study guide
Feminism
Acknowledges oppression of women within patriarchal society
Work “WITH” as opposed to For
Uses heterogeneity- quality or state of being diverse in character or content
Not Homogeneity- everyone fits into a “box”
Minimizes/ exposes power imbalances
Rejects androcentric models
Challenges medicalization and pathophysiology
Seeks social and political change to address women’s health issues
Health
A state of complete physical, mental, and social well-being and not merely the absence of
disease or infirmity
Research
Evidence Based Practice- Clinical research + Patient Preference + Clinical Experience
-Help to standardize care or eliminate wide variations in care
-Assists w/ development of outcome based performance measures
-Eliminates unnecessary processes or procedures and sort through research
*Began w/ Nightingale
Randomized Controlled Trial- Considered Gold Standard
Systematic Review- literature review, collects and critically analyzes multiple research
Meta-Analyses- subset of systematic reviews; Qualitative + Quantitative =1 conclusion
Quasi-Experimental- treatment and control groups may not be comparable at baseline
Qualitative- researcher cannot be fully removed, “naturalistic”- uncontrolled setting
Questions are often exploratory
Stetler Model of Research Utilization
Preparation (Purpose?), Validation (examine/critique),
Comparative Evaluation- synthesize evidence and decide whether to use it or not
Translation (dissemination of change), Evaluation (is it working?)
Prevention
Primary= preventing disease in susceptible populations
Secondary= focus on early detection of disease to severity and short and long-term problems
Tertiary= services limit disability and promote rehabilitation from disease states
#1 Preventable Death in US- Smoking
Killers- Cardiac
Cancer (top 3) In Women Worldwide
Breast, Lung, Colorectal
Leading Causes of Cancer Death in Women
Lung, Breast, Colorectal
Leading Cause of Gyn Death
Ovarian
Immunization
MMR, Zoster, Varicella, HPV, MPSV4- CI for pregnancy
Tdap in 3rd Trimester of Every Pregnancy
, Pregnancy Not Attempted Until 28 Days After Rubella Vaccine
Hep B in Risk- 2+ Partners in 6 months, Eval/Tx for STD, IV use
G&D Theories
Erickson’s
Trust/Mistrust =Infancy
Autonomy/Shame= Early Childhood 18 months – 3 years
Initiative/Guilt= Play Age 3-5
Industry/Inferiority= School Age 5-12
Identity/Role Confusion= Adolescence 12-18
Intimacy/Isolation= Young Adult 18-40
Generativity/Stagnation= Adult 40-65
Ego Integrity/Despair= Maturity 65+
Tanner Stages
Stage 1- Prepubertal (Vellus Hair- No Pubic)
Stage 2- Breast bud stage w/ elevation of breast and papilla; enlarged areola
Thelarche (8-13) and Menarche is 1-3 Years Later
Adrenarche ~6 months After Thelarche
Sparse, long, slightly pigmented, straight or slightly curved
Mean age- 12.1 = undetectable estradiol to 24
Stage 3- Further enlargement, no separation of contour
Darker, coarser, curlier, sparsely over pubic symphysis
Mean age- 13.6 = undetectable estradiol to 60
Stage 4- Secondary Mound and Menarche typically (9-17)
Coarse and curly, covered greatly, but not including the thighs
Mean age- 15.1 = estradiol 15-85
Stage 5- Mature- projection of papilla only; Hair adult in quantity and quality
Mean age- 18 = estradiol 15-350
Screening
All Women- Depression (women at risk), ask about mood and ADL pleasure
IPV, BMI (25-29.9= overweight), HTN, Rubella Immunity, Tobacco Use
Ovarian Cancer- risks w/ screening outweighs benefits, family history BRCA1 BRCA2
How to screen for BRCA?
Adolescents- #1 Chlamydia (sexually active 24 and younger)
Chlamydia and Gonorrhea – Nucleic acid amplification test (NAAT) recommended
Middle age & Older
Breast Ca- 50-74- Mammogram Q2
Colorectal- 50+, FOBT Q1, Sigmoid q5 or Colonoscopy q10
Cholesterol- 45+
Older Women- hearing, visual changes
Osteoporosis- 60+ DEXA Q2
Menstrual Cycle
Hypothalamus, Anterior Pituitary, Ovaries, Uterus, Outflow Tract
Caucasian- 12.6; AA- 12.1; Latinas 12.2
, BMI Earlier onset of puberty
Thelarche Then Menarche 2-3 Years Later
Refer for primary amenorrhea by 15; or absent menarche 3 years after thelarche
Ovary
Functional unit is the follicle- oocyte surrounded by granulosa and theca cells
LH to theca cells= androgen production
Androgen then to granulosa cells
FSH to granulosa cells convert androgens to estradiol
Estradiol goes to oocyte and allows maturation
Estradiol drives proliferative phase of endometrial cycle
Estradiol surge LH surge Ovulation (beginning of secretory phase)
After ovulation, residual follicle become CL- secretes progesterone primarily
Hemorrhage into CL can result in hemorrhagic CL cyst, esp. during pregnancy
Degeneration of follicle follicular cysts (PCOS)
PCOS= LH but not enough FSH = Androgens not converted to estradiol
Ovarian Cycle (Ovaries- Full Of Life)
Day 1-14 Follicular- FSH and Estrogen mature ovarian follicle
FSH stimulates Inhibin B release, which inhibits FSH
Day 14 Ovulation- LH Prominent- Ovulation 36 hours’ after LH surge BBT
Day 15-28 Luteal- Progesterone & Estrogen prominent thanks to new corpus luteum
FSH stimulates Inhibin A release, inhibin suppresses FSH
Endometrial Cycle
Day 1-5 (variable)- Menses (Part of Proliferative)- Prostaglandins prominent (pain, inflame.)
Endometrium slough if no ovum fertilization
Day 1-14 Proliferative- Estrogen prominent to proliferate endometrium
Day 14-28 Secretory- Progesterone Prominent to thicken endometrium for implantation
Fixed 14 Days
Average Cycle- 21-34 Days ( 1st 3 years’ post-menarche, normalizes around 6th year)
Normal Menses ~ 4-6 days (25-60 mL/cycle Lost)
Evaluate- Absence of cycle 3 years after thelarche, new onset irregularity
Absence by 13 w/out signs of pubertal development
Cycles closer than 21 days’ (poly) and farther apart than 45 days’
Menses lasting > 7 days’ or Requiring new pad 1-2 hours
Normal is 1 Tampon Q6
Painful menses (Dysmenorrhea)
Primary- Progesterone (from CL) Arachidonic Acid PG F
Vasoconstriction/Smooth Muscle Contraction
Uterine contractions, Blood flow, and Peripheral nerve Sensitivity
Tx- Heat, dairy intake, vitamins (B, E, Fish oil), acupuncture, yoga
#1 Rx= NSAIDs day before menses for 2-3 days
Secondary- underlying pelvic pathology- endometriosis/ adenomyosis
Estradiol Levels (Highest around ovulation & Lowest= PMP)
Midfollicular- 27-123
, Periovulatory- 96-436
Mid-luteal- 49-294
Postmenopausal- 0-40
Menopause- typically between ages of 48 and 55, median of 51
Vasomotor symptoms happen in perimenopause (~40-45)
Ovaries stop producing estradiol or progesterone and estrogen
Pituitary secretion of FSH (and ~LH) become markedly
Prolactin Normal- 4-23 (Pituitary Adenoma= > 100)
Pregnant- 34-386
LH & FSH = 5-20
LH: FSH = 3:1 (PCOS)
Abnormal Uterine Bleeding
Acute- episode of sufficient quantity to require immediate intervention to prevent further loss
Chronic- present for the majority of the last 6 months
Structural Abnormalities
P- Polyps AUB-P
A- Adenomyosis AUB-A (70% have AUB)
Inner lining of the endometrium breaks through to the muscular layer
L- Leiomyoma AUB-L (Most common benign tumor of the genital tract)
M- Malignancy AUB-M (Primary symptom of endometrial neoplasia)
Non-Structural Abnormalities
C- Coagulopathy AUB-C (Von Willebrand’s Disease?)
O- Ovulatory Disorders AUB-O (Endocrinopathies-PCOS, eating disorders, thyroid disease)
Generally, presents w/ irregular timing and flow
E- Endometrial AUB-E
I- Iatrogenic AUB-I
Most commonly caused by IUD placement and also TCAs
N- Not Classified AUB-N
Incidence- 1/3 of all gynecological visits are for AUB, >40 = 70% of visits
47% have uterine abnormality
Risk- anovulation, hormone replacement anovulation, obesity, nulliparity, >35, DM
Personal/family history of coagulation disorder, Liver disorder, anticoagulation/chemo
Serum hCG always precedes evaluation of female of menstruating age w/ vaginal bleeding
hCG produced by trophoblasts
CBC, ABO/Rh if pregnancy suspected or bleeding severe, STD testing/wet prep, cervical cytology
CMP (renal/hepatic), coagulation studies, Thyroid, endometrial biopsy
Prolactin and Progesterone are possible also GC/CT
Imaging- TVUS is first line, saline sonohysterography for leiomyomas, adenomyosis, polyps
Hysteroscopy for guided endometrial biopsy & removal of polyps
Do Sonohysterography if symptomatic and –TVUS and EMB
Rx- NSAIDs (cyclic AUB), COC, Danazol or GnRH agonists if treatments fail
Intravaginal Estrogen- vaginal atrophy, Iron replacement PRN, infection- Antibiotics
Complications- EP is leading cause of first-trimester maternal death
Feminism
Acknowledges oppression of women within patriarchal society
Work “WITH” as opposed to For
Uses heterogeneity- quality or state of being diverse in character or content
Not Homogeneity- everyone fits into a “box”
Minimizes/ exposes power imbalances
Rejects androcentric models
Challenges medicalization and pathophysiology
Seeks social and political change to address women’s health issues
Health
A state of complete physical, mental, and social well-being and not merely the absence of
disease or infirmity
Research
Evidence Based Practice- Clinical research + Patient Preference + Clinical Experience
-Help to standardize care or eliminate wide variations in care
-Assists w/ development of outcome based performance measures
-Eliminates unnecessary processes or procedures and sort through research
*Began w/ Nightingale
Randomized Controlled Trial- Considered Gold Standard
Systematic Review- literature review, collects and critically analyzes multiple research
Meta-Analyses- subset of systematic reviews; Qualitative + Quantitative =1 conclusion
Quasi-Experimental- treatment and control groups may not be comparable at baseline
Qualitative- researcher cannot be fully removed, “naturalistic”- uncontrolled setting
Questions are often exploratory
Stetler Model of Research Utilization
Preparation (Purpose?), Validation (examine/critique),
Comparative Evaluation- synthesize evidence and decide whether to use it or not
Translation (dissemination of change), Evaluation (is it working?)
Prevention
Primary= preventing disease in susceptible populations
Secondary= focus on early detection of disease to severity and short and long-term problems
Tertiary= services limit disability and promote rehabilitation from disease states
#1 Preventable Death in US- Smoking
Killers- Cardiac
Cancer (top 3) In Women Worldwide
Breast, Lung, Colorectal
Leading Causes of Cancer Death in Women
Lung, Breast, Colorectal
Leading Cause of Gyn Death
Ovarian
Immunization
MMR, Zoster, Varicella, HPV, MPSV4- CI for pregnancy
Tdap in 3rd Trimester of Every Pregnancy
, Pregnancy Not Attempted Until 28 Days After Rubella Vaccine
Hep B in Risk- 2+ Partners in 6 months, Eval/Tx for STD, IV use
G&D Theories
Erickson’s
Trust/Mistrust =Infancy
Autonomy/Shame= Early Childhood 18 months – 3 years
Initiative/Guilt= Play Age 3-5
Industry/Inferiority= School Age 5-12
Identity/Role Confusion= Adolescence 12-18
Intimacy/Isolation= Young Adult 18-40
Generativity/Stagnation= Adult 40-65
Ego Integrity/Despair= Maturity 65+
Tanner Stages
Stage 1- Prepubertal (Vellus Hair- No Pubic)
Stage 2- Breast bud stage w/ elevation of breast and papilla; enlarged areola
Thelarche (8-13) and Menarche is 1-3 Years Later
Adrenarche ~6 months After Thelarche
Sparse, long, slightly pigmented, straight or slightly curved
Mean age- 12.1 = undetectable estradiol to 24
Stage 3- Further enlargement, no separation of contour
Darker, coarser, curlier, sparsely over pubic symphysis
Mean age- 13.6 = undetectable estradiol to 60
Stage 4- Secondary Mound and Menarche typically (9-17)
Coarse and curly, covered greatly, but not including the thighs
Mean age- 15.1 = estradiol 15-85
Stage 5- Mature- projection of papilla only; Hair adult in quantity and quality
Mean age- 18 = estradiol 15-350
Screening
All Women- Depression (women at risk), ask about mood and ADL pleasure
IPV, BMI (25-29.9= overweight), HTN, Rubella Immunity, Tobacco Use
Ovarian Cancer- risks w/ screening outweighs benefits, family history BRCA1 BRCA2
How to screen for BRCA?
Adolescents- #1 Chlamydia (sexually active 24 and younger)
Chlamydia and Gonorrhea – Nucleic acid amplification test (NAAT) recommended
Middle age & Older
Breast Ca- 50-74- Mammogram Q2
Colorectal- 50+, FOBT Q1, Sigmoid q5 or Colonoscopy q10
Cholesterol- 45+
Older Women- hearing, visual changes
Osteoporosis- 60+ DEXA Q2
Menstrual Cycle
Hypothalamus, Anterior Pituitary, Ovaries, Uterus, Outflow Tract
Caucasian- 12.6; AA- 12.1; Latinas 12.2
, BMI Earlier onset of puberty
Thelarche Then Menarche 2-3 Years Later
Refer for primary amenorrhea by 15; or absent menarche 3 years after thelarche
Ovary
Functional unit is the follicle- oocyte surrounded by granulosa and theca cells
LH to theca cells= androgen production
Androgen then to granulosa cells
FSH to granulosa cells convert androgens to estradiol
Estradiol goes to oocyte and allows maturation
Estradiol drives proliferative phase of endometrial cycle
Estradiol surge LH surge Ovulation (beginning of secretory phase)
After ovulation, residual follicle become CL- secretes progesterone primarily
Hemorrhage into CL can result in hemorrhagic CL cyst, esp. during pregnancy
Degeneration of follicle follicular cysts (PCOS)
PCOS= LH but not enough FSH = Androgens not converted to estradiol
Ovarian Cycle (Ovaries- Full Of Life)
Day 1-14 Follicular- FSH and Estrogen mature ovarian follicle
FSH stimulates Inhibin B release, which inhibits FSH
Day 14 Ovulation- LH Prominent- Ovulation 36 hours’ after LH surge BBT
Day 15-28 Luteal- Progesterone & Estrogen prominent thanks to new corpus luteum
FSH stimulates Inhibin A release, inhibin suppresses FSH
Endometrial Cycle
Day 1-5 (variable)- Menses (Part of Proliferative)- Prostaglandins prominent (pain, inflame.)
Endometrium slough if no ovum fertilization
Day 1-14 Proliferative- Estrogen prominent to proliferate endometrium
Day 14-28 Secretory- Progesterone Prominent to thicken endometrium for implantation
Fixed 14 Days
Average Cycle- 21-34 Days ( 1st 3 years’ post-menarche, normalizes around 6th year)
Normal Menses ~ 4-6 days (25-60 mL/cycle Lost)
Evaluate- Absence of cycle 3 years after thelarche, new onset irregularity
Absence by 13 w/out signs of pubertal development
Cycles closer than 21 days’ (poly) and farther apart than 45 days’
Menses lasting > 7 days’ or Requiring new pad 1-2 hours
Normal is 1 Tampon Q6
Painful menses (Dysmenorrhea)
Primary- Progesterone (from CL) Arachidonic Acid PG F
Vasoconstriction/Smooth Muscle Contraction
Uterine contractions, Blood flow, and Peripheral nerve Sensitivity
Tx- Heat, dairy intake, vitamins (B, E, Fish oil), acupuncture, yoga
#1 Rx= NSAIDs day before menses for 2-3 days
Secondary- underlying pelvic pathology- endometriosis/ adenomyosis
Estradiol Levels (Highest around ovulation & Lowest= PMP)
Midfollicular- 27-123
, Periovulatory- 96-436
Mid-luteal- 49-294
Postmenopausal- 0-40
Menopause- typically between ages of 48 and 55, median of 51
Vasomotor symptoms happen in perimenopause (~40-45)
Ovaries stop producing estradiol or progesterone and estrogen
Pituitary secretion of FSH (and ~LH) become markedly
Prolactin Normal- 4-23 (Pituitary Adenoma= > 100)
Pregnant- 34-386
LH & FSH = 5-20
LH: FSH = 3:1 (PCOS)
Abnormal Uterine Bleeding
Acute- episode of sufficient quantity to require immediate intervention to prevent further loss
Chronic- present for the majority of the last 6 months
Structural Abnormalities
P- Polyps AUB-P
A- Adenomyosis AUB-A (70% have AUB)
Inner lining of the endometrium breaks through to the muscular layer
L- Leiomyoma AUB-L (Most common benign tumor of the genital tract)
M- Malignancy AUB-M (Primary symptom of endometrial neoplasia)
Non-Structural Abnormalities
C- Coagulopathy AUB-C (Von Willebrand’s Disease?)
O- Ovulatory Disorders AUB-O (Endocrinopathies-PCOS, eating disorders, thyroid disease)
Generally, presents w/ irregular timing and flow
E- Endometrial AUB-E
I- Iatrogenic AUB-I
Most commonly caused by IUD placement and also TCAs
N- Not Classified AUB-N
Incidence- 1/3 of all gynecological visits are for AUB, >40 = 70% of visits
47% have uterine abnormality
Risk- anovulation, hormone replacement anovulation, obesity, nulliparity, >35, DM
Personal/family history of coagulation disorder, Liver disorder, anticoagulation/chemo
Serum hCG always precedes evaluation of female of menstruating age w/ vaginal bleeding
hCG produced by trophoblasts
CBC, ABO/Rh if pregnancy suspected or bleeding severe, STD testing/wet prep, cervical cytology
CMP (renal/hepatic), coagulation studies, Thyroid, endometrial biopsy
Prolactin and Progesterone are possible also GC/CT
Imaging- TVUS is first line, saline sonohysterography for leiomyomas, adenomyosis, polyps
Hysteroscopy for guided endometrial biopsy & removal of polyps
Do Sonohysterography if symptomatic and –TVUS and EMB
Rx- NSAIDs (cyclic AUB), COC, Danazol or GnRH agonists if treatments fail
Intravaginal Estrogen- vaginal atrophy, Iron replacement PRN, infection- Antibiotics
Complications- EP is leading cause of first-trimester maternal death
