Women

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Womens Health Part 2

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Infertility

• Definition Unprotected sexual intercourse for 1
  year without conception.
• 1 year length relates to rate of fertile couples
  50 in 3 months, 75 in 9 months 90
  in 1 year will get pregnant

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Infertility cont.

• Causes Inadequate sperm, lack of ovulation,
  tubal damage, uterine pathology, cervical
  abnormalities,vaginal factors, luteal phase
  defect, recurrent fetal loss.
• 10-20 are unknown causes
• Contributing factors Aging, reduced frequency
  of intercourse, timing, use of lubricants/spermici
  dal, douching, exposures to environmental,
  occupational hazards, excessive weight loss,
  stress

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Diagnostic Tests

• Males Medical history and physical, sperm
  counts, evaluation of fluids.
• Females Medical history and physical, serum
  pregnancy test, pap smear, pelvic exam,
  vaginal/cervical cultures for any infections,
  cycle day 3 FSH/LH/TSH labs, Hysterosalpingogram,
  Hysteroscopy, Laparoscopic surgery

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Treatment

• Treatment depends upon cause!
• 3 month trial in office
• Provera Challenge
• Check for UPT
• Provera x 10 days to produce menses
• CD 1 or 3-7 or 5-7 take Clomid 50-100mg 1 po x 5
  days
• CD 10,12, 14, 16 have intercourse
• CD 32-35 will have menses if not check UPT
• If menses repeat cycle 2 more times, then refer
  to fertility specialist

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Breast Health/BSE

• Regular self-exams will help you come familiar
  with what is normal for your breasts.
• You will be able to recognizes changes promptly
  and bring it to the attention of your health care
  provider.
• Monthly Self-Breast Exams will ease your mind and
  is good breast health.
• Regular clinical exams and mammograms are also
  recommended

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When to do the Self-Breast Examination

• Establish a regular time each month to do your
  exam.
• If you are still menstruating, a few days after
  your period when your breasts are not sore,
  around the 4th day.
• Women who no longer menstruate, should pick the
  same time every month to do the exam

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Nonmodifiable Risk Factors for Br.Ca

• Female Gender
• Advanced Age
• (Race/Ethnicity) Older white women have slightly
  greater incidence
• Personal history/family history of breast cancer
• Menarche before age of 12
• Menopause after age 55

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Modifiable Risk Factors

• Excessive Alcohol (2-5 drinks daily)
• Cigarette Smoking
• Nulliparity
• First born after age 30
• No breast-feeding
• Oral Contraceptive use
• Prolonged PMP HRT
• Obesity
• Sedentary lifestyle

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Non Risk Factors

• Deodorant Use
• Under wire Bras
• Spontaneous or Induced Abortions
• Breast Implants
• Oral Contraceptives use is a minimal risk and
  temporary with risk returning to baseline 10
  years after discontinuing use.

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Abnormal Findings

• Dimpling, puckering, irritation, discoloration or
  bulging of the skin.
• A change in a nipple, discharge, pain, or an
  inverted nipple.
• Redness, soreness, rash or swelling.
• Unusual lumps or thickening of the breast tissue

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Diagnostic Imaging Options

• Mammography
• Detects calcifications, densities, and
  architectural distortions.
• Lower sensitivity in younger woman
• Inability to differentiate between solid and
  cystic masses.

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Diagnostic Imaging Options

• Ultrasound
• Differentiating between solid and cystic masses
• Inability to identify calcifications
• MRI
• Identifying tissue with increased blood supply
  (tumor)
• Expensive, limited specificity, false-positive
  results

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Breast Screening RecommendationsACOG, ACS

• Self-Breast Exams
• Monthly beginning at age 20
• Clinical Breast Exams
• Every 3 years age 20-40
• Yearly after age 40 or 35 at risk
• Mammography
• Every 1-2 years older than 39, higher risk,
  start earlier

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Breast Health Recommendations

• Minimize caffeine intake
• Regular exercise, at least 2 hours a week
• Supportive bra during strenuous exercise
• Low Fat Diet
• Manage Stress
• Mammogram starting at age 40 every 1-2 years

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Breast Cancer

• Less than 20 of breast lumps are malignant or
  need treatment.
• Upper outer quadrant (Axillary Tail of Spence)
  has about 50 of cancers
• Early detection and treatment remains the best
  for improving both quality of life and survival

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Breast Cancer Statistics

• Age risk for breast cancer
• From birth to age 39 1 out of 231 (lt0.5)
• Age 40-59 1 in 25 (4 risk)
• Age 60-70 1 in 15 (7 risk)
• Age 80 and above 1 in 7 (14.3 risk)

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Treatment

• Local
• Surgeryradical modified radical/simple
• Mastectomy
• Lumpectomy
• Radiation Therapy

• Systemic
• Chemotherapy
• Hormonal therapy
• Combo of above
• Bone marrow transplant

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Care of Post-op Mastectomy

• Position patient in semi-fowlers with arm
  elevated
• Wound care JP suction, check for bleeding,
  swelling, temperature
• Monitor circulation of arm
• AVOID BPs on affected side
• TCDB/pain management/comfort care

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Care of Post-op Mastectomy

• Patient Teaching
• Encourages arm exercises
• Emotional Support (groups)
• Reconstruction options
• Avoid constrictive clothing
• No BPs or injections on affected side
• Report symptoms of edema, redness, breakdown of
  scar tissue, mass/lump in other breast

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Cancer Risks

• Cervical
• Uterine
• Ovarian

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Cancer Risks

• Cervical
• HPV types 16,18
• Multiple pregnancies
• Early age of sexual intercourse
• Obesity with diet low in veggies/fruits
• Low socioeconomic
• History of STDs/multiple partners

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Cancers cont.

• Preventable
• Gardasil Vaccine
• Currently for ages 9-26
• 3 dose intervals Now, 2 months, 4 months

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Cancer Risks cont.

• Uterine
• African American ethnicity
• Obesity
• Never been pregnant
• Middle age to elderly (gt55 yrs.old)
• Diabetes
• Breast,Colon,Ovarian cancer
• ERT

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Cancer Risks cont.

• Ovarian
• Start menses before age 12
• Late Menopause (older than 55 yr)
• Infertility/Infertility drugs
• No children/1st after age 30
• Family history of cancer
• Personal history of breast cancer

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Cancer Risks

• Health Maintenance
• Annual check-ups
• Get concerns looked at ASAP
• DUB/Abd. bloating/Masses/lumps
• Treatment may be medication or surgery

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Urinary Incontinence

• Stress Incontinence Sudden loss of urine from
  intra-abdominal pressure without detrusor muscle
  contraction (sneezing, coughing, laughing)
• Urge Incontinence Loss of urine with strong
  desire to void as bladder contracts, result of
  detrusor instability. Strain to empty bladder,
  but emptying is incomplete

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Urinary Incontinence

• Mixed Incontinence Symptoms of both stress and
  urge incontinence with one being more bothersome.
• Overflow Incontinence Involuntary loss of urine
  associated with over-distention of the bladder
  from and underactive or contractile detrusor or
  outlet obstruction. In men results from benign
  prostatic hyperasia

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Urinary Incontinence cont.

• Treatment
• Kegels exercises
• Biofeedback
• Pelvic stimulation
• Urodynamics for further evaluation.
• Prolapsed Pessary or surgery
• Consult

• Medications
• Estrogen Vaginal creams
• Anticholinergics
• Surgery
• Bladder Neck Sling
• (TVT)

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Benign Disorders

• Fibroids consisting of muscle tissue that grows
  in or on the wall of the uterus
• Polyp Single or multiple fingers of soft
  uterine tissue that dangle from the uterine wall
• Adhesions Areas of scar tissue
• Cysts Fluid-filled sac
• Can cause dysfunctional uterine bleeding
• Do pelvic ultrasound
• Decide how to treat (surgery or not?)

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Pelvic Organ Prolapse

• Cystocele bladder drops into vagina
• Rectocele Rectum bulges into vagina
• Enterocele Small Intestine bulges into vag.
• Uterine Prolapse Uterine drops into vagina
• Vaginal Vault Prolapse Uterus removed, walls of
  vaginal fall into themselves

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Nonsurgical Treatment

• Help ease the symptoms of the prolapse if it is
  mild
• Wearing a Pessary to help support the organ
• Doing Kegal exercises to strengthen the pelvic
  floor muscles
• Kegel Contract your pelvic floor muscle as if to
  stop the urine stream. 10 times a couple times a
  day

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Surgical Intervention

• Cystocele Anterior Repair (sutures)
• Rectocele/Enterocele Posterior repair (sutures)
• Uterine Prolapse Hysterectomy
• Vaginal Vault Prolapse Suspension

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Post-op Care

• Monitor Fluids, Vitals, Dressing check
• TCDB Q2 hrs.
• Foley Check color and record drainage
• Pain management
• Prevent DVTs TEDS, leg exercises q 1 hr., early
  ambulation

• Emotional support
• Discharge teaching
• No heavy lifting, nothing in vaginal for 6 weeks,
  driving for 2-3 weeks, check s/s for infection
• F/U in Office

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Hormones

• Estrogen Secreted by the ovaries
• Protects against heart disease, stroke,
  osteoporosis, dementia, and memory disorders.
• Improves thickness and elasticity of skin,
  vaginal and bladder walls
• Improves brain function, body balance and
  coordination

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Hormones cont.

• Progesterone secreted by ovaries
• Progesterone prepares the uterus for pregnancy.
• Protects against uterine, breast cancers,
  osteoporosis, fibrocystic breast disease and
  ovarian cysts

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Hormones cont.

• Testosterone secreted by testes, ovaries, and
  adrenal gland.
• Affects energy levels, muscle mass, strength,
  endurance, fat development, exercise tolerance
  and mood.
• Protects against heart attacks, strokes, HTN,
  obesity, and arthritis

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Hormones cont.

• Thyroid secreted by thyroid gland
• Regulates blood circulation, body temperature,
  metabolism and brain function
• Protects against heart attacks and strokes,
  improves brain metabolism. Helps prevent memory
  problems

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Perimenopause

• H/A
• Changes in Menstrual cycle
• Urinary Problems
• Decreased Libido

• Symptoms can last as long as 7-10 years
• Hot Flashes
• Night Sweats
• Vaginal Dryness
• Mood Swings
• Forgetfulness

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Perimenopausal What to do?

• Help with Symptoms
• Soy-rich diet
• Hormonal therapy ERT/HRT
• Dress layers
• Vaginal creams
• Vitamin D and Calcium
• Diet and exercise (Kegels)
• FSH Levels gt then 8 into 40 range

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Drug Therapy

• Most common symptoms treated are Hot flashes,
  Night Sweats, and Vaginal Dryness

• Oral Contraceptives
• HRT
• ERT with no uterus

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Low Dose Oral Contraceptives

• Estrogen and Progestin
• Help with regulate periods, improve sleep and
  mood swings
• Will continue to have uterine bleeding even after
  menopause which can make it difficult to
  determine whether menopause is reached.

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ERT/HRT

• Pros
• Effectively manages symptoms
• Protect against Osteoporosis
• May reduce risk of colon cancer

• Cons
• Does not protect against heart disease
• Slightly increases the risk of heart attack,
  strokes, blood clot, and slight increase in
  breast cancer

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HRT

• Alleviates hot flashes, night sweats, and vaginal
  dryness symptoms
• Prevents bone loss
• Improves cholesterol levels
• Good candidate if you do not have a history of or
  high risk factors for breast cancer, bloods
  clots, stroke, or heart disease

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HRT

• Cyclic HT Estrogen for 25 days, add Progesterone
  on last 10-14 days, then 3-6 days of no therapy
• Continuous-cyclic HT Estrogen every day,
  Progesterone on last 10-14 days,
• Continuous-combined Estrogen and Progesterone
  every day
• Intermittent-combined Estrogen every day,
  Progesterone add three days on, three days off

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HRT

• Combined Estrogen/Progesterone
• Oral (Premphase/Prempro)
• Transdermal (Climara Pro) Twice weekly
• Progestogen Only
• Oral (Provera, Prometrium)

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ERT

• Estrogen only without a uterus.
• Oral Pills (Premarin)
• Transdermal Patches (Climera) Once weekly
• Vaginal Creams (Estrace)

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Menopause

• Cessation of menses over a 12 month period
• Considered a transition of biological and
  cultural event.
• Natural or Surgical
• Menstrual periods stop occurring because the
  ovaries no longer produce the hormones
  progesterone and estrogen. (90 of bodies total
  production)
• Median age is 51

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Menopause

• It frees women from periods
• No pregnancy/contraceptive concerns
• Fewer child care responsibilities
• Increased opportunities to pursue other goals
• More leisure time/community involvement
• Some have few to no symptoms

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Menopause cont.

• Drug Therapy ERT/HRT
• Once after menopause, not normal to have any
  vaginal bleeding
• If occurs then recommend endometrial biopsies
  (done in office)
• Period of rapid bone loss (3-5 years) Dexa Bone
  Scan, Calcium/Vitamin D/ wt. bearing exercise

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Heart Disease

• Cardiovascular Disease is the leading cause of
  mortality in women. Natural and surgical
  menopause is associated with changes in lipid
  profiles (decrease in HDL, and increase in
  LDLs). These changes may be factors in the
  women's increased risk of postmenopausal heart
  disease

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Heart Disease cont.

• S/S of CHD Unique to women
• Unspecific pain and vague symptoms
• Chest, arm, neck, and back pain
• Risk Factors Diabetes, Smokers, HTN, Family
  history, High LDL, Low HDL, gt55 years old,
  Obesity, large waist to hip ratio

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Prevention

• Lifestyle Changes
• Exercise 30-60 minutes most days of the week
• Lose Weight if overweight
• Control your Blood sugar
• Stop smoking
• Decrease alcohol intake

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Prevention

• Eat a healthy diet
• Increase soluble fiber
• Limit Cholesterol
• Limit total fat
• Limit saturated and trans fat
• Get fasting lipid panel done about q5 years
• Colonoscopy by age 50