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U of C Well Woman 8063 Exam 1 Questions
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Normal Menstrual cycle physiolgy Menarche-avg age is 12-13 yrs---if no pubertal development by 13 or menses by 15--work up for pubertal delay Normal Cycle length First year: avg of 32 days (range of 20-60 days) Least variable between ages of 20-40 years--then it is 21- days with no more than 7 days variability Flow length First year: 2-7 days, ABNORMAL if less than 2 or greater than 8 days in length, flow amount 20-80 mL, 2nd day is heaviest, Crescendo-Decrescendo pattern is normal, greater than 3 days of light spotting before onset of heavy flow is abnormal--as well as prolonged light or brown at tail end of flow is abnormal What does the hypothalamus release? GnRH (gonadotropin releasing hormone) What does the anterior pituitary secrete? FSH and LH What does the Ovary secrete?
estrogen and progesterone Growing follicle secrete estrogen, with higher levels of estrogen this tells the anterior pituitary to release LH--this LH surge allows ovulation to occur--the Corpus Luteum now releases progesterone which thickens the endometrial lining, How does too much Cortisol effect ovulation? high stress states increase Cortisol--this causes a decrease in GnRH, LH, and FSH which leads to Anovulation How does Hyperprolactinemia effect ovulation? decreased GnRH, LH, and FSH--increased testosterone, decreased estrogen--shortens the luteal phase and amenorrhea How does Hyperthyroid effect ovulation? increased SHBG, total Testosterone and Estrogen are decreased, Loss of pre-ovulatory LH surge--irregular menses, anovulation, infertility How does Hypothyroid effect ovulation? decrease SHBG, increase Total Testosterone and Estrogen, increase in TRH, increase in TSH and PRL, increase dopamine, decrease GnRH, heavy breakthrough bleeding, spotting, infertility How does a Vit D deficiency effect ovulation? decreases Estrogen and Progesterone, increases LH and FSH and Testosterone--leads to ovulatory dysfunction
LH surge (then body temp rise) What is the main hormone of the luteal phase? progesterone Estradial (E2) Rise and fall, 24-36 hours before Ovulation LH (luteinizing hormone) Surges in blood prior to ovulation, tells ovary to release mature follicle--35 hours before ovulation (peak LH value is 10- hours before ovulation) Progesterone (P4) pre-ovulatory rise 24 hours before ovulation post ovulatory rise maintains the pregnancy (corpus luteum) Cervical Mucous Peak Day, +/- 3 days Endometrial phases of menstrual cycle -Menses (day 1-5), low E and P levels -Proliferative (days 6-13), endometrium thickens d/t increasing Estrogen levels -Secretory phase (days 14-28)--begins at ovulation, Progesterone is produced by the corpus luteum--endometrial lining gets thicker for a fertilized ovum to implant
Ovarian Cycle Phases Follicular-day 1 of menses to just before ovulation (about 14 days--this phase can vary in time) Ovulatory-High Estrogen levels and LH surge-then ovulation (if no LH surge, no ovulation) Luteal-Progesterone produced by corpus luteum, negative feedback to Hypothalamus and Ant Pituitary prevents further ovulation--this phase is constant in terms of number of days-- usually 14--depends on woman) What are some physiologic biomarkers of ovulation? Increased temp due to progesterone once ovulation occurs, Estrogen causes: thin, watery, slippery, egg white, cervical mucous--easy for sperm to swim through--last day of this type of cervical mucous in about 12 -24 hours after ovulation, mittleschmerz (sharp pain on either side where ovary is) What type of cervical mucous does progesterone produce? thick, not good for sperm to swim through, not fertile, forms a barrier What type of menstrual cycle would you expect with a woman with PCOS? Anovulatory with high constantly Estrogen levels Breast A and P
1 External inspection and palpation 2 Speculum 3 Bimanual 4 Rectal What are benefits associated with preconception counseling and care visits? Improved outcomes associated with early health screening, prevention and management of chronic illnesses 28 year old with 6 month old twin delivered at 34 weeks, miscarriage at 12 weeks 2 years ago: Record using GTPAL G2, T0, P1, A1, L2 Twins = 1 gravida You are reviewing med list during a preconception visit. Which med is safe to continue? Fluticasone HFA inhaler Name the parasitic infection transmitted by contact with contaminate food and animals? think cat litter Toxoplasmosis Folic Acid recommendation in woman with no added NTD risk? 0.4 to 1.0 mg of folic acid per day at least 2-3 months before conception and through pregnancy and lactation What tests should all women who have risk factors be tested for at first prenatal visit?
Chlamydia, Hep B, HIV, and Syphillis Criteria for satisfactory PAP smear: Done to see change in endocervical area, use endocervical spatula THEN the brush--stay in contact with the inner surface of the OS, liquid cytology--sample can be used to test for pap test, HPV, Gonorrhea, and Chlamydia testing Differentiate between subjective and objective data: Subjective: What patient tells provider Objective: Data and information provider collects upon exam Where do most injuries occur to a domestic abuse woman? chest, face, breast, abdomen Leading cancers for women that cause death: Lung--leading cancer that causes death, followed by breast cancer then colorectal cancer then cervical cancer, Skin cancer is most PREVALENT cancer among women, followed by breast cancer When does ACOG say to begin HPV/PAP testing? Age 21 and continue every 3 years until age 29, then between ages 30-59 done every 5 years with HPV DNA testing (if not DNA testing not available--PAP every 3 years between ages 30- 65), after age 65 stop if all prior PAPs normal or total hysterectomy
10-22 days Normal Luteal phase length? 11-17 days by urinary Estrogen 9-18 days by cervical mucous peak When is LH SURGE? 35 hours before ovulation When is LH PEAK? 10-14 hours before ovulation When to give TDap in pregnancy? 27-36 weeks to give passive immunity to baby What type of flu shot to give in pregnancy? Inactivated form (not live) Max of Vitamin A to give in pregnancy? 8000 IU/day--more can cause birth defects How much Folic Acid for High Risk mom (Hispanic, IDDM, Epileptic, BMI >35, Family History of NTD or personal history of prior NTD) 4.0 mg 2-3 months prior to conception until 12 weeks gestation then decrease to 0.4 mg per day Breast Development--
Ovaries: Estrogen: stimulates growth of glands and ducts Progesterone: stimulates growth of milk cells Anterior Pituitary: Prolactin: mammary gland development Growth Hormone: mammary gland development Posterior Pituitary: Oxytocin: milk ejection in relation to suckling First line use in HTN in pregnancy: Labetolol and Nifedipine (NO ACE/ARB) May use Methyldopa but not as effective Derm: in pregnancy--do NOT use: Accutane for acne OR Soriatane for severe psoriasis DM in pregnancy: NO Statins, A1C goal is 6.5 or less Epilepsy in pregnancy: No Depakote or Tegretol Heart disease or CHF in pregnancy: NO coumadin At higher risk of CV events **Watch if NYHA Class 2 or higher, also if EF less than 40% Hypothyroidism in pregnancy:
treatment for gonorrhea Ceftriaxone 500mg IM for one dose if less than 150kg If > 150kg: Ceftriaxone 1 G --one dose Give Doxy if Chlamydia not excluded Primary Syphilis symptom and treatment: Primary: Painless Chancre Adults: Benzathine PCN G 2.4 million units IM times one dose Infants and Children: Benzathine PCN G 50,000 u/kg IM up to max adult dose of 2.4 m units--single dose Alternate if PCN allergy: Doxycline 100mg PO BID for 14 DAYS OR Tetracycline 500mg PO QID 14 DAYS Secondary syphilis symptoms Malaise Maculopapular rash--on chest or elsewhere Lymphadenopathy tertiary syphilis symptoms -Gummatous lesions (skin and bone nodules) -Cardiovascular problems (aortic regurg or aneurysm) Neuro symptoms may develop at any time--increase risk of getting HIV
Treatment for Syphilis: Primary, Secondary, and Early Latent (within 12 months) Adults: Benzathine PCN G 2.4 million units IM times one dose Infants and Children: Benzanthine PCN G 50,000 u/kg IM up to max adult dose of 2.4 m units--single dose Alternate if PCN allergy: Doxycline 100mg PO BID for 14 DAYS OR Tetracycline 500mg PO QID 14 DAYS How to treat Late Latent Syphilis or Unknown stage: 3 doses of Benzathine PCN G 2.4 million units IM each at 1 week intervals Alternate: Doxycycline 100 mg PO BID for 28 days OR Tetracycline 500mg PO QID 28 days How to treat tertiary syphilis? With normal CSF: Benzathine PCN G 7.2 million units total, administer as 3 doses: 2.4 units each 1 week intervals--ID referral How to treat reportable Chancroid: PAINFUL Genital ulcer WITH positive suppurative inguinal adenopathy **Ask about travel to Africa or Carribean Clinical Criteria: 1 or more PAINFUL genital ulcers POSITIVE reginal lymphadenopathy NO evidence of T. Pallidum at least 7 days after onset HSV PCS or HSV culture of exudate negative
- Treatment can be extended if healing not complete after 10 days * How to treat Genital herpes--Suppressive Treatment: Acyclovir 400 mg PO BID per Epocrates reassess treatment need at 1 year
- Asymptomatic Transmission * How to treat Genital Herpes--Episodic treatment (within one day of prodrome) Acyclovir 800mg PO BID 5 days Facts about Genital Warts--HPV: Most common STD in US HPV 16 and 18 causes oral, anal and genital cancers (Gardisil vaccine) HPV 6 and 11 is a lower risk infection, causes genial warts Facts about Molluscum Contagiosum: Pox Virus White/Pink Pearly White head occurs anywhere on body resolves after 12-14 months or up to 4 years can get with close contact, sharing towels etc.. DERM Referral Facts about Pubic Lice:
Spread Sexually NOT spread by dogs and cats TREATMENT: Permethrin 1 % cream, rinse and wash off after 10 min Facts about Scabies: Prolonged skin to skin contact Close body contact TREATMENT: Permethin 5% (Elimite) leave on 8-14 hours; may give with oral Ivermectin, itching may persist even after effective treatment Facts about PID: upper genital tract G or C untreated Fallopian tubes abscess and scar--increase r/o ectopic **Increased r/o PID within fist 21 days of IUD insertion ** Early treatment is critical ** S/S: G and C is asymptomatic, Abdominal, pelvic, and low back pain, abnormal vaginal discharge, post coital bleed, fever, n/v TREATMENT: Ceflasporin (3rd Gen) 500mg IM one dose PLUS Doxycyline 100mg PO BID 14 days, PLUS metronidazole (Flagyl) 500mg PO BID 14 days
- May need IV antibiotics * Facts about Bacterial Vaginosis (BV):
Fluconazole 150mg PO single dose --may repeat 2nd dose 72 hours later if severe VAGINAL CREAMS: Butoconazole 2% 5G single dose Terconazole 0.4% 5G 7days Terconazole 0.8% 5G 7days Terconazole 80mg vag supp. daily for 3 days OTC Azole vaginal creams or suppositories OK in pregnancy! Facts about Asymptomatic Bacteriuria:
- bacteria in urine but no symptoms only complicated in pregnancy Facts about Cystitis: Involves urinary bladder AND urethra Uncomplicated: NO fever, CVAT, or flank pain COMPLICATED: pregnant, recent antibiotics, recent UTI's, decreased immunity, fever, CVAT, + flank pain Facts about Pyelonephritis: Involves 1 or both kidneys Uncomplicated: fever, CVAT, + flank pain, not pregnant, no vomiting, no underlying chronic dz COMPLICATED: Pregnant, Vomiting, Immunodeficient. How to treat Acute Simple Bacterial Cystitis:
Fist line: Macrobid Nitrofurantion 100mg PO BID 5-7 days Bactrim DS 160/800mg PO BID 3 days if uncomplicated Monural 3G powder mixed with water in single PO Dose How to treat UTI in pregnancy: E coli is most common pathogen GBS + in 15-25 % of all women TREAT ALL GBS + Bacteriuria > 1M cfu./mL with antibiotics--Macrobid (nitroruantoin) 100mg PO every 12 hours 5-7 days--NOT in first trimester or at term if other options available 25 % of asymptomatic GBS bacteriuria will progress to acute Pyelonephritis--very sick, systemic symptoms Acute Cystitis: + 100,000 cfu/mL with symptoms What is a leiomyoma? benign uterine fibroid of the smooth muscle, classified based on location, seen in women by menopause and the main reason for hysterectomy in US, Diagnosed by ultrasound, 25 % of women symptomatic, genetic, cumulative Estrogen exposure increased prevalence What is the adnexa? ovaries, fallopian tubes and supporting ligaments Facts about Endometriosis:
