, ischemic heart disease, liver tumors).

Answer 90

**Primary dysmenorrhea** refers to the recurrent crampy pain in the pelvic area caused by menstruation that is not caused by disease. **Secondary dysmenorrhea** refers to the same type of pain caused by a disease such as endometriosis. **Endometriosis** is associated with heavy menstrual periods (menorrhagia) with severe cramping. The treatment options are NSAIDs, acetaminophen (paracetamol), and/or hormonal methods. All NSAIDs are probably effective

Answer 91

***Mefenamic acid (Ponstel):*** 250 mg every 6 hours for pain as needed * Naproxen sodium (Aleve):* 275 mg every 6 to 8 hours as needed * Ibuprofen (Advil):* 400 mg to 600 mg every 4 to 6 hours as needed * Ketoprofen (Orudis):* 25 mg to 50 mg every 6 to 8 hours as needed * Acetaminophen (Tylenol):* One to two tablets every 4 to 6 hours as needed (if NSAIDs contraindicated)

Answer 92

If poor to no relief, consider extended-cycle OCs such as Yaz (24/4) or extended-cycle OCs (Seasonale). Progestin-only methods may also be effective. Refer to gynecologist to rule out endometriosis if severe menstrual cramp pain with heavy menses (can cause iron-deficiency anemia).

Answer 93

Absence of menses, which can be transient, intermittent, or permanent. **Primary amenorrhea** is the absence of menarche by age 15 years (or older). **Secondary amenorrhea** is the absence of menses for more than 3 months in girls/women who previously had regular menstrual cycles, or if irregular cycles, it is missing menses for 6 months. The most common cause of secondary amenorrhea is pregnancy.

Answer 94

Very common condition found in reproductive-aged women between the ages of 30 and 50 years. Previously called *fibrocystic breast disease*. These are nonmalignant breast lesions, which are either nonproliferative (benign) or proliferative (fibroadenomas, fibrosis, papillomas, mild-to-moderate hyperplasia, others). Women with proliferative lesions have a slightly increased risk of breast cancer. Many have cyclic monthly breast changes that occur in the premenstrual period, such as breast engorgement and breast pain (mastodynia), which improve after menses starts.

Answer 95

Woman aged 30 to 50 years complains of the cyclic onset of bilateral breast tenderness and breast lumps that start from a few days (up to 2 weeks) before her period for many years. Once menstruation starts, the tenderness disappears, and the size of breast lumps decreases. May report that the lesion or mass has grown in size. During breast examination, the breast may feel lumpy, nodular, or cystic. If mass present, it is mobile with discrete edge, not attached to the skin, and feels rubbery to firm texture (not hard). Nipples and/or breast may feel tender.

Answer 96

_Objective Findings_ Multiple mobile and rubbery to firm (not hard) masses on one or both breasts. _Treatment Plan_ Stop caffeine intake. Take vitamin E and evening primrose capsules daily. Wear bras with good support. Referral needed if dominant mass, skin changes, fixed mass.

Answer 97

Breast cancer is the most common type of cancer in women, and it is also the second most common cause of death among women in the United States (leading cause of death is heart disease). Most cases of breast cancer in the United States are diagnosed by an abnormal mammogram, but up to 15% of women have a breast mass that is not detected on a mammogram (mammographically occult disease). **The gold standard diagnostic** is **biopsy** of the breast/axillary mass.

Answer 98

* Older age (50 years or older) * Genetic mutations (*BRCA 1/2*) * Early menarche (before age 12), late menopause (after age 55) * Dense breast * Personal or Family history of breast cancer * Radiation therapy to the chest/breast before age 30 (treated for Hodgkin’s lymphoma) * Mother took diethylstilbestrol (DES; 1940–1971)

Answer 99

* Not being physically active * Obese after menopause * Hormones (estrogen and progesterone) taken during menopause for \>5 years * Pregnancy at age 30 or older * Not breastfeeding * Nulliparity * Moderate-to-high alcohol intake.

Answer 100

* Breast cancer types:* Ductal carcinoma in situ (DCIS), infiltrating lobar carcinoma (CA), infiltrating ductal CA, mixed lobar and ductal CA, PDB, inflammatory breast CA, phyllodes tumor, breast sarcoma (rare). * Breast cancer receptors:* Estrogen receptor (ER), progesterone receptor (PR), HER2 (human epidermal growth factor receptor). Most breast cancers (80%) are hormone-receptor positive (ER and/or PR).

Answer 101

**Biennial** screening mammography for women aged **50 to 74 years.** There is insufficient evidence for digital breast tomosynthesis (DBT) as the screening method for breast cancer.

Answer 102

Patient (or clinician) detects a dominant breast mass that is painless. Mass feels hard, has irregular edges, and is not mobile. May have axillary adenopathy, skin changes (dimpling or peau de orange, thickening), or erythema (IBC). May have nipple discharge (bloody) or erosion. Scaling on the nipple and/or areola is a sign of PDB. Symptoms of metastases include bone (back pain, leg pain), liver (nausea, jaundice, anorexia, pain), lungs (shortness of breath, cough), and/or brain (headache).

Answer 103

* Mammogram:* Grouped microcalcifications, spiculated high-density mass. * Breast ultrasound/sonogram:* Distinguish if mass is cystic or solid/malignant (e.g., calcifications). * MRI of the breast (with gondolium):* Used to screen women at high risk of breast cancer. Most invasive breast cancers are enhanced on gondolium-contrast MRI.

Answer 104

* Age 30 years or older with dominant breast mass:* Order **diagnostic mammogram** and breast ultrasound (to determine if cystic or solid). If abnormal mammogram, refer to breast specialist. * Age 30 years or younger:* Order **breast ultrasound** with/without diagnostic mammogram/breast biopsy. If low clinical suspicion, may observe for one or two menstrual cycles.

Answer 105

* Skin changes (peau de orange, dimpling):* Order **diagnostic mammogram with biopsy** of underlying mass. * If family history of breast and/or ovarian cancer* (first-degree includes parents/siblings and second-degree relatives are aunts/uncles/cousins): Refer to **geneticist. Ashkenazi Jews** are at higher risk of *BRCA 1/2* mutations.

Answer 106

* Physical exam:* Breast examination search for masses, axillary, supraclavicular, and cervical adenopathy. * Secondary prevention:* Aspirin use at least once per week (associated with up to 50% reduction in death from breast cancer); tamoxifen for certain patients at higher risk at age 35 years or older.

Answer 107

Polycystic Ovary Syndrome

Answer 108

These females are at higher risk for **type 2 diabetes, dyslipidemia, metabolic syndrome, endometrial hyperplasia**, obesity, nonalcoholic fatty liver disease, depression, and obstructive sleep apnea.

Answer 109

Obese teen or young adult complains of excessive facial and body hair (hirsutism 70%), bad acne, and amenorrhea or infrequent periods (oligomenorrhea). Dark thick hair (terminal hair) is seen on the face, cheek, and beard areas. May have male-pattern baldness when older.

Answer 110

*Transvaginal ultrasound:* Enlarged ovaries seen with multiple small follicles (“ring of pearls” appearance) Serum testosterone, dehydroepiandrosterone (DHEA), and androstenedione are elevated. FSH levels are normal or low. Fasting blood glucose and 2-hour oral glucose tolerance test (OGTT) are abnormal.

Answer 111

* First line treatment* **= Oral contraceptives (t**o suppress ovaries) * Second line treatment* **= Medroxyprogesterone** (Provera) to induce menses **Spironolactone** *for hirsutism* **Metformin** to *induce ovulation* **Weight Loss** to *reduce androgen and insulin levels* *medroxyprogesterone tablets (Provera) 5 to 10 mg daily for 10 to 14 days (repeat every 1–2 months to induce menses).*

Answer 112

Coronary heart disease (CHD) Type 2 diabetes mellitus and metabolic syndrome Cancer of the breast and endometrium Central obesity Infertility Nonalcoholic fatty liver disease

Answer 113

Screen women aged _\>_ 65 years for osteoporosis

Answer 114

Osteopenia and osteoporosis are caused by a gradual loss of bone density secondary to estrogen deficiency and other metabolic disorders. Most common in older women (White or Asian descent) who are thin with small body frames, especially if positive family history. Treat postmenopausal women (or men aged 50 years or older) who have osteoporosis (T-score −2.5 or less) or history of hip or vertebral fracture.

Answer 115

* Patients on **chronic steroids** (e.g., severe asthma, autoimmune disorders) are at high risk for glucocorticoid-induced osteoporosis; rule out osteoporosis in older women (or men) on chronic steroids, especially if accompanied by other risk factors (lower testosterone, small frame, thin, White, or Asian). * Patients who have **anorexia nervosa and bulimia** * Long-term use of **proton-pump inhibitors (PPIs),** such as omeprazole (Prilosec)

Answer 116

* Gastric bypass, celiac disease, hyperthyroidism, ankylosing spondylitis, rheumatoid arthritis (RA), and others * The **“female athlete triad”** is a combination of **low weight** with history of **amenorrhea** or menstrual dysfunction and l**ow bone density**; at higher risk for osteoporosis

Answer 117

Low calcium intake (low intake of dairy), vitamin D deficiency, inadequate physical activity Alcohol consumption (three or more drinks per day), high caffeine intake Smoking (active or passive)

Answer 118

DEXA of hip and spine ***Osteopenia T-score = -1.5-2.4*** ***Osteoporosis T-Score = -2.5 or lower standard deviations (SD) at lumbar spine, femoral neck, or total hip region*** Pharm therapy if osteoporosis or postmenopausal with hx of fragility fracture/hip fracture/recent fracture Repeat DEXA in 2 years after treatment

Answer 119

Weight-bearing exercises 30 minutes three times per week * Weight-bearing exercises are walking, jogging, aerobic dance classes, most sports, yoga, tai chi. * Swimming and biking are not considered a weight-bearing exercise (but good for severe arthritis). * Isometric exercises are not considered a weight-bearing type of exercise.

Answer 120

Calcium with vitamin D 1,200 mg/day with vitamin D 800 IU daily Smoking cessation if a smoker (smoking cigarettes accelerates bone loss) ***FRAX** (Fracture Risk Assessment Tool) will give the 10-year probability of hip fracture and major osteoporotic fracture (spine/forearm/shoulder). Website is* [**https://www.sheffield.ac.uk/FRAX/**](https://www.sheffield.ac.uk/FRAX/).

Answer 121

**First line = Bisphosphonates** * Selective Estrogen Receptor Modulator Class (Raloxifene, Tamoxifen)* * Parathyroid Hormone Analog* * Other: Miacalcin and Calcitriol*

Answer 122

**First-line drugs** for treating postmenopausal osteoporosis, glucocorticoid-induced osteoporosis (women and men), and osteoporosis in men Potent **esophageal irritant** (advise patients to report sore throat, dysphagia, midsternal pain); may cause esophagitis, esophageal perforation, gastric ulcers, reactivation/bleeding peptic ulcer disease (PUD) Increases BMD and decreases bone resorption

Answer 123

Fosamax (alendronate) PO (by mouth) daily or weekly Actonel (risedronate) PO daily, weekly, or monthly * Take immediately upon awakening in morning with full glass (6–8 ounces) of plain water (do not use mineral water). * Take tablets sitting or standing and wait at least 30 minutes before lying down. * Do not crush, split, or chew tablets; swallow the tablets whole. * Never take these drugs with other medications, juice, coffee, antacids, vitamins. * Will cause severe esophagitis or esophageal perforation if lodged in the esophagus.

Answer 124

Consider prophylaxis for high-risk postmenopausal women with osteopenia. Repeat DEXA after 2 years of therapy. *Contraindications:* Inability to sit upright, esophageal motility disorders, history of PUD or history of gastrointestinal [GI] bleeding, chronic kidney disease, certain types of bariatric surgery (e.g., Roux-en-Y gastric bypass) **Osteonecrosis of the jaw** (mandible or maxilla) more likely if on intravenous or intramuscular bisphosphonates; patient complains of jaw heaviness, pain, swelling, and loose teeth.

Answer 125

Raloxifene (Evista) is category X drug. Does not stimulate endometrium or breast tissue, since it blocks ERs. Approved for use in postmenopausal women with osteoporosis who are at higher risk for breast cancer Do not use to treat menopausal symptoms (aggravates hot flashes). *Black box warning:* Increases risk of DVT, pulmonary embolism, and endometrial/uterine cancers; increased risk of death from stroke (postmenopausal women with history of heart disease)

Answer 126

These drugs reduce risk of breast cancer (if taken long term up to 5 years). Selective estrogen receptor modulators (SERMs) are an option for patients who cannot tolerate or have contraindications to bisphosphonates. Used as adjunct treatment for estrogen-receptor-positive breast cancers

Answer 127

Tamoxifen (Nolvadex) is a category X drug. Used for treatment of breast cancer that is hormone-receptor positive and for prophylaxis in women at high risk for breast cancer; can be taken up to 5 years. Increased risk of DVT, endometrial cancer, strokes, and pulmonary emboli *Common side effects (SERMs):* Causes hot flashes, white or brownish vaginal discharge, weight gain or loss

Answer 128

**Teriparatide (Forteo)** injection is recombinant human parathyroid hormone (PHT) for treatment of osteoporosis; it comes as a prefilled injector. Warning: It increased the incidence of osteosarcoma in rats.

Answer 129

* Miacalcin:* Calcitonin salmon, derived from salmon; weak antifracture efficacy compared with bisphosphonates and PTH. * Calcitriol:* Vitamin D analog; must be on a low-calcium diet; monitor patient for hypercalcemia, hypercalciuria, and renal insufficiency; may be effective in preventing glucocorticoid and posttransplant-related bone loss.

Answer 130

Average age of menopause for women in the United States is 51 years. The Women’s Health Initiative (WHI) showed that combined estrogen–progestin replacement therapy (ERT) increased the risk of stroke, heart disease, VTE, breast cancer, and pulmonary embolism.

Answer 131

The USPSTF **does not recommend** for use of combined estrogen–progestin or unopposed estrogen for prevention of chronic conditions (heart disease, osteoporosis). But the advice does not apply to women who want hormone therapy for relief of menopausal symptoms. Experts recommend duration of therapy of \<5 years because of increased risk of breast cancer. Many experts consider it safe for healthy women within 10 years of menopause (younger than 60 years) with no contraindications for estrogen. Women who have a uterus need both estrogen and progesterone (decreases risk of endometrial cancer); use unopposed estrogen for women with hysterectomy.

Answer 132

Estrogen can alleviate dyspareunia and vaginal/urethral atrophy. Estrogen increases the risk of developing or exacerbating systemic lupus erythematosus (birth control pills are contraindicated in women with lupus).

Answer 133

Ovarian cancer is the fifth most common cancer in women in the United States. It is seldom diagnosed during the early stages of the disease. Most often, an older woman complains of vague symptoms, such as abdominal bloating and discomfort, low-back pain, pelvic pain, urinary frequency, and constipation (frequently blamed on benign conditions) for certain women with *BRCA1* and *BRCA2* mutations. By the time the cancer is diagnosed, it has almost always metastasized. Symptoms in patients with metastatic disease depend on area affected and may include bone pain, abdominal pain, headache, blurred vision, and others.

Answer 134

**USPSTF does not recommend routine screening for ovarian cancer in the general population (Grade D)** **High-risk women with suspected** ***BRCA 1*****/*****2*** **mutations** should be referred for **genetic counseling and testing.** If ovarian cancer screening is done, a **transvaginal ultrasound with serum cancer antigen (CA-125)** is ordered. The screening starts at age 30 years (or 5–10 years before earliest age of first diagnosis of ovarian cancer in a family member).

Answer 135

Some experts recommend **risk-reducing** **Bilateral Salpingo-Oophorectomy (BSO**) between ages 35 and 40 years (after childbearing is complete) for certain women with *BRCA1* and *BRCA2* mutations. This procedure has a significant effect in reducing ovarian cancer risk in this population

Answer 136

Bacterial Vaginosis Candidal Vaginitis Trichomonal Vaginitis(Trichomoniasis) Atrophic Vaginitis

Answer 137

“**Fish**-**like**” vaginal odor; profuse **milk-like discharge** that coats the vaginal vault Not itchy/vulva not red; overgrowth of anaerobes

Answer 138

**Clue cells** NOWBCs **Whiff test** = positive **pH \> 4.5**

Answer 139

**Cheesy or curd-like white discharge** **Vulvovagina red/irritated** *Labs* **=** **Pseudohyphae\***, **spores, numerous WBCs**

Answer 140

**“_Strawberry_ cervix”** **_Bubbly_ discharge** **Vulvovagina red/irritated** *Labs =* **Mobile protozoa** with **flagella**, numerous WBCS

Answer 141

Scant to no discharge **Fewer rugae, vaginal color pale; dyspareunia (painful intercourse); may bleed slightly during speculum examination** (if not on hormones) * Pap test =* Atrophic changes * FSH and LH levels =* Elevated * low estrogen causes high FSH and LH postmenopause*

Answer 142

Caused by an overgrowth of anaerobic bacteria in the vagina. Risk factors include sexual activity, new or multiple sex partners, and douching. Not an STD; therefore, sexual partner does not need treatment. Treatment is especially important for pregnant women. Pregnant women with BV are at higher risk for premature labor or low birth-weight babies.

Answer 143

Sexually active female complains of an unpleasant and fish-like vaginal odor that is worse after intercourse (if no condom is used). Vaginal discharge is copious and has milk-like consistency. Speculum examination reveals off-white to light-gray discharge coating the vaginal walls. There is no vulvar or vaginal redness or irritation (vaginal anaerobic bacteria do not cause inflammation).

Answer 144

* Findings:* Clue cells and very few white blood cells (WBCs). May see *Mobiluncus* bacteria (82%), a gram-negative anaerobic rod-shaped bacteria. * Clue cells:* Made up of squamous epithelial cells with a large amount of bacteria coating the surface that obliterates the edges of the squamous epithelial cells

Answer 145

*_Whiff Test_* Apply one drop of KOH to a cotton swab that is soaked with vaginal discharge. Positive: A strong “fishy” odor is released. *_Vaginal pH_* Alkaline vaginal pH \>4.5. Normal vaginal pH is between 4.0 and 4.5 (acidic).

Answer 146

**Metronidazole (Flagyl)\*** BID x 7 days ## Footnote *Alternative:* Metronidazole vaginal gel one applicator at bedtime for 5 days. Watch for disulfiram (Antabuse) effect if combined with alcohol (e.g., severe nausea, headache). Prescribe clindamycin (Cleocin) cream at HS × 7 days (oil based). Oil-based creams can weaken condoms. *Sex partners:* Treatment is not recommended by the CDC, because BV is not an STD. Abstain from sexual intercourse or use condoms until treatment is done (increases cure rate by 50%).

Answer 147

Overgrowth of *Candida albicans* yeast in the vulva/vagina. Considered normal vaginal flora but can also be pathogenic. Diabetics, as well as those who are HIV positive, on antibiotics (e.g., amoxicillin), or have any type of immunosuppression, are at higher risk. (The male penis can also be infected [balanitis].) Asymptomatic women and sexual partners do not need treatment.

Answer 148

Adult female presents with complaints of white cheese-like (“curd-like”) vaginal discharge accompanied by severe vulvovaginal pruritus, swelling, and redness (inflammatory reaction). May complain of external pruritus of the vulva and vagina.

Answer 149

Wet smear microscopy * Swipe cotton swab with vaginal discharge in the middle of a glass slide. * Add a few drops of normal saline (to the discharge). * Cover the sample with a cover slip and examine it under the microscope (set it at high power). *Findings:* **Pseudohyphae\* and spores\* with a large number of WBCs**

Answer 150

Antifungal - AZOLES * OTC:* **Miconazole** (Monistat), **clotrimazole** (Gyne-Lotrimin) × 7 days (OTC) * Prescription:* **Fluconazole** (Diflucan) 150 mg tablet × 1 dose, **terconazole** (Terazol-3) vaginal cream/suppository. * *Severe symptoms or immunocompromised:* Fluconazole (Diflucan) 150 mg in two sequential doses given 3 days apart. Do not use oral fluconazole in pregnancy, since it is teratogenic. * Lactobacillus (oral or vaginal) does not prevent postantibiotic vulvovaginitis.

Answer 151

*Trichomonas vaginalis* is a unicellular **protozoan parasite with flagella** that infects genitourinary tissue (both males and females). Infection causes inflammation (**pruritus, burning, and irritation**) of vagina/urethra. The most common sites are the urethra (dysuria) and vagina. It can also infect the paraurethral glands, Bartholin glands, cervix, bladder, and prostate.

Answer 152

Adult female complains of very pruritic, reddened vulvovaginal area. May complain of dysuria. Copious grayish-green and bubbly vaginal discharge. Male partners may have dysuria and frequency (urethritis) or may be asymptomatic.

Answer 153

**“Strawberry cervix”** from small points of bleeding on cervical surface (punctate hemorrhages) Swollen and reddened vulvar and vaginal area; vaginal pH \>5.0 Dysuria (burning) with urination, copious foamy purulent vaginal discharge

Answer 154

*Microscopy (use low power):* **Mobile unicellular organisms with flagella (flagellates) and a large amount of WBCs**. Trichomonads will remain motile for only 10 to 20 minutes after collection. **Nucleic acid amplification test (NAAT)** for *T. vaginalis* (vaginal samples better than first-voided urine)

Answer 155

Metronidazole (Flagyl) 2 g PO × 1 dose or 500 mg BID × 7 days Tinidazole 2 g PO × 1 dose Treat sexual partner because trichomoniasis is considered an STI; avoid sex until both partners complete treatment.

Answer 156

**Chronic lack of estrogen** in estrogen-dependent tissue of the urogenital tract; results in atrophic changes in the vulva and vagina of menopausal women. **Estrogen** is the **most effective treatment** for moderate-to-severe vaginal atrophy. **Low-dosed topical estrogen** therapy is preferred because of low systemic absorption.

Answer 157

Menopausal female complains of vaginal **dryness**, itching, and pain with sexual intercourse (**dyspareunia**). Some may have vulvar or vaginal bleeding (fissures) after intercourse. Complains of a great deal of discomfort with speculum examinations (e.g., Pap tests). **Pap test** result is “**abnormal**” secondary to atrophic changes. Worsens over time as she gets older. More than half of women do not report symptoms.

Answer 158

Atrophic labia with decreased rugae; vulva or vagina may have fissures. Dry, pale pink color to vagina

Answer 159

Nonhormonal vaginal moisturizers and lubricants. Vaginal moisturizers (e.g., **Replens)** are intended for use 2 to 3 days per week routinely. Lubricants can be water based (e.g., **K-Y Jelly**), silicone based, or oil based (can break down latex condoms).

Answer 160

Topical estrogen It comes in several forms (cream, tablet, capsule, or vaginal ring). Progesterone supplementation is required (if intact uterus) if using long term to decrease risk of endometrial hyperplasia. * Tablet or capsule vaginal estradiol inserts:* 4 mcg (Imvexxy), 10 mcg (Vagifem, Yuvafem, Imvexxy). Insert into vagina daily for 2 weeks, then use weekly thereafter. * Ring form of estradiol:* Estring designed to release 7.5 mcg of estradiol in the vagina daily. Effective for 90 days only, then replace with new ring.

Answer 161

If Pap shows **atrophic smear,** it needs to be **repeated in 3 months** because atrophic smears are difficult to analyze and can be misinterpreted. Estrogen can change vaginal cytology back to premenopausal state. Can be used for 2 to 3 months only, then repeat Pap, or it can be used for longer periods for consistent relief of moderate-to-severe vaginal symptoms.

Answer 162

**Lichen Sclerosus** Previously known as lichen sclerosus et atrophicus

Answer 163

Early skin lesion appears as flat-topped and slightly scaly hypopigmented, white, or mildly red polygonal papules that may coalesce to form larger plaques with peripheral erythema. Over time, when inflammation lessens, the lesion resembles cigarette paper (**wrinkled appearance**; [**Figure 1**](https://examprepconnect.springerpub.com/app/family-nurse-practitioner-fnp#)).

Answer 164

*Endometriosis is an often painful disorder in which tissue similar to the tissue that normally lines the inside of your uterus — the endometrium — grows outside your uterus. Endometriosis most commonly involves your ovaries, fallopian tubes and the tissue lining your pelvis* One theory is that it is due to retrograde menstruation where endometrial cells leave the uterus and start growing on the ovaries, pelvis, uterine ligaments, bowel, bladder, or thorax. The lesions are stimulated by estrogen (just like the endometrium where the cells originated). Can result in **infertility** (25%–35% infertile women have it).

Answer 165

Reproductive-aged woman between 25 and 35 years of age with history of **moderate-to-severe pelvic pain during menses, heavy cramping, and dyspareunia.** The dysmenorrhea may start approximately 1 to 2 days before menses, during menses, or a few days after menses. Ectopic endometrial tissue (endometriomas) can grow on the pelvis, ovary, peritoneum, bladder, bowel, abdominal wall, or thorax.

Answer 166

Physical exam findings that suggest endometriosis include nodules in the posterior fornix, adnexal masses, and pain with manipulation of the pelvic organs. Pelvic exam may be normal. Large lesions may show up in pelvic/intravaginal ultrasound. Refer to gynecologist.

Answer 167

**Estrogen/progesterone contraceptives\*** (birth control pills, patch, or vaginal ring) or **progestin-only therapy\*** will suppress the ovary and prevent ovulation and hormonal levels. **NSAIDs** for dysmenorrhea pain. Gonadotropin-releasing hormone **(GnRH) analogues** (e.g., leuprolide/Lupron Depot) and **aromatase inhibitors** for severe cases (anastrozole/Arimidex).

Answer 168

Postmenopausal women’s breasts will feel softer to palpation with less volume. Know female body changes in menopause. If palpable ovary (abnormal), order an intravaginal ultrasound. Know physical exam findings (hard irregular mass that is not mobile) and follow-up for breast cancer. Mefenamic acid (Ponstel) is an NSAID that is very effective for menstrual pain. Know how to take bisphosphonates (e.g., Fosamax, Actonel) and their contraindications = can cause esophagitis (if gets lodged) so take sitting up/standing, take asap in morning with full glass of water, swallow whole do not crush/chew, do not take with any other drugs

Answer 169

Know the bone density score for osteoporosis (T-score of \>−2.5 SD) and for osteopenia (T-score of −1.5 to −2.4 SD). There will be questions on all the types of vaginitis (BV, trichomonal, candidal, atrophic vaginitis). The questions range from diagnosis, workup, and lab tests to treatment. Become familiar with BV. “Clue cells” are squamous epithelial cells that have blurred edges due to the large number of bacteria on the cell’s surface.

Answer 170

Should be screened for underlying glucose metabolism disorders and diabetes.

Female Reproductive Flashcards

(194 cards)