Transcript Women`s Health 2016x

NURS 870 - 2016
Objectives: Class participants will be able to
address, diagnose and treat the common
following concerns in primary care:
1.
2.
3.
4.
5.
6.
Breast & Cervical CA screening
Breast concerns
Pelvic pain & PID
Vaginitis
STD Screening – Taking a Sexual History
Contraception
American Cancer Society
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Women ages 40 to 44 should have the choice to start annual breast
cancer screening with mammograms (x-rays of the breast) if they wish to
do so.
Women age 45 to 54 should get mammograms every year.
Women 55 and older should switch to mammograms every 2 years, or
can continue yearly screening.
Screening should continue as long as a woman is in good health and is
expected to live 10 more years or longer.
All women should be familiar with the known benefits, limitations, and
potential harms linked to breast cancer screening. They also should know
how their breasts normally look and feel and report any breast changes
to a health care provider right away.
Some women – because of their family history, a genetic tendency, or
certain other factors – should be screened with MRIs along with
mammograms. (The number of women who fall into this category is very
small.) Talk with a health care provider about your risk for breast cancer
and the best screening plan for you.
Title
Screening for Breast Cancer Using Film Mammography - USPSTF
Population
Women aged 40-49 years
Women aged Women aged
50-74 years ≥75 years
Recommendation
Individualize decision to begin biennial screening according to the patient's circumstances and values.
Grade: C
Screen every 2
years.
Grade: B
Risk Assessment
This recommendation applies to women aged ≥40 years who are not at increased risk
by virtue of a known genetic mutation or history of chest radiation. Increasing age is
the most important risk factor for most women.
Screening Tests
Standardization of film mammography has led to improved quality. Refer patients to
facilities certified under the Mammography Quality Standards Act (MQSA), listed
athttp://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMQSA/mqsa.cfm.
No
recommendation.
Grade: I
(Insufficient
Evidence)
Timing of Screening Evidence indicates that biennial screening is optimal. A biennial schedule preserves
most of the benefit of annual screening and cuts the harms nearly in half. A longer
interval may reduce the benefit.
Benefits of Benefits
and Harms
There is convincing evidence that screening with film mammography reduces breast
cancer mortality, with a greater absolute reduction for women aged 50 to 74 years
than for younger women.Harms of screening include psychological harms, additional
medical visits, imaging, and biopsies in women without cancer, inconvenience due to
false-positive screening results, harms of unnecessary treatment, and radiation
exposure. Harms seem moderate for each age group.
False-positive results are a greater concern for younger women; treatment of cancer
that would not become clinically apparent during a woman's life (overdiagnosis) is an
increasing problem as women age.
Rationale for No
Recommendation
(I Statement)
Other Relevant
USPSTF
Recommendations
Among
women 75
years or
older,
evidence of
benefit is
lacking
The USPSTF has made recommendations on mammography screening for breast
cancer, screening for ovarian cancer, and chemoprevention of breast cancer. These
recommendations can be found at www.uspreventiveservicestaskforce.org.
American Cancer Society
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Cervical cancer testing should start at age 21. Women under age 21 should not be
tested.
Women between the ages of 21 and 29 should have a Pap test done every 3 years.
HPV testing should not be used in this age group unless it’s needed after an
abnormal Pap test result.
Women between the ages of 30 and 65 should have a Pap test plus an HPV test
(called “co-testing”) done every 5 years. This is the preferred approach, but it’s OK
to have a Pap test alone every 3 years.
Women over age 65 who have had regular cervical cancer testing in the past 10
years with normal results should not be tested for cervical cancer. Once testing is
stopped, it should not be started again. Women with a history of a serious cervical
pre-cancer should continue to be tested for at least 20 years after that diagnosis,
even if testing goes past age 65.
A woman who has had her uterus and cervix removed (a total hysterectomy) for
reasons not related to cervical cancer and who has no history of cervical cancer or
serious pre-cancer should not be tested.
All women who have been vaccinated against HPV should still follow the screening
recommendations for their age groups.
Some women – because of their health history (HIV infection, organ transplant, DES
exposure, etc.) – may need a different screening schedule for cervical cancer. Talk
to a health care provider about your history.
Title
Screening for Cervical Cancer - USPSTF
Population
Women ages 21
to 65
Recommendation
Screen with cytology
(Pap smear) every 3
years.
Grade: A
Risk Assessment
Human papillomavirus (HPV) infection is associated with nearly all cases of cervical cancer. Other factors that put a woman at
increased risk of cervical cancer include HIV infection, a compromised immune system, in utero exposure to diethylstilbestrol, and
previous treatment of a high-grade precancerous lesion or cervical cancer.
Screening Tests
Screening women ages 21 to 65 years every 3 years with cytology provides a reasonable balance between benefits and harms.Screening
with cytology more often than every 3 years confers little additional benefit, with large increases in harms.
HPV testing combined with cytology (co-testing) every 5 years in women ages 30 to 65 years offers a comparable balance of benefits
and harms, and is therefore a reasonable alternative for women in this age group who would prefer to extend the screening interval.
Timing of Screening
Screening earlier than age 21 years, regardless of sexual history, leads to more harms than benefits. Clinicians and patients should base
the decision to end screening on whether the patient meets the criteria for adequate prior testing and appropriate follow-up, per
established guidelines.
Interventions
Screening aims to identify high-grade precancerous cervical lesions to prevent development of cervical cancer and early-stage
asymptomatic invasive cervical cancer.High-grade lesions may be treated with ablative and excisional therapies, including cryotherapy,
laser ablation, loop excision, and cold knife conization.
Early-stage cervical cancer may be treated with surgery (hysterectomy) or chemoradiation.
Benefits of Benefits and
Harms
The benefits of
screening with
cytology every 3 years
substantially outweigh
the harms.
Other Relevant USPSTF
Recommendations
The USPSTF has made recommendations on screening for breast cancer and ovarian cancer, as
well as genetic risk assessment and BRCA mutation testing for breast and ovarian cancer
susceptibility. These recommendations are available
athttp://www.uspreventiveservicestaskforce.org/.
Women ages
30 to 65
Women younger than
age 21
Women older than age 65
who have had adequate prior
screening and are not high
risk
Screen with cytology Do not screen.
every 3 years or coGrade: D
testing (cytology/HPV
testing) every 5 years.
Grade: A
The benefits of
screening with cotesting (cytology/HPV
testing) every 5 years
outweigh the harms.
The harms of
screening earlier than
age 21 years outweigh
the benefits.
Do not screen.
Grade: D
The benefits of
screening after age 65
years do not outweigh
the potential harms.
Women after
Women younger
hysterectomy with
than age 30
removal of the cervix
and with no history of
high-grade precancer
or cervical cancer
Do not screen.
Grade: D
The harms of
screening after
hysterectomy
outweigh the benefits.
Do not screen
with HPV testing
(alone or with
cytology)
Grade: D
The potential
harms of
screening with
HPV testing
(alone or with
cytology)
outweigh the
potential
benefits.
Epidemiology
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16% of women have breast problems over a 10
year period
Most breast symptoms are benign, but breast
CA is the most commonly diagnosed CA and a
leading cause of CA-related death in US women
Breast masses, nipple discharge or
inflammatory skin changes require immediate
evaluation
Breast masses are a common complaint;
require detailed history to determine odds of
malignancy
Risk Factors for Breast CA
Demographics
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Advanced age
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Overweight or obesity (particularly in postmenopausal women)
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White race or Ashkenazi Jewish descent
Medical history
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BRCA1 or BRCA2 mutation
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First-degree relative with breast or ovarian cancer
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History of atypical hyperplasia or lobular carcinoma in situ
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One prior breast biopsy (regardless of results)
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Personal history of breast or ovarian cancer
Medications and diet
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Alcohol consumption (more than one drink per day)
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Current or prior use of hormone therapy or oral contraceptives
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Reproductive history
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Menarche before 12 years of age
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Menopause after 55 years of age
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Nulliparity or age older than 35 years at first delivery
Other
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High breast density on mammography
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Prior thoracic radiation exposure
Characteristics of Masses
Benign Mass:
Discrete margins with NO skin changes
 Smooth, soft to firm, mobile
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Dominant Mass (concerning for CA):
three-dimensional lesion distinct from surrounding
tissues
 Asymmetric relative to the other breast
 Hard, immobile, fixed to surrounding tissue
 Poorly defined margins
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American College of Radiology
classification of findings on mammogram
Epidemiology
Mastalgia accounts for up to 66% of visits
 Mastalgia has NOT been shown to be a risk factor for
breast CA
 Asses the quality, duration, location and radiation of
pain
 Assess aggravating activities
Cyclic Pain: related to menstrual cycle, bilateral, diffuse,
radiates to axillae, most commonly during luteal phase
prior to menses (increased hormones, increased water
content)
Noncyclic Pain: not related to menstrual cycle, and may
be unilateral or focal
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Epidemiology
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Benign in 97% of cases
Ask about characteristics: color, number of ducts
involved, if it is associated with amass, and if unilateral
or bilateral
Pathologic: discharge that is unilateral, bloody, serous,
clear, or associated with a mass. Most common sources of
pathologic d/c: intraductal papilloma, duct ectasia,
carcinoma, infection.
Physiologic: discharge that is bilateral, involves multiple
ducts, is associated with nipple stimulation or breast
compression
Medications that may cause nipple discharge:
Antihypertensive agents
 Methyldopa, reserpine, verapamil
Gastrointestinal agents
 Cimetidine (Tagamet), metoclopramide (Reglan)
Hormones
 Estrogen, oral contraceptives
Opiates
 Codeine, heroin, methadone, morphine
Psychotropic agents
 Antipsychotics, monoamine oxidase inhibitors,
neuroleptics, selective serotonin reuptake inhibitors,
tricyclic antidepressants
Epidemiology
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Symptoms often non-specific; a diagnostic challenge
Differential:
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UTI, pyelonephritis, kidney stone, mittleschmerz,
endometriosis, ovarian cyst, uterine fibroid, diverticulitis,
Urgent considerations:
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Ectopic pregnancy
Ruptured ovarian cyst
Ovarian torsion
Appendicitis
Pelvic inflammatory disease (PID)
Recommended Parenteral Regimen A
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Cefotetan 2 g IV every 12 hours
OR
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Cefoxitin 2 g IV every 6 hours
PLUS
Doxycycline 100 mg orally or IV every 12 hours
Recommended Parenteral Regimen B
•
Clindamycin 900 mg IV every 8 hours
PLUS
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Gentamicin loading dose IV or IM (2 mg/kg of body
weight), followed by a maintenance dose (1.5 mg/kg)
every 8 hours. Single daily dosing (3–5 mg/kg) can be
substituted.
Outpatient Rx for Mild-Moderate Disease
Ceftriaxone 250 mg IM in a single dose
PLUS
Doxycycline 100 mg orally twice a day for 14 days
WITH or WITHOUT
Metronidazole 500 mg orally twice a day for 14 days
OR
Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally
administered concurrently in a single dose
PLUS
Doxycycline 100 mg orally twice a day for 14 days
WITH or WITHOUT
Metronidazole 500 mg orally twice a day for 14 days
OR
Other parenteral third-generation cephalosporin (e.g.,
ceftizoxime or cefotaxime)
PLUS
Doxycycline 100 mg orally twice a day for 14 days
WITH or WITHOUT
Metronidazole 500 mg orally twice a day for 14 days
Epidemiology
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2.
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A spectrum of conditions that cause vaginal and/or
vulvar symptoms of itching, burning, irritation, odor and
vaginal discharge
One of the most common reasons women seek medical
advice
Most common infectious causes:
Bacterial Vaginosis
Vulvovaginal Candidiasis
Trichomoniasis
Epidemiology
In review of studies from 1966-2003 of symptomatic
women:
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BV diagnosed in 22-55%
Vulvovaginal candidiasis in 17-39%
Trichomoniasis in 4-35%
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30% remained undiagnosed after clinical evaluation
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Key Symptoms:
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A lack of itching makes candidiasis unlikely
A lack of perceived odor makes BV unlikely
Inflammatory signs more common with
candidiasis
Fishy odor on exam is predictive of BV
Bacterial Vaginosis
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Most prevalent cause of vaginal discharge or
malodor
Occurs in up to 30% OF WOMEN
When normal Lactobacillus species in the vagina
are replaced with anaerobic bacteria
More than 50% are asymptomatic
Odor more prevalent after IC when vaginal
alkalinity increases (also during menses)
Associated with late miscarriages, premature
rupture of membranes, and preterm birth
Also linked with increased risk for HIV infection
BV Diagnosis:
In clinical practice, bacterial vaginosis is diagnosed by
the presence of three out of four Amsel criteria :
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Thin, homogenous vaginal discharge
Vaginal pH greater than 4.5
Positive whiff test (fishy amine odor when 10
percent potassium hydroxide solution is added)
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At least 20 percent clue cells (vaginal epithelial cells
with borders obscured by adherent coccobacilli on wetmount preparation or Gram stain)
BV Diagnosis:
In clinical practice, bacterial vaginosis is diagnosed by
the presence of three out of four Amsel criteria :
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Thin, homogenous vaginal discharge
Vaginal pH greater than 4.5
Positive whiff test (fishy amine odor when 10
percent potassium hydroxide solution is added)
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At least 20 percent clue cells (vaginal epithelial cells
with borders obscured by adherent coccobacilli on wetmount preparation or Gram stain)
 Click
link below:
Best instructional vaginal microscopy video!
BV Treatment:
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A Cochrane review of 24 randomized controlled trials (RCTs) showed
that clindamycin and metronidazole (Flagyl) are equally effective,
achieving clinical cure in 91 and 92 percent of cases, respectively,
after two to three weeks of treatment.33
Six RCTs showed topical and oral antibiotic preparations to be equally
effective. One disadvantage of oral regimens is a longer duration of
treatment.33
Intravaginal clindamycin cream is preferred in case of allergy or
intolerance to metronidazole.
Metronidazole in a single 2-g dose has the lowest effectiveness for
treating bacterial vaginosis and is no longer recommended.
Metronidazole, 500 mg twice daily for one week, is effective for
treating bacterial vaginosis and trichomoniasis.
Although lactobacillus probiotics are safe, there is no conclusive
evidence that they are superior to or enhance the effectiveness of
antibiotics in the treatment of bacterial vaginosis or prevent its
recurrence.34 Treatment of sex partners and follow-up visits if
symptoms are resolved are not recommended.
Recurrent BV:
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Most relapses of bacterial vaginosis occur within the first year
and strongly correlate with new sex partners.
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Reported recurrence rates are 15 to 30 percent within three
months.
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One RCT on persistent bacterial vaginosis indicated that
metronidazole gel 0.75% (Metrogel), used twice weekly for six
months after initial treatment, effectively maintained a clinical
cure for six months.
Trichomoniais Diagnosis
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Symptoms and signs of trichomoniasis are not specific, and
diagnosis by microscopy is more reliable.
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Features suggestive of trichomoniasis are trichomonads seen with
saline, leukocytes more numerous than epithelial cells, positive
whiff test, and vaginal pH greater than 5.
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The wet-mount preparation is an inexpensive and quick test with
variable sensitivity of 58 to 82 percent,40 and is influenced by
the experience of the examiner and the number of parasites in
the vaginal fluid sample
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Click here to see motile trichomonads . Click here for close up!
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Adding examination of the spun urine specimen can increase the
detection rate of Trichomonas vaginalis from 73 to 85 percent.41
Trichomoniais Treatment
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A single 2-g dose of metronidazole is adequate but can cause
dyspepsia and metallic taste
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Metronidazole 500 mg BID for seven days will treat bacterial
vaginosis and Trichomoniasis and is better tolerated
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Metronidazole in a dosage of 2 to 4 g daily for seven to 14
days is recommended for metronidazole-resistant strains.
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The parasitologic cure rate of intravaginal nitroimidazole
creams is an unacceptably low 50 percent
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Sex partners should be treated simultaneously.
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To reduce recurrence, partners should avoid resuming sexual
intercourse until both have completed treatment and are
asymptomatic.
Vulvoginal Candidias Diagnosis:
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symptoms such as pruritus, vaginal soreness, dyspareunia,
and vaginal discharge are common, but not specific
Most patients can be diagnosed by microscopic
examination of vaginal secretions with a 10% potassium
hydroxide solution (sensitivity, 65 to 85 percent).
Vaginal pH is usually normal (4.0 to 4.5).
Vaginal culture should be considered in recurrently
symptomatic women with negative microscopy and a
normal pH.
Non-infectious Vaginitis
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Irritant contact dermatitis OR allergic contact dermatitis
May be associated with use of feminine hygiene products or
contraceptive materials, among many other causes
Atrophic vaginitis can manifest clinically with symptoms of vaginal
dryness, itching, discharge, irritation, and dyspareunia. It affects 10
to 40 percent of women who have conditions associated with
estrogen deficiency
Diagnosis is based on history and physical findings, supplemented
by vaginal pH levels, vaginal wet-mount preparation (to exclude
superimposed infection), and, rarely, culture or cytology.
Both systemic and topical estrogen treatments are effective in
relieving symptoms. Topical vaginal estrogen is preferred because
of the low systemic absorption and reduced risk of adverse
effects compared with oral therapy.
Estrogen-containing creams, pessaries, intravaginal tablets, and
the estradiol vaginal ring appear equally effective for the
symptoms of atrophic vaginitis
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A sexual history needs to be taken during a patient’s initial
visit, during routine preventive exams, and when you see
signs of sexually transmitted diseases (STDs).
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The dialogue lends itself to the opportunity for riskreduction counseling and sharing information about
behaviors that may place your patient at risk of contracting
STDs.
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A sexual history allows you to identify those individuals at
risk for STDs, including HIV, and to identify appropriate
anatomical sites for certain STD tests.
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Some patients may not be comfortable talking about their
sexual history, sex partners, or sexual practices.
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Try to put patients at ease and let them know that taking a
sexual history is an important part of a regular medical
exam or physical history.
Sample Dialogue:
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I am going to ask you a few questions about your sexual
health and sexual practices. I understand that these
questions are very personal, but they are important for
your overall health.
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Just so you know, I ask these questions to all of my adult
patients, regardless of age, gender, or marital status.
These questions are as important as the questions about
other areas of your physical and mental health. Like the
rest of our visits, this information is kept in strict
confidence. Do you have any questions before we get
started?
The five “P”s stand for:
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Partners
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Practices
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Protection from STDs
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Past history of STDs
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Prevention of pregnancy
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All adults and adolescents from ages 13 to 64 should be tested at least
once for HIV.
Annual chlamydia screening of all sexually active women younger than 25
years, as well as older women with risk factors such as new or multiple
sex partners, or a sex partner who has a sexually transmitted infection
Annual gonorrhea screening for all sexually active women younger than
25 years, as well as older women with risk factors such as new or
multiple sex partners, or a sex partner who has a sexually transmitted
infection.
Syphilis, HIV, chlamydia, and hepatitis B screening for all pregnant
women, and gonorrhea screening for at-risk pregnant women starting
early in pregnancy, with repeat testing as needed, to protect the health
of mothers and their infants.
Screening at least once a year for syphilis, chlamydia, and gonorrhea for
all sexually active gay, bisexual, and other men who have sex with men
(MSM). MSM who have multiple or anonymous partners should be screened
more frequently for STDs (i.e., at 3-to-6 month intervals).
Anyone who has unsafe sex or shares injection drug equipment should get
tested for HIV at least once a year. Sexually active gay and bisexual men
may benefit from more frequent testing (e.g., every 3 to 6 months).
 Blood
test for HIV/RPR
 Urine for GC/CT dna amplfication
 HSV
– must unroof and culture vesicle in viral
medium
 HPV – visual or PAP test (HPV DNA)
 CDC’s
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STD Treatment Guidelines
Last major publication was 2015
Updates in 2012 focused on gonorrhea resistance
to oral meds
Check this site frequently for updates
 http://www.cdc.gov/std/std-tx-app.htm
 Get
it!
 Includes:
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Diagnosis and treatment of 21 STDs and sexual assault.
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Access to the full STD Treatment Guidelines.
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"A Guide to Taking a Sexual History."
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http://www.hhs.gov/opa/pdfs/emergency-contraception-fact-sheet.pdf
There are two types of emergency contraception (EC):
1. Emergency contraceptive pills (ECPs)
a. Plan B One-Step, Next Choice One Dose, and My Way consist of one pill
that the instructions state must be taken with 3 days (72 hours).
b. Levonorgestrel Tablets consist of two pills. Although the instructions
state that the first one must be taken within 3 days (72 hours) and another must be
taken 12 hours later, both pills can be taken at the same time within four days (96
hours) after unprotected sex.
c. ella consists of one pill that must be taken within 5 days (120 hours).
Research has shown that the pills in a and b above are equally effective when taken
on the first-fourth days after unprotected sex and are ineffective thereafter. ella is
equally effective when on the first-fifth days.
2. Emergency insertion of a copper T intrauterine device (IUD) within 5 days (120
hours)
How effective are ECPs?
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Plan B One-Step, Next Choice One Dose, My Way and Levonorgestrel Tablets: 7
out of 8 women who would have gotten pregnant will not become pregnant after
taking these pills.
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ella: 6 or 7 out of every 100 women who would have gotten pregnant will not
become pregnant after taking ella.
What are the side effects of ECPs?
headache, nausea, abdominal pain, menstrual pain, tiredness, dizziness
Can I use ECPs if I am pregnant?
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Women who are pregnant or suspect they are pregnant should not use ECPs.
This is because they are ineffective; ECPs will not cause any adverse effects on
an existing pregnancy.
Emergency contraceptive pills prevent pregnancy and are different from
medications which cause abortions.
How does the copper T IUD work as emergency
contraception?
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The copper T IUD is a method of emergency contraception when it
is inserted within five days of unprotected intercourse.
The copper T IUD is a T-shaped device that is put into the uterus
by a health care provider.
It prevents sperm from reaching the egg, from fertilizing the egg,
and may prevent the egg from attaching in the uterus.
It does not stop the ovaries from making an egg each month. One
advantage is that it can remain in place for up to ten years as a
women’s regular contraception. After the IUD is taken out, you can
get pregnant.
Major disadvantage to Emergency
Contraception:
 No
protection from STDs.
 Concern patients may take more risks when
pregnancy less of a concern.