Lecture 6: Health Maintenance Flashcards
1
Q
What qualifies as postmenopause?
A
No menstrual flow for 12+ months
2
Q
What is metrorrhagia?
A
Menstrual bleeding between cycles
aka intermenstrual bleeding
3
Q
What is considered polymenorrhea?
A
20 days or less
4
Q
What is menometrorrhagia?
A
Completely irregular bleeding
metrorrhagia is between cycles
5
Q
What is considered oligomenorrhea?
A
35 days or more
poly is 20
6
Q
What time period qualifies as amenorrhea?
A
No menstrual period in over 6 months
7
Q
What is cryptomenorrhea and what is it AKA
A
unusually light menstrual flow or spotting only
“hypomenorrhea”
8
Q
What might contact bleeding suggest?
A
Cervical cancer
Postcoital, contact cervical
9
Q
What does a radical hysterectomy remove?
what about a subtotal hysterectomy?
A
- Uterus
- Cervix
- Pericervical tissue
- Upper vagina
subtotal = uterine corpus only (not cervix)
10
Q
what is removed during the following propcedures:
1. oophorectomy
2. Salpingectomy
3. salpingo-oophorectomy
A
- one or both ovaries
- one or both oviducts
- one or both ovaries and oviducts
11
Q
What is a BSO?
A
Bilateral salpingo-oophorectomy
Removal of ovaries and tubes
12
Q
TAH and TVH
A
- TAH: total abdominal hysterectomy
- TVH: total vaginal hysterectomy
13
Q
what is the timing of preterm infants vs abortion considered
A
preterm - 20-36 wks
abortion - <20 wks
14
Q
what is the difference between a spontaneous, therapeutic and elective abortion
A
- spontaneous - due to natural causes
- therapeutic - induced for medical reasons
- elective - induced for non-medical reasons
15
Q
what is stillborn
A
birth of an infant who has died in the womb typically after 20 weeks gestation:(
16
Q
what is:
grand multigravida
grand multipara
great grand multipara
A
- grand multigravida: a woman who has been pregnant 5+ times
- grand multipara - a woman who has delivered 5+ infants 24+ weeks gestation
- great grand muulti para - same but 7+ infants delivered
17
Q
When does the first reproductive health visit tend to occur?
A
13-15
start of puberty?
18
Q
What occurs at the first reproductive health visit?
A
- Health info
- If symptomatic: pelvic or STD screen may be needed
19
Q
When do we start pap smears and pelvic exams?
A
- Pap smears: 21 unless symptomatic, even if active
- Pelvic exams: 21, but depends on s/s and hx.
20
Q
do you need a pelvic exam prior to starting birth control
A
NO
21
Q
How often are pap smears?
A
Every 3-5 yrs
Usually start at age 21.
22
Q
When are CBE indicated?
A
- controversial
- if done, do every 1-3 yrs for 20-39 y/o
- yearly CBE and mammogram for 40+ y/o
- does NOT replace mammogram
no longer routinely recommended if no s/s
23
Q
Ideal setup for a well woman exam
A
- Cloth gowns
- Calming + aesthetic environment
- One breast at a time (cover the other)
- Allow companion if no issues
24
Q
Although SBE is no longer recommended, what should a woman keep in mind if she still intends to examine her breasts?
A
- Visual exam for changes/dimpling
- Palpate all quadrants
- Examine same time every month
25
What test needs to be done prior to the bimanual exam?
Pap smear
26
PANCE-wise, what do you lubricate the speculum with?
Warm water
27
Describe a traditional pap smear
1. Cervical scraping around external os via SPATULA
2. BRUSH in endocervical canal. 360deg rotation. apply on same slide as step one.
| brOOm Outside, brush inside
## Footnote
for newer method: use ThinPrep test
28
What structures are palpated during a bimanual exam? what are normal findings?
* Cervix - 3/4 cm in diameter and moderately firm/mobile w/o discomfort
* Uterus - half size of pts fist. smooth, regular outline, nontender, mobile.
* Adnexa: fallopian tubes and ovaries - usually only palpable in sim women. not in overwieght/postmenopausal women!
29
describe a rectovaginal examination
| which finger goes where, what are you palpating?
* insert well-lubricated middle finger of examining hand into rectum.
* insert index finger of examining hand into vagina
* raise cervix towards anterior abdominal wall and palpate uterosacral ligaments
30
According to ACS guidelines, when are comprehensive skin exams indicated?
* For 20-40, Q3y
* For 40+, Q1y
| encourage UV ray SPF 30 or higher
31
Pap smear frequencies
1. 21-29: **every 3 years**
2. 30-65: **every 3 years** OR HPV +/- pap every 5
3. **65+: can stop** if no hx of dysplasia/cx + 3 negative paps or 2 negative paps/HPVs in past 10y
4. **Guidelines do not apply to cervical cx, HIV+, immuno, or DES exposure**
32
What STDs should all pregnant women be screened for regardless of risky behavior?
1. Hep B
2. HIV
3. Syphilis
| HHS
33
What age should pregnant women be screened for gonorrhea/chlamydia?
< 25y
| or anyone w high risk sexual behavior. also Hep c if high risk.
34
For non-pregnant women, what are the STD screenings?
* **HIV once if low risk**
* Gonorrhea/Chlamydia annually if < 25
* If high risk: HIV/syph/trich/hepB/C/Gonorrhea/Chlamydia/(+/- HSV)
35
what is considered high risk sexual behavior
non-intuitive ones (in my head at least):
* young age
* African american race
* unmarried
* living in low Socioeconomic area
* new partner in last 60 days
Intuitive ones (in my head):
* illicit drug use
* admission to correctional facility
* multiple sexual partners
* hx of prior STI
* contact w sex workers
* meeting partners on internet.
36
Generally, when do you start mammograms?
* ACS/ACOG/ACR: annually at 40-45 (can change to biennial esp at age 55)
* USPSTF/WHO/ACP/AAFP: Biennial starting at 50
| USPSTF -"insufficient evidence to continue past age 74"
## Footnote
many providers do it as long as woman is in good health and expects to live 10+ more years
37
When do you stop mammograms?
* **Life expectancy < 10y** and in poor health
* **After age 74 on average**
38
Generally, when do you start colonoscopy screening?
45
| USPSTF - no screening after 75
39
When is DEXA scan recommended?
* **women 65+**
* woman < 65 but you have the fx risk of a 65+ white female with no other RFs
* **No recommendations for men**
| You do it about every 2 years, no set frequency
40
What does a 65y white woman with no other RFs have for their osteoporotic risk?
**9.3% 10 year risk**
| FRAX?
41
How are pap smears graded?
Bethesda system
42
What are the two types of atypical squamous cells in the besthesda system?
* ASC-US (undetermined significance)
* ASC-H (cannot exclude high-grade lesion)
43
What does LGSIL/LSIL (low-grade squamous intraepithelial lesion) correspond to? (CIN ranking)
CIN-I
| CIN = cervical dysplasia (gogle says Cervical intraepithelial neoplasia)
## Footnote
CIN 1 = lower 1/3 of epithelial lining of cervix
CIN 2 = lower 2/3^^
CIN 3 = over 2/3 ^^
44
What does high-grade squamous intraepithelial lesion (HGLSIL/HSIL) correspond to? (CIN ranking)
CIN-II or CIN-III
45
What are atypical grandular cells/AGC associated with?
**Adenocarcinoma of the endocervix or endometrium**
46
Describe CIN 1/2/3
1. CIN-I = disordered growth of lower 1/3
2. CIN-II = disordered growth of lower 2/3
3. CIN-III = disordered growth of over 2/3; considered full thickness
47
When do you always treat CIN?
CIN-2/3 always treated **unless pregnant or CIN 2 in adolescents.**
## Footnote
adolescent = high chance of spontaneous regression and lower risk of cancer
48
Top 2 highest risk HPV strains
1. HPV **16**: 50-70% of all cervical cancers
2. HPV-**18**: 7-20% of all cervical cancers
| HPV is in 80% of all CIN lesions + 99.7% of all invasive cervical cx.
## Footnote
BUT most HPV + women do not develop CIN or cervical cancer
48
What is the major estrogen prior to menopause? After?
* **Estradiol/E2** is the major secretory product of the ovaries, and is far more MC than estrone/E1
* **After menopause: estrone/E1 is MC** as long as you're not on hormone replacement.
| EstrONE = 1st, estraDIol = 2
49
What secondary risk factor tends to synergistically **increase risk of cervical cancer?**
HPV with **SMOKING**
49
What is the major estrogen during pregnancy?
Estriol/E3
| prEgnancy
50
Tx for ASC-US
* **Repeat cytology q6m until 2 normal.**
* Test for high-risk HPV (16/18)
* Colposcopy
| Any option viable. **Colposcopy if top 2 are abnormal.**
## Footnote
Make sure to tx hormones and infections prior to repeating smears.
50
When are estrone levels ordered?
* Monitoring antiestrogen therapy
* Adjunct assessment in fx risk
* Disorders of sex steroid metabolism
* Delayed/precocious puberty
| typically only doninant in menopause
51
Next step in management for LSIL/HSIL/ASC-H/AGC
Colposcopy
51
When is estriol ordered?
* Quad screen in 2nd trimester
* Screening for fetal pathologies
* Marker for fetal demise
* Assess preterm labor risk
| primary estrogen in pregnancy
52
When is estradiol ordered?
* Monitoring antiestrogen therapy
* Disorders of sex steroid metabolism
* Evalulating ovarian function
* Monitoring HRT
* **Elevated in hepatic cirrhosis or hyperthyroidism**
| primary estrogen prior to menopause
52
what is a colposcopy
illuminated low-power magnification to inspect cervix, vagina, vulva, and anal epithelium
53
What is done in colposcopy?
* **Biopsies**
* **Endocervical samples** via curette or brushing
| Addition of **acetic acid** makes lesions turn white
## Footnote
no endocervical sampling done if pt is preggo
53
Where can progesterone be secreted by?
* Corpus luteum (post ovulation)
* Adrenal glands (conversion to other steroids, **no contribution unless tumor**)
* Placenta (primary by end of 1st trimester)
54
Indications for colposcopy (5)
1. Abnormal cervical cytology/HPV testing
2. Clinically abnormal cervix
3. Unexplained metrorrhagia or contact bleeding
4. Vulvar/vaginal neoplasia
5. History of in utero DES exposure
54
What can interfere with progesterone readings? (2)
* Adrenal tumors
* Biotin > 5mg/dl
55
Management of CIN-1 after colposcopy
* 2 pap Q 6 months OR pap + HPV test at 6mo.
* if cytology abnormal or HPV + then repeat colposcopy.
* if 2 cytology smears normal and/or HPV neg then routine screening resumes
| monitor because HIGH chance of spontaneous REGRESSION
55
When are FSH/LH low?
* Pituitary failure
* Hypothalamic failure
* **Pregnancy**
* Anorexia/malnutrition
* OCPs
56
Management of CIN 2/3 & invasive cx or abnormal findings after colposcopy
Surgery
56
When are FSH/LH high?
* **Menopause**
* Castration
* **Precocious puberty** (age-adjusted)
| FSH/LH are high when estrogen and progesterone are low.
57
Summary of pap smear/biopsy results and followup
Currettage for AGC and HSIL
57
Main inihibitor of prolactin
Dopamine
58
What drug classes can boost prolactin?
* Antipsychotics
* Antiemetics
* Antidepressants
* THC
* Ergots
* Opiates
* Methyldopa
* Verapamil
| Meds tend to cause a 2-4x ULN rise.
## FOOTNOTE
Mainly psych meds
59
S/S of hyperprolactinemia
* Men: impotence
* Women: oligomenorrhea/amenorrhea
* MSK: decreased muscle mass and osteoporosis
60
Pap smear result and treatment chart for abnormal findings/abbreviations
