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CDC Selected Practice Recommendations for Contraceptive Use 2016 article

A health care provider can be reasonably certain that a woman is not pregnant if she has no symptoms or signs of pregnancy and meets any one of the following criteria: • is ≤7 days after the start of normal menses • has not had sexual intercourse since the start of last normal menses. • has been correctly and consistently using a reliable method of contraception • is ≤7 days after spontaneous or induced abortion • is within 4 weeks postpartum • is fully or nearly fully breastfeeding (exclusively breastfeeding or the vast majority [≥85%] of feeds are breastfeeds), amenorrheic, and <6 months postpartum For contraceptive methods other than IUDs, the benefits of starting to use a contraceptive method likely exceed any risk, even in situations in which the health care provider is uncertain whether the woman is pregnant. can consider contraceptive methods other than IUDs at any time, with a follow-up pregnancy test in 2-4 weeks. risks of not starting to use contraception should be weighed against the risks of initiating contraception use in a woman who might be already pregnant. In contrast, for women who want to begin using an IUD (Cu-IUD or LNG-IUD), in situations in which the health care provider is uncertain whether the woman is pregnant, the woman should be provided with another contraceptive method to use until the health care provider is reasonably certain that she is not pregnant and can insert the IUD. higher risk for complications such as spontaneous abortion, septic abortion, preterm delivery, and chorioamnionitis cu IUD article If the day of ovulation can be estimated, the Cu-IUD also can be inserted >5 days after sexual intercourse as long as insertion does not occur >5 days after ovulation. No additional contraceptive protection is needed after Cu-IUD insertion. can be inserted at any time postpartum, including immediately postpartum, should not be inserted in a woman with postpartum sepsis (e.g., chorioamnionitis or endometritis). can be inserted within the first 7 days, including immediately postabortion. can be inserted immediately if it is reasonably certain that the woman is not pregnant. timing of Cu-IUD insertion in relation to the menstrual cycle in non-postpartum women had little effect on longterm outcomes (rates of continuation, removal, expulsion, or pregnancy) or on short-term outcomes (pain at insertion, bleeding at insertion, or immediate expulsion) LNG-IUDs can be inserted at any time if it is reasonably certain that the woman is not pregnant. within the first 7 days since menstrual bleeding started, no additional contraceptive protection is needed. amenorrhea- needs to abstain from sexual intercourse or use additional contraceptive protection for the next 7 days. can be inserted at any time, including immediately postpartum. a woman who is ≥21 days postpartum and has not experienced return of her menstrual cycle needs to abstain from sexual intercourse or use additional contraceptive protection for the next 7 days. If her menstrual cycles have returned and it has been >7 days since menstrual bleeding began, she needs to abstain from sexual intercourse or use additional contraceptive protection for the next 7 days. inserted within the first 7 days, including immediately postabortion. not be inserted immediately after a septic abortion. additional contraceptive protection for the next 7 days unless the IUD is placed at the time of a surgical abortion. can be inserted immediately if it is reasonably certain that the woman is not pregnant. If a woman needs to use additional contraceptive protection when switching to an LNG-IUD from another contraceptive method, consider continuing her previous method for 7 days after LNG-IUD insertion. exams & tests- Bimanual examination and cervical inspection are necessary before IUD insertion. A baseline weight and BMI measurement might be useful for monitoring IUD users over time. If a woman has not been screened for STDs according to STD screening guidelines, screening can be performed at the time of insertion. Women with current purulent cervicitis or chlamydial infection or gonococcal infection should not undergo IUD insertion. unnecessary screening- HnH, lipids, liver enzymes, breast exam, cervical cytology, HIV, HTN, diabetes, thrombogenic mutations. Misoprostol might be helpful in select circumstances (e.g., in women with a recent failed insertion). Prophylactic antibiotics are generally not recommended for Cu-IUD or LNG-IUD insertion. Advise the woman to return at any time to discuss side effects or other problems, if she wants to change the method being used, and when it is time to remove or replace the contraceptive method. No routine follow-up visit is required. • At other routine visits, health care providers who see IUD users should do the following: - Assess the woman's satisfaction with her contraceptive method and whether she has any concerns about method use. - Assess any changes in health status, including medications, that would change the appropriateness of the IUD for safe and effective continued use on the basis of U.S. MEC (e.g., category 3 and 4 conditions and characteristics). - Consider performing an examination to check for the presence of the IUD strings. - Consider assessing weight changes and counseling women who are concerned about weight changes perceived to be associated with their contraceptive method. Unscheduled spotting or light bleeding, as well as heavy or prolonged bleeding, is common during the first 3-6 months of Cu-IUD use, is generally not harmful, and decreases with continued Cu-IUD use. • If clinically indicated, consider an underlying gynecological problem, such as Cu-IUD displacement, an STD, pregnancy, or new pathologic uterine conditions (e.g., polyps or fibroids), especially in women who have already been using the Cu-IUD for a few months or longer and who have developed a new onset of heavy or prolonged bleeding. If an underlying gynecological problem is found, treat the condition or refer for care. • If an underlying gynecological problem is not found and the woman requests treatment, the following treatment option can be considered during days of bleeding: - NSAIDs for short-term treatment (5-7 days) Unscheduled spotting or light bleeding is expected during the first 3-6 months of LNG-IUD use, is generally not harmful, and decreases with continued LNG-IUD use. Over time, bleeding generally decreases with LNGIUD use, and many women experience only light menstrual bleeding or amenorrhea. Heavy or prolonged bleeding, either unscheduled or menstrual, is uncommon during LNG-IUD use. Amenorrhea does not require any medical treatment. Provide reassurance. - If a woman's regular bleeding pattern changes abruptly to amenorrhea, consider ruling out pregnancy if clinically indicated. when a Cu-IUD or an LNG-IUD User Is Found To Have PID • Treat the PID according to the CDC Sexually Transmitted Diseases Treatment Guidelines (15). • Provide comprehensive management for STDs, including counseling about condom use. • The IUD does not need to be removed immediately if the woman needs ongoing contraception. • Reassess the woman in 48-72 hours. If no clinical improvement occurs, continue antibiotics and consider removal of the IUD. • If the woman wants to discontinue use, remove the IUD sometime after antibiotics have been started Found To Be Pregnant • Evaluate for possible ectopic pregnancy. • Advise the woman that she has an increased risk for spontaneous abortion (including septic abortion that might be life threatening) and for preterm delivery if the IUD is left in place. The removal of the IUD reduces these risks but might not decrease the risk to the baseline level of a pregnancy without an IUD. IUD Strings Are Visible or Can Be Retrieved Safely from the Cervical Canal • Advise the woman that the IUD should be removed as soon as possible. If the IUD is to be removed, remove it by pulling on the strings gently. - Advise the woman that she should return promptly if she has heavy bleeding, cramping, pain, abnormal vaginal discharge, or fever. Not Visible and Cannot Be Safely Retrieved • If ultrasonography is available, consider performing or referring for ultrasound examination to determine the location of the IUD. If the IUD cannot be located, it might have been expelled or have perforated the uterine wall. implants: If the implant is inserted >5 days since menstrual bleeding started, the woman needs to abstain from sexual intercourse or use additional contraceptive protection for the next 7 days. inserted at any time if it is reasonably certain that the woman is not pregnant. abstain from sexual intercourse or use additional contraceptive protection for the next 7 days. a woman who is ≥21 days postpartum and has not experienced return of her menstrual cycle needs to abstain from sexual intercourse or use additional contraceptive protection for the next 7 days. If her menstrual cycles have returned and it has been >5 days since menstrual bleeding started, she needs to abstain from sexual intercourse or use additional contraceptive protection for the next 7 days. same for postpartum. The implant can be inserted within the first 7 days, including immediately after the abortion. needs to abstain from sexual intercourse or use additional contraceptive protection for the next 7 days unless the implant is placed at the time of a surgical abortion. switching from another- If it has been >5 days since menstrual bleeding started, the woman needs to abstain from sexual intercourse or use additional contraceptive protection for the next 7 days after insertion. switching from IUD- retain the IUD for at least 7 days after the implant is inserted and return for IUD removal. If the woman cannot return for IUD removal and has not abstained from sexual intercourse or used barrier contraception for 7 days, advise the woman to use ECPs (with the exception of UPA) at the time of IUD removal. test & exams- baseline weight and BMI measurement might be useful for monitoring implant users over time unnecessary screening- pelvic exam, lipids, liver enzymes, breast exam, hypertension, diabetes, anemia, thrombogenic mutations, cervical intraepithelial neoplasia, cervical cancer, STDs, or HIV infection. • At other routine visits, health care providers seeing implant users should do the following: - Assess the woman's satisfaction with her contraceptive method and whether she has any concerns about method use. - Assess any changes in health status, including medications, that would change the appropriateness of the implant for safe and effective continued use based on U.S. MEC (e.g., category 3 and 4 conditions and characteristics). - Consider assessing weight changes and counseling women who are concerned about weight change perceived to be associated with their contraceptive method. heavy/irregular bleeding, if underlying gyn problem not found- NSAIDS for short-term treatment (5-7 days) Hormonal treatment (if medically eligible) with lowdose COCs or estrogen for short-term treatment (10-20 days) injectables: DMPA is started >7 days since menstrual bleeding started, the woman needs to abstain from sexual intercourse or use additional contraceptive protection for the next 7 days. if amenorrhea- The woman needs to abstain from sexual intercourse or use additional contraceptive protection for the next 7 days. woman who is ≥21 days postpartum and has not experienced return of her menstrual cycle needs to abstain from sexual intercourse or use additional contraceptive protection for the next 7 days. If her menstrual cycles have returned and it has been >7 days since menstrual bleeding started, she needs to abstain from sexual intercourse or use additional contraceptive protection for the next 7 days. same for postpartum. post abortion- needs to abstain from sexual intercourse or use additional contraceptive protection for the next 7 days unless the injection is given at the time of a surgical abortion. switching from another method- If it has been >7 days since menstrual bleeding started, the woman needs to abstain from sexual intercourse or use additional contraceptive protection for the next 7 days. switching to IUD- keep inplace 7 days or ECP if recently active. tests & exams- baseline weight and BMI measurement might be useful to monitor DMPA users over time. unneccessary screenings- pelvic exam, blood pressure, glucose, lipids, liver enzymes. breast exam, anemia, thrombogenic mutations, cervical intraepithelial neoplasia, cervical cancer, HIV infection, or other STDs. -same follow up as others. repeat DMPA injections every 3 months (13 weeks). given early when necessary. can be given up to 2 weeks late (15 weeks from the last injection) without requiring additional contraceptive protection. (>15 weeks from the last injection) for a repeat DMPA injection, she can have the injection if it is reasonably certain that she is not pregnant , abstain from sex/addition contraceptive- 7 days, ECP if appropriate. irregular bleeding- If an underlying gynecologic problem is not found and the woman wants treatment, the following treatment option during days of bleeding can be considered: - NSAIDs for short-term treatment (5-7 days) heavy prolonged bleeding- If an underlying gynecologic problem is not found and the woman wants treatment, the following treatment options during days of bleeding can be considered: - NSAIDS for short-term treatment (5-7 days) - Hormonal treatment (if medically eligible) with lowdose COCs or estrogen for short-term treatment (10-20 days COCs started >5 days since menstrual bleeding started, the woman needs to abstain from sexual intercourse or use additional contraceptive protection for the next 7 days. amenorrhea- The woman needs to abstain from sexual intercourse or use additional contraceptive protection for the next 7 days. Postpartum breastfeeding women with other risk factors for venous thromboembolism generally should not use combined hormonal contraceptives 4-6 weeks after delivery. ≥21 days postpartum and has not experienced return of her menstrual cycle needs to abstain from sexual intercourse or use additional contraceptive protection for the next 7 days. If her menstrual cycles have returned and it has been >5 days since menstrual bleeding started, she needs to abstain from sexual intercourse or use additional contraceptive protection for the next 7 days. post abortion: The woman needs to abstain from sexual intercourse or use additional contraceptive protection for the next 7 days unless combined hormonal contraceptives are started at the time of a surgical abortion. switching form another method- If it has been >5 days since menstrual bleeding started, she needs to abstain from sexual intercourse or use additional contraceptive protection for the next 7 days. from IUD- Advise the women to retain the IUD for at least 7 days after combined hormonal contraceptives are initiated and return for IUD removal. If the woman cannot return for IUD removal and has not abstained from sexual intercourse or used barrier contraception for 7 days, advise the woman to use ECPs at the time of IUD removal. Combined hormonal contraceptives can be started immediately after use of ECPs (with the exception of UPA). Combined hormonal contraceptives can be started no sooner than 5 days after use of UPA. tests and exams- Blood pressure should be measured before initiation of combined hormonal contraceptives. Baseline weight and BMI measurements might be useful for monitoring combined hormonal contraceptive users over time. Women who have more severe hypertension (systolic pressure of ≥160 mmHg or diastolic pressure of ≥100 mm Hg) or vascular disease should not use combined hormonal contraceptives (U.S. MEC 4), and women who have less severe hypertension (systolic pressure of 140-159 mm Hg or diastolic pressure of 90-99 mm Hg) or adequately controlled hypertension generally should not use combined hormonal contraceptives . unnessecary screening- pelvic exam, glucose, lipids, livier enzymes, thrombogenic mutations, breast exam, anemia, cervical intraepithelial neoplasia, cervical cancer, HIV infection, or other STDs. • At the initial and return visits, provide or prescribe up to a 1-year supply of COCs (e.g., 13 28-day pill packs), depending on the woman's preferences and anticipated use. • A woman should be able to obtain COCs easily in the amount and at the time she needs them. f/u is same as others as well as assessing blood pressure. late or missed- a dose is considered late when <24 hours have elapsed since the dose should have been taken. A dose is considered missed if ≥24 hours have elapsed since the dose should have been taken. For example, if a COC pill was supposed to have been taken on Monday at 9:00 a.m. and is taken at 11:00 a.m., the pill is late; however, by Tuesday morning at 11:00 a.m., Monday's 9:00 a.m. pill has been missed and Tuesday's 9:00 a.m. pill is late. Women who frequently miss COCs or experience other usage errors with combined hormonal patch or combined vaginal ring should consider an alternative contraceptive method that is less dependent on the user to be effective (e.g., IUD, implant, or injectable). unsheduled bleeding/spotting- Advise the woman to discontinue combined hormonal contraceptive use (i.e., a hormone-free interval) for 3-4 consecutive days; a hormone-free interval is not recommended during the first 21 days of using the continuous or extended combined hormonal contraceptive method. A hormone-free interval also is not recommended more than once per month because contraceptive effectiveness might be reduced. POPs started >5 days since menstrual bleeding started, the woman needs to abstain from sexual intercourse or use additional contraceptive protection for the next 2 days. amenorrhea- needs to abstain from sexual intercourse or use additional contraceptive protection for the next 2 days. woman who is ≥21 days postpartum and has not experienced return of her menstrual cycles, she needs to abstain from sexual intercourse or use additional contraceptive protection for the next 2 days. If her menstrual cycles have returned and it has been >5 days since menstrual bleeding started, she needs to abstain from sexual intercourse or use additional contraceptive protection for the next 2 days. POPs can be started at any time, including immediately postpartum. POPs can be started within the first 7 days, including immediately postabortion. abstain from sexual intercourse or use additional contraceptive protection for the next 2 days unless POPs are started at the time of a surgical abortion. switching from other method- >5 days since menstrual bleeding started, the woman needs to abstain from sexual intercourse or use additional contraceptive protection for the next 2 days. Advise the women to retain the IUD for at least 2 days after POPs are initiated and return for IUD removal. cannot return for IUD removal and has not abstained from sexual intercourse or used barrier contraception for 7 days, advise the woman to use ECPs at the time of IUD removal. POPs can be started immediately after use of ECPs (with the exception of UPA). POPs can be started no sooner than 5 days after use of UPA. exams & tests- baseline weight and BMI measurement might be useful for monitoring unnecessary screening- pelvic exam, liver enzymes, lipids, breast exam, hypertension, diabetes, anemia, thrombogenic mutations, cervical intraepithelial neoplasia, cervical cancer, STDs, or HIV. • At the initial and return visit, provide or prescribe up to a 1-year supply of POPs (e.g., 13 28-day pill packs), depending on the woman's preferences and anticipated use. • A woman should be able to obtain POPs easily in the amount and at the time she needs them. f/u same as others except COC- • Advise the woman to return at any time to discuss side effects or other problems or if she wants to change the method being used. No routine follow-up visit is required. • At other routine visits, health care providers seeing POP users should do the following: - Assess the woman's satisfaction with her contraceptive method and whether she has any concerns about method use. - Assess any changes in health status, including medications, that would change the appropriateness of POPs for safe and effective continued use based on U.S. MEC (e.g., category 3 and 4 conditions and characteristics). - Consider assessing weight changes and counseling women who are concerned about weight change perceived to be associated with their contraceptive method. missed- dose is considered missed if it has been >3 hours since it should have been taken. • Take one pill as soon as possible. • Continue taking pills daily, one each day, at the same time each day, even if it means taking two pills on the same day. • Use back-up contraception (e.g., condoms) or avoid sexual intercourse until pills have been taken correctly, on time, for 2 consecutive days. Emergency contraception should be considered (with the exception of UPA) if vomit or diarrhea- same algorhythm as COC Use of SDM Among Women with Various Durations of the Menstrual Cycle Menstrual Cycles of 26-32 Days • The woman may use the method. • Provide a barrier method of contraception for protection on days 8-19 if she wants one. • If she has unprotected sexual intercourse during days 8-19, consider the use of emergency contraception if appropriate. Two or More Cycles of <26 or >32 Days Within Any 1 Year of SDM Use • Advise the woman that the method might not be appropriate for her because of a higher risk for pregnancy. Help her consider another method. avoid unprotected sexual intercourse on days 8-19 of the menstrual cycle initiating after ECP- Levonorgestrel and Combined Estrogen and Progestin ECPs • Any regular contraceptive method can be started immediately after the use of levonorgestrel or combined estrogen and progestin ECPs. • The woman needs to abstain from sexual intercourse or use barrier contraception for 7 days. • Advise the woman to have a pregnancy test if she does not have a withdrawal bleed within 3 weeks Routine use of antiemetics before taking ECPs is not recommended. • A woman can rely on sterilization for contraception immediately after laparoscopic and abdominal approaches. No additional contraceptive protection is needed. • Before a woman can rely on hysteroscopic sterilization for contraception, a hysterosalpingogram (HSG) must be performed 3 months after the sterilization procedure to confirm bilateral tubal occlusion. • The woman should be advised that she needs to abstain from sexual intercourse or use additional contraceptive protection until she has confirmed bilateral tubal occlusion. • A semen analysis should be performed 8-16 weeks after a vasectomy to ensure the procedure was successful. • The man should be advised that he should use additional contraceptive protection or abstain from sexual intercourse until he has confirmation of vasectomy success by postvasectomy semen analysis. • The man should refrain from ejaculation for approximately 1 week after the vasectomy to allow for healing of surgical sites and, after certain methods of vasectomy, occlusion of the vas. When Women Can Stop Using Contraceptives • Contraceptive protection is still needed for women aged >44 years if the woman wants to avoid pregnancy Both the American College of Obstetricians and Gynecologists and the North American Menopause Society recommend that women continue contraceptive use until menopause or age 50-55 years conclusion: Most women can start most contraceptive methods at any time, and few examinations or tests, if any, are needed before starting a contraceptive method. follow-up for most women includes assessment of her satisfaction with the contraceptive method, concerns about method use, and changes in health status or medications that could affect medical eligibility for continued use of the method. changes in bleeding patterns are one of the major reasons for discontinuation of contraception ECPs and emergency use of the Cu-IUD are important options for women Male and female sterilization are highly effective methods of contraception for men, women, and couples who have completed childbearing; for men undergoing vasectomy and women undergoing a hysteroscopic sterilization procedure, additional contraceptive protection is needed until the success of the procedure can be confirmed.

UTI- schuilling

Questions to Identify Complicated Cystitis and Pyelonephritis Are you or could you be pregnant? Have you had any fever or chills? Do you have any flank pain or back pain? Are you nauseated or have you vomited? Have you ever had a urinary tract (bladder or kidney) infection before? If so, when? How was it treated? Have you taken any medicines recently? Antibiotics? Pain relievers? Over-the-counter products? Do you have any other medical problems? Do you take any medications on a regular basis? Are you having any vaginal discharge or other vaginal problems? PE: Some women with uncomplicated UTI have suprapubic tenderness. Flank pain may be present, but usually is not with uncomplicated UTI. Its presence would raise the index of suspicion for pyelonephritis. Typically, the woman with pyelonephritis feels acutely ill. She may have fever, chills, nausea, vomiting, and costovertebral angle tenderness, as well as the symptoms of cystitis— namely, dysuria, frequency, urgency, and suprapubic pain labs: If the clinician cannot rule out a complicated UTI or an upper tract infection by history alone, laboratory testing is necessary. Tools available for this purpose include the urine dipstick, microscopic urinalysis, and urine culture with sensitivities, each of which has its own place in the diagnostic process. The urine dipstick is an inexpensive screening tool that may be used to confirm the UTI diagnosis if the history is ambiguous. A concentrated first-voided specimen is most reliable. dipstick that is positive for leukocyte esterase or nitrite is 75% sensitive and 82% specific for UTI. symptomatic woman with neg dip stick should have microscopic U/A and cx & sensitivity. falsely negative for a number of reasons— often because the sample is too dilute or because the leukocytes have lysed due to the passage of time. it is possible to collect the first part of the urine stream to use in nucleic acid amplification testing (NAAT) or polymerase chain reaction (PCR) testing for gonorrhea and chlamydia; the second midstream part can then be used for urine culture. E. coli (the most common uropathogen) does convert nitrates to nitrites, not all uropathogens do so. Therefore, failure to identify nitrites on dipstick or urinalysis does not rule out a UTI. Urine microscopy for the woman with pyelonephritis will usually reveal red blood cells, white blood cells, and white blood cell casts. Urine culture is the reference standard for diagnosis of a UTI. Sensitivities to antibiotics guide tx but empiric tx should not be delayed. Urine culture is not needed for symptomatic women who meet the criteria for uncomplicated bacterial cystitis, treated based on history alone. Indications for a Urine Culture in a Woman with Urinary Tract Infection: Symptoms Pregnancy Signs of upper tract infection (fever, costovertebral angle tenderness, and/or flank pain) Recent urinary tract infection Recent antibiotic treatment Chronic disease affecting the immune system In contrast, a urine culture and sensitivity test are indicated in any woman with a complicated cystitis or symptoms of upper tract disease. empiric tx should be modified later if the results indicate resistance or the patient is not improving. Blood cultures have not been shown to be useful unless the diagnosis is uncertain, the patient is immunocompromised, or assessment of the patient suggests the presence of descending infection from the blood to the kidney. differentials: bacterial cystitis, pyelonephritis, interstitial cystitis/painful bladder syndrome. urethritis related to a sexually transmitted infection— usually gonorrhea or chlamydia. woman with pyelonephritis symptoms should also include nephrolithiasis. Usually fever associated with pyelonephritis will resolve within 72 hours of treatment with appropriate antibiotics. Failure to resolve may indicate abscess, obstruction, or a resistant organism. treatment: clinicians should prescribe the least expensive and narrowest-spectrum drug to avoid increasing the problem of microbial resistance and to decrease costs for both patients and the health system uncomplicated, acute bacterial cystitis- Trimethoprim- sulfamethoxazole One tablet (160 mg trimethoprim + 800 mg sulfamethoxazole), twice daily for 3 days AR- Fever, rash, photosensitivity, neutropenia, thrombocytopenia, anorexia, nausea and vomiting, pruritus, headache, urticaria, Stevens-Johnson syndrome, toxic epidermal necrosis, and hemolysis in individuals with glucose-6-dehydrogenase deficiency Trimethoprim 100 mg, twice daily for 3 days Rash, pruritus, photosensitivity, exfoliative dermatitis, Stevens-Johnson syndrome, toxic epidermal necrosis, and aseptic meningitis Ciprofloxacin 250 mg, twice daily for 3 days Rash, confusion, seizures, restlessness, headache, severe hypersensitivity, hypoglycemia, hyperglycemia, and Achilles tendon rupture (in patients older than 60 years) Levofloxacin 250 mg, once daily for 3 days Same as for ciprofloxacin Norfloxacin 400 mg, twice daily for 3 days Same as for ciprofloxacin Gatifloxacin 200 mg, once daily for 3 days Same as for ciprofloxacin Nitrofurantoin macrocrystals 50- 100 mg, 4 times daily for 7 days Anorexia, nausea, vomiting, hypersensitivity, peripheral neuropathy, hepatitis, hemolytic anemia, and pulmonary reactions Nitrofurantoin monohydrate macrocrystals 100 mg, twice daily for 7 days Same as for nitrofurantoin macrocrystals Fosfomycin tromethamine 3 g dose (powder), single dose Diarrhea, nausea, vomiting, rash, and hypersensitivity Although 7-day treatment has been the norm in the past, research has shown that 3-day regimens of many of these drugs have equal effectiveness in women; thus the shorter-duration regimens are now recommended Symptoms should resolve within 72 hours of the initiation of antibiotic treatment. If they do not, the clinician must consider a change in therapy or another diagnosis. Some women will desire treatment of the dysuria for 1 or 2 days with phenazopyridine, which is now available in the United States on an over-the-counter (OTC) basis. This drug will color the urine orange and is associated with numerous adverse effects, including gastrointestinal upset, headaches, rash, hemolysis in those women with glucose-6-dehydrogenase deficiency, and nephrotoxicity. Most authorities agree that uncomplicated pyelonephritis may be treated on an outpatient basis if the woman is likely to be able to complete the treatment regimen and is able to return for follow-up. Treatment for 10 to 14 days is recommended, usually with a fluoroquinolone if the level of resistance to this antibiotic does not exceed 10% Severely ill women with pyelonephritis may need hospitalization to receive parenteral antibiotics. Indications for Hospitalizing a Woman with Pyelonephritis: Severe illness Pregnancy Immunocompromise Inability to tolerate oral treatment due to vomiting Inability to adhere to oral treatment or return for followup due to age, living situation, or lack of social support drinking to alleviate thirst can be helpful as well as not delaying voiding. The importance of completing the treatment regimen even if symptoms resolve before all medications are taken should be emphasized to avoid the development of resistant organisms. Most importantly, a woman who has been diagnosed with a UTI should be advised to contact the clinician if her symptoms persist after 48 hours of antibiotic treatment. recurrent UTI is defined as three or more UTIs in a 12-month period. Increasing fluids, wiping front to back, and avoidance of delayed urination have not been adequately studied. Single-dose postcoital antibiotics may be helpful for women who find an association between sexual activity and UTIs. Trimethoprim- sulfamethoxazole (TMP/SMX), trimethoprim alone, nitrofurantoin, and fluoroquinolones have all been shown to be effective for this purpose. Alternatively, continuous daily or everyother-day prophylaxis with nitrofurantoin, TMP/SMX, or a fluoroquinolone can decrease recurrence rates. Most UTIs derive from intestinal and/or vaginal bacteria. On the theory that ingestion of lactobacilli could potentially change the flora of the intestine or the vagina, various forms of lactobacilli have been suggested as a preventive measure- L. crispatus vaginal suppositories and L. rhamnosus GR-1 and L. reuteri RC-14 oral capsules. At this time, the evidence does not support use of cranberry products as a UTI-preventive measure in the general population. Chinese herbal medicine, used independently or in conjunction with antibiotics, may be beneficial for treating recurrent UTIs and reducing recurrence. a UTI in a teenager may indicate the initiation of sexual activity. A discussion of pregnancy risk and sexually transmitted infection prevention is appropriate for adolescents. Whether an adolescent with pyelonephritis needs to be hospitalized will depend on the clinician's judgment of whether she will be able to adhere to outpatient treatment. Studies suggest topical— but not oral— estrogen therapy decreases the risk of recurrent UTIs in postmenopausal women. no support for treating asymptomatic bacteriuria in older community-dwelling women. Anatomic and physiologic changes related to pregnancy place the pregnant woman at increased risk of UTI, including pyelonephritis. A urine culture is recommended for all women at the first prenatal visit, regardless of symptoms, and bacteriuria should be treated whether symptomatic or not. Pyelonephritis during pregnancy is associated with preterm labor, sepsis, acute respiratory failure, and even death. Many clinicians will choose to hospitalize the pregnant woman with pyelonephritis to monitor for complications and ensure adequate treatment. women in the military, nurses, teachers, and factory workers, who often work in settings where voiding on demand is restricted or difficult, are all susceptible to UTIs. Education about the need for voiding when the urge is present can decrease the incidence of UTIs in these women. cautioned against limiting fluids to decrease the need to urinate. Some who have worked under these conditions for a long time will no longer feel a need to urinate until the bladder is already overdistended. timed voiding may be helpful in reestablishing normal bladder responsivity and avoiding UTI

FC2 resource kit

When discussing the use of FC2, there are several reoccurring themes that arise. Here are some tips to addressing those themes: 1. Some women are afraid to use FC2 because they are unaware of their anatomy. o Approach: Providers educate their clients about general female anatomy as it related to FC2 insertion and use. Focus on cervix, pubic bone, vaginal canal, vaginal opening, and clitoris. 2. Some women are not comfortable touching themselves, but are too embarrassed to say this. o Approach: Assessment of a clients comfort level with using FC2 by discussing feelings regarding tampon use, looking at, and/or touching one's own vagina can help address insertion related issues. If a woman is absolutely not going to touch herself or is not comfortable inserting her finger into her vagina in order to adjust the inner ring, you can suggest that her partner put FC2 in for her as part of foreplay. If your client is uncomfortable with this option as well, then FC2 is not a realistic option for her. 3. Some women may say "yes I understand how to use the female condom" or say they'll try it and then do not. o Approach: Allow client to feel FC2 to become familiar with it. o Approach: Provide thorough instructions for insertion and demonstrate these steps on a pelvic model. Diagrams and/or anatomical models should be used to illustrate correct use of FC2. They can also be a valuable tool for illustrating problems that may be encountered when using FC2, allowing you to demonstrate the appropriate way to combat/ correct the issue. o Approach: Provide the client a pelvic model and an opportunity to practice insertion on the model with you, the provider, walking her through the steps and providing a proper insertion check. o Approach: Encourage the client to try practicing insertion first without a partner and then with a partner. o Approach: Reassure clients that it may take several attempts before they can use this method confidently with a partner for sex, but that after practicing most women are comfortable with FC2. 4. Some women are just too embarrassed to ask questions, if they have them. o Approach: Provide counseling in either individual or small group sessions with other women providing peer support. o See 3-time approach with client on page 18. 5. Some women are just afraid of its size and feel: o Approach: Counsel the client that FC2 may be slippery to work with at first, but becomes easier with practice. o Approach: Providers can unroll a male condom and hold it next to FC2. They are the same length. 6. Some women have heard the FC2 Female condom can pull out or slip into the vagina. o Approach: Lubricant is a key problem solver for many mechanical use challenges for FC2. Most problems people have using FC2 can be fixed by adding lubricant (oil or water-based) to the inside of the condom or to the penis. Add more lubricant if: • FC2 is being pushed inside the vagina • FC2 is riding on the penis (i.e. being pulled in and out with the penis) • There is noise 7. Some women might want to know why you are even talking with them about the female condom. o Approach: Tell clients you are empowering them with another option. A choice. Natural rubber latex condoms for men are highly effective at preventing sexually transmitted infections, including HIV/AIDS, if used correctly. And FC2 Female Condom can also protect yourself and your partner. o Approach: Remind the client that FC2 cannot be used simultaneously with a male condom. The most important tips to remember: Difficulty with insertion is one of the most common barriers to use with FC2. However, studies show insertion difficulties can be overcome with practice and instruction. Basic knowledge of female anatomy and enough opportunity to practice are important indicators for success with using FC2. Insertion practice, first without and then with a partner, can increase acceptability and sustained use of FC2. Providing clients with the following can also help address use-related challenges: o Tips for insertion of FC2. o Insertion checks on vaginal models. o Emphasis on practice. Providing the following tips to clients helps with any use related issues: o If FC2 feels dry during use, add a few drops of lubricant to the partner's penis or inside the condom. o Gently hold the outer ring of the condom against your body. o Guide the penis into the opening of FC2. Note - once the penis is in place you can let go... you DO NOT need to hold FC2 while you are having sex! The 3-time approach with clients: 1. While you are talking with the client hand her a lubricated FC2 and ask her to: hold it, feel it, squeeze it while you are talking, pinch it, rub it against her arm. Let it warm up against her skin. Show her how it is clearer, more pliable, it has heated up against her skin. 2. Allow the client several opportunities to do a demonstration in your office, using her hand or a pelvic model. Next suggest that she go home and "try it". Put it in, walk around with it. Practice inserting while in difference positions. Figure out which position feels best. 3. Insert for sex. FC2 is not just for women- don't forget to promote the product to your male clients.... Give them the same opportunity to feel the product- to get comfortable with it, so they can take it home to their partners. Below is a list of promotional messages that you can discuss with clients. FC2 can increase a woman's sense of empowerment as she is taking the initiative to protect herself and her partner. FC2 Increases sexual stimulation because the material adjusts to body temperature and stays warm. External ring rubs against clitoris and increases pleasure for many women. Men do not have to have/ maintain an erection to use FC2. FC2 is a good option for men who are unable to maintain an erection with the male condom. Men do not have to withdraw right after ejaculation, which may lead to more intimacy when using FC2. FC2 can be inserted ahead of time so there are no interruptions to "spoil the mood". Insertion of FC2 can be incorporated into sexual play, the partner can watch as it is put in place OR can help insert it. FC2 is a great choice for people with sensitivities to latex. FC2 can be used with any kind of lubricant (water or oil-based lubricants). FC2 provides an option for those times when a couple does not want to use the male condom (NOTE: Clients should never use a male condom and FC2 at the same time). FC2 is not tight or constricting around the penis; some men prefer FC2 to the male condom. The inner ring of FC2 can stimulate the tip of the penis during intercourse. The man does not have to worry about wearing a condom. FC2 provides effective dual protection, reducing the worry during sex about pregnancy and STIs/HIV. Increased sensation compared to latex male condom because nitrile is very thin. latex male condom- roll on penis made of latex fits on penis only put on erect removed immediately after covers most of penis little lub only use water based lub FC2 female condom- inserted in vagina made of synthetic rubber- latex free loosely in vagina prioe to intercourse insertion, not dependant on erection no need to remove immediately but removed before getting up covers internal external genetalia and base of penis- better protection highly lubricated used with oil or water based lub when your partner says- you can say... it kills the mood- it puts me in the mood, can put in me you wont catch anything- its sexy that you care and dont want to get me pregnant it takes too long-turns me on if you watch me insert it doesnt feel good- conforms and feels more natural it looks weird- its something new we can make it fun we have not been using condoms- i will be more relaxed and enjoy more if i dont have to worry i dont use condoms- then im not having sex i will find someone who doesnt care- then you dont care about me go ahead condoms break- this is nitrile and strong

VII. Discuss the following components of adolescence and their implications for the provision of gynecologic care: Risk taking, Experimentation, Sense of invulnerability

cognitive competence develops more slowly over time. As a consequence, adolescents still require guidance in some of their decision making: They are prone to jumping to conclusions and making poor decisions, which can lead to risky behavior. older adolescent girls are usually able to connect intercourse with the potential for pregnancy, but younger adolescents might not be able to appreciate the logical sequencing of these events. Adolescents are particularly influenced by their peers, so it is important for adults to understand the importance of peer pressure and provide the support the adolescent needs to make healthy decisions about risky behaviors such as consuming alcohol, having unprotected intercourse, and driving too fast. Additionally, using her newly developed hypothetical and deductive reasoning skills to make decisions can be especially difficult when the adolescent is confronting her peers. Maturation in thinking behavior is supported by understanding family members, an emotionally stable environment, parental discipline, and positive life experiences. The cognitive development of adolescents helps to lay the groundwork for their development of moral reasoning, honesty, and willingness to help and care for others. Role modeling by caring adults is important as it reinforces positive behaviors. major health problems of adolescents relate to their risk-taking behaviors. behaviors in females are more often influenced by a desire to maintain important relationships than a desire to "take on" adult behaviors. Female adolescent morbidity is most likely to include pregnancy, sexually transmitted infections, running away, and suicide. Risk taking can also be a result of the young girl's environment, or it may be an expression of symptoms of depression. Trust is a key component of any therapeutic relationship. example, "Tell me about your friends or who you hang out with" and "How would you describe yourself in relation to your friends?" are the types of questions that can be asked of an adolescent during a healthcare visit to assess who influences the adolescent and how she sees herself in relationship to others. goal is not to isolate the behavior from the relational context in which it occurs, but rather to acknowledge the health implications of behaviors. This enables a more effective approach to risk reduction because the behavior is addressed along with the context in which it occurs.

contraception- adolescent article

Adolescents often do not seek reproductive healthcare for 6-12 mo after initiating sex; many will become pregnant and/or acquire an STI during this interval. Appropriate counseling and educational interventions with adolescents, including the healthcare provider raising the topic of prevention, can decrease sexual risk behavior; youth who plan sexual initiation (as opposed to "it just happened") are 75% more likely to use contraception at sexual debut. The most commonly used method is the condom, followed by withdrawal and then the pill. Use of contraception at first sex has greatly increased over the last 50 yr and the condom is currently the most common method used at first sex, as reported by more than 75% of males and females. More than half of sexually experienced female teens are currently using most effective or moderately effective contraceptive methods, such as an intrauterine device (IUD) or contraceptive implant, oral contraceptive pills, the contraceptive patch, the vaginal ring, an injectable contraception, or, rarely, sterilization. The health screening interview during the adolescent preventive visit offers opportunities to identify and discuss unsafe sexual practices among sexually active adolescents and to identify and reinforce safe sexual behaviors including abstinence The goals of counseling with adolescents are to (1) understand adolescent perceptions and misperceptions about pregnancy and use of contraceptives; (2) help adolescents put unprotected intercourse risk in a personal perspective; (3) educate adolescents regarding the true risks and benefits for the various methods available; and (4) help adolescents choose a safe and effective method that can either be provided on site or be easily obtained by referral. Necessary concepts to address while discussing individual methods include how effective the method is, how long the method works, what behaviors are required for correct and consistent use, what side effects may be seen, and what signs or symptoms of complications should prompt a return visit. Once an adolescent chooses a method, the provider and teen should discuss clear plans on correct and consistent use of the chosen method and strategies for appropriate follow-up A pelvic examination is only required for placement of an IUD, unless otherwise indicated. STI screening is appropriate once sexual activity has begun; gonorrhea and chlamydia screening via a self-collected or provider-collected vaginal swab or urine sample is recommended unless symptoms require a pelvic exam. Guidelines from the American Congress of Obstetrics and Gynecology (ACOG) recommend that the first female teen visit to a gynecologist occur between the ages of 13 and 15 yr unless necessary at an earlier age. This visit aims to establish rapport, educate the patient and parents or guardian on healthy sexual development, and provide routine preventive services. Pap test for cervical cancer screening is not recommended until age 21 yr. DMPA is particularly attractive for adolescents who have difficulty with compliance, are intellectually or physically impaired, and are chronically ill or have a condition for which estrogen use is not recommended. Healthcare providers may want to consider a contraceptive containing estrogen in teens who are already at high risk for low bone density, such as those on chronic corticosteroids or those with eating disorders Progestin-only oral contraceptives are available for the adolescent in whom the use of estrogen is potentially deleterious, such those with active liver disease, replaced cardiac valves, or hypercoagulable states COCs Even though teenage smokers who use oral contraceptives have more than twice the risk of myocardial infarction, the likelihood of its occurrence is very small, and thus clinically insignificant, compared to the risk of dying from other pregnancy-related complications. The effectiveness of COCs is dependent on compliance, and unfortunately adolescents may forget to take a pill each day. Teens can access EC information through a hotline at 1-888-NOT-2-LATE to obtain EC pills over the counter. The American Academy of Pediatrics recommends advance provision of EC pills for teens who are or may become sexually active. A follow-up appointment is also recommended to determine the effectiveness of treatment and to diagnose a possible early pregnancy. The visit also provides an opportunity to counsel the adolescent, explore the situation leading up to the unprotected intercourse or contraceptive failure, test for STIs, offer HIV testing, and initiate continuing contraception when appropriate. Pap smear screening is not initiated until 21 yr of age. Ulipristal Acetate This is the newest formulation available for EC and was FDA approved in 2010 for use up to 120 hr after unprotected sex. It is available only by prescription regardless of age. It has been shown in a few studies to be more effective than levonorgestrel at and beyond 72 hr. Levonorgestrel In 2009, the FDA approved the emergency contraceptive drug Plan B as an over-the-counter option for women age 17 yr and older. Experience in adolescent women demonstrates more effective use of EC with advance provision and is not associated with more frequent unprotected intercourse or less condom or pill use. Nausea and vomiting are uncommon side effects, and in a recent comparison, levonorgestrel proved more effective at preventing pregnancy than the Yuzpe method. Dual protection is the protection against STIs/HIV as well as effective contraception. Although condoms can provide both, providers should encourage more highly effective contraceptive methods along with condoms for each act of intercourse. A female condom is available over-the-counter in single-size disposable units. It is a second choice over the male latex condom because of the complexity of properly using the device, its high typical use failure rate of 21%, Most adolescents would require intensive education and hands-on practice to use it effectively. Adolescents tend to object to the messiness of the jelly or to the fact that the insertion of a diaphragm may interrupt the spontaneity of sex, or they may express discomfort about touching their genitals. Spermicides should be used in combination with other barrier methods as their typical use failure rate alone is 28%. withdrawal- high typical use failure rate of 22% should be specifically addressed with young adolescents; especially since over half (58%) of teens have used withdrawal for contraception. FABM less common in teens, these should be used with caution. The lactational amenorrhea method may be a highly effective temporary contraceptive method if all of the following criteria are met: (a) no return of menses, (b) the infant is <6 mo old, and (c) exclusively breastfeeding.

Clinical Pathology Screening Guidelines for the Prevention and Early Detection of Cervical Cancer article

The optimal screening strategy should identify those cervical cancer precursors likely to progress to invasive cancers (maximizing the benefits of screening) and avoid detection and unnecessary treatment of transient HPV infection and its associated benign lesions that are not destined to become cancerous (minimizing the potential harms associated with screening). Cervical cancer screening should begin at age 21 years. Women under the age of 21 should not be screened regardless of the age of sexual initiation or other risk factors. earlier recommendations for annual screening were excessive and led to an increased rate of harms. Today, there is little evidence to support annual screening of women at any age. Annual screening leads to a very small increment in cancers prevented, at the cost of a very large excess of unnecessary procedures and treatments. high prevalence of transient, benign HPV infections and associated lesions, most of which will regress within a year or two or, of those that do not, are many years on average from causing cancer. Women at any age should NOT be screened annually by any screening method; rather, recommended screening intervals for women are based on age and clinical history. For women 21-29 years of age, screening with cytology alone every 3 years is recommended. HPV testing should not be used to screen women in this age group, either as a stand-alone test or as a cotest with cytology. Because of the high prevalence of HPV in women under the age of 30 HPV testing should not be used to screen women in this age group due to the potential harms as described above. Women ages 30-65 years should be screened with cytology and HPV testing (''cotesting'') every 5 years (preferred) or cytology alone every 3 years (acceptable). For women 30Y65 years of age, even with a history of negative cytology tests, the limited available evidence does not support a screening interval longer than 3 years. s increase in diagnostic lead-time with cotesting translates into lower risk following a negative screen, permitting a longer interval between screens with incident cancer rates similar to or lower than screening with cytology alone at shorter intervals. The lack of greater benefits and the increase in potential harms associated with screening more frequently support a recommendation of cotesting every 5 years. Compared with cytology, HPV testing is more sensitive but less specific for identifying women with prevalent CIN3+. When compared with women with negative cytology, those with negative HPV tests have a lower subsequent risk of CIN3+. healthcare providers can rely on the negative predictive value of the HPV test to assure women who cotest negative that they are at very low risk for CIN3 and cancer for at least 5 years after negative cotesting. HPV pos cytology negative cotest- Women cotesting HPV positive, cytology negative should be followed with either (as noted in the interim ASCCP guidelines: Option 1) repeat cotesting in 12 months, or Option 2) immediate HPV genotype-specific testing for HPV16 alone or for HPV16/18. If cotesting is repeated at 12 months, women testing positive on either test* should be referred to colposcopy; women testing negative on both tests** should return to routine screening. If immediate HPV genotypespecific testing is used, women testing HPV16 positive or HPV16/18 positive should be referred directly to colposcopy; women testing HPV16 negative or HPV16/18 negative should be cotested in 12 months, with management of results as described in option 1. Women cotesting HPV positive, cytology negative should not be referred directly to colposcopy. Furthermore, they should not be tested for individual HPV genotypes other than HPV16/18. The use of HPV genotype-specific testing for HPV16 or HPV16/18 is recommended only for the management of HPV-positive, cytology-negative women. Women with ASC-US cytology and a negative HPV test result should continue with routine screening as per age-specific guidelines. Women with HPV-positive ASC-US or abnormal cytology more severe than ASC-US (LSIL or more severe) regardless of their HPV status should be referred to colposcopy. The risks of CIN3+ and cancer following HPV-negative, LSIL+ cytology results are too great to warrant a return to routine screening. absolute risk of a true precancerous lesion in the HPV-negative, ASC-US cytology population is very low (less than 2% overall, and less than 1% when based on the most robust studies). This level of risk does not warrant more frequent screening. In most clinical settings, women ages 30-65 years should not be screened with HPV testing alone as an alternative to cotesting at 5-year intervals or cytology alone at 3-year intervals. lack of an internal standard for specimen adequacy for some HPV assays may provide false reassurance among a small number of women whose negative screening results may be a function of specimen inadequacy rather than true absence of disease. Such an event is less common with cytology since specimen adequacy assessment is a routine component of the evaluation, and inadequacy prompts intervention and follow-up on the part of the clinician and patient. Thus, the inclusion of cytology with HPV testing, i.e. cotesting, provides some additional reassurance against testing errors due to specimen inadequacy, although the benefits in terms of sensitivity and negative predictive values are only incremental. HPV testing alone for primary screening appears promising in women aged 30 years and older, as this group may be at greatest risk for developing CIN3+. HPV testing is more sensitive for detection of CIN2+ and CIN3+ than cytology alone and is almost as sensitive as cotesting. negative HPV test provided greater reassurance against CIN3+ in the subsequent 5Y7 years than cytology alone and is nearly as reassuring as a negative cotest. Therefore an acceptable screening interval for use of HPV testing alone should be comparable to that of cotesting. secondary biomarkers included HPV genotyping (for HPV16 or HPV16/18) [92, 100], HPV mRNA testing [112], and/or detection of other non-HPV biomarkers (e.g. p16INK4. no direct comparisons of these various triage strategies and the specificity of such an approach, and the consequential potential harms (or benefits) have not yet been well defined. Women over 65 years of age with evidence of adequate negative prior screening and no history of CIN2+ within the last 20 years should not be screened for cervical cancer with any modality. Once screening is discontinued it should not resume for any reason, even if a woman reports having a new sexual partner.* Following spontaneous regression or appropriate management of CIN2, CIN3, or adenocarcinoma in situ (AIS), routine screening should continue for at least 20 years (even if this extends screening past age 65). In well-screened women older than the age of 65 in the United States, CIN2+ prevalence is low [29, 113] and cervical cancer is rare [1]. In the U.S., cervical cancer is most commonly diagnosed in unscreened and under-screened women. Based on the extended natural history of the disease, it is improbable that incident HPV infections and newly detected CIN3 after the age of 65 will have sufficient time to progress to invasive cancer in the woman's lifetime but it is unlikely. most new carcinogenic HPV infections in women age 65 years or older should clear spontaneously, and only a small percentage is likely to persist. Since the transformation zone of older women is smaller and less accessible than in younger women. cancer develops at a median of approximately 20 to 25 years after an incident infection, screening this population would detect a very small number of new cases of CIN2+ and prevent very few cancers and even fewer cancer deaths. The risks associated with over-treatment in the elderly population outweigh the benefits. Women at any age following a hysterectomy with removal of the cervix who have no history of CIN2+ should not be screened for vaginal cancer using any modality. Evidence of adequate negative prior screening is not required. Once screening is discontinued it should not resume for any reason, including a woman's report of having a new sexual partner. vaginal cytology screens for primary vaginal cancer. Vaginal cancer is an uncommon gynecologic malignancy. Abnormal vaginal cytology is rarely of clinical importance. Therefore, there is no justification for continuing to screen these women for lower genital tract malignancies. Women who have had a hysterectomy for cervical intraepithelial lesions may be at increased risk of vaginal cancer, but the data are limited. even if women with hysterectomy were at an increased risk of vaginal cancer, there is no proven method to effectively intervene before vaginal cancer develops. Recommended screening practices should not change on the basis of HPV vaccination status. there are no data at this time that support changes in the age when screening is to be initiated or in the screening interval for U.S. women that have been vaccinated. The same recommendation applies to the individual woman who reports having been vaccinated

contraceptives- schuilling

Women who use contraceptives consistently and correctly account for only 5% of all unintended pregnancies. approximately 18% of women at risk of unintended pregnancy who use contraceptives but do so inconsistently account for 41% of unintended pregnancies; the 14% of women at risk of unintended pregnancy who do not use contraceptives at all or have a gap in use of 1 month or longer account for the remaining (54%) unintended pregnancies. A woman who is pressured into choosing a certain method is more likely to feel ambivalent about its use, leading to higher rates of inconsistent use and discontinuation. use of hormonal contraceptive methods may actually protect future fertility by decreasing the risk of endometriosis, ectopic pregnancy, pelvic inflammatory disease (PID), and abortion-related complications. Hormonal methods also decrease the risk of ovarian, endometrial, and colon cancer. the best method for any woman is the one that she wants and is motivated to use. Efficacy describes the likelihood that an unintended pregnancy will occur even when the method is used consistently and exactly as prescribed. inconsistent use or incorrect use are not included in "method failure" rates. Effectiveness , also termed "user failure" or "typical use" failure rates, is how well a method works in actual practice. Effectiveness describes all unintended pregnancies that occur if a method is not used properly, such as in the case of inconsistent or incorrect use. not all unintended pregnancies occur as a result of user errors. Clinicians should avoid implying that unintended pregnancies are the user's fault. any method used by younger women will have a higher failure rate than when the same method is used by older women. Other factors contributing to contraceptive success include the fertility of the male partner, the motivation to avoid pregnancy (as opposed to simply wanting to space pregnancies), relationship status, and frequency of sexual intercourse. nonhormonal: Physiologic methods: abstinence, coitus interruptus, lactational amenorrhea method (breastfeeding), and fertility awarenessbased (FAB) methods Barrier methods: male condoms, vaginal barrier methods, and spermicides Permanent contraception (sterilization): male and female the copper intrauterine device (IUD) The physiologic and barrier reversible nonhormonal contraceptive options generally require motivated users, and most of these methods necessitate taking action with every act of sexual intercourse. In general, their efficacy is less than that of hormonal methods, but these options do not have systemic side effects. also chosen for cultural beliefs. The permanent contraceptive options— that is, male and female sterilization— are the only permanent forms of contraception and require certainty that future childbearing is not desired. abstinence: Although abstinence is generally promoted as the method of choice for adolescents, counseling should include all contraceptive options. Efficacy and Effectiveness- Abstinence is 100% effective at preventing pregnancy. Safety and Side Effects- There are no contraindications to or side effects from using abstinence. Noncontraceptive Benefits- There are no noncontraceptive benefits of abstinence. Abstinence is readily available and completely effective. Abstinence prevents sexually transmitted infections (STIs), including infection with the human immunodeficiency virus (HIV) via penile- vaginal transmission, but users must be cautioned to avoid other sexual practices (e.g., oral sex and anal sex) that put them at risk for STIs. major disadvantage of abstinence is that it is unrealistic for most couples in long-term relationships to use abstinence exclusively for an extended period of time. coitus interruptus: Efficacy and Effectiveness- The theoretical efficacy of coitus interruptus is high, but the estimated typical use failure rate is around 22%. The long-held belief that preejaculatory fluid contains sperm, which could theoretically cause pregnancy even if withdrawal were used correctly, has been subjected to small clinical studies, with conflicting results. Safety and Side Effects- There are no contraindications to or side effects from using coitus interruptus. Noncontraceptive Benefits- There are no noncontraceptive benefits of coitus interruptus. Coitus interruptus is readily available, requires no supplies or cost, and is user controlled. Couples can use coitus interruptus intermittently when other methods are unavailable. Disadvantages include the need to use this method with every act of intercourse, and the need to exert the self-discipline and control necessary to stop intercourse. Coitus interruptus does not prevent STI transmission because penile- vaginal contact occurs, and HIV and other STIs can be present in pre-ejaculatory fluid. Women who use coitus interruptus should be educated about emergency contraception as a backup method. lactation amenorrhea: Infant suckling during breastfeeding increases maternal prolactin levels, which in turn inhibit ovulation, Three conditions must be met- exclusive BF, amenorrhea, <6mths. Efficacy and Effectiveness- Breastfeeding is an extremely effective method of contraception if the conditions for its use are met. Failures typically occur when breastfeeding is nonexclusive or after the infant reaches 6 months of age. In these instances, the likelihood of ovulation increases and the woman may be unaware of her return to fertility. Safety and Side Effects- There are no contraindications to LAM, but breastfeeding is not recommended for women who are HIV positive in countries such as the United States where infant formula is accessible, or for women who are taking medications that could be harmful to the infant. The only side effects of LAM are those associated with breastfeeding, such as sore nipples and mastitis. Noncontraceptive Benefits- Women who breastfeed their infants have decreased risk of ovarian, endometrial, and breast cancers. Breastfeeding also has numerous benefits for infant health. Advantages and Disadvantages- LAM is readily available, free, and can be used immediately postpartum. The disadvantages of LAM are that it is available only to women who are breastfeeding, its duration of use is limited, and women may have difficulty sustaining the patterns of breastfeeding required to maintain contraceptive effectiveness. In addition, LAM does not provide protection from STIs. fertility awareness based methods: "fertile window" or time when intercourse is most likely to result in pregnancy comprises the 5 days before plus the day of ovulation. The fertile window can be identified with calendar methods or by using signs and symptoms of ovulation. calendar FAB method, the woman records the length of 6 to 12 menstrual cycles and determines the longest and shortest cycles. She then uses that information to identify the first (days in shortest cycle minus 18) and last (days in longest cycle minus 11) fertile days each month. Calculations must be updated with each cycle. requires careful calculations that can be confusing, the Standard Days Method (SDM) was developed as a simpler calendar method. Women using the SDM are advised to use abstinence or a barrier contraceptive on days 8 to 19. CycleBeads can be used in conjunction with the SDM to help women keep track of their fertile window. is recommended for women whose cycles are 26 to 32 days. apps for smartphones and tablets that can be used to track cycles for the FAB method. post ovulation method- woman subtracts 14 days from her average cycle length to predict the day of ovulation. Abstinence or a barrier method is used during the first half of the cycle until the fourth morning after the predicted day of ovulation.requires longest period of abstenance or use of contraception. Signs and symptoms of ovulation include a rise in the basal body temperature (BBT) and changes in cervical mucus. The BBT increases at the time of ovulation and remains elevated for the rest of the cycle. Using BBT charting in conjunction with the postovulation observations is beneficial, but predicting the fertile period with BBT is difficult because ovulation has already occurred once the rise in temperature is observed. Billings ovulation method uses assessment of cervical mucus to determine the fertile window. Women check daily for the increased, clear, stretchy, slippery cervical secretions associated with ovulation. The fertile time lasts from the day when ovulatory cervical secretions are first observed until 4 days after they are last observed. The TwoDay Method is a simplified version of the ovulation method. The woman checks daily for cervical secretions, fertile any day that she has cervical secretions present or had them present the day before. The symptothermal method involves observing multiple indicators of the fertile window; the most common combination is assessment of cervical mucus and daily BBT charting. The cervical secretions can be used to identify the beginning of the fertile window, and the BBT can be used to detect the end. Some women using the symptothermal method also assess cervical position and signs of ovulation (e.g., mittelschmerz). Home ovulation tests originally used for women with infertility (e.g., Clearblue Easy Fertility Monitor) can be used in conjunction with the calendar, ovulation, or symptothermal methods to improve their effectiveness. Efficacy and Effectiveness The theoretical efficacy of FAB methods varies according to the specific technique used. typical use failure rate reflects the difficulty of using these methods correctly and consistently. typical use effectiveness rates of 88% and 86% for the SDM and the TwoDay Method, respectively. Safety and Side Effects- There are no health concerns with the use of FAB methods, but certain circumstances or conditions complicate their use. These factors include the postpartum period, breastfeeding, having an abortion immediately before their use, recent menarche or perimenopause when cycles may be irregular, medications that alter the regularity of cycles or fertility signs, vaginal discharge, irregular vaginal bleeding, and conditions associated with elevated body temperature. There are no side effects of FAB methods. Noncontraceptive Benefits- The principles of FAB methods can also be used to conceive when couples decide they want children. Advantages and Disadvantages- Women may have to pay for FAB methods training or supplies (e.g., basal body thermometer, CycleBeads), but there is no ongoing cost unless a barrier contraceptive is used during the fertile window. These methods are user controlled and may be the only acceptable form of contraception for members of some religions and cultures. Disadvantages include the need for detailed education, ongoing attention to identifying the fertile window, and abstaining from intercourse or using an additional contraceptive method several days each month. FAB methods do not protect either partner from STIs, and users should be educated about emergency contraception. barrier methods: hormone-free aspects of barrier methods, but largely indicates recognition of their potential role as dual protection against pregnancy and STIs, including HIV. The cervix is the point of entry for many sexually transmitted pathogens. Protecting the cervix via chemical or physical barriers is an expanding area of research in the prevention of STIs. Finally, barrier contraceptives can be used by most people because contraindications to the use of these methods are rare. Nonlatex condoms are odorless, colorless, and nonallergenic. They transmit body heat better and have a looser fit, theoretically allowing more sensitivity. They can be used with any lubricant and do not usually deteriorate with the use of oil-based lubricants or under adverse storage conditions. Nonlatex condoms appear to have twice the odds of breakage or slippage during intercourse or withdrawal compared to latex condoms. Efficacy and Effectiveness- When used correctly and consistently, latex condoms are an effective form of contraception. Condom failures are commonly related to breakage of the condom, or slippage during intercourse or while removing the condom. In general, pregnancy rates for nonlatex condoms are slightly higher than the corresponding rates for latex condoms, but within the range considered acceptable for barrier methods. As noted, nonlatex condoms have higher reported rates of breakage and slippage than latex condoms. It is unclear whether this difference is related to the product or to a lack of familiarity with the product. Safety and Side Effects- Latex condoms should not be used by persons with known latex allergies. Some women report genital irritation and discomfort from the use of condoms, an issue that may be related either to the condom or to concomitant lubricant use. Some condoms are lubricated with a spermicide (nonoxynol-9 [N-9]) that may produce genital irritation in some women. female partners in the polyurethane group had significantly less genital pain, pruritus, and vaginal pain than their counterparts in the latex condom group. Noncontraceptive Benefits- Condoms are routinely recommended for their noncontraceptive benefit of protection from STIs. Consistent use of latex condoms in sexually active HIV-serodiscordant couples can result in an 80% reduction in the incidence of HIV infection. Condoms also offer statistically significant protection against gonorrhea, chlamydia, herpes simplex virus (HSV) type 2, and syphilis, and they may protect women from trichomoniasis. While condoms do not appear to offer protection against human papillomavirus (HPV) infection, their use is associated with higher rates of cervical intraepithelial neoplasia regression and cervical HPV infection clearance. Advantages and Disadvantages- Condoms have the advantage of being widely available on an over-the-counter basis, without the need for clinician visit or prescription. The nonlatex condoms tend to be more expensive than their latex counterparts. The effectiveness of condoms is coitus dependent. Correct use is critical to prevent breakage, slippage, and resultant unintended pregnancy. A potential disadvantage of using condoms as a contraceptive method is that they are male controlled. Women who are in relationships where they cannot negotiate condom use with their partners need a method they can control. spermicides: chemical barriers that are used either alone or in conjunction with a physical barrier (such as a condom, diaphragm, or sponge) to prevent pregnancy. The most common spermicides currently marketed in the United States contain N-9. This product may be formulated as a gel, cream, foam, suppository, foaming tablet, or film, and is generally provided in 50to 150-milligram (mg) dosages. Efficacy and Effectiveness- Studies comparing N-9 in various formulations (vaginal contraceptive film, foaming tablets, suppositories, and gels), each used without condoms or other physical barriers, showed typical use pregnancy rates over 6 months that ranged from 10% to 15% to a high of 28%. These rates are higher than those for other barrier contraceptives. Formulations containing at least 100 mg of N-9 are associated with lower unintended pregnancy rates. Although the effectiveness of spermicides used as a sole agent is less than that of other contraceptive methods, spermicide use is more effective than using no method at all. Safety and Side Effects- N-9 is a surfactant, and surfactants can disrupt cell membranes. By extension, it was envisioned that the surfactant in this product would also act against pathogenic organisms and protect the user against gonorrhea, chlamydia, herpes, and syphilis. Studies from the late 1980s suggested that N-9 could inactivate HIV and other STIs. However, more recent studies have shown that N-9 is an irritant to both animal and human tissue. Frequent use is associated with increased reports of vaginal irritation. As an irritant, N-9 has the potential to disrupt or damage epithelial tissue in both the vagina and the rectum. The risk of this disruption increases with frequency of use and dose. Because intact tissue is the first defense against infection, use of N-9 could, therefore, potentially. increase the risk of transmission of infection by causing microabrasions in the epithelium. In addition, strong evidence indicates that N-9 does not reduce STIs among sex workers or women attending STI clinics. In fact, some research suggests that N-9 use can even increase the risk of HIV acquisition in high-risk women. N-9 should not be used for purposes of STI protection. N-9 should not be used by women who engage in multiple daily acts of intercourse. N-9 should not be used by women at high risk for HIV acquisition. N-9 should not be used rectally. The likelihood of women who use N-9 for contraception developing specific genitourinary symptoms after 6 to 7 months of use is 13% to 17% for a yeast infection, 8% to 12% for bacterial vaginosis, 19% to 27% for vulvovaginal irritation, and 11% to 15% for urinary tract symptoms (but only 3% to 6% for culture-proven urinary tract infection). reported rates are high enough to warrant counseling women to report symptoms so that they can be evaluated, diagnosed, and properly treated. Noncontraceptive Benefits- Despite concerns about the potential for cervicovaginal epithelial disruption with N-9-based spermicides, vaginally applied chemical barriers remain appealing. This attraction stems largely from their potential to provide dual protection— they can be both spermicidal and microbicidal. Woman-controlled, vaginally applied, lubricating microbicides offer great potential for protection against STIs, including HIV. Advantages and Disadvantages- Spermicides containing N-9 are widely available as over-thecounter products and do not require a prescription or clinician visit. Thus they are readily accessible to women who need personally controlled, discreet, low-cost contraception. The effectiveness of spermicides is coitus dependent. Disadvantages include the low contraceptive effectiveness and the potential for symptoms of cervicovaginal irritation. As noted earlier, women who engage in multiple daily acts of intercourse or who are at high risk for STIs should avoid use of spermicides containing N-9. diaphragms: shallow dome shaped cup, inserted into vagina to cover cervix. Efficacy and Effectiveness- The contraceptive efficacy of the diaphragm is similar to that of the male condom. Traditional diaphragms are designed to be used in conjunction with a spermicide. During sexual excitement, the upper part of the vagina expands; thus, diaphragms and other devices that might be in contact with the vaginal walls during fitting may no longer provide a complete physical barrier to sperm migration during intercourse. Theoretically, an additional and important function of the diaphragm would be to maintain spermicide in contact with the cervical os, thereby ensuring that sperm are trapped by the chemical barrier. Safety and Side Effects- The spermicide side effects. diaphragm as a category 3 or 4 method for women with HIV/AIDS or at high risk of HIV infection; this is solely due to concerns about the spermicide. made of silicone and can be used by women with latex allergies. Water-based products (rather than those containing silicone) are recommended for women who wish to use a lubricant with silicone diaphragms. Irritation or even abrasions of the vaginal mucosa have been noted in women with improperly sized diaphragms or prolonged retention of the diaphragm in the vagina. Although no clear association with toxic shock syndrome has been demonstrated, diaphragms and other contraceptive barrier devices should not be left in the vagina for more than 24 hours, and their use during menses is discouraged. Urinary tract infections are more common in diaphragm users than among women using hormonal contraceptives. mechanical: The rim of the diaphragm may exert pressure against the urethra, which might be perceived as frequency, dysuria, or incomplete bladder emptying, and may lead to infection. The second factor is that the spermicides used with the diaphragm can alter normal vaginal flora and may increase the likelihood of Escherichia coli bacteriuria. Noncontraceptive Benefits- The diaphragm has possible or theoretical value in protecting the cervix from infection, but data demonstrating such a protective effect are not currently available. The only barrier methods known to reduce STIs are male and female condoms. Advantages and Disadvantages- Diaphragms are user-controlled, nonhormonal contraceptive methods that are needed only at the time of intercourse. One of the diaphragms currently available in the United States comes in multiple sizes, varying in diameter . This device must be fit by a clinician and requires a prescription to purchase. A new one-size-fits-all diaphragm is also available in the United States by prescription. As a result of the need for a clinician visit, diaphragms have a higher initiation cost than condoms, but can be used for years with proper care. The only additional cost is the spermicide that must be used with the diaphragm. Diaphragms are washable and reusable. Proper use is important. Users should be counseled on the timing of insertion and removal, use of spermicide, appropriate care of the device, and need for periodic reevaluation of the size. cervical caps: cuplike devices that cover the cervix. Smaller than diaphragms, they maintain their position over the cervix by suction, adhering to the cervix, or via a design that uses vaginal walls for support. FemCap. silicone and has a design like an inverted sailor's cap. The dome covers the cervix, and the longer side of the brim fits into the back of the vagina. Three sizes are available, and selection is determined by pregnancy and birth history (the 22-cm FemCap is for women who have never been pregnant; the 26-cm FemCap is for women who have had a miscarriage, abortion, or cesarean birth; the 30-cm FemCap is for women who have had a vaginal birth). The FemCap can be worn for as long as 48 hours, but, as with all vaginal devices, should not be used during menses. The device is designed to be used with a thin layer of spermicide around the outer brim. Efficacy and Effectiveness- The FemCap was not as effective in preventing pregnancy as the traditional diaphragm in clinical studies; the extrapolated annual failure rates slightly exceed 20%. Cervical caps may be less effective in women who have had children than in those who have not. Safety and Side Effects- FemCap users had significantly fewer urinary tract infections (7.5%) than those in the diaphragm group (12.4%). In this same study, there were no differences in vaginitis, irritation, dysmenorrhea, or Pap test changes between the groups. Noncontraceptive Benefits- The cervical cap has possible or theoretical value in protecting the cervix from infection, but there are no data to support this benefit. The only barrier methods known to reduce STIs are male and female condoms. Advantages and Disadvantages- Cervical caps are coitus dependent and may be appropriate for women who do not want or cannot use hormonal contraception. The latex-free FemCap is appropriate for women who have, or whose partners have, latex allergies. Insertion and removal of cervical caps may be complex for some women; these women will need additional teaching and counseling to use this contraceptive method consistently and correctly. more insertion and removal problems were noted with FemCap than with the traditional diaphragm. Approximately 10% to 15% of research participants could not be fit with the FemCap or were unable to insert or remove it. Caps require an initial cost for fitting and purchase, but should last for approximately 2 years with proper care. Ongoing costs include the purchase of spermicides. The FemCap website ( http://www.femcap.com ) provides detailed information about obtaining this device. vaginal sponges: single-use, soft, absorbent, polyurethane device that contains approximately 1,000 mg of N-9 spermicide; when moistened, the sponge gradually releases 125 to 150 mg of spermicide over 24 hours of use. Its primary contraceptive effectiveness derives from the gradual release of spermicide, but it also provides a physical barrier to the cervix and absorbs semen. The vaginal sponge can be used for multiple episodes of coitus over 24 hours without inserting more spermicide. Efficacy and Effectiveness Typical use pregnancy rates are somewhat higher among parous women who use contraceptive sponges than among women who use diaphragms, although rates for nulliparous women are similar. Safety and Side Effects- Women who use the vaginal sponge tend to discontinue use of their method at higher rates than women who use the diaphragm. Allergic-type reactions, such as dermatitis, erythema, irritation, and vaginal itching, were more common with the sponge. Four cases of toxic shock syndrome among users of the sponge were reported in 1983. These were associated with recent childbirth, use of the method for more than 24 hours, and/or difficult removal with fragmentation of the sponge. Given the number of sponges sold during that time, experts estimated that the risk of toxic shock syndrome was extremely low— approximately 10 cases per year per 100,000 women using sponges. Noncontraceptive Benefits- There are no data to suggest that the contraceptive sponge has value in protecting the cervix from infection; the only barrier methods known to reduce STIs are male and female condoms. Advantages and Disadvantages- The sponge shares the advantages and disadvantages of other nonhormonal barrier, coitus-dependent methods. It does not require a clinician visit or fitting and is available on an over-the-counter basis. Its single-use application may prove more expensive over time than methods that can be reused. female condoms: barrier device designed to protect the cervix, vagina, and part of the vulva and perineum. It was developed as an alternative to male condoms to give women a nonprescription barrier contraceptive method that they could control and that would reduce their exposure to STIs. The female condom available in the United States is a sheath made from a nitrile polymer, which is soft and smooth, and quickly warms to body temperature. A small ring at the closed end of the sheath is inserted high in the vagina. A larger ring rests outside the vagina against the vulva and acts as a guide during penetration. This ring also maintains the sheath covering the full length of the vagina and prevents it from "bunching up" inside the vagina. The sheath is coated with a silicone-based, nonspermicidal lubricant, and women can use additional lubricant as well. should not be used simultaneously with a male condom, as this practice increases the risk of breakage. It should not be used with the diaphragm, cervical cap, or contraceptive vaginal ring, as the inner ring of the female condom fits into the same place by the cervix as those methods. Efficacy and Effectiveness- The effectiveness of the female condom in preventing pregnancy is in the same range as that of other barrier methods. Safety and Side Effects- Female condoms are made of a synthetic rubber called nitrile and so do not present problems for people with latex allergies. Noncontraceptive Benefits- The female condom can protect against some STIs. Advantages and Disadvantages- The female condom is a nonhormonal, female-controlled method that is available as an over-the-counter product. users prefer the male condom to the female condom. Some women find the female condom difficult to insert, although this problem decreases with proper education. male partner cooperation may still be necessary for consistent use; the partner's lack of acceptance is often cited as a reason for discontinuation. Female condoms can be used only once, and are more expensive than male condoms, so this method can be costly over time. permanent contraception: Permanent contraception, or sterilization, is one of the most prevalent contraceptive methods in the United States. People choose sterilization when they are sure they do not want any children or any more children. Approximately 600,000 tubal occlusions and 200,000 vasectomies are performed annually in the United States. female sterilization: Female sterilization involves permanently blocking the fallopian tubes, which prevents sperm from ascending the reproductive tract and thereby meeting and fertilizing an egg released from the ovary. Female sterilization can be performed postpartum, post abortion, or as an "interval" procedure unrelated to pregnancy. surgical approaches employed include laparoscopy, mini-laparotomy, transcervical or hysteroscopic methods, and procedures concurrent with a cesarean birth. mechanical occlusion using clips, rings, or bands; and ligation or salpingectomy. generally effective immediately. (Essure) is performed via hysteroscopy and can be done in an office setting. Essure involves placement of micro-inserts of metal and fibers into the fallopian tubes. After placement, tissue grows into the insert or matrix, effectively blocking the tubes. A hysterosalpingogram (HSG) must be performed 3 months after the procedure to confirm tubal occlusion, and women must continue to use reliable contraception until sterilization effectiveness is confirmed with HSG. Efficacy and Effectiveness- Tubal sterilizationis a highly effective contraceptive method. Although its overall failure rate is low, failures do occur and are more frequent in women who are younger at the time of sterilization. Failure rates are similar to those of other highly effective, long-term contraceptive methods such as the progestin implant and intrauterine contraception. pregnancy probability at 1 year and cumulatively over 10 years is expected to be higher in women having hysteroscopic sterilization as compared to laparoscopic sterilization. Many experts recommend timing an interval procedure during the follicular phase of the menstrual cycle and using a highly sensitive pregnancy test prior to surgery to reduce the risk of pregnancies that are conceived but not recognized before sterilization is performed. Safety and Side Effects- Sterilization is a very effective method of contraception, but when pregnancy does occur after tubal sterilization, the risk of ectopic pregnancy is high. The rate was 3.5 times higher in women sterilized before the age of 28 years than in women sterilized after age 33. Other risks are related to the surgical procedures used and include infection, hemorrhage, anesthesia complications, and surgical trauma or injury. The likelihood of these complications is very low, with such events occurring in fewer than 1% of all procedures. The transcervical sterilization methods avoid the risks of abdominal incisions and anesthesia. A "post-tubal syndrome" has been described, which typically includes increased dysmenorrhea and abnormalities in the menstrual cycle. Most authorities believe such symptoms are more likely related to discontinuing hormonal contraceptives, or simply getting older and entering perimenopause. There is no consistent evidence of a true post-tubal syndrome within the first 2 years after the procedure. Noncontraceptive Benefits- There is a decreased risk of ovarian cancer following tubal sterilization. lower risk of PID among women who have been sterilized compared to women who have not undergone sterilization. The reasons for this effect are not entirely clear but could be related to mechanical blockage of the ascending spread of pathologic organisms. Advantages and Disadvantages- Tubal sterilization is a highly effective permanent method of contraception, and one that is well suited to women who do not desire future fertility. The surgical procedures are expensive, however, and insurance coverage for them varies. Additional barriers to access include requirements for a waiting period after signing consent and minimum age requirements. Studies in the United States suggest that women who have been sterilized are less likely to return for annual checkups or to use other preventive health services such as Pap tests. Counseling for women contemplating or undergoing sterilization should include the continued need for preventive health services. The younger the woman is at the time of her sterilization, the more likely she is during subsequent years to express regret about having the procedure. Younger women are also more likely to inquire about or seek a reversal of the procedure than older women male sterilization: vasectomy, cut/block right and left vas deferens (carries sperm from testes. vasectomy, vassal occlusion, and vassal injection. Vasectomy is the most common. Sperm account for only 5% of the semen that is produced by the prostate and other glands; thus, there is only a minimal decrease in the amount of seminal fluid following male sterilization. Vasectomies have no effect on sex drive, male hormone production, or sexual function. With the "no-scalpel" method, the skin of the scrotum is pierced and the vas exposed and blocked through an opening so small it does not require stitches. A systematic review showed that the no-scalpel approach resulted in less bleeding, hematoma, infection, and pain as well as a shorter operation time than the traditional incision technique- just as effective. takes between 15 and 20 ejaculations to clear all sperm from the reproductive tract and be assured of contraception. The current recommendation is for men to wait 3. months, rather than a specific number of ejaculations, before relying on vasectomy. Men are usually advised to have a follow-up visit and examination of ejaculate to ensure the absence of sperm before they stop using other contraceptive methods. Efficacy and Effectiveness- failure rate of vasectomy to be less than 1%, which is similar to the rate associated with female sterilization. Safety and Side Effects- Most men will experience some degree of postoperative discomfort; infection and scrotal hematoma occur on rare occasions. Some men experience chronic testicular pain after vasectomy, but only a small percentage (3% or fewer) report pain that negatively affects their life or causes them to regret having had the procedure. Antisperm antibodies are more common among men who have had vasectomies than the general population, although this condition does not appear to be associated with any adverse health consequences. Vasectomy does not increase the risk of prostate cancer. No benefits other than contraception have been demonstrated to date for vasectomy. Advantages and Disadvantages- Vasectomy is a simple procedure that is less complicated and less costly than female sterilization for couples wishing permanent contraception. As is true with tubal sterilization, regret may occur with certain unanticipated life changes. Reversal has a better chance of success when performed within 10 years of vasectomy; pregnancy rates decrease as the interval between vasectomy and reversal increases. Men need to be counseled that vasectomy does not prevent STIs. barrier methods advantages- non hormonal, dont require daily action, some available w/o Rx, some offer protection against STI. disadvantages- require planning, application at time of intercourse, interruptive, break or slip during intercourse increase risk of pregnancy.

6. Define HT (there is no 7)

definition: (google) treatment with estrogens with the aim of alleviating menopausal symptoms or osteoporosis. schuilling: Prior to prescribing HT, it is imperative that clinicians and their patients review any cautions or contraindications to hormone use. must engage the woman in the decisionmaking process and weigh the risks, benefits, and scientific uncertainty with each woman to individualize her treatment options. The risk of breast cancer increases after 3 to 5 years of EPT. HT should not be used for protection against CVD or dementia. Use of HT within the first 10 years of menopause has not been shown to increase the risk for CVD. Recent data do not support a decreased risk of dementia with HT use. estrogen progestogen therapy: Combination estrogen and progestogen therapy can be taken either sequentially (CS-EPT) or continuously (CC-EPT). In the sequential regimen, an estrogen is taken daily with the addition of a progestogen in a cyclic fashion, usually on days 1 to 12 of the month. One side effect often noted with this therapy is that most women will have a withdrawal bleed monthly. To avoid this consequence, the continuous regimen was developed, in which the estrogen and progestogen are taken on a daily basis. Another option includes pulsed combination therapy, wherein the progestogen is taken for 2 days, followed by a day off, in a repeating pattern. The original idea was to reduce potential side effects from the progestogen; however, breakthrough bleeding is usually more problematic with this regimen. A less frequently used regimen is the cyclic regimen, in which estrogen is taken daily for the first 21 days of the cycle and then progestogen is added for days 12 to 21. A withdrawal bleed usually occurs between days 22 and 28, during which neither estrogen nor progestogen is taken. In addition, menopause-related symptoms usually rebound when the estrogen is not taken; therefore, few women opt for the cyclic regimen. estrogens: A variety of estrogen compounds exist: estrogens that are bioidentical and transformed into human estrogens, such as 17beta estradiol, estriol, and estrone; synthetic estrogen analogues, such as ethinyl estradiol; and nonhuman conjugated estrogens, such as CEE, conjugated estrogens, A and B. CEE is the most widely used estrogen and has been the product used in the majority of clinical trials, including the WHI and the Heart and Estrogen/Progestin Replacement Study (HERS). Estrogens differ in their target tissue response and dose equivalency. They can be administered either systemically or locally. Systemic preparations are available as oral tablets and transdermal patches, creams, sprays, and gels. Local preparations are available as creams, tablets, and rings. The vaginal ring releasing 0.5 mg or 0.1 mg/day of estradiol acetate over 3 months is the only local treatment that has proved effective in treating hot flashes (ePocrates, updated daily; NAMS, 2014 ). Local treatment with estrogen theoretically avoids systemic absorption; however, in a review of the studies on vaginal preparations, Crandall ( 2002 ) found that the ring has slightly more systemic absorption. Women who want to avoid systemic effects, such as breast cancer survivors, should probably use a different preparation until more evidence is available. Progestogens are hormones that possess progestational properties. The most commonly prescribed progestogen has been MPA, but others are being used with more regularity, such as micronized progesterone (which is bioidentical), norgestimate, and norethindrone acetate. Many women seek "natural" hormones, believing that they are less likely to cause harmful side effects than pharmaceutically manufactured hormones. The term natural actually refers to any product with principal components that originate from plant, animal, or mineral sources. Thus, this definition encompasses pharmaceutically manufactured hormones, which are also derived from animal, plant, or mineral substances. Natural hormones are not necessarily identical to the hormones produced by a woman's body. Hormones that are identical to those made in the human body are available through prescription from both usual and compounding pharmacies. Several hormones that are pharmaceutically manufactured are available that are bioidentical to the hormones produced in women's bodies. Frequently women requesting "natural hormones" are actually seeking bioidentical formulations. Pharmaceutically manufactured estrogens are available in bioidentical formulations such as estrone, estriol, and 17-beta estradiol. Bioidentical progesterone is also available in micronized form. "Bioidentical" hormones can also refer to hormones compounded for a specific woman and made in a compounding pharmacy rather than by a commercial pharmaceutical company. clarify exactly what a women is requesting and to ensure that the source is following FDA regulations. The FDA ( 2008a ) does not recognize the marketing term bioidentical hormone replacement therapy- FDA took action against compounding pharmacies to stop unwarranted and misleading claims in advertisements that their products are safer than the estrogen products produced by traditional pharmaceutical companies. In reality, all estrogens carry a similar safety and risk profile. Several different progesterone creams are available as over-thecounter products and from compounding pharmacies. FDA regulations are not currently enforced for these products, again raising concerns about their purity and content. Over-the-counter progesterone creams include products such as PhytoGest, ProGest, Endocreme, and Pro-Dermex.

CDC med eligibility criteria for contraceptive article

elements considered when choosing appropriate method of contraceptive- include safety, effectiveness, availability (including accessibility and affordability), and acceptability. category 1 means that the methodp can be used in that circumstance with no restrictions with regard to safety but does not necessarily imply that the method is the best choice for that person; other factors, such as effectiveness, availability, and acceptability, might play an important role in determining the most appropriate choice. In choosing a method of contraception, dual protection from the simultaneous risk for HIV and other STDs also should be considered. Although hormonal contraceptives and IUDs are highly effective at preventing pregnancy, they do not protect against STDs, including HIV. male latex condom reduces the risk for HIV infection and other STDs, including chlamydial infection, gonococcal infection, and trichomoniasis. female condoms can provide protection from acquisition and transmission of STDs. All patients, regardless of contraceptive choice, should be counseled about the use of condoms and the risk for STDs, including HIV infection. effectiveness of contraceptive methods depends both on the inherent effectiveness of the method itself and on how consistently and correctly it is used. IUDs and implants are considered long-acting, reversible contraception (LARC); these methods are highly effective because they do not depend on regular compliance from the user. conditions that might make pregnancy an unacceptable health risk, long-acting, highly effective contraceptive methods might be the best choice. While the woman's medical condition may not affect her eligibility to use certain contraceptive methods, women using teratogenic drugs are at increased risk for poor pregnancy outcomes; long-acting, highly effective contraceptive methods might be the best option to avoid unintended pregnancy or delay pregnancy until teratogenic drugs are no longer needed. Conditions associated with increased risk for adverse health events as a result of pregnancy: Breast cancer Complicated valvular heart disease Cystic fibrosis Diabetes: insulin dependent; with nephropathy, retinopathy, or neuropathy or other vascular disease; or of >20 years' duration Endometrial or ovarian cancer Epilepsy Hypertension (systolic ≥160 mm Hg or diastolic ≥100 mm Hg) History of bariatric surgery within the past 2 years HIV: not clinically well or not receiving antiretroviral therapy Ischemic heart disease Gestational trophoblastic disease Hepatocellular adenoma and malignant liver tumors (hepatoma) Peripartum cardiomyopathy Schistosomiasis with fibrosis of the liver Severe (decompensated) cirrhosis Sickle cell disease Solid organ transplantation within the past 2 years Stroke Systemic lupus erythematosus Thrombogenic mutations Tuberculosis effectiveness of methods: less than 1 per 100 women/yr- reversible (implant and IUD) permanent male/female sterilization (use another method for first 3mths 6-12 per 100women/yr- injection (get inj. on time), pill (take pill each day), patch & ring (keep in place change on time), diaphragm (use correctly every time) 18or more per 100/yr- male condom, female condom, withdrawal, sponge (use correctly every time) least effective- fertility awarement (calender- abstain or use condoms on fertile days), spermicide. Classifications for intrauterine devices (IUDs) are for the copper-containing IUD and levonorgestrel-releasing IUD (containing a total of either 13.5 mg or 52 mg levonorgestrel). women using these methods should be counseled that consistent and correct use of the male latex condom reduces the risk for transmission of HIV and other STDs. IUD is not indicated during pregnancy and should not be used because of the risk for serious pelvic infection and septic spontaneous abortion. Concern exists both about the risk for expulsion from nulliparity and for STDs from sexual behavior in younger age groups <20yrs. Insertion of IUDs among postpartum women is safe and does not appear to increase health risks associated with IUD use such as infection. Higher rates of expulsion during the postpartum period should be considered as they relate to effectiveness, along with patient access to interval placement (i.e., not related to pregnancy) when expulsion rates are lower. immediate postplacental (<10 minutes) and early postpartum (10 minutes up until 72 hours) placement of Cu-IUDs and LNG-IUDs is associated with increased risk for expulsion. Breastfeeding women using IUDs do not have an increased risk for certain IUD-related adverse events including expulsion, infection, pain, or bleeding compared with nonbreastfeeding women. The risk for perforation is increased independently among breastfeeding women and among women ≤36 weeks postpartum, compared with non-postpartum women; however, the absolute risk for perforation remains low. IUDs can be inserted immediately after spontaneous or induced abortion. The absolute risk for ectopic pregnancy is extremely low because of the high effectiveness of IUDs. However, when a woman becomes pregnant during IUD use, the relative likelihood of ectopic pregnancy increases substantially. The LNG-IUD might be a useful treatment for menorrhagia in women receiving long-term anticoagulation therapy. Theoretical concern exists about the effect of LNG on lipids. Use of Cu-IUDs has no restrictions. IUD insertion might induce cardiac arrhythmias in healthy women; women with peripartum cardiomyopathy have a high incidence of cardiac arrhythmias. Persons with SLE are at increased risk for ischemic heart disease, stroke, and VTE. The LNG-IUD might be a useful treatment for menorrhagia in women with severe thrombocytopenia. Unusually heavy bleeding should raise suspicion of a serious underlying condition. treatment effects of the LNG-IUD among women with heavy or prolonged bleeding reported no increase in adverse effects and found the LNG-IUD to be beneficial in treating menorrhagia. If pregnancy or an underlying pathological condition (e.g., pelvic malignancy) is suspected, it must be evaluated and the category adjusted after evaluation. The IUD does not need to be removed before evaluation. LNG-IUD use among women with endometriosis decreased dysmenorrhea, pelvic pain, and dyspareunia. Dysmenorrhea might intensify with Cu-IUD use. LNG-IUD use has been associated with reduction of dysmenorrhea. For women with suspected or confirmed intrauterine disease, an IUD should not be inserted because of theoretical risk for perforation, infection, and hemorrhage. For women who already have an IUD in place, individual circumstance along with the benefits of effective contraception must be weighed against theoretical risks of either removal or continuation of the IUD. concern exists that LNG-IUDs might enhance progression of cervical intraepithelial neoplasia. cervical & endometrial ca- Concern exists about the increased risk for infection and bleeding at insertion. The IUD most likely will need to be removed at the time of treatment but until then, the woman is at risk for pregnancy. Breast cancer is a hormonally sensitive tumor. Concerns about progression of the disease might be less with LNG-IUDs than with COCs or higher-dose POCs. Among women with endometrial hyperplasia, no adverse health events occurred with LNG-IUD use; most women experienced disease regression. Women with ovarian cancer who undergo fertility-sparing treatment and need contraception may use an IUD. Among women with uterine fibroids using an LNG-IUD, most experienced improvements in serum levels of hemoglobin, hematocrit, and ferritin and in menstrual blood loss. An anatomical abnormality that distorts the uterine cavity might preclude proper IUD placement. IUD insertion poses little risk for PID. Treat the PID using appropriate antibiotics. The IUD usually does not need to be removed if the woman wants to continue using it. Continued use of an IUD depends on the woman's informed choice and her current risk factors for STDs and PID, clinical course did not differ regardless of whether the IUD was removed or left in place. If a woman with risk factors for STDs has not been screened for gonorrhea and chlamydia according to CDC STD treatment guidelines, screening may be performed at the time of IUD insertion and insertion should not be delayed. Women who undergo same-day STD screening and IUD insertion have low incidence rates of PID. Among IUD users, limited evidence shows a low risk for PID among HIV-infected women using IUDs and no higher risk for pelvic infectious complications in HIV-infected than in HIV-noninfected women or among women with varying degrees of HIV severity. IUD use did not adversely affect progression of HIV during 6-45 months of follow-up or when compared with hormonal contraceptive use among HIV-infected women. Furthermore, IUD use among HIV-infected women was not associated with increased risk for a. Clinically well receiving ARV transmission to sex partners or with increased genital viral shedding. progestin-only contraceptives (POCs) include those for progestin-only implants, depot medroxyprogesterone acetate (DMPA; 150 mg intramuscularly or 104 mg subcutaneously), and progestin-only pills (POPs). POCs do not protect against sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV), and women using these methods should be counseled on consistent and correct use of the male latex condom. No known harm to the woman, the course of her pregnancy, or the fetus occurs if POCs are inadvertently used during pregnancy. women lose BMD during DMPA use but recover BMD after discontinuation. POCs may be started immediately postabortion. no adverse side effects occur when implants (Norplant) or progestin-only injectables (NET-EN) are initiated after first trimester abortion. POP users have a higher absolute rate of ectopic pregnancy than do users of other POCs but still lower than women using no method. Bariatric surgical procedures involving a malabsorptive component have the potential to decrease oral contraceptive effectiveness, perhaps further decreased by postoperative complications such as long-term diarrhea, vomiting, or both. When multiple major risk factors exist, risk for cardiovascular disease might increase substantially. Certain POCs might increase the risk for thrombosis, although this increase is substantially less than with COCs. The effects of DMPA might persist for some time after discontinuation. Limited evidence indicates that intramuscular injections of DMPA in women receiving chronic anticoagulation therapy does not pose a significant risk for hematoma at the injection site or increase the risk for heavy or irregular vaginal bleeding. Progestin-only implants might induce cardiac arrhythmias in healthy women; women with peripartum cardiomyopathy have a high incidence of cardiac arrhythmias. Persons with SLE are at increased risk for ischemic heart disease, stroke, and VTE. POCs might be useful in treating menorrhagia in women with severe thrombocytopenia. DMPA use among women receiving longterm corticosteroid therapy with a history of, or with risk factors for, nontraumatic fractures is classified as category 3. Irregular menstrual bleeding patterns are common among healthy women. POC use frequently induces an irregular bleeding pattern. Implant use might induce irregular bleeding patterns, especially during the first 3-6 months. Unusually heavy bleeding should raise the suspicion of a serious underlying condition. If pregnancy or an underlying pathological condition (e.g., pelvic malignancy) is suspected, it must be evaluated and the category adjusted after evaluation. POCs might cause irregular bleeding patterns, which might mask symptoms of underlying pathologic conditions. The effects of DMPA might persist for some time after discontinuation. Among women with persistent human papillomavirus infection, long-term DMPA use (≥5 years) might increase the risk for carcinoma in situ and invasive carcinoma. cervical ca- concern exists that POC use might affect prognosis of the existing disease. While awaiting treatment, women may use POCs. Breast cancer is a hormonally sensitive tumor, and the prognosis for women with current or recent breast cancer might worsen with POC use. endometrial- While awaiting treatment, women may use POCs. In general, treatment of this condition renders a woman sterile. ovarian ca- While awaiting treatment, women may use POCs. In general, treatment of this condition can render a woman sterile. POCs do not appear to cause growth of uterine fibroids. Overall, evidence does not support an association between POC use and progression of HIV. Absorption of POPs among women with IBD might be reduced if the woman has substantial malabsorption caused by severe disease or small bowel surgery. Combined hormonal contraceptives (CHCs) include lowdose (containing ≤35 µg ethinyl estradiol) combined oral contraceptives (COCs), the combined hormonal patch, and the combined vaginal ring. COCs, the patch, and the ring do not protect against sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV), and women using these methods should be counseled that consistent and correct use of the male latex condom reduces the risk for transmission. Use of CHCs is not required. No known harm to the woman, the course of her pregnancy, or the fetus occurs if CHCs are inadvertently used during pregnancy. CHC use has little to no effect on BMD in premenopausal women (60-74) and might preserve bone mass in those who are perimenopausal (75-83). The risk for cardiovascular disease increases with age and might increase with CHC use. In the absence of other adverse clinical conditions, CHCs can be used until menopause. One study examined use of CHCs during the postpartum period and found that VTE rates were higher for CHC users compared with nonusers at all time points postpartum. VTE risk is increased during pregnancy and the postpartum period; this risk is most pronounced in the first 3 weeks after delivery, decreasing to near baseline levels by 42 days postpartum. For women with other risk factors for VTE, these risk factors might increase the classification to a category 4. CHCs may be started immediately postabortion. Women who started taking COCs immediately after first trimester medical or surgical abortion did not experience more side effects or adverse vaginal bleeding outcomes or clinically significant changes in coagulation parameters than did women who used a placebo, an IUD, a nonhormonal contraceptive method, or delayed COC initiation. The risk for future ectopic pregnancy is increased among women who have had an ectopic pregnancy in the past. CHCs protect against pregnancy in general, including ectopic gestation. COC users who smoked were at increased risk for cardiovascular diseases, especially myocardial infarction, compared with those who did not smoke. Obese women who use COCs are more likely than obese women who do not use COCs to experience VTE. Although the absolute risk for VTE in otherwise healthy women of reproductive age is small, obese women are at 2-3 times higher risk for VTE than normal weight women regardless of COC use. Effectiveness of the patch might be reduced in women >90 kg. Bariatric surgical procedures involving a malabsorptive component have the potential to decrease oral contraceptive effectiveness, perhaps further decreased by postoperative complications, such as long-term diarrhea or vomiting. When a woman has multiple major risk factors, any of which alone would substantially increase her risk for cardiovascular disease, use of CHCs might increase her risk to an unacceptable level. Among women with hypertension, COC users were at higher risk than nonusers for stroke, acute myocardial infarction, and peripheral arterial disease. Discontinuation of COCs in women with hypertension might improve blood pressure control. Women using anticoagulant therapy are at risk for gynecologic complications of therapy, such as hemorrhagic ovarian cysts and severe menorrhagia. Hormonal contraceptive methods can be of benefit in preventing or treating these complications. When a contraceptive method is used as a therapy, rather than solely to prevent pregnancy, the risk/benefit ratio might differ and should be considered on a case-by-case basis. Among women with thrombogenic mutations, COC users had a twofold to twentyfold higher risk for thrombosis than did nonusers. Superficial venous thrombosis might be associated with an increased risk for VTE. Among women with valvular heart disease, CHC use may further increase the risk for arterial thrombosis; women with complicated valvular heart disease are at greatest risk. COCs might increase fluid retention in healthy women; fluid retention may worsen heart failure in women with peripartum cardiomyopathy. COCs might induce cardiac arrhythmias in healthy women; women with peripartum cardiomyopathy have a high incidence of cardiac arrhythmias. Persons with SLE are at increased risk for ischemic heart disease, stroke, and VTE. Among women with migraine, oral contraceptive use is associated with about a threefold increased risk for ischemic stroke compared with nonuse, The risk for ischemic stroke is increased among women using COCs, compared with women not using COCs. The risk for ischemic stroke is also increased among women with migraine with aura, compared with women without migraine. COC use was not associated with increased depressive symptoms in women with depression or scoring above threshold levels on a validated depression screening instrument compared with baseline or with nonusers with depression. Irregular menstrual bleeding patterns are common among healthy women. Unusually heavy bleeding should raise the suspicion of a serious underlying condition. If pregnancy or an underlying pathological condition (e.g., pelvic malignancy) is suspected, it must be evaluated and the category adjusted after evaluation. Risk for side effects with COC use was not higher among women with dysmenorrhea than among women not using COCs. Some COC users had a reduction in pain and bleeding. Among women with persistent human papillomavirus infection, long-term COC use (≥5 years) might increase the risk for carcinoma in situ and invasive carcinoma (213). Limited evidence on women with low-grade squamous intraepithelial lesions found use of the vaginal ring did not worsen the condition. cervical ca- Theoretical concern exists that CHC use might affect prognosis of the existing disease. While awaiting treatment, women may use CHCs. In general, treatment of this condition can render a woman sterile. Breast cancer is a hormonally sensitive tumor, and the prognosis for i. Current 4 women with current or recent breast cancer might worsen with CHC use. COC use reduces the risk for endometrial cancer; whether patch or ring use reduces the risk for endometrial cancer is not known. While awaiting treatment, women may use CHCs. In general, treatment of this condition renders a woman sterile. COC use reduces the risk for ovarian cancer; whether patch or ring use reduces the risk for ovarian cancer is not known. While awaiting treatment, women may use CHCs. In general, treatment of this condition can render a woman sterile. COCs do not appear to cause growth of uterine fibroids, and patch and ring also are not expected to cause growth. COCs might reduce the risk for PID among women with STDs. evidence does not support an association between COC use and progression of HIV. barrier contraceptive methods include those for condoms, which include male latex condoms, male polyurethane condoms, and female condoms; spermicides; and diaphragm with spermicide or cervical cap. Women with conditions that make pregnancy an unacceptable risk should be advised that barrier methods for pregnancy prevention might not be appropriate for those who cannot use them consistently and correctly because of the relatively higher typical-use failure rates of these methods. Women should be counseled that consistent and correct use of the male latex condom reduces the risk for transmission. None of these methods are relevant for contraception during known pregnancy. Risk for cervical cap failure is higher in parous women than in nulliparous women. Diaphragm and cap are unsuitable until uterine involution is complete and until 6 weeks after second trimester abortion. Severe obesity might make diaphragm and cap placement difficult. cervical ca- The cap should not be used. Diaphragm use has no restrictions. Repeated and high-dose use of the spermicide nonoxynol-9 can cause vaginal and cervical irritation or abrasions. The diaphragm cannot be used in certain cases of prolapse. Cap use is not appropriate for a woman with markedly distorted cervical anatomy. HIV- Repeated and high-dose use of the spermicide nonoxynol-9 was associated with increased risk for genital lesions, which might increase the risk for HIV infection and Diaphragm use is assigned category 4 because of concerns about the spermicide, not the diaphragm. Toxic shock syndrome has been reported in association with contraceptive sponge and diaphragm use. Use of diaphragms and spermicides might increase risk for urinary tract infection. Fertility awareness-based (FAB) methods of family planning involve identifying the fertile days of the menstrual cycle, whether by observing fertility signs such as cervical secretions and basal body temperature or by monitoring cycle days. No medical conditions worsen because of FAB methods. In general, FAB methods can be used without concern for health effects in persons who choose them. 1) use of these methods should be delayed until the condition is corrected or resolved, or 2) persons using FAB methods need special counseling, and a provider with particular training in use of these methods is generally necessary to ensure correct use. Women with conditions that make pregnancy an unacceptable risk should be advised that FAB methods might not be appropriate for them. Symptoms-based and calendarbased methods do not protect against sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV), and women using these methods should be counseled that consistent and correct use of the male latex condom reduces the risk for transmission. not relevant during pregnancy. Menstrual irregularities are common in postmenarche and perimenopause a. Postmenarche Caution Caution and might complicate the use of FAB methods. Use of FAB methods when breastfeeding might be less effective than when not breastfeeding. Women who are primarily breastfeeding and are amenorrheic are unlikely to have sufficient ovarian function to produce detectable fertility signs and hormonal changes during the first 6 months postpartum. When the woman notices fertility signs, particularly cervical secretions, she can use a symptoms-based method. First postpartum menstrual cycles in breastfeeding women vary significantly in length. Return to regularity takes several cycles. When she has had at least three postpartum menses and her cycles are regular again, she can use a calendar-based method. four postpartum menses and her most recent cycle lasted 26-32 days, she can use the standard days method. Before that time, a barrier method should be offered. Nonbreastfeeding women are likely to have sufficient ovarian function to produce detectable fertility signs, hormonal changes, or both at this time; likelihood increases rapidly with time postpartum. After abortion, women are likely to have sufficient ovarian function to produce detectable fertility signs, hormonal changes, or both; likelihood increases with time postabortion. IVB makes FAB methods unreliable. Therefore, barrier methods should be recommended until the bleeding pattern is compatible with proper method use. The condition should be evaluated and treated as necessary. vaginal discharge makes recognition of cervical secretions difficult, the condition should be evaluated and treated if needed before providing methods based on cervical secretions. Use of certain mood-altering drugs such as lithium, tricyclic antidepressants, and antianxiety therapies, as well as certain antibiotics and anti-inflammatory drugs, might alter cycle regularity or affect fertility signs. Elevated temperatures might make basal body temperature difficult to interpret but have no effect on cervical secretions. Thus, use of a method that relies on temperature should be delayed until the acute febrile disease abates. lactation amenorrhea guidelines include the following three criteria, all of which must be met to ensure adequate protection from an unplanned pregnancy: 1) amenorrhea; 2) fully or nearly fully breastfeeding (no interval of >4-6 hours between breastfeeds); and 3) <6 months postpartum. No medical conditions exist for which use of the lactational amenorrhea method for contraception is restricted. However, breastfeeding might not be recommended for women or infants with certain conditions. Women with conditions that make pregnancy an unacceptable risk should be advised that the lactational amenorrhea method might not be appropriate for them because of its relatively higher typical-use failure rates. The lactational amenorrhea method does not protect against sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV), and women using this method should be counseled that consistent and correct use of the male latex condom reduces the risk for transmission. coitus interruption: traditional family planning method in which the man completely removes his penis from the vagina and away from the external genitalia of the female partner before he ejaculates. Coitus interruptus prevents sperm from entering the woman's vagina, thereby preventing contact between spermatozoa and the ovum. This method might be appropriate for couples • who are highly motivated and able to use this method effectively; • with religious or philosophical reasons for not using other methods of contraception; • who need contraception immediately and have entered into a sexual act without alternative methods available; • who need a temporary method while awaiting the start of another method; or • who have intercourse infrequently if used correctly, does not affect breastfeeding and is always available for primary use or use as a back-up method. In addition, coitus interruptus involves no economic cost or use of chemicals and has no directly associated health risks. Coitus interruptus does not protect against sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV), and women using this method should be counseled that consistent and correct use of the male latex condom reduces the risk for transmission. Coitus interruptus is unforgiving of incorrect use, and its effectiveness depends on the willingness and ability of the couple to use withdrawal with every act of intercourse. Women with conditions that make pregnancy an unacceptable risk should be advised that coitus interruptus might not be appropriate for them because of its relatively higher typical-use failure rates. Tubal sterilization for women and vasectomy for men are permanent, safe, and highly effective methods of contraception. no medical conditions absolutely restrict a person's eligibility for sterilization (with the exception of known allergy or hypersensitivity to any materials used to complete the sterilization method). However, certain conditions place a woman at high surgical risk; in these cases, careful consideration should be given. do not protect against sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV), and women using these methods should be counseled that consistent and correct use of the male latex condom reduces the risk for transmission. Because these methods are intended to be irreversible, persons who choose sterilization should be certain that they want to prevent pregnancy permanently. (1%-26% from different studies, with higher rates of regret reported by women who were younger at sterilization) among men about vasectomy has been reported to be approximately 5%, women who report regretting their husbands' vasectomy (6%). appropriately counseled about the permanency of sterilization and the availability of highly effective, reversible methods of contraception. A copper-containing intrauterine device (Cu-IUD) can be used within 5 days of unprotected intercourse as an emergency contraceptive. However, when the time of ovulation can be estimated, the Cu-IUD can be inserted beyond 5 days after intercourse, if necessary, as long as the insertion does not occur >5 days after ovulation. eligibility criteria for interval Cu-IUD insertion also apply for the insertion of Cu-IUDs as emergency contraception. Classifications for emergency contraceptive pills (ECPs) are given for ulipristal acetate (UPA), levonorgestrel (LNG), and combined oral contraceptives (COCs). Cu-IUDs, UPA, LNG, and COCs do not protect against sexually transmitted diseases. women using these methods should be counseled that consistent and correct use of the male latex condom reduces the risk for transmission. IUD is not indicated during pregnancy and should not be used because of the risk for serious pelvic infection and septic spontaneous abortion. ECP- no harm to the woman, the course of her pregnancy, or the fetus if ECPs are inadvertently used is known to exist. poor pregnancy outcomes are rare among pregnant women who used ECPs during conception cycle or early in pregnancy. Breastfeeding is not recommended for 24 hours after taking UPA because it is excreted in breast milk, with highest concentrations in the first 24 hours, and maximum maternal serum levels are reached 1-3 hours after administration. Mean UPA concentrations in breast milk decrease markedly from 0 to 24-48 hours and then slowly decrease over 5 days- Breast milk should be expressed and discarded for 24 hours after taking UPA. Bariatric surgical procedures involving a malabsorptive component have the potential to decrease oral contraceptive effectiveness, perhaps further decreased by postoperative complications such as long-term diarrhea, vomiting, or both. Because of these malabsorptive concerns, an emergency IUD might be more appropriate than ECPs. Recurrent ECP use is an indication that the woman requires further counseling about other contraceptive options. treatment guidelines, routine presumptive treatment of chlamydia, gonorrhea, and trichomonas is recommended after sexual assault (3). Women with current purulent cervicitis or chlamydial infection or gonococcal infection should not undergo IUD insertion (category 4). ECPs might be less effective among women with BMI ≥30 kg/m2 than among women with BMI <25 kg/m2. Despite this, no safety concerns exist.

absolute contraindications to progestogen use

Active thrombophlebitis or thromboembolic disorders Liver dysfunction or disease Known or suspected cancer of the breast Undiagnosed abnormal vaginal bleeding Pregnancy adverse effects of estrogen-progestogen therapy: Mood changes Possible increased uterine bleeding than if taking estrogen therapy alone

amenorrhea video- missed 3 cycles

tell me your concerns today? -3 months no periods, i know im not pregnant but im worried about not having my period... diagnoses- secondary amenorrhea pregnancy stress disorder of eating/exercise PCOS hypothyroid "there are alot of things that could be causing this, i am going to ask you some questions to help narrow it down and figure out what is going on so i can help you"... do you have any idea about what could be causing this? can you tell me about the pattern of your periods starting with the first time you got your period... -12 onset, then every few mths, never really regular, never went 4 mths with no period. had last period around christmass when i broke up with my bf and havent had one since then. normally what is the time btw your periods? -1mth-a couple of mths, usually about a mth or so. you meantioned youre not pregnant, how do you know your not pregnant? -we broke up around christmass, not sexually active since then were you sexually active with your bf? what were you using for contraceptive/protection against pregnancy/STI? -condoms clarify: so you werent on the pill, using depo or enything else? did you use condoms everytime? -no, i trusted him tell me about your break up... -describes normal break up how are you feeling about the breakup? -im pretty ok, i was sad at first but i have good friends. are you feeling depressed or sad lately? -no im getting over it, im usually a pretty happy person. tell me about your exercise? what kind and how much? -treadmill, not a finatic how have you been feeling since xmas? -fine have you been having breast tenderness, morning sickness, or any nausea? -no any weight gain/weight loss since xmass? -i think i gained a few pounds maybe like 20lb any idea as to how you couldve gained the weight? -no im a pretty healthy eater except for chocolate. have you changed anything about your eating since xmas? -no not really since you noticed you gained weight, have you been trying to diet? -no just careful about some things, ice cream have you had spotting or vaginal discharge? -no any leaking or discharge from your breast? -no changes in your skin? -neck is getting darker/thick feeling, few months ago changes in hair? -hair on face, noticing more. any voice changes? -no i noticed you have some acne on your forehead, can you tell me about that? -flaired in past few mths, using medication but not helping much, always had issues any bowel changes? -no heart rate? fast or slow -no, measured it its usually around 60 doubles when i run feel tired? -no sx in the past? scraping of uterus? -no hx of headaches? -no changes in urination? more than usual -no how about your family, has your mother or other female family members had these issues or lost there periods at a really young age? -no, she was more regular than me meds- Rx, OTC, herbal? -no, just multivitamin is there anything else i should know? -no i think thats it thank you, next i am going to exam you to figure out what may be going on. health history complete- handhygiene before PE vital signs: temp, BP, HR, RR, wt skin thyroid abdomen neurological exam (visual fields/fundus) potentially external genital/pelvic hair on lip and chin check skin darker and raised, examine axillae in same manner thyroid- oberve swallow and palpate; normal abdomen- masses, SP tenderness/enlargement; normal focused neuro- 6 cardinal movements, visual fields, fundi exam, reflexes, coordination, gait. since youve had periods in the past well defer the pelvic exam for now. disgnostic considerations: pregnancy- most commmon cause amenorrhea (unprotected sex around time of last period) *PCOS- hirsutism, acanthosis nigricans, acne, and overweight. presents during adolescence, triad of androgen excess, amenorrhea/oligomenorrhea, and polycystic ovaries on US, and insulin resistance complications if untreated- metabolic syndrome, diabetes, and endometrial carcinoma functional hypothalamic, amenorrhea (stress-induced) eating healthy diet, exercising, denies breast leakage, not taking medication that may induce galactorrhea reduce the likelyhood. thyroid disease (hypothyroid)- p/w fatigue, constipation, wt gain, and cold intolerance. myalgias, skin changes, and secondary amenorrhea. generally dry/doughy skin. w/o tx complications ensue. CNS tumor/pituitary lesion- sometimes accompanied by galactorrhea. dx workup- 1. urine HCG (any patient with secondary amenorrhea) 2. hormonal and metabolic studies- TSH, fT4 (TSH elevated, fT4 low = hypothyroid) prolactin level (elevated = hyperprolactinemia) LH (elevated) FSH (normal) total testosterone, free testosterone, and DHEAS concentrations (elevated) = PCOS FSH elevated = primary ovarian failure estradiol- low in anorexia nervosa *given the multiple signs of androgen excess, reasonable alternative- pregnancy test, LH/FSH, TSH fT4. 3. US of ovaries- PCOS (cysts) Rotterdam criteria = atleast 12 follicles/ovary 2-9mm diameter/increased ovarian volume. 4. glucose insulin levels- if PCOS = help dx T2D common with this disorder. 5. cranial MRI (if strongly suggestd CNS or pituitary tumor- not the case here) help differentiate pituitary adenomas form other causes of hyperprolactinemia. **PCOS** wt loss- healthy eating and exercise, HR therapy- pill, depo, vaginal ring, IUD improve menstrual cycle, endometrial ca risk, hair groth and acne. metformin- improved insulins ability to lower BG, lower both insulin and androgen levels, can help restart ovulation after a few mths of use. positive effect on lowering body mass and improving cholesterol, and spirinolactone (neither are FDA approved from PCOS)

I. Define puberty and identify its usual timing.

adolescent years are generally described as the time of transition from childhood to young adulthood and are biologically defined as beginning with the onset of puberty and lasting until young adulthood onset of puberty depends on a changing body accumulation of adipose tissue. this event marks the beginning of a tension between biologic development and the social context in which it occurs. Significant physical changes occur as an adolescent reaches puberty. Adult height and weight are usually attained during this time. Probably most significant to many young girls, however, are the physical changes associated with puberty, especially the development of secondary sex characteristics. Female pubertal events are initiated by the production of low amounts of estrogen, which stimulate long bone growth. As the amount of estrogen increases, breast buds are developed, long bone growth slows, and epiphyseal closure occurs, signaling that peak height has been attained. It is believed that women acquire the majority of their bone mass during early adolescence; thus this critical period lays the groundwork for prevention of osteoporosis in later years of life. The changes that occur during puberty usually happen in an ordered sequence, beginning with thelarche (breast development) at around age 10 or 11, followed by adrenarche (growth of pubic hair due to androgen stimulation), peak height velocity, and finally menarche (the onset of menses), occurs around age 12 or 13. Peak height usually occurs about 2 years after breast budding and about 1 year prior to menarche The timing of the growth spurt or peak height velocity in young girls occurs approximately 2 years earlier in puberty than it does for boys Thelarche normally occurs between the ages of 8 and 13 years; it is stimulated by hormones, but is also affected by race and ethnicity. Approximately 48% of African American girls will begin breast development between 8 and 9 years of age, whereas only 15% of white girls this age will experience thelarche Adrenarche generally begins within 6 months of the advent of thelarche; thus it generally begins between ages 11 and 12. In some girls, pubic hair may be evident prior to thelarche; this development is particularly noted in young African American girls. tends to occur later in girls from lower-resource countries.

V. Identify the components of the Tanner staging and their use in the assessment of pubertal changes.

commonly used scale for assessing sexual maturity and pubertal development is the Tanner scale, which, for girls, relies on development of the breasts and growth of pubic hair. It divides sexual physical maturity into five stages that extend from preadolescence to the adult. Tanner model is widely accepted for staging sexual maturity. because of the variability in timing of stages and of pubic hair growth, both of which are important elements of Tanner staging, the scale should not be used as originally developed for staging individuals of Asian ethnicity. (i got this from a text in the HSC library under FNP books- CURRENT Diagnosis & Treatment: Obstetrics & Gynecology, 11e Alan H. DeCherney, Lauren Nathan, Neri Laufer, Ashley S. Roman) Stage-Breast Development-Pubic Hair Development I-Papillae elevated (preadolescent), no breast buds-None II-Breast buds and papillae slightly elevated- Sparse, long, slightly pigmented III-Breasts and areolae confluent, elevated- Darker, coarser, curly IV-Areolae and papillae project above breast- Adult type pubis only V-Papillae projected, mature-Lateral distribution

patient education

schuilling: NAMS recommends initiating estrogen as ET and EPT at low doses, such as 0.3 mg CEE, 0.25 to 0.5 mg 17-beta estradiol patch, or the equivalent. Studies have shown that these dosages provide adequate vasomotor relief, although the level of endometrial protection afforded by these regimens has not been evaluated in long-term clinical trials. Vasomotor symptoms usually begin to resolve 2 to 6 weeks after initiating HT. return for a follow-up visit with the clinician in 6 to 8 weeks to evaluate their progress; if the initial dose of ET/EPT/CEE-BZA does not provide adequate symptom relief, it can be increased or a different combination can be tried. The decision to continue or discontinue HT should be revisited at least annually. On average, vasomotor symptoms last 7.4 years, but some women may experience them for 14 years or more. women should take the lowest dose of HT for the shortest period of time. Recommendations for length of time on therapy for women with longer duration of symptoms varies from 3 to 5 years to ongoing if the woman's risk factors are low. Most sources agree that women who experience menopause early should stay on therapy at least until the age when natural menopause usually occurs— age 51 years in North America. if decided to discontinue therapy, she should be advised there is approximately a 50% chance her symptoms will recur. Rates of recurrence are similar whether HT is tapered or stopped abruptly; therefore, NAMS ( 2014 ) recommends individualizing the decision and considering both symptom severity and risks and potential benefits for the individual woman. Visits to alternative providers now outnumber visits to primary care clinicians, but most patients who use CAM do not report this usage to their primary care clinicians. Furthermore, women are the largest group of CAM users, and the use of CAM to manage menopause-related symptoms is growing. ask patients about the use of CAM and to become knowledgeable about the CAM therapies that women are using. herbals: Although many women seek relief of menopause-related symptoms, especially vasomotor symptoms, by using herbal preparations, few studies exist to offer information regarding their efficacy or safety. Because these products are generally identified as diet supplements, rather than as medications, they are not regulated by the FDA in the same way as prescription medications and other over-the-counter products are. Isoflavones are compounds derived from plants that have both estrogenic and nonestrogenic properties. They are present in foods, such as soy (daidzein, genistein, and glycitein) and red clover ( Trifolium pratense ), as well as in commercial preparations. Isoflavones are often referred to as phytoestrogens- ability to bind weakly with estrogen receptors, especially the beta receptors, and have been extensively studied as means of reducing vasomotor symptoms. NAMS ( 2014 ) has concluded that short-term use of soy isoflavones is effective for vasomotor symptoms, does not induce harmful effects on the endometrium or breast, and may be safe for breast cancer survivors. Other classes of phytoestrogens include flavonoids, lignans, and coumestans. These phytoestrogens have much lower hormonal affinity and are generally not thought to be useful for menopauserelated symptom management. They are found in some foods and food products and demonstrate some of the cardioprotective properties of isoflavones. Flavonoids are found in oils, spices, wine, tea, and some vegetables. Lignans are found in flaxseed oil, whole grains, and some fruits and vegetables. Coumestans are found in alfalfa sprouts, red beans, split peas, spinach, and some species of clover. Coumestan phytoestrogens can interfere with bleeding profiles and may interact with anticoagulants. research suggests that true acupuncture is beneficial for vasomotor symptoms, sleep, and mood among women experiencing menopause-related symptoms.

Practical Tips for Intrauterine Devices Use in Adolescents article

it is appropriate to present LARC methods of contraception as a very easy, very effective, very safe option that many teens find appropriate, and that the clinician recommends that the adolescent consider. For clinicians who do not themselves insert IUDs, it can be useful to develop a list of colleagues in the community who provide care for adolescents and who do include IUD insertion in their practices. Contacting the local obstetrics-gynecology society may help in the development of this list. Beyond a strong positive introduction to LARC methods, it can be helpful to ask whether an adolescent has heard anything about these methods, and then to address any myths or misinformation (See Review in this supplement), as well as answer all questions about the methods. Adolescents may be more likely than adults to have misconceptions about genital anatomy, and to require concrete explanations about IUD insertion. think that the IUD string protrudes from the vaginal introitus like a tampon string. Plastic representations of the pelvis or uterus and actual-size IUD models may be helpful. If the teen expresses interest in a LARC method, additional counseling should consider the elements captured in the acronym BRAIDED- Benefits, Risks, medical and surgical Alternatives; the fact that Inquiries about the physician's recommendations are the patient's right and responsibility; that Decisions to withdraw from the choice are the patient's right; Explanation of the indications for and the type of procedure planned; and Documentation in the medical record of the above components on consent. side effects of progestin IUDs, telling teens that "you may have irregular bleeding" may be interpreted by adolescents as "it can't/won't happen to me," given the developmentally normal response within the context of a "personal fable." Adolescent egocentrism includes the concept of the personal fabledthe belief that the individual is special, unique, and invulnerable to harm. This concept, as originally described, suggested this belief was strongest in early adolescence, and declined in middle adolescence egocentrism may re-emerge and influence behavior when an individual enters into a new environment, such as going off to college, with the idea that this may be an effective coping mechanism during transitions to new social contexts [8]. Thus egocentrism may be a factor in adolescent tolerance of side effects such as breakthrough bleeding. Data indicate that unscheduled irregular bleeding or spotting occurs frequently in the first 4e6 months after levonorgestrel intrauterine system (LNG-IUS) insertion. potentially overstate the likelihood for side effects, by saying, for example, "You WILL have breakthrough bleeding in the first 1-3 months after the progestin IUD is inserted," rather than "You MAY have breakthrough bleeding." can then help an adolescent to think concretely about how she would respond to the presence of breakthrough bleeding, for example, by asking, "What will you do when the bleeding starts while you're at school?" or "What will you say when you or your partner don't want to have sex when you're having bleeding?" This approach may help her to make a more informed decision about use of a method- NSAIDs should be considered first-line therapy. Adolescents who have been informed that amenorrhea is a possibility may assume that it WILL happen for them. Rates of amenorrhea of 20% are quoted in the patient package insert, although studies suggest rates of amenorrhea of approximately 50% at 1-2 years, similar to rates of amenorrhea experienced with dimethylolpropionic acid (DMPA). Adolescents can be reminded that amenorrhea over time is not worrisome and does not mean that there will be problems with future conception, when desired. A negative pregnancy test can provide reassurance if the teen is concerned about the possibility of a current pregnancy. Realistic information is important and helpful as preventive guidance; studies suggest that discontinuation rates are lower. counseling about expected menstrual changes, an adolescent can be asked how she would feel if she didn't get her periods, and her response can inform her decisionmaking about IUD type. how long will it take? how big is it?- It is not unusual for a teen to be surprised that the entire procedure typically takes less than 5 minutes, or upon seeing a model of the device, to comment, "I thought it would be bigger." Given new guidelines recommending that the initial Pap test be performed at age 21 for most young women, and the ability to screen for sexually transmitted infections (STIs) using urine-based testing, many fewer girls are having pelvic examinations during adolescence. family planning clinics would provide IUD insertion whenever the patient presents for this option, if it reasonably certain that she is not pregnant, and if there are no contraindications, arguing that this is efficient of the patient's and the clinician's time as well as cost effective. young women report anxiety prior to their first examination. Some young women ask their mother or a girlfriend about the experience, but this does not assure that they will get accurate or unbiased information. The first gynecologic/pelvic examination has been described as a "rite of passage into. womanhood, and can be a frightening experience or potentially a positive empowering one" [18e20]. It is the author's contention that a positive first gynecologic exam, performed after appropriate anticipatory guidance and education and with gentle technique (including appropriate speculum selectiondtypically a Pederson speculum), can facilitate and foster healthy attitudes about preventive care for an adolescent's future. Thus avoiding painwith that first exam can have long-term benefits. An adolescent who has experienced a pelvic examination will be better able to give a truly informed consent for IUD insertion. routine pelvic examination including an internal/ speculum exam prior to an uncomfortable and potentially painful IUD insertion, the examination will allow the clinician to visualize the cervix, to perform a microscopic examination of vaginal secretions to assess for bacterial vaginosis (BV) or trichomonas vaginalis, to test for N. gonorrhea and chlamydia from the endocervix, and to visually assess for a mucopurulent cervicitis, which is a contraindication to IUD insertion. Outside of the possible exception of use of a copper IUD for emergency contraception, the practice of same day IUD insertion for routine contraception in young adolescents who have not previously experienced a pelvic examination may not be in their best interests. A more recent study specifically assessed the pain with insertion of the LNG-IUS and found no benefit of ibuprofen use for pain associated with IUD insertion [38]. Misoprostol for cervical ripening/"priming" has not been found to reduce the pain of insertion, although it did reduce the number of difficult insertions. history of dysmenorrhea has also been associated with greater pain with insertion. adolescents can benefit from these efforts to relieve pain. Whether this is attributable to alleviating the anticipation of pain by the reassurance that multiple efforts to provide analgesia will be offered, or to a true benefit, is not possible to state. A slow and gentle technique during IUD insertion can be calming, and particularly necessary with anxious adolescents, who frequently describe the gynecologic examination as "awkward." maintain a gentle, even, and soothing tone of voice, and an ongoing stream of conversation that includes warning the patient prior to any manipulation of the cervix or instruments, stating, "Next you'll feel me opening the speculum so I can see your cervix," and "You'll feel pressure as I inject the local anesthetic," Vasovagal syncope is precipitated by fear, emotional stress, and pain. occur more frequently in young women, nulliparous and primiparous women, and to be associated with reports of moderate to severe pain. Management of vasovagal syncope during IUD insertion consists of monitoring the reflex bradycardia and hypotension, which are brief and transient, and providing reassurance and education about the risks of recurrence with triggers (e.g., with venipuncture, prolonged standing, or hot environment). After the IUD insertion, a brief interval of rest on the exam table to allow cramping to dissipate can provide an interval during which a reminder of what to expect post-procedure can be given. Teens should be reminded that return of fertility is rapid after removal, and that there is no long-term effect on fertility. Patients should be counseled to use back-up contraception for 7 days if a LNG-IUS was inserted more that 7 days beyond the onset of menses [54]. Adolescents are encouraged to prospectively chart their episodes of bleeding; a teen's report of "bleeding all the time" may or may not be accurate, and documentation with a paper chart or with a smartphone app can be helpful. Post-insertion pain Most women have mild to moderated cramps for the first day or so Ibuprofen 400 mg (Advil or Motrin) or naproxen 200mg (Aleve) are available without a prescription and are helpful. Take as directed and with food If pain is severe or you also have fever, CALL THE OFFICE at xxx-xxx-xxxx No tampons, no douching, no sex (Don't put anything in your vagina) for the next 24 hours. What to expect with bleeding Bleeding or spotting are common for the first few days or so With the hormone IUD (Mirena), In the first few months, most women have unpredictable bleeding for 1-3 months; After the first few months, most women have regular bleeding that gets lighter and lighter; 1 year after insertion, 20-60% of women have stopped their periods With the copper IUD (Paraguard) Most women continue to have regular monthly periods Bleeding may get somewhat heavier with the IUD than before Cramping may be somewhat worse Ibuprofen 400 mg (Advil or Motrin) or naproxen 200mg (Aleve) are available without a prescription and are helpful. Take as directed and with food To be sure that the IUD is still in place You can reach inside your vagina to feel the string An IUD does not protect against STDs USE A CONDOM every time you have sex Write down the dates of your periods and all bleeding Call the office if You have fever or chills and lower abdominal pain You have a vaginal discharge You are worried about an STD Can't feel the string, or feel that it seems longer Have pain or bleeding with sex Think you are pregnant Have unusually heavy bleeding Come back to the office In 6 weeks to let us check for the string. a follow-up visit in 6 weeks can allow for an assessment of tolerance of the IUD, with an assessment of bleeding, cramping, and questioning about whether or not she has been able or willing to check the string. An exam will assure that the string is visible, and that it remains the same length as was documented at the time of insertion. This visit provides the opportunity to assess for expulsion or possible pregnancy. adolescents may require counseling and reassurance to tolerate the initial irregular bleeding that occurs with the LNG-IUS, with encouragement that bleeding patterns typically improve, and amenorrhea remains a possibility over time. rates of IUD expulsion appear to be higher in nulliparous women, it has been suggested that more frequent visits (for example at 1, 3, and 6 months) are indicated for this group to detect displacement or expulsion. The risks of PID are highest in the first 3 weeks after insertion, and are uncommon after that interval. follow-up visit, therefore, provides an opportunity to assure that there is no evidence of mild pelvic infection. reinforce consistent condom use in a population where ongoing encouragement toward this goal may be more important. It has also been the author's practice to plan to see teens who may require ongoing encouragement to use effective contraception at approximately 3 months after insertion. In older and more mature teens who are doing well and who understand the precautions and symptoms to be aware of (e.g., college students), the follow-up visits may well be unnecessary. Reassurance can be provided that bleeding changes typically improve with time and do not mean that the method is ineffective. While some individuals worry that amenorrhea is not "healthy," reassurance can be given that there are no adverse medical sequelae from lack of bleeding, and that the menstrual blood is not "backing up," nor will it "come out their ears." An adolescent can be encouraged to accept the initial few months of bother and "hassles" of irregular bleeding in exchange for the next few years of extremely effective and easy contraception. A recurrence of abnormal bleeding after it has resolved should warrant testing for sexually transmitted diseases (STDs) or mild PID. A recurrence of bleeding after an interval of amenorrhea should prompt an exam to assure that the IUD has not been expelled, along with testing for pregnancy.

strategies to prevent osteoporosis

schuilling: Adequate intake of calcium (1,200 mg/day in postmenopausal women) Adequate intake of vitamin D (800- 1,000 international units/day for adults 50 and older) Weight-bearing and resistance exercise Fall prevention Avoiding tobacco Moderating alcohol intake (fewer than 2 drinks per day for women). Medication management is recommended for women with T -scores of -2.5 or less, and for those with hip or vertebral fractures. For women with T -scores in the low bone mass range (-1.0 to -2.5), medication is recommended if they also have fractures or are at high risk for fracture (e.g., immobilized, taking glucocorticoids, at high risk for falls).

HPV types

high risk- types 16 & 18 low grade and high grade cervical changes, cervical cancer, cancers of vagina, vulva, anus, penis low risk- types 6 and 11 benign low grade cervical changes, genital warts

non pharm intervention education- menopause

schuilling: dietary: hot flash triggers that include hot drinks, spicy foods, caffeine, and alcohol; however, little evidence has been found among large groups of women to support a causative relationship. Avoidance or moderate intake of these substances should be recommended in an attempt to provide some relief from symptoms if women are seeking nonpharmacologic strategies to manage symptoms. Increased water intake is also recommended because of the augmented insensible loss of fluids through sweating. Despite limited data supporting the contention that consuming cool drinks improves menopause-related symptoms, water intake (especially intake of cold water) appears to reduce symptoms such as skin dryness, and may reduce the discomfort associated with hot flashes and sweating. The usual water intake of 6 to 8 glasses per day should be recommended. However, for women who experience urinary incontinence, water consumption may need to be restricted for social occasions when there is no easy access to a bathroom, or limited to the morning for women who experience nocturia. exercise: Lower levels of physical activity have been linked with a higher frequency of menopause-related symptoms. Nevertheless, a recent Cochrane Review of five RCTs found insufficient evidence to state definitively that exercise is an effective treatment for menopause-related vasomotor symptoms. Regular exercise reduces cardiovascular and osteoporosis risks; improves sleep; and assists with maintaining a healthy weight, relieving stress, reducing moodiness, and improving mental function. As a result, the overall benefits of exercise are important even if exercise does not mediate menopause-related vasomotor symptoms for all women. encouraged to engage in 30 minutes of moderate exercise on a daily basis; if they are attempting to lose weight, at least 60 minutes of physical activity is recommended. Vitamin E in doses up to 800 international units (IU)/day has been shown to produce either small improvements or no changes in hot flashes. USPSTF ( 2014 ) recommends against the use of vitamin E for prevention of cardiovascular disease or cancer. the Institute of Medicine (IOM) recommended daily intake amounts of calcium (1,200 mg/day) and vitamin D (600 international units (IU)/day) to maintain bone health and prevent fracture in women older than 50 years. In women older than 70 years, 800 IU/day of vitamin D is recommended. Limiting dietary supplements and encouraging midlife women to maintain a healthy diet that includes fruits, vegetables, low-fat dairy products, whole grains, chicken, fish, and nuts is recommended, as a healthy diet appears to have greater health benefits and is associated with reduced rates of diabetes, hypertension, CVD, and colorectal adenoma or cancer. terminology genitourinary syndrome of menopause (GSM) , rather than VVA or atrophic vaginitis, to encompass the physiologic genitourinary tract changes and the variety of vulvovaginal (e.g., dryness, burning, irritation), sexual (e.g., inadequate lubrication, pain), and urinary (e.g., urgency, dysuria, urinary tract infections) symptoms associated with decreased estrogen levels . mild symptoms of GSM often respond well to use of vaginal lubricants and moisturizers, and these should be offered as an initial treatment option. Vaginal lubricants can be used to relieve the friction and dyspareunia that results from vaginal dryness during intercourse. Several nonhormonal water-, silicone-, and oil-based lubricants as well as vaginal moisturizers are available as over-the-counter products. products are applied several times weekly (lubricants are applied prior to sex, moisturizers applied daily or 2-3x/wk), not just at the time of sexual activity. The moisturizers replenish and maintain moisture in the vaginal epithelial cells and provide longer relief. Moisturizers may be particularly beneficial for women who experience daily discomfort, and they can reduce symptoms of vaginitis by supporting a normal pH. cautioned against using petroleum jelly-based products (Vaseline), as these preparations can injure vaginal tissue, are not easily removed, and may increase the incidence of bacterial vaginosis. Use of other products that contain fragrances should also be discouraged, as they often cause vaginitis or irritation. Douching is not effective for moisturizing and will remove normal flora, thereby increasing the risk for infection. testing for 24 hours on a small skin area prior to intravaginal use is recommended. If irritation does occur, a silicone-based, iso-osmolar, or propylene glycol-free product may be better tolerated. propylene glycol can cause irritation in some. lubricants: water based- astroglide liquid/gel, astroglide, KY jelly, liquid silk, pre-seed, slippery stuff. silicon based- astroglide X, ID milennium, KY intrigue, pink, body glide oil based- elegance, coconut oil, olive oil, vit E oil moisturizers: replens, Me again, vagisil, feminease, KY silke, luvena, silken secret clothing/environment: Wearing layered clothes, breathable fabrics (e.g., cotton, linen), or moisture-wicking fabrics (e.g., those worn by runners) is recommended to reduce the discomfort associated with hot flashes and sweats. Avoiding turtlenecks, fabrics that do not allow circulation or absorb sweat (e.g., polyester, silk), and extra layers (e.g., slips, full-length stockings) is also recommended. Keeping the room temperature cool, opening a window or using a fan to circulate air, and using chilling towels and a chilling pillow can help to reduce core body temperature and may be beneficial in reducing the symptoms of menopause. Smoking is associated with increased morbidity and mortality, especially related to CVD and cancers; earlier age at menopause; increased rate of bone loss; and increased prevalence of vasomotor symptoms. best program is the one that is of greatest interest to a specific woman. She needs to be both interested in quitting and motivated to quit. Support from a clinician and use of medications or nicotine replacement therapy (NRT) can significantly improve cessation rates. Stress and anxiety have been associated with increases in the severity and frequency of hot flashes. stress can negatively affect quality of life by causing sleep disturbances and decreasing libido as well as aggravating medical conditions such as CVD. encouraged to identify their own life stressors and find stress-relieving measures that work for them. Some suggestions include regular exercise, meditation, relaxation techniques such as deep breathing, yoga, tai-chi, taking a lukewarm bath, reading, having a massage, seeking support from friends, or activities related to spirituality or religion. women find that yoga breathing— a variation of paced respiration— can enhance relaxation and reduce hot flashes. Yoga breathing consists of a deep inhalation for a count of 4, holding the breath for a count of 7, and slowly exhaling over a count of 8. Evaluating the cause of sleep disruptions is important for developing a plan of management. Light blankets, cotton sleepwear or moisture-wicking pajamas, and a well-ventilated room are recommended for reducing nocturnal hot flashes. Developing good sleep hygiene is especially important for perimenopausal and postmenopausal women. Sleep hygiene refers to actions that cue the mind that it is time for sleep and allow the part of the brain that controls the body during sleep to take over. Developing regular routines prior to bedtime, such as brushing the teeth or changing into sleepwear, and doing something relaxing, such as paced respirations, progressive relaxation, guided imagery, taking a warm bath, reading a relaxing book, or drinking a warm beverage without caffeine, can help cue the mind that it is time to sleep. Similarly, activities that tend to stimulate the mind should be avoided just before bed, such as watching television, reading a fast-paced or stimulating book, doing work, or exercise. The bedroom should be reserved for sleep and sexual activities. This consideration is especially important for individuals who have difficulty falling asleep, as doing work or watching television in bed can have a stimulating effect. Establishing regular times for sleep and waking is also important for developing good sleep patterns, as this consistency will facilitate the development of normal daily routines. avoiding caffeine, alcohol, or nicotine. The effects of caffeine can last as long as 20 hours in some individuals, so total elimination is preferable. Although alcohol initially can have a sedative effect, it may cause interruptions in normal sleep patterns after falling asleep, including fragmented sleep and rebound awakening. nicotine can prolong sleep onset and reduces overall sleep duration. Exercise can enhance sleep quality, reduce sleep latency, and increase the amount of time spent in deep sleep. However, timing of exercise is important, as engaging in exercise right before bedtime will increase sleep latency. nicotine can prolong sleep onset and reduces overall sleep duration. Exercise can enhance sleep quality, reduce sleep latency, and increase the amount of time spent in deep sleep. However, timing of exercise is important, as engaging in exercise right before bedtime will increase sleep latency. may require less sleep as they age. Although the amount of sleep required by adults is very individualized and it is difficult to specify an exact amount of sleep that an individual may need, few postmenopausal women need 8 hours of sleep per night; rather, 6 to 7 hours may be sufficient. Difficulty remembering or concentrating commonly occurs among women during the menopausal transition but will often return to premenopause levels when they reach a postmenopausal state. Although poor mental functioning is often associated with lack of sleep or high levels of stress, cognitive impairment can also be related to a myriad of medical problems. Thus the first step in evaluating mental function is to complete a comprehensive assessment to identify potential causes of the cognitive deficit. engage in certain activities or lifestyle changes experience improved memory function and protection against dementia. Maintaining an extensive social network and remaining physically active as well as mentally active by participating in activities that keep the mind engaged (e.g., intellectually stimulating work, puzzles, or other activities) can help to maintain cognitive function. Increasing the intake of omega-3 fatty acids, not smoking, consuming alcohol only in moderation, and adapting lifestyle measures to reduce the risk for hypertension, diabetes, and high cholesterol have the added benefit of protecting against dementia and cognitive decline.

International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases article

6. b-Lactam agents, including amoxicillin-clavulanate, cefdinir, cefaclor, and cefpodoxime-proxetil, in 3-7-day regimens are appropriate choices for therapy when other recommended agents cannot be used (B-I). Other b-lactams, such as cephalexin, are less well studied but may also be appropriate in certain settings (B-III). The b-lactams generally have inferior efficacy and more adverse effects, compared with other UTI antimicrobials (B-I). For these reasons, b-lactams other than pivmecillinam should be used with caution for uncomplicated cystitis. 7. Amoxicillin or ampicillin should not be used for empirical treatment given the relatively poor efficacy What Is the Treatment for Acute Pyelonephritis? Recommendations Oral ciprofloxacin (500 mg twice daily) for 7 days, with or without an initial 400-mg dose of intravenous ciprofloxacin, is an appropriate choice for therapy in patients not requiring hospitalization where the prevalence of resistance of community uropathogens to fluoroquinolones is not known to exceed 10% If the prevalence of fluoroquinolone resistance is thought to exceed 10%, an initial 1-time intravenous dose of a long-acting parenteral antimicrobial, such as 1 g of ceftriaxone (B-III) or a consolidated 24-h dose of an aminoglycoside, is recommended A once-daily oral fluoroquinolone, including ciprofloxacin (1000 mg extended release for 7 days)or levofloxacin (750 mg for 5 days), is an appropriate choice for therapy in patients not requiring hospitalization where the prevalence of resistance of community uropathogens is not known to exceed 10% (B-II). If the prevalence of fluoroquinolone resistance is thought to exceed 10%, an initial intravenous dose of a long-acting parenteral antimicrobial, such as 1 g of ceftriaxone (B-III) or a consolidated 24-h dose of an aminoglycoside, is recommended Oral trimethoprim-sulfamethoxazole (160/800 mg [1 double-strength tablet] twice-daily for 14 days) an initial intravenous dose of a long-acting parenteral antimicrobial, such as 1 g of ceftriaxone (B-II) or a consolidated 24-h dose of an aminoglycoside, is recommended Oral b-lactam agents are less effective than other available agents for treatment of pyelonephritis (B-III). If an oral b-lactam agent is used, an initial intravenous dose of a long-acting parenteral antimicrobial, such as 1 g of ceftriaxone (B-II) or a consolidated 24-h dose of an aminoglycoside, is recommended (B-III). i. Data are insufficient to modify the previous guideline recommendation for a duration of therapy of 10-14 days for treatment of pyelonephritis with a b-lactam agent. Women with pyelonephritis requiring hospitalization should be initially treated with an intravenous antimicrobial regimen, such as a fluoroquinolone; an aminoglycoside, with or without ampicillin; an extended-spectrum cephalosporin or extended-spectrum penicillin, with or without an aminoglycoside; or a carbapenem. The choice between these agents should be based on local resistance data, and the regimen should be tailored on the basis of susceptibility results ------------------------------- nitrofurantoin, fosfomycin, and mecillinam had good in vitro activity in all the countries investigated. Thus, these 3 antimicrobials could be considered appropriate antimicrobials for empirical therapy in most regions The preserved in vitro susceptibility of E. coli to nitrofurantoin, fosfomycin, and mecillinam over many years of use suggests these antimicrobials cause only minor collateral damage [8, 10], perhaps because of minimal effects on normal fecal flora affect the normal fecal flora more significantly- trimethoprim, trimethoprim-sulfamethoxazole, quinolones, and ampicillin uncomplicated cystitis, there are 2 reasons why collateral damage merits consideration. First, there is minimal risk of progression to tissue invasion or sepsis. Moreover, studies of placebo for treatment of uncomplicated cystitis demonstrate that clinical cure can be achieved in 25%-42% of women who are not treated or are treated with a drug without in vitro activity against the uropathogen [28, 29]. Thus, spontaneous resolution may attenuate differences in clinical outcomes when a drug with 80% efficacy is compared with one with 95% efficacy. GUIDELINE RECOMMENDATIONS FOR THE TREATMENT OF ACUTE UNCOMPLICATED CYSTITIS AND PYELONEPHRITIS I. What Is the Optimal Treatment for Acute Uncomplicated Cystitis? Recommendations Nitrofurantoin monohydrate/macrocrystals (100 mg twice daily for 5 days) is an appropriate choice for therapy due to minimal resistance and propensity for collateral damage (defined above) and efficacy comparable to 3 days of trimethoprim-sulfamethoxazole Trimethoprim-sulfamethoxazole (160/800 mg [1 doublestrength tablet] twice-daily for 3 days) is an appropriate choice for therapy, given its efficacy as assessed in numerous clinical trials, if local resistance rates of uropathogens causing acute uncomplicated cystitis do not exceed 20% or if the infecting strain is known to be susceptible The fluoroquinolones, ofloxacin, ciprofloxacin, and levofloxacin, are highly efficacious in 3-day regimens (A-I) but have a propensity for collateral damage and should be reserved for important uses other than acute cystitis and thus should be considered alternative antimicrobials for acute cystitis b-Lactam agents, including amoxicillin-clavulanate, cefdinir, cefaclor, and cefpodoxime-proxetil, in 3-7-day regimens are appropriate choices for therapy when other recommended agents cannot be used. The b-lactams generally have inferior efficacy and more adverse effects, compared with other UTI antimicrobials (B-I). For these reasons, b-lactams other than pivmecillinam should be used with caution for uncomplicated cystitis Amoxicillin or ampicillin should not be used for empirical treatment given the relatively poor efficacy The main concern regarding fluoroquinolone use for acute cystitis is the promotion of fluoroquinolone resistance, not only among uropathogens but also other organisms, causing more serious and difficult-to-treat infections at other sites. There is also concern about the association between fluoroquinolone use and increased rates of MRSA [22]. Many experts now call for restricting use of fluoroquinolones to those episodes of uncomplicated cystitis when other UTI antimicrobials are not suitable [53]. The panel agrees and recommends that fluoroquinolones be reserved as an alternative only when other UTI agents cannot be used overall evidence of the efficacy of b-lactams for treatment of acute cystitis has not changed since the previous guideline [1]. Most studies demonstrate that b-lactams are generally inferior in cure rates to the fluoroquinolones Broad-spectrum cephalosporins, in particular, have been associated with collateral damage, the most concerning of which is ESBL resistance among gram-negative bacteria. currently available data supports avoidance of b-lactams other than pivmecillinam for empirical therapy of uncomplicated cystitis unless none of the recommended agents are appropriate. In the event of diagnostic uncertainty regarding cystitis versus early pyelonephritis, use of agents such as nitrofurantoin, fosfomycin, and pivmecillinam should be avoided, because they do not achieve adequate renal tissue levels. Such uncertainly may exist in the setting of cystitis symptoms accompanied by subjective fever that is not verified at the time of examination, a prolonged duration of cystitis symptoms (typically greater than 5-7 days), or vague flank pain or tenderness which is not otherwise explained. performance measures: -Use of a recommended antimicrobial for treatment of uncomplicated cystitis in cases in which it is not prohibited because of allergy history or availability -Use of fluoroquinolones for treatment of acute uncomplicated cystitis only when a recommended antimicrobial cannot be used -Use of a recommended antimicrobial for treatment of uncomplicated pyelonephritis in cases in which it is not prohibited because of allergy history or availability -Initiation of empirical therapy for acute uncomplicated pyelonephritis with performance of a pretherapy urine culture and modification of empirical therapy as indicated by culture results

conditions classified as category 3 or 4 for COC use

CATEGORY 4 Complicated valvular heart disease Current breast cancer Severe decompensated cirrhosis Deep venous thrombosis/Pulmonary embolism (acute; history, not on anticoagulation or on established therapy for at least 3 mo with higher risk recurrence; major surgery with prolonged immobilization) Complicated diabetes with nephropathy, retinopathy, neuropathy or other vascular disease or duration of diabetes >20 yr Migraine with aura Hypertension (blood pressure above 160/100 mm Hg) or hypertension with vascular disease Ischemic heart disease (history of or current) Hepatocellular adenoma Malignant liver tumor Peripartum cardiomyopathy (diagnosed <6 mo prior or with moderately or severely impaired cardiac function) Postpartum <21 days History of cerebrovascular accident Systemic lupus erythematosus with positive antiphospholipid antibodies Thrombogenic mutations Viral hepatitis (acute or flare) CATEGORY 3 Past breast cancer with no evidence of disease for 5 yr Breastfeeding and <1 mo postpartum Deep venous thrombosis/pulmonary embolism (history of deep venous thrombosis/pulmonary embolism with lower risk recurrence) Gall bladder disease (current, medically treated) Migraine without aura (if worsens or first starts while using combined hormonal contraceptives) History of malabsorptive bariatric surgery History of cholestasis and past combined oral contraceptive-related Hypertension (adequately controlled or blood pressure less than 160/100 mm Hg) Peripartum cardiomyopathy with mild impairment or >6 months Postpartum 21-42 days with other risk factors for venous thromboembolism Drug interactions (Ritonavir-boosted protease inhibitors; certain anticonvulsants; rifampin or rifabutin)

pelvic pain- schuilling

Often pelvic pain is caused by multiple factors, requiring clinicians to take a multidisciplinary, holistic approach to its assessment and management. An appreciation for the intertwining influence of the mind and the body during assessment and in planning interventions is important. This approach places the woman at the center of her management plan, and respects her credibility as the authoritative "knower." Pelvic pain is a broad term encompassing a number of etiologies, within or across body systems. Such pain can be acute, chronic, cyclic, or noncyclic and may or may not be related to gynecologic organs. It may be symptomatic of an underlying cause, or it can be a syndrome unto itself. Pelvic pain can be so severe that it adversely affects a woman's normal functioning, keeping her from maintaining her normal lifestyle. two types: acute and chronic. Onset of acute pelvic pain may be the result of pelvic disorders, such as pelvic inflammatory disease (PID), ruptured ovarian cyst, ectopic pregnancy, or torsion of an ovarian cyst, ovary, or fallopian tube. PID accounts for approximately 20% of acute pelvic pain in women, ovarian cysts for approximately 40%, and adnexal torsion for approximately 16% . Nearly 10% of women who present with concerns about acute pelvic pain are experiencing an extrapelvic condition, such as anal fissure, thrombosed external hemorrhoids, or appendicitis. Acute pelvic pain is generally defined as pain that occurs in the pelvis or lower abdomen and is of less than 3 months' duration. intense and generally characterized as being sudden in onset, sharp in nature, and short in duration. Almost half of all visits to the emergency department by women of reproductive age are for complaints of acute pelvic pain, pelvic inflammatory disease, and lower genital tract infections (e.g., cervicitis, candidiasis, Bartholin's abscess). wrong diagnosis of acute pelvic pain can lead to serious sequelae, such as impaired fertility, rupture of an ectopic pregnancy or a hemorrhagic ovarian cyst, and even death. chronic pelvic pain (CPP) is described as pain lasting at least 6 months that can be sudden or gradual in onset and severity. chronic pelvic pain is defined as "noncyclic pain of six or more months duration that localizes to the anatomic pelvis, anterior abdominal wall at or below the umbilicus, the lumbosacral back, or the buttocks, and is of sufficient severity to cause functional disability or lead to medical care". commonly affects women with a mean age of approximately 30 years. use significantly more medications, have nongynecologic operations much more often, and are more likely to have a hysterectomy and reduced quality of. The loss of daily functioning because of pelvic pain creates increased psychosocial stressors including hopelessness, marital distress, loss of interest in sexual intimacy, and despair compounded by financial stress, all of which can lead to anxiety and depression. CPP should include cyclic pain (e.g., dysmenorrhea associated with menses or pain during a particular phase of the menstrual cycle), sporadic pain (e.g., dyspareunia), or noncyclic pain of unpredictable onset. many women with pelvic pain have more than one diagnosis as the possible cause of their pain, and women who have multiple diagnoses related to pelvic pain. one-third of women with endometriosis also present with comorbid conditions, such as interstitial cystitis or irritable bowel syndrome. endometriosis-associated pelvic pain, women may experience only partial improvement in their symptoms if urologic and gastrointestinal components are missed in the initial assessment and diagnosis and, therefore, they are not treated correctly. Musculoskeletal dysfunction of the abdominal wall or pelvic floor can also contribute. visceral source, such as the gynecologic, genitourinary, or gastrointestinal tracts, or from a somatic source, such as the pelvic bones, ligaments, muscles, and fascia- initial diagnostic approach to CPP should entail a comprehensive history. The physical examination is conducted in a systematic manner to connect the stated history with identified areas of pain and to distinguish between somatic and visceral types of pain. Somatic pain may be either superficial or deep. Superficial pain occurs when the body surface is stimulated, whereas deep pain originates in muscles, joints, bones, or connective tissue. sharp or dull, and is usually localized; that is, it is found on either the right or the left within specific dermatomes that correspond to the innervations of the involved tissue. Chronic pain is often sensed as deep pain. Visceral pain arises from internal organs and is often associated with strong contractions of visceral muscles. Stretching, distention, ischemia, or spasm of abdominal organs can stimulate visceral pain. visceral innervation of the pelvic structures share common neural pathways, isolating the source of visceral pain may prove challenging. transmitted through the sympathetic tracts of the autonomic nervous system, and is usually described as being dull, crampy, or poorly localized; it may be associated with autonomic phenomena such as nausea, vomiting, and sweating. Nociceptive pain is "pain with a purpose" that arises from damage or injury to non-neural tissue and is a result of activation of nociceptors in a normally functioning somatosensory nervous system. inflammatory pain, serves as a defense mechanism that alerts the sufferer to tissue injury and/or disease. noxious stimulus is removed, the activity of the sensory pain receptors (also known as nociceptors) quickly ceases. subsides with proper treatment and/or healing of the associated injury and/or disease. Neuropathic pain is described as complex type of "pain without purpose" and arises as a direct consequence of a lesion or disease affecting the somatosensory system. complex pain syndrome requires a multimodal treatment approach that includes both pharmacologic and nonpharmacologic management strategies. noxious stimuli have sustained action, producing continuous central sensitization and loss of neuronal inhibition that becomes permanent. result is a decreased pain threshold and complaints of pain that may seem disproportionate to the amount of coexisting disease. When neuropathic pain occurs in the context of chronic pelvic pain, it often presents as burning, paresthesia, or lancing pain. assessment of the underlying etiology of CPP should also include evaluation of the level of functional disability (e.g., the woman's ability to work, engage in daily activities, and emotional and sexual relationships). psychological factors must always be considered. especially if history of sexual abuse, physical abuse, depression, or anxiety. physical abuse linked to greater pain-related disability and depression. etiologies of CPP can be complex and may encompass the gastroenterologic, urologic, gynecologic, oncologic, musculoskeletal, and psychosocial systems. Many of the diseases believed to cause pelvic pain do not meet the epidemiologic criteria for causality; that is, the evidence may strongly suggest such factors as the cause, but research results do not yet provide definitive support for such a relationship- majority of clinicians treat the condition empirically. clinical presentation: Pelvic pathology causing acute pain is common, and the presenting complaint may be diffuse or lower abdominal pain, pelvic pain, or low back pain. Acute pelvic pain is generally accepted to comprise pain in the lower abdomen or pelvic region that is present for less than 7 days. may or may not be recurrent or related to the menstrual cycle. usually describes acute pelvic pain that has a rapid onset and a sharp intensity. The discomfort may consist of colicky pain, or it may come and go like menstrual cramps. Vital signs may be unstable because of the sharpness of the pain. of reproductive age, the first priority is to rule out pregnancy. Chronic pelvic pain is often classified as either gynecologic or nongynecologic. Categorizing the pain further into cyclic or noncyclic categories assists the clinician in determining whether the pain may be related to the woman's menstrual cycle. somtimes no relationship to menstrual cycle and unrelated to pelvic organs. PP often have had the pain for some time and do not come for treatment until they are so negatively affected by the pain that they can no longer perform activities of daily living. They do not always appear to be experiencing the amount of distress that individuals with severe pain often display. affect may reflect the fact that these women have lived with the pain for so long that they have normalized it and, therefore, do not present as the typical individual suffering from significant pain. Frequently they will describe an inability to work or function at home and a pain that is unrelenting. history: The multiple roles most women play are all altered by pain, and obtaining information about how the pain affects the individual woman physically and emotionally, how it impacts her activities of daily living, and how it changes her relationships is important. A pain history should be taken during the first visit, to include the nature of each pain symptom (i.e., location, radiation, severity, aggravating and alleviating factors); the effects of the menstrual cycle, stress, work, exercise, intercourse, and orgasm on the pain; the context in which pain arose; the social and occupational toll of the pain; and prior or current opioid use. A = Associated symptoms: Gynecologic (dyspareunia, dysmenorrhea, abnormal bleeding, discharge, infertility), gastrointestinal (constipation, diarrhea), genitourinary (dysuria, urgency, incontinence), and neurologic (specific nerve involvement). painscale is important If there is a language barrier related to culture or mental ability, the Wong-Baker FACES pain-rating scale ask about her number of sexual partners and the possibility of her partner having multiple partners. A detailed obstetric history. Pregnancy and childbirth are traumatic events for the musculoskeletal system. Peripartal risk factors include poor musculoskeletal conditioning, delivery of a large baby, and lumbar lordosis. pregnancy and vaginal birth can damage neuromuscular structures and have been linked to pelvic floor, symphyseal, and sacroiliac joint pain. Cesarean birth has been linked to lower abdominal wall pain and adhesions. surgical history provides information about the woman's risk for adhesions, peritoneal injuries, infections, and related diagnoses (endometriosis). disorders have a tendency to persist or recur; thus information about prior surgeries for endometriosis, adhesive disease, or malignancy. hx abues- should be couseled and psycosocial hx is critical. screen for depression. Always inquire about the use of narcotics, alcohol, and recreational drugs when assessing clients who have chronic pelvic pain. The therapeutic goal is to administer the minimum amount of pain medication to achieve a reasonable therapeutic effect. key elements of care for women requiring opioid use: A pain diagnosis must be established with a reasonable differential diagnosis. Consider psychological factors. Institute an opioid treatment agreement. Assess pain level and function at each visit. Avoid opioid monotherapy. Monitor compliance with periodic random urine drug screens. Adhere to strict documentation guidelines. For new patients to the practice, obtain all previous records prior to initiating opioid therapy. physical exam: commonly overlooked facet of the physical examination is sensitivity to the acute and chronic pain that the woman may have endured for years. baseline vital signs, including blood pressure, temperature, pulse, and respirations, prior to performing the physical examination. If the woman has not had a complete physical examination in the last year, one should be performed during the first visit. be sure to let her know that she has the ability to halt the examination at any time. allow the woman to recall aspects of the history that may have been previously omitted, and relate this information to real-time physical findings during the physical examination. slow, careful, and deliberate step-by-step fashion to minimize pain and allow for the woman to relax. Observe the woman's gait, movement, and sitting pose. Women with intraperitoneal pathology or myofascial pain syndromes may compensate for their symptoms by changing their posture or sitting off to one side. musculoskeletal structures may be the site of referred pain from these organs; thus an orthopedic evaluation is important in women with pelvic pain. head, neck, cardiac, and respiratory systems to rule out abnormalities. brief neuro exam. inspection, palpation, and percussion of the spinal column, can be helpful in ruling out radiculopathy. supine position, inspect the abdomen, noting any scars, auscultating for bowel sounds, percussing, and palpating for organomegaly. differentiate abdominal wall pain from visceral sources of pain perform the Carnett test: Ask the woman to raise her head off of the table while she is in the supine position and then have her straight-raise her legs, then palpate the area, tenderness to palpation, the source is most likely abdominal wall pain. Palpating over the area the woman identifies as the origin of the pain and pain mapping may also aid diagnosis- asking the woman to point or specify the exact location of the pain or painful areas. can use a diagram of the body. focus on one area at a time and move methodically to ensure that all areas that hurt are identified or mapped. Women who feel as if they hurt all over are often relieved to realize their pain is actually localized and that other areas are not painful. One way to improve pain mapping by digital pelvic examination is through use of a tenderness-guided endovaginal ultrasound (EVUS). EVUS probe as an extension of the clinician's digit to palpate difficult-to-reach structures while also imaging the anatomic landmarks to confirm the structure that is being palpated. especially useful in making the differential diagnosis of endometriosis— endometriosis is found in approximately 25% of women with CPP. pelvic examination should begin with visual inspection, making particular note of areas of discoloration, dermatologic disorders, or signs of infection. Q-tip examination using light touch provides evaluation of the sensory and neurologic systems of the perineum. pay particular attention to the woman's reaction when the vagina is palpated to observe if she experiences discomfort from pressure along the pelvic floor- myofasial pain syndrome. Tenderness of the urethra or bladder may indicate involvement of the genitourinary system. Pain with deep palpation may indicate endometriosis, whereas cervical motion tenderness is suggestive of PID, adhesions, and other conditions. rectal exam should be included. diagnostics: CBC ESR serologic testing for syphilis U/A and cx (where appropriate) pregnancy test( if appropriate) vaginal smears/culture r/i infection stool guaiac for GI patho TSH thyroid disease affects body functions and may be found in women with bowel or bladder symptoms. pelvic pain in women who were of reproductive and postmenopausal ages was conducted by ultrasound (US). Transvaginal ultrasound is useful for real-time assessment of the pelvis. most effective for detection of pelvic masses (adnexal, some gastrointestinal tumors, uterine fibroids) as well as characterization of the uterus and adnexa". diagnosis of PID if evidence of salpingitis is found, or a ruptured cyst if a characteristic ovarian appearance is combined with presence of a small amount of free fluid. Ultrasound may be used to examine the appendix, although it is not as reliable as computed tomography (CT) in making a diagnosis of appendicitis. modality of choice for initial imaging remains US, although it is often followed by CT scan. endometriomas, adhesions, and neoplastic processes are better identified by CT. additional diagnostic imaging if indicated- barium enema, in women with bowel symptoms; in contrast, if pelvic congestion is suspected, pelvic venography. urinary symptoms are primarily associated with the pelvic pain, then a cystoscopy is typically advised. Laparoscopy is considered the gold standard for evaluation of chronic pelvic pain and is used when pelvic pathology cannot be detected by physical examination or other testing; it allows direct visualization and may enable direct treatment of intra-abdominal pathology. differentials: gynecological orgin- endometriosis chronic pelvic inflammatory disease dysmenorrhea, primary/secondary adhesions pelvic congestion mittelschmerz vulvodynia uterine prolapse ovarian cyst ovarian remnant syndrome adenomyosis fibroids ovarian ca cervica ca torsion of adnexa tubo-ovarian abscess uterine fibroids ectopic pregnancy abortion, threatened/incomplete GI- IBS diverticulities constipation bowel obstruction appendicitis colon ca gastroenteritis genitourinary- interstitial cystitis UTI urinary retention renal calculi pyelo ureteral lithiasis bladder neoplasm MS- scoliosis radiculopathy arthritis herniated disk hernia abdominal wall hematoma other- Aortic aneurysm pelvic thrombophlebitis acute prphyria abdominal angina depression somatiziation disorder prior or current physical or sexual abuse substance abuse hypochondriasis noncyclic diff diagnosis- s/s location of pain: abortion (threatened, inevitable, incomplete)- Crampy, intermittent pain that is in the midline or bilateral lower abdomen- Pregnancy test usually positive Vaginal bleeding usually present If infection: elevated WBC and ESR Ectopic pregnancy- Unilateral crampy pain that is often continuous- Usually vaginal bleeding is present May have very slight elevation of temperature ESR and WBC may be slightly elevated Serum β-hCG is positive US may help with diagnosis PE may reveal an adnexal mass Pelvic inflammatory disease- Lower abdominal, uterine adnexal, and cervical motion tenderness- Pain is often described as dull or achy and may radiate to back or upper thighs May have nausea and vomiting due to pain Low-grade fever Purulent discharge Elevated WBC Elevated ESR Ovarian cysts- Pain is mild to moderate and selflimiting unless it is due to a hemorrhagic corpus luteum cyst, which can result in significant blood loss and hemoperitoneum Onset of pain is usually sudden and midcycle Note: corpus luteum cyst is the most prone to rupture and mimics ectopic pregnancy- Hypovolemia only if there is hemoperitoneum Most critical sign is significant abdominal tenderness, often associated with rebound tenderness due to peritoneal irritation May be able to palpate a mass during the pelvic examination if the cyst is still leaking and not entirely ruptured Adnexal torsion- Results in ischemia and rapid onset of acute pelvic pain Pain is usually severe and constant, unless torsion is intermittent, in which case the pain will come and go Pain may worsen with lifting, exercise, and intercourse.- Tender abdomen with PE and localized rebound tenderness in lower abdominal quadrants Most important sign: large pelvic mass on PE Mild temperature elevation Mild elevated WBC Uterine fibroids- Often asymptomatic, can have increased uterine bleeding, pelvic pressure or pain, and dyspareunia (pain with intercourse) Acute pain with torsion or rupture Note: may be confused with subacute salpingo-oophoritis- Palpation of abdomen reveals mass(es) arising from uterus May note tenderness with palpation May have elevated temperature and WBC Endometriosis- Often asymptomatic Most common symptoms are dysmenorrhea, deep dyspareunia, and sacral backache during menses- PE findings may be absent or limited Laparoscopy with biopsy is the gold standard for diagnosis nongyeno differentials: system- sx- signs- comment Appendicitis (GI)- Diffuse abdominal pain, generally periumbilical- Anorexia, nausea, vomiting Pain usually in RLQ (McBurney's point) Chills May have low-grade fever High fever if ruptured Chills Rebound tenderness Positive psoas sign c Rovsing's sign a shift to left Positive obturator sign b elicited May observe leukocyte- Most common source of acute pelvic pain in women May be confused with gastroenteritis, pelvic inflammatory disease, urinary tract infection, or ruptured ovarian cyst Diverticulitis (GI)- Often asymptomatic May experience abdominal bloating, constipation, and diarrhea- Severe LLQ pain Distended abdomen with LLQ tenderness with palpation Localized rebound tenderness May palpate a doughy, mobile mass in the LLQ Hypoactive bowel sounds May see elevated WBC- Mimics IBS Fistulas can occur Note: diverticulitis can present with perforations or abscess that produce peritonitis Intestinal obstruction (GI)- Colicky abdominal pain Abdominal distention Vomiting Constipation and obstipation, Higher and acute obstruction presents with early vomiting Colonic obstruction presents with greater degree of abdominal distention and obstipation- Significant abdominal distention Bowel sounds are abnormal: at onset they are high pitched during pain and later will decrease and may be absent due to ischemia Elevated WBC and fever are noted as the condition progresses Irritable bowel syndrome (GI)- Acute abdominal pain (may also cause chronic pelvic pain) Bloating Urgency of defecation Diarrhea Constipation - Abdominal pain with palpation May note blood with stool and/or rectal bleeding- IBS is the most commonly identified functional bowel disorder It is diagnosed more often in women than in men Gastroenteritis (GI)- Vomiting Diarrhea Abdominal cramping and pain May have systemic toxicity such as fever and tachycardia- Marked abdominal tenderness with palpation- Causes generally are viral or bacterial Usually self-limited Ureteral lithiasis (GU)- Severe, colicky pain in suprapubic area and in pelvis Urinary frequency Dysuria Nausea, vomit- Hematuria Flank and costovertebral angle pain- Can mimic ectopic pregnancy Cystitis (GU)- Lower abdominal or pelvic pain usually midline- Dysuria, urinary urgency and frequency Urine dipstick positive for leukocyte esterase or nitrite Abdominal wall hernia (MU)- Sharp pain sometimes radiates to lower back Pain intensity is related to position- Abdominal tenderness increases when abdominal wall is tensed most common cause of pelvic pain r/t gyno = endometriosis and adhesions (caused by sx, endometriosis, infection). in sx exacerbate during partions of mentrual cycle- hormone therapy. if constant- NSAIDs and other analgesics/ possible referral to pain specialist. surgical lysis of adhesions is not recommended (may create more/risk of more visceral pain) unless there is evidence of bowel obstruction or infertility ovarian remnent syndrome/retention syndrome- ovary tissue left behind after oopherectomy or purposely with hysterectomy. Ovarian hyperstimulation syndrome from infertility tx- can cause rupture of multiple cysts- life-threatening. Symptoms of increasing severity include enlarging abdominal girth, acute weight gain, and abdominal discomfort. Treatment of moderate to severe disease includes careful fluid management particularly directed at maintenance of intravascular blood volume. After a few days, third-space fluid is absorbed into intravascular spaces, hemoconcentration reverses, and natural dieresis occurs. resolution in 10-14days, sx in extreme cases- ruptured cyst, torsion, internal hemorrhage- AVOID AGRESSIVE PALPATION OF ABDOMEN if OHSS suspected. pelvic congestion- uterine blood vessels remain chronically dilated- reflux of blood into ovarian veins. causes pelvic vascular congestion (retrograde clood flow and venous dilation). common noncyclic gyno: causes of chronic pain-signs-symptoms-dx-mgmt Adhesions- Lower abdominal or pelvic pain that occurs or increases when the peritoneum or organ serosa is stretched Dyspareunia- May elicit abdominal pain with light palpation Decreased motility of pelvic organs Adnexal enlargement- Laparoscopy is the diagnostic tool of choice if somatic causes are ruled out and the psychosocial evaluation is negative- Surgical lysis of adhesions only after a thorough evaluation and failed medical therapy Ovarian remnant syndrome; ovarian retention syndrome- Lateral pelvic pain described as sharp and stabbing or dull and not radiating May have dyspareunia, constipation, or flank pain May have genitourinary and/or gastrointestinal symptoms that accompany pelvic pain- Pelvic mass identified during bimanual examination May observe that the vulva and vagina remain in a persistent estrogenized state US Note: US may be improved by treating the woman with clomiphene citrate (Clomid) 100 mg for 5- 10 days prior to the US to stimulate follicular development- Initial treatment with danazol or high-dose progestins may be helpful in some cases GnRH agonist may help but cannot be used for longterm therapy Surgical excision is often required Pelvic congestion syndrome- Bilateral lower abdominal and back pain Dysmenorrhea Dyspareunia Abnormal uterine bleeding Chronic fatigue Irritable bowel syndrome- Bulky feeling to uterus when palpated during the bimanual examination Ovaries may be enlarged and there may be many functional cysts on the ovaries Uterus, parametria, and uterosacral ligaments are tender to touch- Transuterine venography is the primary method used for diagnosis Other methods include the following: Ultrasound Magnetic resonance imaging Laparoscopy- Begin with the least invasive measures Hormonal measures include progestin or GnRH agonist administration Ovarian vein embolization or ligation Hysterectomy with bilateral salpingooophorectomy should be the last resort Irritable bowel syndrome (IBS) is the most common functional gastrointestinal disorder, accounting for as many as 60% of referrals to the gynecologist for complaints of chronic pelvic pain; women who have had a hysterectomy for chronic pelvic pain are twice as likely to have IBS IBS is a diagnosis of exclusion. Other causes of bowel dysfunction must first be ruled out, such as Crohn's disease, diverticulitis, sprue, lactose allergy, and chronic appendicitis. IBS is characterized by a recurrent abdominal pain or discomfort at least 3 days a month for the past 3 months, and is usually accompanied by constipation or diarrhea. Clinical features of IBS - shifting abdominal pain with constipation or diarrhea, or both. Bloating, nausea, and vomiting, pain may be identified in one quadrant of the abdomen but then relocate during the next attack. Typically, defecation provides relief from the pain. dysregulation in interactions between the central nervous system and the enteric nervous system. This brain- gut dysfunction my ultimately disrupt the GI mucosal immune response, intestinal motility and permeability, and visceral sensitivity. diagnosis is based on the symptoms. The Rome criteria are used to categorize the symptoms and make the diagnosis. These criteria constitute a system developed to classify functional gastrointestinal disorders (FGIDs)— symptoms cannot be explained by the presence of structural or tissue abnormality— based on clinical symptoms. The Rome III Diagnostic Criteria for IBS include: recurrent abdominal pain or discomfort that has occurred for at least 3 days each month for the past 3 months and has been accompanied by at least two of the following: (1) improvement with defecation, (2) onset associated with a change in frequency of stool, and (3) onset associated with a change in form (appearance) of stool. g physical examination of the abdomen, areas of hard feces may be felt in the transverse and descending colon, and the rectal examination may reveal the presence of a hard, lumpy stool if constipation. passage of mucus is common. Other gastrointestinal causes of pelvic pain to keep in mind (although not as common as IBS) include chronic appendicitis, adhesions from previous bowel surgery, and abdominal wall hernia, including umbilical hernias. Often psychologic support is helpful, especially education regarding stress reduction. diet that eliminates carbohydrates —specifically, fructose, lactose, and sorbitol. increase in fiber consumed as part of the diet. medication aimed at tx symptoms- Medications to decrease anxiety have been used with some success. Low-dose tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and serotonin/norepinephrine reuptake inhibitors (SNRIs) have all been used successfully in the treatment of IBS Other medications are prescribed to treat the symptoms of diarrhea and constipation. Antispasmodics such as dicyclomine (Bentyl) and hyoscyamine (Levsin) have been used to decrease abdominal pain due to spasm MS pelvic pain: myofascial pain originating from trigger points in skeletal muscle. Testing for Carnett's sign assists in making the diagnosis and identifying the trigger points. can be injected with local anesthetic— a technique that has been shown to bring relief of the symptoms Urologic causes of chronic pelvic pain, such as interstitial cystitis, occur more often in women than in men. Most are between 40 and 60 years of age. Cystoscopy findings of petechiae or decreased bladder capacity (less than 350 mL) are considered diagnostic for interstitial cystitis. Symptoms include severe urinary frequency and pain, nocturia, and dysuria, in the absence of infection . Hematuria may also be present. Pain is frequently noted in the suprapubic area, lower back, or buttock, and dyspareunia . Anterior pain that occurs when palpating the vaginal wall over the border of the bladder is suggestive of interstitial cystitis. Diagnosis based on symptoms and findings on cystoscopy. management is empirical. Diet changes, stress reduction, and behavior changes are often suggested, and the woman is encouraged to do pelvic floor exercises, which sometimes bring relief of urge frequency. Urethral syndrome is associated with incomplete emptying of the bladder and burning during urination, especially after intercourse. thought to involve noninfectious, stenotic, or fibrous changes in the urethra, often associated with multiparity, delivery without episiotomy, and generaly pelvic relaxation. Diagnosis is made by exclusion. a clean-catch or catheterized urine specimen should be ordered to rule out urinary tract infection. Sometimes sterile pyuria is present; if it is, a course of doxycycline or erythromycin is helpful. A trial of local estrogen therapy, if there is no improvement after 2 months, urethral dilation is a consideration management: Nonpharmacologic Treatment even a distinct diagnosis does not ensure that treatment will be curative; indeed, recurrence of CPP is common. Awareness of the many causative possibilities, formulation of a differential diagnosis, and initiating appropriate treatment strategies will ensure the best possible outcomes for women with CPP. Enlisting the woman's input in developing her treatment plan and encouraging her to take an active role in and feel ownership of the plan are encouraged and often critical to the success of the management plan. pharmacologic and complementary approaches. If no pathology is identified, however, treatment is aimed at relieving the dominant symptoms. Exercise and physical therapy have been shown to be helpful, specialized physiotherapist for initial evaluation to determine an appropriate plan. restore and maintain tissue and joint flexibility, improve posture and body mechanics, restore strength and coordination, reduce nervous system irritability, and restore function. pelvic floor physical therapy is an effective treatment for myofascial pelvic pain. significant improvement in pelvic pain. Both aerobic exercises and nonaerobic exercises, such as weight lifting, have shown positive results. especially in cases where no known cause can be found. Pharmacologic Treatment Pharmacologic oral analgesic such as acetaminophen (Tylenol) or NSAIDs, and then moves to both nonselective and the cyclooxygenase 2 (COX-2) inhibitors. If pain relief is not satisfactory, consider mild opioid such as codeine or hydrocodone, although use of opioid therapy in individuals with chronic pain is controversial. Risk of addiction low in women with chronic pain. pain persists, stronger opioids such as morphine or fentanyl can be considered, although close and regular surveillance is important. Hormonal treatment offers another alternative. Combined oral contraceptives (COCs) are useful in providing relief from primary dysmenorrhea and endometriosis. The gonadotropin-releasing hormone (GnRH) agonist goserelin may be helpful in reducing pelvic pain from endometriosis and dyspareunia. Progestogen therapy can be useful in treating chronic pelvic pain that results from endometriosis and pelvic congestion syndrome. If the chronic pelvic pain is neuropathic in origin, then tricyclic antidepressants may be helpful. treating the depression that often accompanies chronic pain. Amitriptyline (Elavil) and its metabolite nortriptyline (Pamelor) have well-documented efficacy in the treatment of both neuropathic and non-neuropathic pain. combining drugs that work via differing mechanisms of action to increase pain relief. For example, an NSAID and an opioid may be prescribed as dual therapy, particularly if inflammation is present. Tramadol is good alternative to opioid analgesia. Transcutaneous electrical nerve stimulation (TENS) treatment of localized or regional chronic pelvic pain. placement of electrodes near nerve pathways; the electrodes deliver electrical impulses control or alleviate some types of pain. Surgical Treatment necessary in some women in reducing CPP that is unrelieved by any other measure. endometriosis is present, excision or laser ablation of the endometrial tissue, have varying success rates. Presacral neurectomy tx pain associated with dysmenorrhea after other treatment methods have failed. Hysterectomy, last resort; only after other methods have failed. If the woman is of reproductive age, every attempt should be made to treat her pain with nonsurgical methods before considering hysterectomy. 30% of the women seen in primary care clinics have already undergone a hysterectomy without relief of pelvic pain symptoms, and 5% may experience worsening pain. interprofessional approach to pelvic pain treatment includes a gynecologist, physical therapist, and psychologist reduce the frequency of hysterectomy and other surgical interventions as management. preoperative history of CPP should be carefully evaluated and counseled for vaginal mesh placement. A combination treatment regimen consisting of medication and physical therapy should be attempted. Psychotherapy should always be considered for a woman with chronic pelvic pain. Physical and sexual abuse is a significant cause of pelvic pain, and as many as 50% of women with chronic pelvic pain have experienced either physical or sexual abuse, or both. Psychotherapies- cognitive therapy, operant conditioning, and behavioral modification If an infection has been confirmed as the source of chronic pelvic pain, antibiotics should be prescribed. The type and length of antibiotic treatment often depend on culture and sensitivity. Alternative and Complementary Treatment holistic manner that investigates all of the potential sources of pain affecting the mind, body, and spirit. offer a wide range of treatment modalities that address the physical and psychosocial sources of pain, coordinating role for the various therapies. yoga and Tai Chi classes. Nontraditional therapies- acupuncture, biofeedback, transcutaneous nerve stimulation, and herbal and nutritional supplements. Pain causes muscular contraction, techniques that relax muscles may help to reduce some types of chronic pelvic pain. the woman needs to be receptive to trying these measures to obtain any degree of effectiveness. herbal, nutritional, and other forms of complementary therapy for the treatment of pelvic pain; evidence base for these treatments is lacking there are no current evidence-based recommendations for their use. referral: CPP involves clinical overlap of gynecologic, gastrointestinal, urologic, musculoskeletal, and psychological disorders. comprehensive history and physical examination to determine a precise differential diagnosis and effective treatment. may include referral to an appropriate specialist in a gynecologic or nongynecologic arena. higher incidences of physical and psychological abuse, drug abuse, and alcohol abuse than women without CPP- psychological referrals should be considered equally as important as medical and surgical referrals. CPP and sexuality are inextricably linked. Women must be helped to find a new level of normalcy to incorporate pleasure into their lives, despite living with CPP, important to relationships, self-image, and quality of life. Helping a women to adjust sexually is a way to effect change, even if the CPP is resistant to treatment. Turning the focus to sexual adjustment can provide a woman with a welcome diversion in coping with the discomfort of CPP. Clinicians do not need to become sexuality experts to make a difference— they can make referrals to trained sexuality counselors if necessary. Adolescents Pelvic pain is usually gynecologic in origin, but nongynecologic sources should also be considered. listed in order of frequency- gynecologic, urologic, gastrointestinal, musculoskeletal, psychological disorders pelvic pain is more likely to be of gynecologic origin than of gastrointestinal origin (specifically IBS) within this age group. rule out PID as a cause of pelvic pain in adolescents commonly diagnosed in adolescents. aggressively pursue the diagnosis and treatment of chronic pelvic pain in adolescents to avoid future reproductive health issues that could potentially lead to diminished quality of life. stages of emotional and physical development, pose challenges to clinicians that are different from those associated with women in their 20s and beyond. Developing a rapport biggest challenge facing the clinician working with members of this age group. maintaining eye contact, demonstrating a nonjudgmental attitude, treating the teen with respect, and giving her undivided attention. validate her symptoms and the feelings she associates with them. be familiar with state and local statutes regarding health care for minors. Many states have parental consent laws. own policy that must follow the legal parameters already in place. Women of Reproductive ages 18 to 50, over a 3-month period. The women were separated into three groups: (1) women without CPP, (2) women with CPP but without functional constipation, and (3) women with CPP with functional constipation as defined by Rome III criteria. women in group 3 had more pregnancies, more cesarean sections, and more pelvic surgeries, also more types of pain, stress, intense physical exercise, and sadness. perimenopausal: A woman born today will typically have a life span of 81 or more years, entering into menopause at the age of 51 or 52 years. spend more than one-third of their lives in menopause. older than 65 years is projected to rise steadily through 2060. It is important that clinicians remain cognizant of the changing age demographics, especially in their provision of primary and preventive care from a gynecologic perspective. 40 years or older when they undergo their first uterus-preserving treatment experience greater CPP symptom resolution than younger women. Promoting UPT as an alternative to hysterectomy may, in fact, be appropriate only for a subset of women who are 40 years or older. age should be considered a risk factor when counseling younger women about treatment options for CPP. older women: treatment exacerbated the pain. Once the participants developed a chronic pain condition, their quality of life was decreased; they suffered from depression, insomnia, social isolation, suicidal ideation, and desire for amputation. The most appropriate way to manage these individuals was to provide symptom management for chronic pain. Influences of Culture Increased susceptibility to pain is linked to factors such as English as a second language, race and ethnicity, income and education, gender, age, geographic location, veterans, cognitive disabilities, surgical history, cancer diagnosis, and end-of-life status. Cultural and social stratification influences decision making for both patient and clinician, as well as the treatment options that are offered and accepted. Should the clinician be shaking hands, making eye contact, or addressing the woman directly? If her husband is present, does the couple's culture dictate that the clinician include him in the conversation as well? How close should the clinician stand or sit when taking a history? These are all culturally significant questions to consider. express pain differently. Validating a woman's feelings and recognizing and appreciating her cultural and ethnic background are important not only in gaining her trust and establishing rapport, the scope of the problem the woman presents. Culture affect symptom reporting and diagnosis. clinician must have a clear understanding of what the illness means to the woman to make an accurate diagnosis and create an appropriate treatment plan. Women with histories of abuse report higher pain-related disability when compared to those reporting no abuse. must remain cognizant of the possibility of abuse and incorporate related discussions into the conversation with each woman. Pain and Gender intimate experience that only the person experiencing it can truly comprehend. subjective phenomenon, assessed from the woman's personal perspective. women were better able to verbalize the emotions they experienced with pain. caused women's responses to pain to be viewed as a psychologic issue and treated accordingly, often viewed with suspicion and the treatment for their pain was less aggressive. In 2007, the IASP launched the Global Year Against Pain in Women, in recognition of the fact that a significant number of women worldwide have chronic pain conditions that negatively affect their lives, their families, and their communities. there is no longer any debate about whether there are sex and gender differences in pain. The evidence reveals that they do, indeed, exist. Pain is an individual experience that is shaped by a variety of biologic, psychological, and social factors mean subjective pain ratings during cold pressor pain induction were higher among women than men. Also, in a study among individuals with chronic noncancer pain, women reported a greater number of tender points and a lower pain threshold than men. gender differences in pain prevalence appear during adolescence. Rates of pain conditions increase as girls enter puberty, whereas rates for adolescent boys remain stable or rise notably less than for girls. analgesic administration practice was not different between genders, although women presenting with complaints of severe pain were more likely than men to receive analgesics. clinicians' gender stereotypes, as well as the clinician's own gender, appear to influence diagnostic and treatment decisions for more chronic pain problems. not well understood. Individual differences in response to pain may significantly affect outcomes, including the development of chronic pain, overreliance on pain medication, and decreased psychosocial functioning. Psychosocial factors may be among the most important predictors in the development of chronic pain-related disability. women who have multiple responsibilities as part of caring for their family view chronic pain as more of a threat because of its potential to affect their daily lives. important that the clinician carefully interview the woman who presents with chronic pelvic pain to assess the level of interference the pain may be having with her life and activities of daily living. Part of effective treatment- identify how some of the activities can be accomplished.

2. Describe the age range at which menopause usually occurs.

age at natural menopause ranges from 40 to 58 years, with the average age of occurrence around 52 years. median age of menopause was estimated to be between 50 and 52. The age at menopause is difficult to predict for an individual woman, but does correlate with the age when her mother or older sisters experienced menopause. number of factors that may affect the age at menopause have been studied, such as parity, age at menarche, obesity, height, and oral contraceptive use. Specifically, women who smoke are likely to experience menopause 1 year earlier than women who do not. Menstrual cycle changes— including length of cycle, amount of bleeding, and 2- and 3- month periods of amenorrhea— are associated with a shorter time to menopause. Cycle lengths less than 21 days have been associated with the early stages of the menopause transition. A combination of symptoms— including irregular cycles, changed hormone levels, age, and smoking— was identified to be predictive. Body size has been identified as a contributing factor to the age at which women experience menopause due to the fact that body fat stores androstenedione and converts it to estrogen. Evidence has shown that undernourished women and vegetarians may experience an earlier menopause, whereas women with higher body weights often have more adipose tissue and may potentially experience a later menopause. A few studies have found that black women experience menopause slightly earlier than other women, with an average age at menopause of approximately 50 years. women who are older than 45 years with periods of amenorrhea lasting for 60 days or more are considered to be in the late menopausal transition stage and are likely closer to menopause than women in the early menopause transition experiencing cycle irregularities of 7 days or greater. Research has identified that AMH, which reflects the number of follicles, may be helpful in identifying when women can expect to be postmenopausal, with its level dropping to an undetectable point approximately 5 years before menopause.

VII. Discuss components of teaching and counseling for adolescent women. Include health related needs, gynecologic/reproductive problems, and contraception.

chap 4 schuilling Patient education and counseling are important components of primary health care and have been identified as a primary responsibility for nurses. Much of that education and counseling is individualized, conducted as part of a plan aimed at managing specific problems or conditions. Alcohol misuse- Women engaged in risky or hazardous drinking= Brief behavioral counseling intervention to reduce alcohol misuse Sexually transmitted infections- All sexually active adolescents and all women at increased risk for infection= Intensive behavioral counseling to prevent sexually transmitted infections Skin cancer- Adolescents and young women age 10- 24 who have fair skin= Counseling with recommendations to minimize exposure to ultraviolet radiation Tobacco- use All pregnant and nonpregnant women= Ask all women about tobacco use and provided cessation counseling and interventions for those who use tobacco. Counseling recommendations regarding seat belt use have also evolved since the early work of the USPSTF. The earliest recommendations were to advise all women about the proper use and placement of lap and shoulder restraints and to avoid riding with an alcohol-impaired driver or driving while alcohol impaired. The USPSTF ( 2014b ) recommends high-intensity behavioral counseling to prevent sexually transmitted infections (STIs) in all sexually active adolescents and all sexually active adult women at increased risk for STIs. Adult women at increased risk for STIs include those with current STIs or infections within the past year and women with multiple current sexual partners. Counseling should be based on individual risk factors, which can be assessed during a careful drug and sexual history, as well as on local information about the epidemiologic risks for STIs. Clinicians who work in practices located in high-prevalence areas should consider all sexually active women in nonmonogamous relationships to be at increased risk of STIs. Patients identified as being at increased risk for the acquisition of an STI need to receive information about risk factors and ways to reduce their likelihood of infection. Such measures include abstinence, maintaining a mutually monogamous sexual relationship with a partner who is not infected, regular use of latex condoms, and avoiding sexual interaction with individuals who are at increased risk. Women who are at increased risk for STIs should be advised to use a condom with every sexual encounter and to avoid anal intercourse. Women who use condoms should be advised to use them in accordance with the manufacturer's recommendations. Measures to reduce the chance of infection when a partner will not use a condom should also be discussed— for example, use of the female condom. All women who are at increased risk for STIs should be offered screening and counseled to receive the hepatitis B vaccine; in addition, all adolescent and young women should be counseled about the appropriateness of the human papillomavirus vaccine. almost half of all pregnancies in the United States each year are unintended; any discussion regarding counseling women about sexual behavior would be incomplete without addressing contraceptive counseling. USPSTF does not address contraceptive counseling in its recommendations for clinical preventive services. However, the CDC ( 2013 ) recommends counseling all women who are sexually active with male partners about effective contraceptive methods. Counseling should be based on information obtained from a detailed sexual history. clinicians should demonstrate sensitivity and an understanding and respect for an individual's preferences when initiating preconception counseling. It is important to keep in mind that some women will choose not to conceive, and not all women who conceive will choose to continue the pregnancy. tobacco- Ask about tobacco use Advise to quit through clear personalized messages Assess willingness to quit Assist to quit Arrange follow-up and support recommends behavioral counseling interventions for all adolescents and school-aged children. Effective strategies include face-to-face individual counseling, group counseling, printed materials, telephone and mobile device messaging, and messages sent through the U.S. mail. Regardless of the methods used or the frequency of counseling, the strategies that appear to be most effective include the provision of age-appropriate information about the consequences of tobacco use, the impact of social pressure, warnings about tobacco marketing, and effective ways to say "no" to tobacco use. Counseling aimed at providing parents with tools to help their children remain tobacco free has also been effective. (i got this from a text in the HSC library under FNP books- CURRENT Diagnosis & Treatment: Obstetrics & Gynecology, 11e Alan H. DeCherney, Lauren Nathan, Neri Laufer, Ashley S. Roman) an excellent opportunity to review basic health care maintenance. For example, current recommendations advise universal vaccination for hepatitis B for all adolescents at ages 11-12 years, with immunization for older adolescents based on risk status and discussion regarding human papillomavirus vaccine. In addition, screening for eating disorders, depression, and behavioral risks including sexual activity and tobacco, alcohol, and substance abuse should be done routinely.

IV. Describe changes that occur during puberty in the following. Include expected time of appearance and the physiologic basis for changes: A. Pubic hair. B. The breasts C. The vagina D. The uterus and fallopian tubes E. Body contours F. Height/weight

(i got this from a text in the HSC library under FNP books- CURRENT Diagnosis & Treatment: Obstetrics & Gynecology, 11e Alan H. DeCherney, Lauren Nathan, Neri Laufer, Ashley S. Roman) During early puberty (age 10-13 years), the external genitalia take on adult appearance. The major vestibular glands (Bartholin's glands) begin to produce mucus just prior to menarche. The vagina reaches adult length (10-12 cm) and becomes more distensible, the mucosa thickens, vaginal secretions grow more acidic, and lactobacilli reappear. With the development of vaginal fornices, the cervix becomes separated from the vaginal vault, and the differential growth of the corpus and cervix becomes more pronounced. The corpus grows twice as large as the cervix. The ovaries descend into the true pelvis. Secondary sexual characteristics develop, often rapidly, during the late premenarchal period. Body habitus becomes more rounded, especially the shoulders and hips. Accelerated somatic growth velocity (the adolescent growth spurt) occurs. At the same time, estrogen increases adipose tissue deposition and initiates stromal and ductal growth in the breasts. Physiologic leukorrhea often is noted. Pubic hair growth, or pubarche (adrenarche), appears to be under the control of adrenal androgens and is a process that is independent of although associated with gonadarche. Sparse, long, slightly curly, pigmented hair over the pubic area gives way to coarse, pigmented curly hair. The pubic hair pattern assumes the characteristic triangle with the base above the mons pubis. Hair growth in the axilla appears later, also as a result of adrenocorticosteroid stimulation. The development of secondary sexual features described by Marshall and Tanner.

Hormone Therapy Position Statement (article)

-Individualization is of key importance in the decision to use HT and should incorporate the woman's health and quality of life priorities as well as her personal risk factors, such as risk of venous thrombosis, CHD, stroke, and breast cancer. -The recommendation for duration of therapy differs for EPT and ET. For EPT, duration is limited by the increased risk of breast cancer and breast cancer mortality associated with 3 to 5 years of use; for ET, a more favorable benefit-risk profile was observed during a mean of 7 years of use and 4 years of follow-up, a finding that allows more flexibility in duration of use. -ET is the most effective treatment of symptoms of vulvar and vaginal atrophy; low-dose, local vaginal ET is advised when only vaginal symptoms are present. -Women with premature or early menopause who are otherwise appropriate candidates for HT can use HT at least until the median age of natural menopause (age 51 y). Longer duration of treatment can be considered if needed for symptom management. -Although ET did not increase breast cancer risk in the WHI, there is a lack of safety data supporting the use of ET in breast cancer survivors, and one RCT reported a higher increase in breast cancer recurrence rates. -Both transdermal and low-dose oral estrogen have been associated with lower risks of VTE and stroke than standard doses of oral estrogen, but RCT evidence is not yet available. conclusion: There is a growing body of evidence that HT formulation, route of administration, and the timing of therapy produce different effects. Constructing an individual benefit-risk profile is essential for every woman considering any HT regimen. A woman's interest in using HT will vary depending on her individual situation, particularly the severity of her menopausal symptoms and their effect on her QOL. The absolute risks known to date for use of HT in healthy women ages 50 to 59 years are low. In contrast, long-term HT or HT initiation in older women is associated with greater risks. Recommendations for duration of use differ between ET and EPT. Given the more favorable safety profile of ET, it could be considered for longer duration of therapy in the absence of adverse effects and risk factors. Women experiencing premature menopause are at increased risk of osteoporosis and, possibly, cardiovascular disease, and they often experience more intense symptoms than do women reaching menopause at the median age. Therefore, HT generally is advised for these young women until the median age of menopause when treatment should be reassessed. Additional research is needed to understand the different effects of ET and EPT and how they apply to individual women. Further research is also needed to more clearly delineate the role of aging versus menopause and the effects of genetics, lifestyle, and individual clinical characteristics on midlife women's health.

10. Discuss the prevalence of sexual abuse in the United States. 11. Discuss the possible short- and long-term consequences of sexual abuse. 12. Describe the immediate care of the sexual abuse victim.

10. 2010, an estimated 270,000 women were victims of sexual assault or rape in the United States. > one-third of the world's women have reported experiencing physical and/or sexual violence. nearly 1 in 5 women in the United States has been raped at some point in her life. equates to almost 22 million women. 80% of cases where women experienced completed rape, the assault occurred before the age of 25, with more than 42% of victims being raped prior to age 18. American Indian/Native Alaskan and multiracial women had a significantly higher incidence of rape— 26.9% and 33.5%. 22% of black women reported that they had experienced rape, compared to 18.8% of white women and 14.6% of women of Hispanic origin. women aged 34 and younger who were living in low-income, rural areas experienced some of the highest rates of sexual violence. During this same period, almost 80% of the incidents of sexual violence were perpetrated by a known individual (family member, intimate partner, friend, or acquaintance). 65% of women who are victims of sexual assault or rape do not report the assault to police. Women ages 18 to 24 years have the highest incidence of rape and sexual assault in the nation, yet only 20% of student victims and 32% of nonstudent victims in this age group report the incident to the police. 11. may present with a variety of acute and chronic health concerns that may be of a physical or psychological nature. seeking acute or initial treatment include concern over sexually transmitted infections (STIs), human immunodeficiency virus (HIV), pregnancy, and physical health. Women who are survivors of sexual assault may also present with chronic health concerns, making more visits to clinicians during their lifetime compared to nonvictims. significantly higher rates of chronic pain, headaches, difficulty sleeping, activity limitations, asthma, irritable bowel syndrome, and overall poor physical and mental health. be familiar with these potential variations in health to provide competent, quality care to women who are victims of sexual violence. may have anogenital injuries. Lacerations or tears, abrasions, and bruising or ecchymosis are the most common genital injuries. most common sites for injury include the labia minora, posterior fourchette, and fossa navicularis. may also occur to the labia majora, hymen, vaginal wall, cervix, and other genital structures. anogenital tissue can heal in as little as 36 to 48 hours. most frequently diagnosed STIs among women who have been sexually assaulted are chlamydia, gonorrhea, trichomoniasis, and bacterial vaginosis. consider prophylactic treatment for these common infections. Transmission of the human immunodeficiency virus (HIV) is also a concern of women who have been sexually assaulted. Women who are victims of sexual assault and who are of reproductive age often fear becoming pregnant. Prompt care for female patients following a sexual assault is critical for preventing unintended or unwanted pregnancy. signs of distress such as crying, trembling, or expressions of anger. Conversely, a woman's reaction may be more composed and controlled, with minimal to no outward sign that she is in distress. shock, denial, embarrased, self blame. Psychological symptoms may become more visible and severe in the weeks and months following the sexual assault. These responses can include fear, anger, anxiety, depression, substance use or abuse, and post-traumatic stress disorder. sexually assaulted are prone to more severe trauma responses when (1) the assault is completed rather than attempted, (2) the assailant is known to the woman, (3) the woman experiences a freeze reaction or is restrained and unable to move during the assault, or (4) the woman has experienced previous psychological trauma or has a history of mental illness. Women who are subject to victim blaming, lack of belief or support, and continued violence have more severe and long-lasting psychological impact from the assault. extremely high risk PTSD- it is essential that a clinician treating a woman who is a victim of sexual assault assess her suicide risk during the initial and all follow-up visits. sexual assault can lead to increased substance use and abuse in women as a means to attempt to cope with the trauma. The more severe the sexual trauma (e.g., completed rape), the more likely the woman is to develop problematic substance use. Further, the substance use may lead to an increase in risky sexual behavior, which in turn puts the woman at risk for STIs and possible sexual dysfunction. Sexual dysfunction is a common and sometimes chronic problem after sexual assault— particularly loss of sexual desire and lack of ability to orgasm. inability to become sexually aroused, slow arousal, pelvic pain associated with sexual activity, a lack of sexual enjoyment, fear of sex, avoidance of sex, intrusive thoughts of the assault during sex, vaginismus, or abstinence 12. Evaluation of a woman who has been sexually assaulted is often referred to as the medical forensic or clinical forensic examination. Sexual assault victims are entitled to a prompt, high-quality medical forensic examination to promote healing, minimize trauma, and increase the likelihood of recovering evidence from the assault. VAWA, which was renewed by the federal government in 2013, ensures that women receive this examination free of charge even if they choose not to report. Sexual Assault Forensic Examiners and SANE are clinicians who are specially educated and clinically trained to evaluate and treat sexual assault patients; they are recommended to conduct the forensic examination to ensure competent, quality care. Clinicians treating women who experience sexual violence must be able to not only treat women's injuries and address healthrelated concerns, but also coordinate crisis intervention, collect evidence and maintain the appropriate chain of custody, follow jurisdictional reporting procedures, and testify in legal proceedings if necessary. The woman should be asked if she would like the victim services organization to be contacted so that an advocate can be made available to offer crisis intervention, advocacy, and support to the patient before, during, and after the medical forensic examination. **Prior to engaging in care of the sexual assault victim, the clinician must obtain two types of informed consent. The first type is a general consent that signifies the woman has agreed to receive medical evaluation and treatment. The second type grants the clinician permission to collect evidence and gives the woman the option to release the evidence to the appropriate law enforcement and criminal justice agencies. In cases of reversible incapacitation (e.g., medication, drug, or alcohol ingestion and intoxication), the sexual assault medical forensic examination should be deferred until the patient is legally able to consent. In cases where the patient is younger than the age of consent, is comatose, or is suffering from a permanent cognitive or developmental disability, consent should be obtained from the person legally responsible for making healthcare decisions for the patient.

Updated Consensus Guidelines for the Management of Abnormal Cervical Cancer Screening Tests and Cancer Precursors article

Box 1. Essential Changes From Prior Management Guidelines* - Cytology reported as negative but lacking endocervical cells can be managed without early repeat. - CIN 1 on endocervical curettage should be managed as CIN 1, not as a positive ECC. - Cytology reported as unsatisfactory requires repeat even if HPV negative. - Genotyping triages HPV-positive women with HPV type 16 or type 18 to earlier colposcopy only after negative cytology; colposcopy is indicated for all women with HPV and ASC-US, regardless of genotyping result. - For ASC-US cytology, immediate colposcopy is not an option. The serial cytology option for ASC-US incorporates cytology at 12 months, not 6 months and 12 months, and then if negative, cytology every 3 years. - HPV-negative and ASC-US results should be followed with co-testing at 3 years rather than 5 years. - HPV-negative and ASC-US results are insufficient to allow exit from screening at age 65 years. - The pathway to long-term follow-up of treated and untreated CIN 2+ is more clearly defined by incorporating co-testing. - More strategies incorporate co-testing to reduce follow-up visits. Pap-only strategies are now limited to women younger than 30 years, but co-testing is expanded even to women younger than 30 years in some circumstances. Women aged 21-24 years are managed conservatively. Studies of the effect of treatment on future pregnancy are conflicting, although many indicate an approximately two-fold increase in preterm delivery risk (27Y29). Although not proven, this is presumed to result from deficient cervical stroma, and risk appears to increase with the volume and number of excisions (30). However, many studies were done in countries where loop excisions are performed with larger loop sizes and deeper excisions than most U.S. clinicians employ. Studies linking ablative treatments to preterm delivery are even more limited and conflicting. Women with CIN may be at increased risk for preterm delivery even when untreated. Nevertheless, because pregnancy complications can be devastating, the potential benefits of treatment should be balanced against the risk. Young women have high regression rates for cervical disease and low cancer risk. ''young women'' indicates those who after counseling by their clinicians consider risk to future pregnancies from treating cervical abnormalities to outweigh risk for cancer during observation of those abnormalities. 2011 screening guidelines recommend not screening adolescents. Many management strategies incorporate follow-up with HPV testing, which can elicit feelings of stigma and shame when positive despite the near-ubiquitous frequency of HPV infection (39, 40). The anxiety and time required for visits to manage abnormal cytology can adversely affect relationships, work-related and school activities, and family matters (41). These potential harms reinforce the concept that colposcopy and other interventions should be avoided when risk for CIN 3+ is low and when identified lesions are likely to resolve. Immunosuppressed women with abnormal results should be managed in the same manner as immunocompetent women. (HIV) For women with an unsatisfactory cytology result and no, unknown, or a negative HPV test result, repeat cytology in 2Y4 months is recommended. For women aged 21-29 years with negative cytology and absent or insufficient EC/TZ component, routine screening is recommended. HPV testing is unacceptable (BIII). For women aged 30 years and older with cytology reported as negative and with absent or insufficient EC/TZ component and no or unknown HPV test result, HPV testing is preferred (BIII). Repeat cytology in 3 years is acceptable if HPV testing is not performed (BIII). If the HPV test is done and is negative, return to routine screening is recommended (BIII). If the HPV test is positive, repeating both tests in 1 year is acceptable (BIII). Genotyping is also acceptable; if HPV type 16 or type 18 is present, colposcopy Management options for pregnant women with ASC-US are identical to those described for nonpregnant women, with the exception that deferring colposcopy until 6 weeks postpartum is acceptable (CIII). Endocervical curettage in pregnant women is unacceptable (EIII). For pregnant women who have no cytologic, histologic, or colposcopically suspected CIN 2+ at the initial colposcopy, postpartum follow-up is recommended Postmenopausal women with ASC-US should be managed in the same manner as women in the general population For pregnant women with LSIL, colposcopy is preferred (BII). Endocervical curettage in pregnant women is unacceptable (EIII). For pregnant women aged 21Y24 years, follow-up according to the guidelines for management of LSIL in women aged 21Y24 years is recommended (discussed in previous paragraph). Deferring colposcopy until 6 weeks postpartum is acceptable (CIII). For pregnant women who have no cytologic, histologic, or colposcopically suspected CIN 2+ at the initial colposcopy, postpartum follow-up is recommended (BIII). Additional colposcopic and cytologic. examinations during pregnancy are unacceptable for these women. Acceptable options for the management of postmenopausal women with LSIL and no HPV test include obtaining HPV testing, repeat cytologic testing at 6 months and 12 months, and colposcopy (CIII). If the HPV test is negative or if CIN is not identified at colposcopy, repeat cytology in 12 months is recommended. If either the HPV test is positive or repeat cytology is ASC-US or greater, colposcopy is recommended (AII). If two consecutive repeat cytology tests are negative, return to routine screening is recommended. The initial evaluation of AGC in pregnant women should be identical to that of nonpregnant women (BII), except that endocervical curettage and endometrial biopsy are unacceptable benign gladular changes postmenopausal women with benign endometrial cells, endometrial assessment is recommended For pregnant women with a histologic diagnosis of CIN 1, follow-up without treatment is recommended (BII). Treatment of pregnant women for CIN 1 is unacceptable In the absence of invasive disease or advanced pregnancy, additional colposcopic and cytologic examinations are acceptable in pregnant women with a histologic diagnosis of CIN 2, CIN 3, or CIN 2,3 at intervals no more frequent than every 12 weeks (BII). Repeat biopsy is recommended only if the appearance of the lesion worsens or if cytology suggests invasive cancer (BII). Deferring reevaluation until at least 6 weeks postpartum is acceptable (BII). A diagnostic excisional procedure is recommended only if invasion is suspected (BII). Unless invasive cancer is identified, treatment is unacceptable (EII). Reevaluation with cytology and colposcopy is recommended no sooner than 6 weeks postpartum. S16 Management of Women With AGC or Cytologic AIS Initial Workup (Fig. 11) For women with all subcategories of AGC and AIS except atypical endometrial cells, colposcopy with endocervical sampling is recommended regardless of HPV result. Endometrial sampling is recommended in conjunction with colposcopy and endocervical sampling in women 35 years of age and older with all subcategories of AGC and AIS (BII). Endometrial sampling is also recommended for women younger than 35 years with clinical indications suggesting they may be at risk for endometrial neoplasia, unexplained vaginal bleeding or conditions suggesting chronic anovulation. women with AGC not otherwise specified cytology in whom CIN 2+ is not identified, co-testing at 12 months and 24 months is recommended. If both cotests are negative, return for repeat co-testing in 3 years is recommended. If any test is abnormal, colposcopy is recommended. For women with AGC ''favor neoplasia'' or endocervical AIS cytology, if invasive disease is not identified during the initial colposcopic workup, a diagnostic excisional procedure is recommended. Pregnant Women The initial evaluation of AGC in pregnant women should be identical to that of nonpregnant women (BII), except that endocervical curettage and endometrial biopsy are unacceptable Management of Benign Glandular Changes. For asymptomatic premenopausal women with benign endometrial cells, endometrial stromal cells, or histiocytes, no further evaluation is recommended (BII). For postmenopausal women with benign endometrial cells, endometrial assessment is recommended Women Aged 21-24 Years It is recommended that ASCCP guidelines for management of AGC be followed for all women, including those aged 21-24 years (BII). posthysterectomy patients with a cytologic report of benign glandular cells, no further evaluation is recommended CIN 1 is the histologic manifestation of HPV infection. Although most CIN 1 lesions are associated with oncogenic HPV, HPV-16 is less common in CIN 1 than in CIN 3, and nononcogenic HPV types are also commonly found in CIN 1 lesions (82, 83). The natural history of CIN 1 is similar to that of HPV-positive ASC-US and LSIL in the absence of CIN, suggesting similar management. Regression rates are high, especially in younger women (32, 64), and progression to CIN 2+ is uncommon Failure to detect CIN 2+ at colposcopy in women with HSIL does not mean that a CIN 2+ lesion has been excluded, although occult carcinoma is unlikely. As a result, women with HSIL who do not have immediate diagnostic excision require close follow-up. minor cytologic abnormalities have similar risk for CIN 3+ whether colposcopy shows CIN 1 or no lesion (64, 68). Since CIN 3+ risk is elevated for women with either HPV-16 or HPV-18 or persistent oncogenic HPV infection of any type even when cytology is negative, guidelines must provide for follow-up for women with these ''lesser abnormalities'' even when no CIN is found. These ''lesser abnormalities'' include HPV-16 or HPV-18 positivity, persistent untyped oncogenic HPV, ASC-US, and LSIL. Management of Women With CIN 1 or No Lesion Preceded by ''Lesser Abnormalities'' (Fig. 13). Co-testing at 1 year is recommended (BII). If both the HPV test and cytology are negative, then age-appropriate retesting 3 years later is recommended (cytology if age is younger than 30 years, co-testing if 30 years of age or older). If all tests are negative, then return to routine screening is recommended (BII). If any test is abnormal, then colposcopy is recommended If CIN 1 persists for at least 2 years, either continued follow-up or treatment is acceptable (CII). If treatment is selected and the colposcopic examination is adequate, either excision or ablation is acceptable (AI). A diagnostic excisional procedure is recommended if the colposcopic examination is inadequate; the endocervical sampling contains CIN 2,CIN 3, CIN 2,3 or ungraded CIN; or the patient has been previously treated definition of terms: Colposcopy is the examination of the cervix, vagina, and, in some instances the vulva, with a colposcope after the application of a 3% to 5% acetic acid solution coupled with obtaining colposcopically directed biopsies of all lesions suspected of representing neoplasia. Adequate colposcopy indicates that the entire squamocolumnar junction and the margins of any visible lesion can be visualized with the colposcope. Co-testing is assessment for cervical disease using a combination of cytology and HPV testing at the same time, regardless of the cytology result. Reflex HPV testing is the performance of HPV testing only in response to an abnormality to stratify risk and guide further management. Endometrial sampling includes obtaining a specimen for histologic evaluation using an endometrial biopsy, dilation and curettage, or hysteroscopy. Endocervical sampling includes obtaining a specimen for either histologic evaluation using an endocervical curette or a cytobrush or for cytologic evaluation using a cytobrush. Endocervical assessment is the process of evaluating the endocervical canal for the presence of neoplasia using either a colposcope or endocervical sampling Diagnostic excisional procedure is the process of obtaining a specimen from the transformation zone and endocervical canal for histologic evaluation and includes laser conization, cold-knife conization, loop or needle electrosurgical excision, and loop electrosurgical conization. Lesser abnormalities are those that carry lower risk of CIN 3+ than other results. These include negative cytology with either HPV-16 or HPV-18 or persistent untyped oncogenic HPV, ASC-US, and LSIL. HPV, human papillomavirus; CIN, cervical intraepithelial neoplasia; ASC-US, atypical squamous cells of undetermined significance; LSIL, low-grade squamous intraepithelial lesions.

hormonal methods- schuilling

COCs (or "the Pill") are some of the best-studied and most widely used medications available today; they remain the most popular form of reversible contraception in the United States. Two types of hormonal contraceptives are available: those that contain progestin (progestin-only) and those that contain progestin and estrogen (combined). Progestin, the synthetic version of the endogenous hormone progesterone, is highly effective alone as a contraceptive, but may cause irregular bleeding. The addition of estrogen to progestin in combined methods results in more predictable bleeding patterns due to stabilization of the endometrium. Estrogen as a single agent for contraception requires doses that may cause unacceptable risks of serious side effects, such as thromboembolic events and endometrial hyperplasia. The synergistic activity of estrogen and progestin makes it possible to combine these hormones in lower doses to produce successful contraception than would be possible using either hormone alone. methods currently available in the United States include COCs, the patch, and the vaginal ring. Progestin methods include progestin-only pills, the depot medroxyprogesterone acetate injection, the subdermal implant, and three levonorgestrel-containing IUDs. Both progestin and estrogen inhibit the hypothalamic- pituitary- ovarian axis and subsequent steroidogenesis. Progestins- preventing the luteinizing hormone (LH) surge and thereby inhibiting ovulation; thickening the cervical mucus, which inhibits sperm penetration and transport; changing the motility of the fallopian tubes so that transport of sperm or ova is impaired; and causing the endometrium to become atrophic. Estrogen suppresses the production of follicle-stimulating hormone (FSH), thereby preventing the selection and emergence of a dominant follicle. The primary mechanism of action of all hormonal contraceptive methods, with the exception of progestin-only pills (POPs) and the levonorgestrel intrauterine systems (LNG-IUSs), is preventing ovulation. progestin secondary mechanisms to prevent pregnancy should ovulation occur. POPs and the LNG-IUSs do not consistently inhibit ovulation, and their primary mechanism of action is thickening the cervical mucus. provision of oral contraceptives without a mandatory pelvic examination does not place women at higher risk of cervical cancer. stress the concomitant use of barrier methods in women who are at risk of exposure to STIs. be proactive in educating clients about the noncontraceptive benefits of these methods. Future fertility may be preserved through the decreased risk of pelvic inflammatory disease and ectopic pregnancy associated with the use of hormonal methods. decreased risk of several cancers (colon, ovarian, and endometrial) as well as a decreased risk of the serious diseases of endometriosis, adenomyosis, rheumatoid arthritis, and asthma. Protection against ovarian and uterine cancer may persist as long as 28 years after discontinuation of use of these methods. The preservation of bone density that occurs in ever-users of COCs may persist up to age 80. The LNG-IUSs are connected with a 50% decreased risk of cervical cancer. The use of COCs is not associated with an increase the risk of breast cancer, lack of association is also seen in carriers of the BRCA1 and BRCA2 mutations. An increased risk of cervical cancer is seen in long-term COC users, though this risk returns to normal after cessation of use. Although an increased risk of a rare type of liver tumor is connected with COC use, the decreased risk of other, more common cancers may lead to an overall decrease in cancer-related mortality. During the first few postpartum weeks, the risk of venous thromboembolism (VTE; deep vein thromboses and pulmonary emboli) is greatly elevated in all women; consequently, estrogen containing contraceptives are contraindicated during this time. Progestin-only methods may be initiated immediately postpartum. COCs are classified as monophasic or multiphasic (biphasic, triphasic, or quadphasic), depending on whether the dosage of hormones is constant or varies. There is no evidence that either monophasic or multiphasic formulations are a superior choice. Most of the COCs available today contain 10 to 35 mcg of ethinyl estradiol, although a few COCs contain 50 mcg of ethinyl estradiol or mestranol, the methyl ether of ethinyl estradiol. Estradiol valerate is found in the new quadphasic COC. COCs also contain one of several different progestins. The progestins are often referred to as belonging to the first, second, or third generation. With the exception of drospirenone, all progestins in COCs available in the United States are derived from C-19 androgens. These derivatives are classified into two categories: (1) the estranes, or chemical derivatives of norethindrone (norethindrone, norethindrone acetate, and ethynodiol diacetate), and (2) the gonanes, or chemical derivatives of norgestrel (norgestrel, its active isomer levonorgestrel, desogestrel, and norgestimate). formulations should be judged on the clinical response of the woman. Drospirenone, the only non-testosterone-derived progestin, is an analogue of the diuretic spironolactone. Drospirenone has a mild potassium-sparing diuretic effect, necessitating that potassium levels be checked during the first cycle in women using angiotensinconverting enzyme (ACE) inhibitors, chronic daily nonsteroidal antiinflammatory drugs (NSAIDs), angiotensin-II receptor antagonists, potassium-sparing diuretics, heparin, or aldosterone antagonists. Women with conditions that predispose them to hyperkalemia should not use COCs containing drospirenone. The initial choice of a particular COC should be made with the goal of providing the woman with safe, effective contraception. All lowdose (less than 50 mcg) COCs meet this requirement, so it is reasonable to provide a woman with whatever formulation is most cost effective, or whatever pill she requests by name. Instructions contained in the pill package insert include options for a Sunday start, a first-day start, and a day 5 start. All of these options are based on the principle that as long as COCs are begun within the first 5 days of the menses, there is contraceptive protection in the first cycle. The Sunday start has been the traditional approach in the United States, because the appearance of COC packages often reflects that regimen, and the withdrawal bleed does not usually occur on the weekend, which couples may find preferable. The advantage of the first-day start is that no backup contraceptive method is required in the first cycle. Women are advised to use additional contraception, such as condoms, with the regimens having other starting points for the first 7 days. An increasingly popular alternative approach is to utilize a "quick start" by beginning the pill regardless of where the woman is in her menstrual cycle, if pregnancy is excluded and with additional contraception for the first 7 days. Instructions are given to take a pregnancy test in 2 to 3 weeks if unprotected sex occurred during the cycle. This practice has been shown to increase continuation rates for COCs and is not associated with an increased incidence of adverse bleeding patterns. With the traditional cyclic schedule, women take 21 to 24 days of active COCs, followed by 4 to 7 days of inactive pills or no pills. During the hormone-free interval, bleeding from the withdrawal of estrogen and progestin occurs. This is technically a withdrawal bleed, rather than menses, and is based primarily on convention rather than on science. Extended (omitting the hormone-free interval for two or more cycles) and continuous (omitting the hormone-free interval indefinitely) COC regimens are becoming increasingly popular, both for medical indications and convenience. Monophasic pills are generally preferred for this use. Efficacy and Effectiveness- COCs require the woman's daily adherence to the dosing schedule, which can be compromised by many factors, resulting in a gap between efficacy and effectiveness. Common reasons for COC failure include not starting a new pack on time, missing pills, "taking a break" from the pill, and discontinuing the pill in response to normal side effects. The counseling and education provided by the clinician are critical to the ultimate success of the woman in avoiding unwanted pregnancy. The most important pills to take in each cycle are the first and last active COCs, which ensure that the hormone-free interval does not exceed 7 days. During the hormone-free interval, pituitary stimulation of the ovaries by FSH is likely to resume and follicular development may begin in many women. Immature follicles stimulated during the hormone-free phase generally regress once the hormonal pills are resumed, and 7 consecutive days of pill use have been shown to be sufficient in suppressing any follicular function. Hormone-free intervals of less than 7 days have become increasingly standard. Patient instructions must stress the importance of starting a new pack on time and not taking more than 7 days off of the active pills. If a woman does extend the hormone-free interval beyond 7 days, she should be instructed to abstain from intercourse or use additional contraception until 7 consecutive pills have been taken. Missing a random pill now and then is unlikely to lead to a method failure. Unfortunately, this fact may lead to complacency regarding the importance of daily adherence to the schedule, as women come to believe that inconsistent pill use is adequate. The probability of pill failure increases with repeated missed pills. Current recommendations are as follows: If one pill is missed and is less than 48 hours late, take the late or missed pills as soon as possible and continue taking the remaining pills at the usual time. No backup method or emergency contraception is needed. If two or more consecutive hormonal pills have been missed and it is more 48 hours or more since a pill should have been taken, take the most recent pill as soon as possible (any other missed pills should be discarded). Continue taking the remaining pills at the usual time and use a backup method or avoid sexual intercourse until hormonal pills have been taken for 7 consecutive days. If pills were missed during the last week of hormonal pills, finish the remaining hormonal pills and start new pill pack the following day. *Emergency contraception should be considered if pills were missed during the first week and sexual intercourse occurred during last 5 days. Many women incorrectly believe that temporarily discontinuing or "taking a break from" COCs is beneficial. It is important to convey to women that the hormones found in the pill do not accumulate in the body, and the occurrence of a withdrawal bleed indicates that the endometrium is responding to the absence of hormones. There are no differences in the long-term fertility of women who use the pill intermittently and those who use the pill for many years. Nearly half of all women who begin taking oral contraceptives discontinue their use before the end of 1 year; the most commonly reported reasons for discontinuation in a recent study were side effects and difficulty obtaining contraception. Clear information about the side effects commonly encountered during the first three cycles of pill use should be given. Whenever a woman begins a new COC, she should be advised to contact the clinician prior to discontinuing the pills if she experiences unwanted side effects. different pill may be substituted without interrupting effective contraception. A number of medications can modify the effectiveness of COCs. Pharmacologic mechanisms that alter medication metabolism include induction of liver enzymes, alterations in sex hormonebinding globulin (SHBG), and medications that alter the first-pass effect in the gut. Medications that can reduce the effectiveness of COCs include antiretroviral therapy, rifampin, griseofulvin, and some anticonvulsants (e.g., carbamazepine, phenytoin, barbiturates, primidone, topiramate, oxcarbazepine, lamotrigine), over-the-counter herbal supplements such as St. John's wort. Broad-spectrum antibiotics have been blamed for COC failures, although pharmacologic evidence to support this assertion is lacking. Given the prevalence of antibiotic use, any pill failures are more likely to be coincidence or to be associated with missed pills. concerned about reduced COC efficacy while on antibiotics can shorten or eliminate the use of the placebo pills in the pill pack or use an additional contraceptive, but it is not necessary. Safety and Side Effects- extremely safe for healthy women. Many of the side effects associated with COCs are bothersome but not dangerous; serious complications are possible and are the basis of contraindications to COC use. direct effects of the hormonal ingredient, as in breast cancer, or they may result from hormonal effects on other systems, as in thromboembolism. One must always weigh the risks of pregnancy in relation to the risks associated with contraceptive use. All COCs increase the risk of VTE. The level of this risk appears to be related to the dose of estrogen and is greatest for women with known clotting disorders, such as factor V Leiden, or a family history of thrombosis. The various progestin components may contribute to the risk of VTE to a differing degree; however, the difference between pills is small. COCs containing less than 50 mcg of estrogen do not appear to increase the risk of arterial thrombosis (myocardial infarction or stroke) in healthy, nonsmoking women, including women older than 40 years. COCs may increase blood pressure in some women through an increase in plasma angiotensin. Because hypertension is a cofactor in the development of cardiovascular disease, blood pressure should be monitored in COC users. Metabolic effects of COCs may include development of benign hepatocellular adenomas, very rare with the low-dose pills. There does not appear to be an association between these benign tumors and the development of liver cancer. Low-dose COCs appear to create negligible changes in insulin levels or glucose levels and have no effect on the development of diabetes. There is no difference in weight gain in pill users versus non-users, a few women may experience an anabolic response to COCs, though they are able to lose weight once the oral contraceptive is discontinued. History of COC use, regardless of duration, does not affect breast cancer risk. Women who are currently taking COCs have a slightly increased risk of developing breast cancer. increase in the incidence of cervical cancer in COC users. Mood changes and changes in libido have been noted among COC users and may respond to a change in the pill formulation. Depression, may justify the use of alternative methods of contraception. Other side effects specific to estrogen include nausea, cervical ectopy and leukorrhea, telangiectasis, chloasma (darkening of sun-exposed skin), growth of breast tissue (ductal tissue or fat deposition), increased cholesterol content within the bile (which can lead to gallstones), benign hepatocellular adenomas, and changes in the clotting cascade. Effects specific to the androgenic impact of progestins include increased appetite and subsequent weight gain, mood changes and depression, fatigue, complexion changes, changes in carbohydrate metabolism, increased low-density lipoprotein (LDL) and decreased high-density lipoprotein (HDL) cholesterol, decreased libido, and pruritus. Effects that can be either estrogen or progestin related include headaches, hypertension, and breast tenderness. Many of the side effects that women associate with COCs occur either during the 7 hormone-free days or appear to be associated with the demise of follicles recruited during the hormone-free interval. a trial of extended use may be recommended to improve the symptoms that women experience at predictable times in their pill cycles. counseling women that they might have side effects such as headaches, nausea, breast pain, and mood changes may be unethical. The prevalence of these nonspecific symptoms is high in the general population of reproductive-age women, and several trials show no difference in these side effects when an oral hormonal contraceptive is compared with placebo. Given that high-quality evidence indicates that the frequency of nonspecific side effects is no greater with COCs than with inert pills, optimistic counseling should be the norm. Noncontraceptive Benefits- relative risk of ovarian cancer is decreased by 20% for each 5 years of COC use, persists more than 30 years after pills are discontinued, although the extent of risk reduction diminishes somewhat with time. reduces the risk of endometrial cancer by approximately 50%. This risk lessens with increasing duration of use and persists for as long as 20 years after the COCs are stopped. lower rates of PID requiring hospitalization, fewer ectopic pregnancies, and a lower incidence of endometriosis. These conditions are the most common causes of infertility; thus the pill helps preserve fertility— not by conservation of ovulation, but rather through prevention of causes of subfertility. menstrualrelated effects, improvement in acne and hirsutism, and reduced incidence of benign breast conditions. reduced risk of developing functional ovarian cysts while women were on COCs, but this effect is less profound with the lower doses of hormones in currently used COCs. they regulate menstrual cycles and are useful in the management of abnormal bleeding patterns. While taking COCs, women experience lighter "periods" (withdrawal bleeds) that may treat or improve anemia. treatment for mittelschmerz, dysmenorrhea, endometriosis, premenstrual symptoms, and the vasomotor symptoms of perimenopause. Women who experience catamenial conditions— those that rise and fall in synchronicity with the menstrual cycle, such as menstrual migraines— may also find that COCs improve those conditions. Decreasing the number of withdrawal bleeding episodes per year may further diminish these problems. Advantages and Disadvantages- COC use is unrelated to coitus. familiar with the instructions for COC use, and this method is widely available in pharmacies and clinics. Confidence in the product is high due to the fact it has been on the market for more than 50 years and has been continually researched. more than 30 different formulations of COCs are available- individualization based on response to the products. The obvious disadvantage of COCs is the need for daily pill taking. The ongoing cost of the method can be problematic as well. Particularly for young women, lack of privacy may also be an issue. Finally, some women experience side effects with COCs that they are unable to tolerate. Combined Contraceptive Patch and Vaginal Ring The contraceptive patch (Evra has been discontinued; a generic version, Xulane, is still available) and vaginal ring (NuvaRing) share many similarities with COCs, yet have some distinct differences. simpler dosing than daily pill taking. Both methods avoid the first-pass metabolism of COCs, allowing for lower-dose administration and potentially avoiding interactions with other medications. The patch releases 20 mcg per day of ethinyl estradiol and 150 mcg per day of the progestin norelgestromin, the active metabolite of norgestimate. rapidly absorbed and reach therapeutic serum concentrations within 24 to 48 hours. The thin, beige patch, size of a matchbook, is applied by the woman and worn for 1 week at a time. The patch is changed weekly on the same day of the week for 3 weeks, and then no patch is worn for 1 week to allow for a withdrawal bleed. As with COCs, no more than 7 days should pass between removal and the beginning of the next patch cycle. worn on the buttocks, upper arm, abdomen, and anywhere on the upper torso except the breasts. The vaginal ring is colorless and flexible, with an outer diameter of about 2 inches. It releases 15 mcg per day of ethinyl estradiol and 120 mcg per day of the progestin etonogestrel, the active metabolite of desogestrel. rapidly diffuse across the mucous membrane of the vagina and reach a steady state in the serum. left in place in the vagina for 21 days and then removed for 1 week, allowing for a withdrawal bleed. The ring provides a steady delivery of hormones, which leads to a very low serum concentration— approximately half of the serum concentration found with a 35-mcg COC. Efficacy and Effectiveness- The patch and the vaginal ring have the same theoretical efficacy and typical use failure rates as COCs. There is less opportunity for user error with the patch and ring, not be remembered daily. Each patch continues to emit hormones at therapeutic levels for at least 9 days. The hormones emitted by the ring also remain at therapeutic levels after 3 weeks; some margin of error if women forget. Extended (omitting the patch/ring-free week for two or more cycles) and continuous (omitting the patch/ring-free week indefinitely) use of the patch and ring, as with COCs, is becoming increasingly common. Locations for contraceptive patch placement: upper arm, upper torso (except breasts), abdomen, or buttocks. The patch is effective only if it is completely attached to the skin; even partial detachment necessitates replacement. The exact placement of the ring in the vagina is not critical to its efficacy. Safety and Side Effects- same criteria for COCs, the patch, and the ring except in women who have undergone malabsorptive bariatric surgery procedures. It is theoretically possible that the nonoral delivery systems may result in different safety and side-effect profiles. Clinicians are cautioned to not presume the patch and ring are "safer" than COCs. A woman who is not a candidate for COCs should not be given the patch or ring either. heightened concern about an increased risk of VTE. warning was added to the label of the patch that includes the following statement: The pharmacokinetic (PK) profile for the ORTHO EVRA® patch is different from the PK profile for oral contraceptives in that it has higher steady state concentrations and lower peak concentrations. Area under the time- concentration curve (AUC) and average concentration at steady state for ethinyl estradiol (EE) are approximately 60% higher in women using ORTHO EVRA® compared with women using an oral contraceptive containing 35 mcg of EE. In contrast, peak concentrations for EE are approximately 25% lower in women using ORTHO EVRA®. It is not known whether there are changes in the risk of serious adverse events based on the differences in PK profiles of EE in women using ORTHO EVRA® compared with women using oral contraceptives containing 30- 35 mcg of EE. Increased estrogen exposure may increase the risk of adverse events, including venous thromboembolism. While hormone levels with the patch are typically higher than those with COCs, the clinical implications of these pharmacokinetic findings are unclear and do not necessarily indicate any increased risk of serious side effects. benefits of the patch (e.g., pregnancy prevention) outweigh the risk of VTE. In general, the side effects of the patch and the vaginal ring are very similar to those of COCs, such as breakthrough bleeding and nausea. In addition, the patch and ring have some unique side effects related to their delivery systems. some skin irritation at the site of application, may be felt during intercourse, no increase in cervical cytologic changes with the vaginal ring, increased incidence of vaginitis and leukorrhea has been noted. Noncontraceptive Benefits- It is theoretically plausible that the noncontraceptive benefits of COCs may be realized with the patch and ring as well, because these methods affect the hypothalamic- pituitary- ovarian axis in the same way as COCs. Caution must be exercised in attributing the same long-term benefits of COCs to the patch and ring in the absence of published evidence. Advantages and Disadvantages- The intrinsic advantage of the patch and ring is the avoidance of daily dosing- greater effectiveness. lack of visible evidence of its use, which may appeal to some women, particularly adolescents, who want to keep their contraceptive use private. The patch may appeal to women who are not comfortable with vaginal placement, but desire a non-daily method of contraception. disadvantage of the patch and ring is that only one formulation of each method is available. The development of a variety of products may allow for individual variations in response to hormones, and patch color choices may appeal to some women as well. associated with ongoing costs. both methods still contain large amounts of active ingredients upon their disposal. The presence of these chemicals has prompted environmental concerns about the effect of high doses of estrogen and progestin seeping into the water supply. recommendation may be issued to place the used devices into a biohazard waste container instead of landfills. Progestin-Only Methods: used continuously; there is no hormone-free interval, as occurs with combined methods. minimal effects on coagulation factors, blood pressure, or lipid levels and are generally considered safer for women who have contraindications to estrogen, cardiovascular risk factors, migraine with aura, or a history of VTE. Progestin-only contraceptives do not provide the same cycle control as methods containing estrogen, and unscheduled bleeding is common with all progestin-only methods. unscheduled bleeding occurs most frequently during the first 6, with a substantial number of users becoming amenorrheic by 12 months. Overall blood loss decreases over time, making progestin-only methods protective against iron-deficiency anemia. With appropriate counseling, many women see amenorrhea as a benefit of these methods. are likely to improve menstrual symptoms, including dysmenorrhea, menorrhagia, premenstrual syndrome, and anemia. The thickening of cervical mucus seen with progestin methods is protective against PID. include the progestin-only pill (POP), an injection, an implant, and three progestin-containing intrauterine devices. Progestin-Only Pills: The POPs or "mini-pills" 0.35 mg of norethindrone. Each pill contains active ingredients; there is no hormone-free interval, must be taken not only daily, but also at the same time each day. Efficacy and Effectiveness- POPs do not suppress ovulation as reliably as COCs, but rather rely primarily on the contraceptive effect of thickened cervical mucus. The onset of cervical mucus thickening occurs 2 to 4 hours after a POP is taken and persists for 22 hours after each dose. if intercourse generally occurs in the morning or evening, the POP should be taken at midday. if ovulates while taking the POP, taking the pill as few as 3 hours late may allow the cervical mucus to return to its fertile state and render the contraceptive effect temporarily void. When POPs are used in combination with lactation, the effectiveness of the two methods is nearly 100%. Safety and Side Effects- fewest contraindications of all hormonal methods. Unscheduled bleeding and spotting are the side effects most commonly associated. Decreased effectiveness of POPs is possible when these agents are used in combination with rifampin or rifabutin. Noncontraceptive Benefits- The reductions in ovarian and endometrial cancer rates seen with COCs have not been reported with POPs. Advantages and Disadvantages- Each package contains one type of pill (versus two or more types in a package of COCs), less confusion about which pill is to be taken. safe method for many women who cannot take estrogen for medical reasons. sensitive to even lowestrogen pills, as manifested by nausea, breast tenderness, or hypertension, may do well on POPs. POPs are preferable to COCs for lactating women because they do not cause adverse effects on the volume or quality of breastmilk. Some recent research has suggested that COCs given as early as 2 weeks postpartum do not adversely affect breastfeeding performance. The contraceptive effect ends immediately upon discontinuation of POPs. Disadvantages of POPs other than the side effects previously mentioned, include the need for careful adherence to the dosing schedule. Utilizing an alarm or watch that beeps daily at the same time may enhance compliance. Progestin Injection The depot medroxyprogesterone acetate (DMPA) injection (DepoProvera) has been approved since 1995, although clinical trials with this agent were conducted in the 1960s and 1970s, used for the treatment of endometriosis and as an off-label contraceptive prior to FDA approval. DMPA is a synthetic progestogen and a member of the pregnane family, but it differs from the estrane and gonane progestins found in oral contraceptives. DMPA is a powerful inhibitor of the hypothalamic- pituitary axis at the level of the hypothalamus 150-mg intramuscular injection or a 104mg subcutaneous injection that can be self-administered. given every 13 weeks (3 mths) Intramuscular by a trained healthcare professional, which requires regular visits for injections. Self-administration of the subcutaneous formulation is feasible and increases this method's convenience for women who find it difficult to get to a clinician's office. The subcutaneous formulation provides a dose that is 30% lower and a reduction in peak blood levels by 50%; however, it is more expensive because is it provided in a proprietary delivery system. Lower doses may reduce the metabolic side effects of weight gain and glucose intolerance. Ovulatory suppression with this method often lasts longer than 13 weeks; however, effect expires at this point in a minority of women, return for repeat doses at 13week intervals. can be initiated at any time it is reasonably certain that the woman is not pregnant. This includes immediately postpartum or post abortion, advise the woman to take a highly sensitive pregnancy test 2 to 3 weeks after the first injection, as amenorrhea may be interpreted as a normal effect of the method. If DMPA is given in early pregnancy, it does not appear to stimulate fetal anomalies or miscarriage (it was previously used to prevent miscarriage). Women given DMPA "off cycle"- outside of first 5 days (ideal parameters for initiation of the method) should be instructed to use a barrier method for the first 7 days while the serum levels are reaching adequate concentrations. The same instructions if late for their injections. engaged in unprotected intercourse in the previous 5 days, offered emergency contraception as well. Efficacy and Effectiveness- The differences between theoretical efficacy and typical use probably reflect the pattern of women not returning on time for subsequent injections. Safety and Side Effects- safer than combination products overall and can be used by women who are not candidates for estrogen contraceptives. warning was added to the DMPA label: Women who use Depo-Provera Contraceptive Injection may lose significant bone mineral density. Bone loss is greater with increasing duration of use and may not be completely reversible. It is unknown if use of Depo-Provera Contraceptive Injection during adolescence or early adulthood, a critical period of bone accretion, will reduce peak bone mass and increase the risk for osteoporotic fracture in later life. Depo-Provera Contraceptive Injection should not be used as a long-term birth control method (i.e., longer than 2 years) unless other birth control methods are considered inadequate. Experts have called for removal of the FDA warning, citing abundant evidence that the effects of DMPA on bone density are considerably less than originally believed. BMD reverses after DMPA discontinuation. This pattern is similar to the BMD changes seen in women who breastfeed. Changes in BMD are an intermediate outcome, but the truly important clinical outcome is fracture risk. Studies examining fracture risk in low-risk women who previously used DMPA are not yet available. not recommend restricting DMPA initiation or duration of use based on concerns about BMD. not considered an indication for BMD screening or initiation of medications to prevent osteoporosis, such as estrogen, bisphosphonates, or selective estrogen receptor modulators. All women, regardless of contraceptive method, should be counseled about osteoporosis prevention, including adequate intake of calcium and vitamin D via diet and/or supplements. The guidelines do not restrict the use of DMPA for women at risk of HIV exposure, but advise that women using progestin-only injectable contraception be strongly advised to use HIV-preventive measures. 150-mg intramuscular dose of DMPA impairs glucose tolerance and that women with borderline glucose tolerance may have an increased risk of developing diabetes when using DMPA. side effects associated with DMPA include changes in bleeding patterns, with breakthrough bleeding and spotting occurring in the majority of women in the first 6 months of use. After 12 months of use, approximately 40% to 50% of women will have become amenorrheic, with this rate increasing to 80% after 5 years of use. With appropriate counseling, many women see amenorrhea as a benefit of. associated with an increase of approximately 2 kg of body weight at 12 months of use, counseling about healthy weight management is essential for all women, with close attention being paid to this issue in women using DMPA. Other side effects- depression, headache, decreased libido, and dizziness. Noncontraceptive benefits of DMPA include a reduction in the number of seizures in women with epilepsy and seizure disorders, not affected by the anticonvulsant medications, making it ideal for the woman with seizure disorders who does not want to become pregnant, associated with a reduction in sickle cell crises in women with sickle cell disease. not affected by any medications except aminoglutethimide, which is used to treat Cushing's disease. less menorrhagia and less dysmenorrhea with DMPA. Ectopic pregnancy, PID, and endometriosis are decreased in DMPA users, protective of future fertility. Advantages and Disadvantages- Advantages high degree of efficacy and longterm nature and its noninterference with coitus. private, there is no visible evidence of DMPA use. achieve amenorrhea in women with mental disabilities who cannot manage their menses. The long-term nature of DMPA may also be considered a disadvantage, as the contraceptive effect may not cease immediately upon discontinuation. The time to return of ovulation varies 15 to 49 weeks after the last injection. requires intramuscular injections be provided by a trained healthcare professional, regular visits for injections. The subcutaneous formulation might improve continuation of contraception among women who find it difficult to get to a clinician's office. possibility of allergic reaction to either the progestin or the vehicle used for injection, or vagal reactions to the injection itself. Like all hormonal methods, DMPA does not provide any protection from STIs. LONG-ACTING REVERSIBLE CONTRACEPTION: IUDs and subdermal implants, refers to methods that prevent pregnancy for extended periods of time with no effort from the user. removes the factors of user consistency and error from the contraceptive equation,effectiveness highest of all contraceptive methods. high satisfaction and continuation rates. Barriers to use of LARC include provider lack of training in insertion and persistent misperceptions about safety. more cost effective than most other methods over time, the high initial cost is a barrier to access. The ease of use, high efficacy, and privacy are particularly relevant considerations for adolescent women. using pills, the patch, or the ring may have as much as a 20-fold increase in contraceptive failure compared to their peers using LARC. The American College of Obstetricians and Gynecologists, WHO, and the CDC all support the use of LARC methods in women younger than age 20. Progestin Implant: is among the most effective methods of contraception, recommended as a first-line method and its use encouraged among most women as a contraceptive option. The single-rod etonogestrel implant (Nexplanon) 40 mm long and 2 mm in diameter and contains 68 mg of etonogestrel that is released slowly over 3 years, active metabolite of desogestrel. Training of clinicians is needed to ensure appropriate placement and skilled removal of the implant. Removing is reported to be easier now: It is a single rod, slightly larger in size than the multiple-rod systems, and made of ethylene vinyl acetate, which is less flexible than the Silastic used to make older rods. inserted during the first 7 days of the menses, postpartum, or post abortion, to avoid pregnancy in the first cycle. After removal of the implant, etonogestrel levels are undetectable in most women within 1 week, and ovulation generally returns within 6 weeks. Efficacy and Effectiveness- Its high rate of effectiveness is related to the intrinsic efficacy of the product and the fact that once inserted, there is no room for user error. Safety and Side Effects-appears to be as safe as other progestin-only methods and is associated with similar side effects, such as irregular bleeding and amenorrhea. Unscheduled bleeding is more common and persistent in implant users than in LNG-IUS users and is the most common reason for discontinuation. Because ovarian activity is not completely suppressed, persistent follicles and small ovarian cysts have been reported in a small percentage of implant users, resolve without treatment. Side effects of the method include bruising and irritation at the insertion site, breast tenderness, and weight gain. Noncontraceptive Benefits- can decrease dysmenorrhea and endometriosis symptoms. Advantages and Disadvantages- Advantages of the subdermal progestin implant include the presence of highly effective contraception following a single insertion procedure. This contraceptive effect is immediately reversible upon removal of the device. The implant is discreet but palpable, providing reassurance to the woman that it is in place and has not migrated. Intrauterine Contraception: infection risk with early devices was high, design improvements led to a variety of IUDs becoming available in the 1960s and 1970s. Popular devices were generally made of inert plastic, with single filament threads that protruded through the cervix into the vagina. The one memorable exception to this design was the Dalkon Shield, which was introduced in 1970. associated with a high risk of pelvic infection and infertility. It had a multifilament tail enclosed in a sheath; when the strings were cut, the protective sheath was compromised and bacteria could ascend into the uterus inside the sheath- adverse publicity and lawsuits associated with the Dalkon Shield tainted all IUDs, and these devices fell out of favor. IUDs are still underused due the high initial cost, lack of provider training in insertion, and misperceptions on the part of both healthcare providers and the public about safety. highly efficacious and effective form of LARC, recommends intrauterine contraception be offered as a firstline method and its use encouraged among most women as an option. Four intrauterine contraceptives are available. The copper IUD (T380A, Paragard) is a T-shaped device of polyethylene with copper wire wound around the stem and arms. A monofilament polyethylene thread is attached to a ball on the end of the stem. The copper adds spermicidal and other effects that allow the device to be smaller than a plain plastic device. The primary contraceptive effect is provided by the reaction to having a foreign body in the reproductive tract— specifically, a sterile inflammatory response that has spermicidal effects Three IUDs containing levonorgestrel are also available: Mirena, Skyla, and Liletta. These T-shaped IUDs feature a reservoir that releases levonorgestrel at varying doses. After insertion, Mirena releases levonorgestrel at a rate of 20 mcg per day, Skyla at 14 mcg per day, and Liletta at 18 to 19 mcg per day. Daily release rates decline over the time as the device remains in place. The local delivery of progestin produces thickening of the cervical mucus and an endometrial reaction, in addition to the foreign body reaction. The LNG-IUS also has a monofilament thread. Ovulation is suppressed in some women with this device, particularly in the first year after its placement, but most cycles are ovulatory. Skyla is the smallest device and may be easier to insert for women with cervical stenosis or small uterine cavities; Liletta is available at a lower cost. The copper IUD is effective for at least 10 years, Mirena for at least 5 years, and Skyla and Liletta for at least 3 years. these are the current FDA approved limits. Insertion of an IUD may occur at any time during the menstrual cycle. Many clinicians perform insertion of LNG-IUSs during menses to be certain the woman is not pregnant. Insertion of the copper IUD will serve as emergency contraception. Postabortion, postplacental (within 10 minutes after expulsion of the placenta), and postpartum (at least 4 weeks postpartum) insertion may also be performed. The procedures for copper IUD and LNG-IUS insertion differ. The manufacturers provide insertion training for clinicians and can be contacted via their websites. Effectiveness and Efficacy- Intrauterine contraception is extremely effective. Pregnancy may occur if partial or complete expulsion of the IUD occurs. The expulsion rate ranges from 2% to 10%, with most expulsions occurring in the first 3 months after insertion of the device. may be associated with cramping or bleeding, it may also go unnoticed. Women should be encouraged to check periodically for the strings. safety and side effects- Despite the negative experience associated with the Dalkon Shield, contemporary intrauterine contraceptives with monofilament threads are very safe for most women. Questions about their safety center on infection, future fertility, ectopic pregnancy, and risk of uterine perforation. A transient increase in infection rates occurs in the first 20 days after insertion, likely due to the insertion process or preexisting infection. with this risk reported to range from 1 to 10 cases per 1,000 women. The risk of infection returns to baseline thereafter. Antibiotic prophylaxis for insertion is not necessary. FDA has removed recommendations against use of intrauterine contraceptives in women with more than one sexual partner. STI screening may occur on the day of insertion, and insertion may take place without waiting for results. If pelvic infection occurs, it can be treated without removing the IUD. The cervical mucus barrier and atrophic endometrium created by the LNG-IUS may actually protect the user from PID. Use of an IUD does not increase the rate of infertility. Actual rates of ectopic pregnancy are among IUD users are up to 10-fold lower than in nonusers, but if the method fails the resulting pregnancies are more likely to be ectopic. Perforation of the uterus during insertion of an IUD occurs at a rate of 1 in 1,000 and is usually a benign event. The risk of perforation is higher in postpartum and breastfeeding women. intrauterine contraception for adolescents is promoted by several professional organizations as the best means to reduce unintended pregnancy. The most common side effects associated with the copper IUD are bleeding and dysmenorrhea. Menstrual blood loss increases by as much as 50% with copper IUDs, as can the duration of the menses. NSAIDs can be used to treat excessive bleeding. Unscheduled bleeding is common with the three LNG-IUSs. As the duration of use increases, menstrual flow declines and amenorrhea often develops. Counseling prior to insertion of the device may help reduce anxiety. Women should be told that the bleeding does not represent hormonal fluctuations, but rather the shedding of the endometrial lining as an atrophic state is achieved. Other side effects linked to LNG-IUSs include lower abdominal pain, complexion changes, back pain, breast tenderness, headaches, mood changes, and nausea, although all of these effects decline with time, and they are noted in only a minority of women. In general, few hormonal side effects are observed with the low dose of progestin found in intrauterine contraceptives. As with other progestin-only methods, benign functional ovarian cysts are common, occurring in 8% to 12% of LNG-IUS users. Most cysts are asymptomatic and resolve spontaneously. Noncontraceptive Benefits- LNG-IUSs have many noncontraceptive benefits. Menstrual flow is reduced by as much as 90%, FDA approved to treat heavy menstrual bleeding. The LNG-IUS can be used to treat idiopathic menorrhagia as well as heavy menstrual bleeding associated with perimenopause, uterine fibroids, and adenomyosis; treatment of endometrial hyperplasia, endometriosis, and dysmenorrhea. Reduced risks of endometrial cancer and cervical cancer are seen in IUD users. The progestin in the device is sufficient to protect the endometrium as a component of hormone therapy. IUDs can be inserted in women's late reproductive years and then left in place through the transition to menopause. Advantages and Disadvantages- long-term contraception that is not coitus dependent and does not require adjustments to daily activities (such as remembering to take a pill every day). Contemporary intrauterine contraception options have effectiveness rates that are comparable to those of sterilization. added advantage of being rapidly reversible, making this method ideal for young women who desire long-term contraception. discreet and private methods. Copper and levonorgestrel-containing IUDs are effective contraceptive methods for women who have contraindications to estrogen-containing contraceptives. The reduced bleeding with the LNG-IUS can lead to substantial savings in the cost of sanitary products. can be high upfront cost for intrauterine contraception. The copper IUD and LNG-IUS cost several hundred dollars, and a visit to a skilled clinician is needed for their insertion. Many clinicians also require a pre-insertion visit to test for infections, and a postinsertion visit after the first menses to ensure the device has not been expelled. long-term contraceptives with no additional costs; among least expensive methods over time. emergency contraceptive: Sperm can live for up to 5 days in the female reproductive tract, and pregnancy can occur with intercourse 5 days prior to ovulation. The highest risk of pregnancy is in the 48 hours immediately preceding ovulation. However, due to the uncertainty of ovulation timing, emergency contraception is offered if unprotected intercourse (UPI) occurs at any time in the menstrual cycle. The Yuzpe, levonorgestrel, and ulipristal acetate emergency contraceptive pill (ECP) regimens as well as the copper IUD may all be used within 120 hours of UPI. The Yuzpe and levonorgestrel methods have a dramatic decline in their effectiveness with time and should be used as soon as possible. The Yuzpe regimen consists of combined ECPs that must contain at least 100 mcg of ethinyl estradiol and 0.50 mg of levonorgestrel, repeated in 12 hours. COCs containing norgestrel are preferable to those with norethindrone, as failure rates are slightly higher with norethindrone. high dose of ethinyl estradiol causes unpleasant side effects, this regimen has largely fallen out of favor. Until recently, the most widely used emergency contraception method was levonorgestrel ECPs, which contain either a 1.5-mg single dose (Plan B One-Step) or two doses of 0.75 mg taken 12 hours apart (Next Choice and Plan B). Women can take both doses in the two-dose products (Next Choice and Plan B) as a single dose. Levonorgestrel ECPs are available over the counter to women and men age 17 and older; women 16 and younger need a prescription to obtain them. Levonorgestrel ECPs are more effective than the Yuzpe regimen and have fewer side effects. Ulipristal acetate (ella), a selective progesterone receptor modulator provided as a single 30-mg dose, is the most effective oral emergency contraception method. The effectiveness of this medication does not decline within the 120-hour window after UPI, as is the case for levonorgestrel and combined ECPs. available only by prescription. The copper IUD can be inserted as long as 5 days after unprotected intercourse. Some contraceptive guidelines recommend its use up to 7 days after UPI. This method is rarely utilized, some women might choose the copper IUD if it is offered as an option. advantage of being highly effective in obese women and providing ongoing contraception. Efficacy and Effectiveness- Factors influencing the risk of pregnancy when ulipristal acetate or levonorgestrel is used for emergency contraception include body mass index (BMI), the day of the cycle, and further intercourse during the same menstrual cycle after use of emergency contraception. Women with a BMI greater than 30 have a 2- to 40-fold higher risk of pregnancy after ECP use. Levonorgestrel may be completely ineffective at reducing pregnancy risk in obese women. The efficacy of levonorgestrel and ulipristal acetate further vary according to the stage of the cycle. Levonorgestrel and ulipristal acetate inhibit ovulation in 96% and 100% of cycles, used prior to the onset of the LH surge. if given after the onset of the LH surge, these medications inhibit ovulation in 14% and 79% of cycles. Levonorgestrel is no more effective than placebo when used in the critical 5 days preceding ovulation. The risk of pregnancy with ulipristal acetate use is half that seen with use of levonorgestrel. Both levonorgestrel and ulipristal acetate delay ovulation. repeated acts of UPI after using ECPs, they are at a 4-fold increased risk of pregnancy compared with women who do not have further intercourse within the same cycle. The copper IUD is by far the most effective of emergency contraception methods, with a pregnancy rate of approximately 1 in 1,000 cases in which it is used for this purpose. Safety and Side Effects- Levonorgestrel ECPs, combined ECPs, and ulipristal acetate should not be given to women with a known or suspected pregnancy; there are no other contraindications to their use. The long history of use of levonorgestrel indicates little risk exists if it is inadvertently taken in early pregnancy. The usual contraindications and precautions for ongoing COC and POP use do not apply to ECPs, but the usual contraindications and precautions to copper IUD use do apply when using this method for emergency contraception. Neither the copper IUD nor oral emergency contraception methods are considered abortifacients. Combined ECPs frequently cause nausea and vomiting, which can be reduced by giving an antiemetic, such as promethazine, prior to treatment. Spotting, changes in next menses, headache, breast tenderness, and mood changes can also occur sometimes noted with levonorgestrel ECPs but are much less frequent and less severe. Headache, dysmenorrhea, nausea, and abdominal pain are the most frequently observed side effects with ulipristal acetate. The copper IUD can cause the side effects discussed in the section on intrauterine contraception. Advantages and Disadvantages- only contraceptive method that can be used after intercourse. It cannot be used as an ongoing method of contraception, provides no STI protection. Access to emergency contraception remains limited because only levonorgestrel ECPs— is available without prescription— available only to women 17 and older. Clinicians can increase access to emergency contraception by providing advance prescriptions to all women of reproductive age for ulipristal acetate. ECPs at home increases the likelihood that they will be used when needed and does not promote sexual risk taking. Providing emergency contraception prescriptions over the phone as needed is another way to increase access.

3. Define perimenopause in terms of age range and characteristic symptoms. (There is no 4)

During the perimenopausal period, which spans approximately 2 to 8 years prior to the last menstrual period, and for the 12 months of amenorrhea preceding menopause, fewer ovarian follicles develop in each menstrual cycle. Anovulation is common during this period as the follicles that do develop are less responsive to follicle stimulating hormone (FSH), and the ovaries produce less estradiol, progesterone, and androgens. Thus the usual negative feedback effect from elevated estrogen and progesterone levels on hypothalamic production of gonadotropin-releasing hormone (GnRH) is lost, and the anterior pituitary production of FSH and luteinizing hormone (LH) continues. Irregular menstrual cycles— characterized by longer or shorter cycles, heavier or lighter flow, periods of amenorrhea, and worsening or newly developing premenstrual symptoms— are common during this time. Eventually, ovarian follicle production stops, estrogen and progesterone levels remain low, FSH and LH levels remain high, and menstruation ceases. Research has identified that AMH, which reflects the number of follicles, may be helpful in identifying when women can expect to be postmenopausal, with its level dropping to an undetectable point approximately 5 years before menopause. high rate of unintentional pregnancies. s/s: Acne Arthralgia Asthenia Decreased libido Decreased vaginal lubrication Depression Dizziness Dry eyes Dry/thinning hair Dyspareunia Dysuria Fatigue Forgetfulness Formication Headache Hirsutism/virilization Hot flashes/flushes Irregular menses/bleeding Irritability/mood disturbances Mastalgia Myalgia Nervousness/anxiety Night sweats Nocturia Odor Palpitations Paresthesia Poor concentration Recurrent cystitis Recurrent vaginitis Skin dryness/atrophy Sleep disturbances/insomnia Urinary frequency Urinary urgency Vaginal atrophy Stress urinary incontinence Vaginal/vulvar burning Vaginal/vulvar irritation/pruritis differentials: must also be considered when a woman presents with perimenopauseand menopause-related symptoms: diabetes, hypertension, arrhythmias, thyroid disorders (hypothyroid or hyperthyroid), anemia, depression, tumors, or carcinoma. Medications, alcohol, or drug use can also cause many symptoms similar to those associated with perimenopause and menopause. thorough history, physical examination, and selective laboratory testing (such as a complete blood count, fasting glucose, serum thyroid-stimulating hormone [TSH] level, and prolactin level) to accurately identify the cause of her symptoms. Often a woman has several diagnoses to contend with at once, such as hypertension, diabetes, and menopause. Controlling her diabetes and hypertension may also reduce her menopause-related symptoms enough so that they no longer are bothersome for her.

5. Compare the hormones used in HT to those used for oral contraception.

HT: oral estrogen: Cenestin- Conjugated estrogens, A- 0.3 mg, 0.45 mg, 0.625 mg, 0.9 mg, or 1.25 mg once daily. Enjuvia- Conjugated estrogens, B- 0.3 mg, 0.45 mg, 0.625 mg, 0.9 mg, or 1.25 mg once daily. Estrace- 17β-estradiol- 0.5 mg, 1 mg, or 2 mg once daily. Menest- Esterified estrogens- 0.3 mg, 0.625 mg, 1.25 mg, or 2.5 mg once daily. Ogen- Estropipate- 0.625 mg (0.75 estropipate, calculated as sodium estrone sulfate 0.625), 1.25 (1.5) mg, 2.5 (3) mg, or 5 (6) mg once daily. Premarin- CEE 0.3 mg, 0.45 mg, 0.625 mg, 0.9 mg, 1.25 mg- once daily Estrogens, transdermal and topical preparations: Minivelle, Vivelle-Dot, Generic- 17β-estradiol matrix patch- 0.025 mg, 0.0375 mg, 0.05 mg, 0.075 mg, or 0.1 mg patch twice weekly (and 0.06 mg in generic only) Alora- 17β-estradiol matrix patch- 0.025 mg, 0.05 mg, 0.075 mg, or 0.1 mg patch twice weekly Climara- 17β-estradiol matrix patch- 0.025 mg, 0.0375 mg, 0.05 mg, 0.075 mg, or 0.1 mg patch once weekly Menostar- 17β-estradiol matrix patch- 0.014 mg once weekly EstroGel- 17β-estradiol transdermal gel- 0.75 mg/1.25 g gel pump once daily (1 metered pump applied from wrist to shoulder) Elestrin- 17β-estradiol transdermal gel- 0.52 mg/0.87 g gel pump once daily (1- 2 metered pumps applied to the upper arm and shoulder) Divigel- 17β-estradiol transdermal gel- 0.25 mg/0.25 g packet, 0.5 mg/0.5 g packet, 1 mg/1 g packet once daily (1 gel packet applied to the upper thigh) Estrasorb- 17β-estradiol topical emulsion- 8.7 mg once daily (2 packets of 1.74 gm of emulsion applied once to each upper leg) Evamist- 17β-estradiol transdermal spray- 1.53 mg/spray once daily (applied as 1- 3 sprays to the forearm) Progestogens, oral: Provera, Generic- MPA- 2.5 mg, 5 mg, or 10 mg continuously or on set cycle schedule Prometrium, Generic- Micronized progesterone- 100 mg or 200 mg continuously or on set cycle schedule Micronor, Nor-QD- Norethindrone- 0.35 mg continuously or on set cycle schedule Aygestin- Norethindrone acetate- 5 mg continuously or on set cycle schedule Megace- Megestrol- acetate 20 mg or 40 mg continuously or on set cycle schedule Combination estrogen- progestogen products, oral: Premphase- CEE (14 tabs), then CEE + MPA (14 tabs)- 0.625 mg E once daily for 14 days, then 0.625 mg E + 5 mg P once daily for 14 days sequentially Prempro- CEE + MPA- 0.3 mg E + 1.5 mg P once daily, 0.45 mg E + 1.5 mg P once daily, 0.625 mg E + 2.5 mg P once daily, or 0.625 mg E + 5 mg P once daily continuously Femhrt- Ethinyl estradiol + norethindrone acetate 2.5 mcg E + 5 mg P or 5 mcg E + 1 mg P once daily, continuously Jinteli- Ethinyl estradiol + norethindrone acetate- 5 mcg E + 1 mg P once daily, continuously Generic- 17β-estradiol + norethindrone acetate- 0.5 mg + 0.1 mg P or 1 mg E + 0.5 mg P once daily, continuously Mimvey- 17β-estradiol + norethindrone acetate- 1 mg E + 0.5 mg P once daily Angeliq- 17β-estradiol + drospirenone- 0.25 mg E + 0.5 mg P or 0.5 mg E + 1 mg P once daily, continuously Activella- 17β-estradiol + norethindrone acetate 0.5 mg E + 0.1 mg P once daily Prefest- 17β-estradiol (3 tabs) then 17βestradiol + norgestimate- (3 tabs) 1 mg E for 3 days, then 1 mg E + 0.09 mg P for 3 days, once daily sequentially Combination estrogen- progestogen products, transdermal: Climara Pro- CombiPatch- 17β-estradiol + levonorgestrel 17β-estradiol + norethindrone acetate 0.045 mg E + 0.015 mg P once weekly 0.05 mg E + 0.14 mg P or 0.05 mg E + 0.25 mg P twice weekly Combination estrogen- BZA product, oral: Duavee- CEE + BZA- 0.45 mg E + 20 mg BZA Combination estrogen- methyltestosterone: Generic- Esterified estrogens + methyltestosterone- 0.625 mg E + 1.25 mg MT or 1.25 mg E + 1.25 mg MT cycle 21 days one, 7 days off vaginal and intrauterine HT: estrogen Vaginal hormone creams: Estrace- 17 β-estradiol- 2- 4 gm intravaginally daily for 2 weeks, then taper gradually to lowest effective dose; use for shortest effective duration Premarin- Conjugated equine estrogens- 0.5- 2 g intravaginally daily for 2 weeks, then taper gradually to lowest effective dose; use for shortest effective duration Vaginal tablets: Vagifem- Estradiol hemihydrate- 10 mcg intravaginally once daily for 2 weeks; use for shortest effective duration Ring: Estring- Micronized 17β-estradiol- 7.5 mcg/24 hours, 2 mg/90 days ring, replace every 90 days Femring- Estradiol acetate- 0.05 mg/day or 0.1 mg/day, replace every 3 months; use for shortest effective duration Gel: Crinone, Prochieve- Progesterone- 4% gel— 45 mg, 1 applicator every other day, give 6 doses; increase to 8%—90 mg if no response Endometrin c- Micronized progesterone- 100 mg insert Intrauterine devices: Mirena c- Levonorgestrel- 20 mcg daily, lasts for 5 years (52 mg over 5 years) Skyla c- Levonorgestrel- 6 mcg/day (13.5 mg over 3 years) ---------------------------------- Contraceptives:

II. Define menarche and identify its usual timing. Discuss physiologic changes necessary for menarche. A. Describe characteristics of first and early menses. B. List conditions that may speed up or delay menarche.

Menarche is often viewed as a significant life event that carries physical, social, and emotional consequences. establishes reproduction and sexual potential. physiologic marker of transitioning to adulthood, albeit framed by biomedical metaphors of scientific knowledge, and as one of the social and cultural junctures at which gender identity and gender relations may be shaped. In many societies, menarche is celebrated as an important entrance into womanhood. In Western societies, however, it is often denied any significance and instead is treated as a taboo subject and an embarrassing hygienic issue around 12 or 13. other research suggests that non-Hispanic black girls start menarche approximately 6 months earlier than they did 30 years ago. The median age for the onset of menstruation has remained stable despite variations worldwide and with the U.S. population— 12.8 years, with a range of ages 9 to 17— in well-nourished populations in developed countries events of puberty during a young woman's adolescence trigger the onset of menses occurs when a positive feedback of estrogen on the pituitary and hypothalamus stimulates a surge of luteinizing hormone at midcycle = ovulation The general time frame from thelarche to menarche is 2 to 3 years. A. The first several menstrual cycles usually do not result in ovulation, and often a girl's first-year experience of menstruating is characterized by irregular anovulatory cycles, along with heavy bleeding B. may be due to heredity, it is important to rule out other factors that may be impacting the young woman's health, such as poor nutrition or eating disorders, involvement in sports/athletics, or genetic and medical conditions. participation in sports has been linked to later onset of menarche, this link has not been found to be causal- confounding factors contribute to this relationship *remind young girls that there is a range as to when puberty begins and that the timing varies from one young girl to another. Adolescent girls often worry about "being on time" for the advent of puberty and need to be reassured of the variations of normal in timing of breast development and menarche. (i got this from a text in the HSC library under FNP books- CURRENT Diagnosis & Treatment: Obstetrics & Gynecology, 11e Alan H. DeCherney, Lauren Nathan, Neri Laufer, Ashley S. Roman) Changes are determined by genetic and environmental factors, such as geographic location and body fat composition, and mediated by the leptin and kisspeptin proteins. As a rule, breast development, which initially may be unilateral, growth of genital hair, and a marked increase in growth rate (adolescent growth spurt) precede uterine bleeding by approximately 2 years. Pubic and axillary hair may appear before, at about the same time, or well after the appearance of breast tissue. The vaginal mucosa, which in prepubertal girls is a deep red color, takes on a moist pastel pink appearance as estrogen exposure increases. Menarche—the first menstrual shedding of thickened endometrial lining—indicates the process of development of secondary sexual features. Regular ovulatory cycles, which usually occur 20 months later, mark the end of pubertal maturation. The first menstrual period occurs at an average age of 12.43 years in girls in the United States. Although the age of menarche in African-American girls is quite similar, secondary sexual features often occur earlier. Normal range of menarche is from age 10 to 14 years. In the presence of secondary sexual characteristics, medical intervention can be deferred until 16 years of age.

vulvovaginal atrophy article

The onset of VVA symptoms after menopause varies from one woman to another. Other hypoestrogenic states also result in VVA, and a careful history and targeted laboratory testing will identify primary ovarian insufficiency, medically induced menopause, surgically induced menopause, hypothalamic amenorrhea, and hyperprolactinemia. Endocrine therapies, including AIs, gonadotropin-releasing hormone agonists or antagonists, and certain selective estrogen-receptor modulators (SERMs) can induce an estrogen-deficient state and contribute to VVA. differential diagnosis includes autoimmune disorders, allergic or inflammatory conditions (eg, desquamative inflammatory vaginitis, contact dermatitis, erosive lichen planus, lichen sclerosis, and cicatricial pemphigoid), chronic vaginitis, infections, trauma, foreign bodies, malignancy, vulvodynia, vestibulodynia, chronic pelvic pain, vaginismus, and other medical (eg, diabetes, lupus erythematosus) or psychological disorders. An alternate etiology is more likely in women with chronic or recurrent vulvovaginal symptoms that appear to predate their menopause. Documentation of VVA should include a description of symptoms, including time of onset, duration, level of associated distress, and effect on QOL. A sexual history that includes partner relationship(s), current level of sexual activity, and the effect of VVA symptoms on sex life and partner relationships is useful in determining management strategies. Previous interventions should be discussed, including whether they were effective or had possible adverse effects. history of cancer, additional information needs to be obtained, including cancer site, hormone dependence, treatments (past, current), age at diagnosis, and type of menopause (spontaneous or induced). Vaginal dryness is a common symptom among women treated for cancer, but it may not always be related solely to estrogen deficiency. PE: epithelium of the vestibule can be thin and dry, and the vagina mildly erythematous. As atrophy progresses, there is loss of the labial fat pad, and the labia minora become less distinct. In severe atrophy, there may be no clear definition between the labia minora and majora. The urethral meatus may be patulous and/or beef red secondary to eversion. The clitoris can recede and in some cases become completely flush with the surrounding tissue. Phimosis of the clitoris is not uncommon. The tissues of the vulva and vagina become progressively pale, thin, and dry. There is shortening and narrowing of the vagina as it loses elasticity and distensibility. The vaginal epithelium becomes very dry, with a glazed appearance and with areas of both erythema and pallor. Loss of vaginal rugae occurs. The fornices may become obliterated, making the cervix flush with the vault. Petechiae may be seen in the vestibule or vagina. atrophic vaginitis, brown or yellow secretions may be present. With severe VVA, there may be such shortening of the vaginal vault and narrowing of the introitus that speculum insertion and visual inspection of the vaginal vault may not be possible. Small pediatric speculums with lubrication may be helpful with severe atrophy. VVA, vaginal pH is typically greater than 5.0. Wet-mount microscopy shows more than 1 white blood cell per epithelial cell, immature vaginal epithelial cells with relatively large nuclei (parabasal cells), and reduced or absent lactobacilli. Repopulation with diverse flora occurs, including enteric organisms commonly associated with UTIs. appearance of the wet mount in severe VVA may be difficult to distinguish from that of desquamative inflammatory vaginitis or vaginal erosive lichen planus. culture or vulvovaginal biopsy should be considered if there are atypical findings or if the vulvovaginal symptoms fail to resolve after a trial of low-dose vaginal estrogen therapy (ET). woman who is not sexually active may have few symptoms, despite signs of advanced VVA on exam. In contrast, a woman with an active sex life may complain of dryness and discomfort with the pelvic exam but not with intercourse, suggesting only mild atrophy. Of note, women who are not sexually active may also be bothered by symptoms related to VVA. Thus, both history and examination are essential to making a correct diagnosis. tx: primary goal of treating symptomatic VVA is to alleviate symptoms. For the woman with symptomatic VVA unrelated to sexual activity and for whom all other causes of her symptoms have been eliminated, first-line therapies include nonhormonal, long-acting vaginal moisturizers and low-dose vaginal estrogen, assuming no contraindications. She may need only a short course (1-3 mo) of therapy to become symptom-free, although symptoms may recur on cessation of treatment. Treatment of the woman with symptomatic VVA related to sexual activity can be approached in a stepwise fashion based on the severity of symptoms. Options include nonhormonal vaginal lubricants to be used with intercourse/vaginal sexual activity, long-acting vaginal moisturizers used regularly (several times per week), and regular sexual activity. For symptomatic VVA that does not respond to these initial management approaches, low-dose vaginal ET is an option. For women with moderate to severe dyspareunia associated with VVA who prefer a nonvaginal therapy, transdermal and oral hormone therapy (HT) as well as ospemifene are options vaginal constriction or vaginismus limiting vaginal penetration. Gentle stretching of the vagina with the use of lubricated vaginal dilators of graduated sizes can play an important role in restoring and then maintaining vaginal function. Reinitiating regular sexual activity once vaginal penetration is again comfortable will help to maintain vaginal health. Many women with this condition benefit from referral to pelvic floor physical therapy.55 Starting vaginal estrogen before initiating vaginal dilatation and/or pelvic floor therapy may facilitate progress. Vaginal creams 17A-estradiol- Estrace Vaginal Creama Initial: 2-4 g/d for 1-2 wk Maintenance: 1 g/1-3 times/wkc (0.1 mg active ingredient/g) Conjugated estrogens- Premarin Vaginal Cream For VVA: 0.5-2 g/d for 21 d then off 7 dc For dyspareunia: 0.5 g/d for 21 d then off 7 d, or twice/wkc (0.625 mg active ingredient/g) Estrone- Estragyn Vaginal Creamb 2-4 g/d (1 mg active ingredient/g) Intended for short-term use; progestogen recommended Vaginal rings: 17A-estradiol- Estring Device containing 2 mg releases approximately 7.5 Kg/d for 90 d (for VVA) Estradiol acetate- Femringa Device containing 12.4 mg or 24.8 mg estradiol acetate releases 0.05 mg/d or 0.10 mg/d estradiol for 90 days (both doses release systemic levels for treatment of VVA and vasomotor symptoms) Vaginal tablet: Estradiol hemihydrate- Vagifem Initial: 1 tablet/d for 2 wk Maintenance: 1 tablet twice/wk (tablet containing 10.3 Kg of estradiol hemihydrates, equivalent to 10 Kg of estradiol; for VVA) education: discuss the concept of preserving sexual function for postmenopausal women. Women with a sexual partner should be informed that regular sexual activity/intercourse or other vaginal stimulation helps to maintain vaginal health and increase the likelihood that sexual activity will remain comfortable in the future. For women without a sexual partner, information can be given on the use of vaginal dilators and vibrators as a means of maintaining vaginal function. Postmenopausal women may benefit from the use of lubricants with sexual activity and regular use of vaginal moisturizers. Although it is likely that regular use of low-dose vaginal ET will prevent the signs and symptoms of VVA, clinical trial data are available for treatment, not prevention. conclusion: -First-line therapies for women with symptomatic VVA include nonhormonal lubricants with intercourse and, if indicated, regular use of long-acting vaginal moisturizers. -For symptomatic women with moderate to severe VVA and for those with milder VVA who do not respond to lubricants and moisturizers, estrogen therapy either vaginally at low dose or systemically remains the therapeutic standard. Low-dose vaginal estrogen is preferred when VVA is the only menopausal symptom. -Ospemifene is another option for dyspareunia. -For women with a history of breast or endometrial cancer, management depends on a womans preference, need, understanding of potential risks, and consultation with her oncologist. [Level C] -Estrogen therapy carries a class effect risk of VTE. Lowdose vaginal estrogen may carry a very low risk, but there has been no report of an increased risk in the vaginal estrogen clinical trials. Data in high-risk women are lacking. [Level C] -A progestogen is generally not indicated when low-dose vaginal estrogen is administered for symptomatic VVA. Endometrial safety data are not available for use longer than 1 year. [Level B] -If a woman is at high risk of endometrial cancer or is using a higher dose of vaginal ET, transvaginal ultrasound or intermittent progestogen therapy may be considered. There are insufficient data to recommend routine annual endometrial surveillance in asymptomatic women using vaginal ET. [Level C] -Spotting or bleeding in a postmenopausal woman who has an intact uterus requires a thorough evaluation that may include transvaginal ultrasound and/or endometrial biopsy. [Level A] -For women treated for non-hormone-dependent cancer, management of VVA is similar to that for women without a cancer history. [Level B] -Vaginal ET or ospemifene, with appropriate clinical surveillance, can be continued as long as bothersome symptoms are present. [Level C] -Proactive education on vaginal health is recommended for postmenopausal women. [Level C]

emergency contraceptive article

adverse effects No deaths or serious complications have been causally linked to emergency contraceptive pills (39). Short-term adverse effects include the following: • Nausea and headache--Ulipristal acetate and levonorgestrel products have similar adverse effect profiles. The most frequently reported adverse effects are headache (19%) and nausea (12%) (14). The combined estrogen-progestin regimen has a significantly higher rate of nausea than the ulipristal acetate and levonorgestrel regimens • Irregular bleeding--After emergency contraceptive pill use, the menstrual period usually occurs within 1 week of the expected time (41). Some patients experience irregular bleeding or spotting in the week or month after treatment; one trial of the levonorgestrel-only regimen found that 16% of women reported nonmenstrual bleeding in the first week after use (10). If emergency contraception is taken earlier in the cycle, it is more likely that a woman will experience bleeding before the expected menses (42). Irregular bleeding associated with emergency contraception resolves without treatment. • Other adverse effects--Some patients have reported experiencing other short-term adverse effects with oral regimens, such as breast tenderness, abdominal pain, dizziness, and fatigue (43). Copper IUD insertion carries a risk of uterine perforation of approximately 1/1,000, is associated with uterine cramping, and may cause increased duration of menstrual flow or dysmenorrhea Emergency contraception should be offered or made available to women who have had unprotected or inadequately protected sexual intercourse and who do not desire pregnancy. These criteria specifically note that women with previous ectopic pregnancy, cardiovascular disease, migraines, or liver disease and women who are breastfeeding may use emergency contraception. Therefore, any emergency contraceptive regimen may be made available to women with contraindications to the use of conventional oral contraceptive preparations. Reproductive-aged women who are victims of sexual assault always should be offered emergency contraception. Hormonal emergency contraception is less effective for long-term contraception than most other available methods. In addition, continued use of hormonal emergency contraception would result in exposure to higher total levels of hormones than would ongoing use of either combined or progestin-only oral contraceptives, and frequent use also would result in more adverse effects, including menstrual irregularities. Therefore, emergency contraception should not be used as a longterm contraceptive. No scheduled follow-up is required after use of emergency contraception. However, clinical evaluation is indicated for women who have used emergency contraception if menses are delayed by a week or more after the expected time or if lower abdominal pain or persistent irregular bleeding develops. The woman should be advised that if her menstrual period is delayed by a week or more, she should have a pregnancy test and seek clinical evaluation. new warning about its use with hormonal contraceptives and a recommendation to delay initiating hormonal contraception until no sooner than 5 days after intake of ulipristal acetate. Any regular contraceptive method can be started immediately after the use of levonorgestrel or combined estrogen-progestin emergency contraception, but the woman should abstain from sexual intercourse or use barrier contraception for 7 days Insertion of a copper IUD is the most effective method of emergency contraception. The copper IUD is appropriate for use as emergency contraception in women who meet standard criteria for an IUD and who desire longacting contraception. Obese women may have higher failure rates with the use of levonorgestrel and ulipristal emergency contraception than women of normal body weight (86, 91, 92). The efficacy of the copper IUD for contraception is not affected by body weight (16, 93). Therefore, consideration should be given to the use of the copper IUD for emergency contraception among obese women. Conclusions (Level A): Ulipristal acetate is more effective than the levonorgestrel-only regimen and maintains its efficacy for up to 5 days. The levonorgestrel-only regimen for emergency contraception is more effective than the combined hormonal regimen and is associated with less nausea and vomiting. Insertion of a copper IUD is the most effective method of emergency contraception. limited or inconsistent scientific evidence (Level B): No clinical examination or pregnancy testing is necessary before provision or prescription of emergency contraception. Treatment with emergency contraception should be initiated as soon as possible after unprotected or inadequately protected sexual intercourse to maximize efficacy. Emergency contraceptive pills or the copper IUD should be made available to patients who request it up to 5 days after unprotected or inadequately protected sexual intercourse. Body weight influences the effectiveness of oral emergency contraception. The efficacy of the copper IUD is not affected by body weight. Therefore, consideration should be given to use of a copper IUD as an alternative to oral emergency contraception in obese women. However, oral emergency contraception should not be withheld from women who are overweight or obese. based primarily on consensus and expert opinion (Level C): Any emergency contraceptive regimen may be made available to women with contraindications to the use of conventional oral contraceptive preparations. To maximize effectiveness, women should be educated about the availability of emergency contraception in advance of need. Information regarding effective long-term contraceptive methods should be made available whenever a woman requests emergency contraception. Oral emergency contraception may be used more than once, even within the same menstrual cycle. Clinical evaluation is indicated for women who have used emergency contraception if menses are delayed by a week or more after the expected time or if lower abdominal pain or persistent irregular bleeding develops. The copper IUD is appropriate for use as emergency contraception in women who meet standard criteria for an IUD and who desire long-acting contraception.

incontinence- schuilling

asking a woman about her experiences while keeping in mind the broad array of symptom presentations and what is of most bother. although a woman may experience leakage with coughing, primary concern may be the extreme urgency she experiences on arriving home, even though she rarely or never actually leaks urine at that time. It is important to ascertain the full scope of both urgency and UI in terms of their presence, frequency, severity, bother, and impact on quality of life; past medical history such as previous treatment, coexisting diseases as precipitating factors, medications, obstetric and menstrual history, and physical impairment; social history such as environmental issues and lifestyle; any measures currently being used to contain the leakage; and the extent to which the individual is seeking or desiring treatment, varying from conservative to aggressive options. A long-standing screening questionnaire has just two questions: "How often do you experience urinary leakage?" and "How much urine do you lose each time?" To quantify low-level leakage in pregnant or postpartum women or others experiencing leakage onset, the eight-item Leakage Index Questionnaire reports leakage with bending or reaching, or says, "I just find myself wet," this is an important indicator of likely intrinsic sphincter deficiency, especially when combined with older age. A 3-day voiding diary Regardless of the type of voiding diary used, four components are critical to record: Time of day and amount of voiding (provide a measurement hat for the toilet) Time of day when an episode of UI occurs A place to write a brief description of the UI episode and associated events Types and amount of beverage intake. driving factor for choosing best treatment. PE/Dx: Assessing bladder capacity is done least invasively through a 3-day voiding diary. The largest void on the diary is an estimate of bladder capacity. Alternatively, a filling cystometrogram can be performed. However, this procedure is invasive and uncomfortable, and it requires equipment that is typically not available in the nonspecialty clinical environment. determine whether the urethra is able to maintain a high margin of continence under "stress conditions" of intra-abdominal pressure rise, a quantified standing stress test can be performed. "paper towel test." It is a quick, inexpensive, and noninvasive way to estimate the severity of stress-type leakage. full bladder; she coughs very hard three times while holding a trifold paper towel against her perineum. Urine loss onto the paper towel can be quantified— that is, visually or measured as wetted area. cause is some combination of low urethral pressure, poor support from the levator ani muscle, and intra-abdominal pressure (how hard she is coughing). If urine pools onto the paper towel and completely saturates it, this finding is a strong indicator of likely low urethral pressure. The clinician should ask, "Do you routinely cough this hard outside of the clinic setting, or undertake activities that would impose an equal level of pressure?" and "Is this the type of leakage that you experience and that you find bothersome?" If not, further assessment should be undertaken to determine the scenarios and additional causative factors that might account for the leakage of bother to her. Varying degrees of levator ani muscle laceration can be definitively ascertained only by MRI Levator ani functional capacity to lift and stabilize the continence structures can be readily observed on 2-D ultrasound. The test uses an external perineal probe and sagittal view of the bladder. aid in instructing a woman in pelvic muscle contraction technique. If ultrasound equipment is not available, the best clinical guess at functional loss (whether from levator ani muscle laceration or genetic weakness) is obtained when a woman continues to bear down or use the gluteal muscles when asked to contract her pelvic floor muscles. Specialty referral is appropriate to determine the cause in such a case. Stress (urinary) incontinence Involuntary leakage with effort or physical exertion, sneezing, or coughing Urgency (urinary) incontinence A strong desire to urinate that is difficult to postpone (involuntary leakage associated with urgency) Postural (urinary) incontinence Involuntary leakage associated with change of body position Nocturnal enuresis Involuntary leakage during sleep Mixed (urinary) incontinence Involuntary urine leakage associated with symptoms of both stress and urgency urinary incontinence Continuous (urinary) incontinence Continuous involuntary urine leakage Insensible (urinary) incontinence Leakage of urine when women unaware Coital incontinence Involuntary urine leakage with coitus Urogynecologists have specialty training in treating women who are experiencing UI. Because of the comorbid nature of UI, full assessment and therapeutic plans for treatment may require collaboration with numerous healthcare professionals. prevention: addressing the following risk factors: obesity, diabetes, and excessive beverage intake. women with more than 450 mg daily caffeine intake had a greater risk of UI compared with women with less than 150 mg daily caffeine intake. Performing pelvic muscle exercises and developing the Knack skill for stress incontinence during pregnancy and postpartum. management: UI is aimed at reducing the factors that allow bladder pressure to exceed urethral pressure. behavioral interventions as a first step for treatment of UI because these measures are less invasive and lower in risk. Interventions related to beverage management and healthy toilet habits form the basis for initial treatment, but are dependent on evaluation of a voiding diary- assessment tool, can be viewed equally as an intervention in and of itself and monitor progress over time. eliminate beverages containing caffeine, artificial sweeteners, and alcohol. women should aim for approximately one cup of urine every 3 to 4 hours, with the urine having a yellow color, neither dark nor nearly colorless. container that fits into their toilet for urine collection to monitor color and amount of output is a valuable tool. Adjusting for healthy levels is called bladder training (also known as retraining) and is especially recommended for women experiencing urge UI (overactive bladder or detrusor instability). habitually empty their bladders on initial urge or whenever a toilet is available, bladder training may be as simple as holding back until approximately 8 ounces is produced on voiding. On the other hand, such training may be as complicated as voiding by the clock every hour and increasing in increments of 15 minutes weekly, until the woman can achieve normal bladder capacity through extending the time interval between voids. A woman can adopt Knack skill and use distraction strategies (counting backward) to ignore the urge. The goal is to gradually retrain the bladder to have a normative capacity of 8 to 10 ounces without fear of leakage. steps in bladder retraining- The voiding diary helps determine baseline voiding frequency. interval should start 15 minutes earlier than the individual woman's normal voiding time to preempt urge sensation. hourly, begin strict bladder retraining at voids every 45 minutes. If the urge to urinate occurs prior to the scheduled time, the woman should attempt to delay emptying until the scheduled time (or at least delay 5 minutes past the initial urge). Each week (or longer if necessary to become comfortable with the new interval), she should try to increase the interval by 15 to 30 minutes until the interval is, on average, 3 to 4 hours between voiding. For most women, an average interval of 3 to 4 hours between voids means 2 to 3 hours in the morning, 4 to 5 hours in the afternoon, and 3 to 4 hours in the evening. The scheduled voiding is followed only during waking hours. Women who take diuretics or have a high fluid intake may have to adjust their voiding to a realistic level. Reverse bladder retaining urge UI experienced as late signaling or detrusor underactivity. These women routinely report high volumes per void (greater than 350 cc) and describe themselves as having no early warning of bladder filling. voiding by the clock until normalized urge sensations can be relied upon. The time interval to begin reverse bladder retraining is again established by the baseline diary. reduce her interval void time to the level that will produce no more than 300 cc per void (the first morning void may be larger). The Knack Skill pelvic muscle contraction (incorporating both the urethral striated muscle and the levator ani) strategically timed to a moment of expected loss of urine, whether from urge or stress-type triggers. allows a woman to volitionally increase her margin of continence (urethral pressure higher than bladder pressure) at any moment of need during her day-to-day activities. Pelvic muscle exercises Kegel exercises, pelvic floor muscle contraction regimen. rehabilitation for women whose muscles are weakened but not torn. Assessment of a woman's ability to contract the levator ani muscle must be completed prior to recommending any pelvic muscle exercise for UI, as such exercises are likely be ineffective (and frustrating) if a woman is unable to voluntarily contract her levator ani muscle— experienced a levator ani laceration. It is important to ascertain that the woman is not bearing down (a potential indicator of levator ani laceration) during her attempt to contract the pelvic floor muscles. Knack Confirm voluntary control. The clinician palpates the levator ani muscle bilaterally through the vaginal wall while the woman attempts a pelvic muscle contraction. A bulking of the muscle should be felt. If not, or if she bears down (Valsalva maneuver), instruct her in an easy flick of the muscles, the same maneuver she would use to hold back gas, to see if this elicits correct isolation. If unable to contract, Knack instruction should be discontinued. contract the pelvic muscles as deeply into the vagina as she is able. In some women, this is most easily accomplished by learning a stacking contraction. Start with a small flick-and-release maneuver and then build into stacking two to three small flicks. This is commonly known as the "elevator" technique (imagined as moving from one floor to the next). For other women, a smooth continuous inward pull of the muscles seems to work better. Teach the woman to maintain a steady hold of the pelvic muscle contraction while inhaling and exhaling. avoid the tendency to incorrectly hold her breath during the pelvic muscle contraction. The Knack urge suppression skill uses small, gentle, pelvic muscle contractions (not strong holds). Several contractions (three to five) are usually sufficient for urge suppression. After a few seconds' rest, an additional set of three to five contractions may be needed. The second maneuver is to be able to reduce leakage during a moment of intra-abdominal pressure rise. The Knack stress suppression skill uses a single strong pelvic muscle contraction timed precisely with a secondary activity that increases intra-abdominal pressure, such as a cough or sneeze. practice the Knack urge suppression skill prior to turning on the water faucet, upon arriving home to suppress latchkey urgency, or at the end of toileting to suppress postvoid dribbling. during planned maneuvers such as blowing the nose, voluntary coughing, lifting, rising from a chair, or momentarily stopping exercise (e.g., jogging) for a moment to "reset the pelvic floor" with a volitional pelvic muscle contraction. As skills with this technique develop, women will be ready to handle the triggers for urge UI and the surprise cough, sneeze that typifies stress UI. pelvic muscle exercise regimen such as the following: Sustain a contraction for 10 seconds, followed by at least 10 seconds of rest, with at least 3 sets of 10 repetitions per day. five levels of training matched to a particular woman's muscle ability, as the majority of women who need pelvic muscle exercise typically cannot sustain a contraction for a full 10 seconds. most notice improvement in strength and control within 1 month, although it may require 3 months or more to see the full results. no improvement within 3 months, referral to a specialist for further evaluation is important to evaluate for levator ani laceration or other problems. Weight Management weight reduction has shown benefit in treatment of UI for overweight and obese women. weight-loss interventions to address UI in overweight women have the potential to improve UI symptoms Barrier Devices for UI Incontinence pessaries are devices that are worn vaginally. increase a woman's urethral pressure by supporting the anterior vaginal wall on which the urethra rests, especially in cases of nonfunctional levator ani muscle or extrinsic sphincter deficiency. number of visits to find the correct size and type. While these devices are effective for many women, some women are not satisfied. Combined behavioral and pessary therapies did not show better results than either single therapy. Pharmacologic Treatment Pharmacologic For urge-type UI, anticholinergic antimuscarinic agents. They target the parasympathetic muscarinic cholinergic receptor sites of smooth muscle in the bladder. reduce the involuntary contractions of the detrusor muscle of the urinary bladder and increase the bladder capacity. side effects of the antimuscarinic agents include dry mouth, blurred vision, constipation, nausea, dizziness, and headaches. If a short trial is not effective, specialty referral is warranted before long-term continuation of the medication is recommended. The drugs approved for treatment of urge UI consist of oxybutynin (Ditropan) in various forms, including extended-release oral and patch products: tolterodine (Detrol), fesoterodin (Toviaz), darifenacin (Enablex), and solifenacin (Vesicare). Immediaterelease oxybutynin is considered the gold standard. side effect with this agent is dry mouth— a side effect less often associated with immediate-release and extended-release tolterodine Tricyclic antidepressants, usually imipramine (Tofranil), off-label basis for urge-type UI, targets detrusor muscle relaxation through activation of β adrenoceptors. no drugs approved specifically for stress UI in the United States. Although off-label use of some agents occurs, these medications should be prescribed only in conjunction with full evaluation by a continence specialist. Alpha-adrenergic agonists act on the alpha -receptor sites in the bladder neck and proximal urethra; ephedrine and pseudoephedrine (Sudafed) are the most often prescribed of these agents. side effects include elevated blood pressure, headaches, dry mouth, insomnia, anxiety, nervousness, tachycardia, and palpitations. Duloxetine is a dual serotonin and norepinephrine reuptake inhibitor that is also known to be used on an off-label basis for stress incontinence. Vaginal estrogen may help to relieve symptoms of UI in postmenopausal women. Surgical Treatment sacral nerve stimulator is one approach to urge incontinence that requires a surgical procedure. Injection of botulinum toxin (Botox) into a patient's bladder— side effects include bacteriuria, urinary retention, and residual urine volume good surgical treatments for stress UI related to extrinsic sphincter deficiency or urethral hypermobility or both. Injection of bulking agents is used for urethral sphincter deficiency when stress UI is primarily caused by poor urethral closure pressure and without hypermobility. under local anesthesia by direct vision into the proximal urethra. UI is not fully understood, they are believed to work by adding bulk to the periurethral tissue, which increases urethral closure pressure and improves resistance to urine outflow Bovine collagens, carbon bead particles (Durasphere), and Dextranomer/hyaluronix copolymer (Zuidex) are approved injectable agents. procedure is repeatable. Surgical treatments for stress UI also include a number of variations on surgical suspensions and slings, support and stabilize the urethra. The tension-free vaginal tape (TVT) sling procedure is the least invasive and is typically performed on an outpatient basis. The current trend is to perform a TVT, pubovaginal sling, or retropubic urethropexy. More-traditional surgeries, including the MarshallMarchetti-Krantz or Burch procedure and transvaginal bladder neck suspensions such as the Stamey-Raz or Gittes surgical approach, are also still performed. Surgical repair of stress UI may also improve the frequency and urge UI components of mixed UI-surgical correction of urine funneling into the urethra for a woman whose urge symptom etiology was striated sphincter insufficiency, not detrusor instability worsened by surgery. Surgery choices can differ depending on whether the patient is a very young or very old woman with stress UI. Priorities for young women when considering a surgical treatment can relate to expectations of future pregnancy and childbirth. minimally invasive procedures with low morbidity are typically the important consideration for older women, especially for frail older women with comorbidities. Complementary and Alternative Therapies biofeedback, acupuncture, yoga, Pilates, and Tai Chi. Biofeedback uses an electronic machine to help women properly contract the right pelvic floor muscles. This adjunct therapy is used along with pelvic muscle exercise to facilitate skill development, particularly in the early stages of such treatment. biofeedback does improve motivation. strong evidence that yoga, Pilates, and Tai Chi improve stress UI. herbal medications for UI, not recommended at this time. When to Refer If management is ineffective, if it does not meet the woman's expectations for improvement, or if complicating factors are suspected, women should be referred to a UI specialist or specialty clinic. If possible, referral to a urogynecologist or advanced practice nurse in urogynecology should be prioritized given these professionals' specialty training and practice. Education It is important to fully recognize UI as a nonspecific symptom of widely varying etiology and impact for each individual woman's situation. Choice of treatment modalities must be made by partnering with the woman to determine her goals and the context of her particular symptom manifestation. PATIENT EDUCATION following components need to be considered: how health providers diagnose UI and type of UI, available treatments, and healthy bladder behavior or lifestyle, including type and amount of fluid intake and appropriate bladder emptying time intervals to foster healthy bladder capacity. The continence mechanism is most effective when all parts function smoothly together. Overall, the etiology of UI tracks back to the situation in which any of these factors is insufficient or overcome by an adverse condition, or when ready-state redundancy in the system is compromised by stressed, injured, weakened, or aged structures, to the point where the woman is experiencing lack of urinary control that is affecting her quality of life. education often involves correcting misinformation or myths- need for all women to drink eight 8 oz glasses of water per day is a myth, with no data-based evidence to support it. SPECIAL CONSIDERATIONS goal is for healthcare providers to form partnerships with women so options for individually optimized bladder health, and a sense of control, can be self-determined. Age, BMI, weight change, and parity are reported to influence the incidence and prevalence of UI. white and Hispanic women had higher prevalence of UI compared with black and Asian women. stress UI was more common in white women, while urgency UI was more common in black women. more risk factors of UI with white and Hispanic women than with black and Asian women. Asian, black, and Hispanic women, as compared to white and American Indian women, had a higher prevalence of any type of UI. Despite these specific differences, the studies are in agreement that UI crosses all age, race, and ethnic groups. Indeed, all women deserve to be asked about their current satisfaction with their bladder health and control. Adolescents Adolescents should receive information about healthy bladder practices. Learning about their own physiologic self-control mechanisms, such as developing the Knack habit and sensible beverage and eating habits, will provide them with tools to use for good bladder health over the course of their entire adult lives. Some adolescents may have experienced UI as a child, which engendered lasting worries about bladder control. Leakage of urine is, in fact, the most common urine symptom in both children and adolescents. Urinary incontinence can lead to psychologic and psychiatric issues that are reflected in behavioral disorders among some children experiencing UI. leakage of urine for those children may have genetic association, as their parents may have suffered from UI and nocturnal enuresis, defined as "intermittent incontinence while sleeping". recommend that UI management for children include a combination of psychologic intervention and UI treatment, so as to ensure optimal outcomes. Pregnant Women The prevalence of UI significantly increases from before pregnancy to the third trimester of pregnancy. practicing pelvic muscle exercises during pregnancy. primiparous women who practice pelvic muscle exercises during pregnancy and on a postpartum basis experience earlier recovery from symptoms of UI. Additionally, pelvic muscle exercises and the Knack skill shown to reduce the severity of stress UI in pregnant women. Older Women Age is a proven etiologic risk factor for developing UI in women. Pelvic muscle exercise with or without combined bladder training and noninvasive transcutaneous electrical posterior tibial nerve stimulation may help improve UI in older women. incontinence pads (not menstrual pads, effective management aids for UI in older women. consider hydration, skin care, and maintenance of mobility in older women who experience UI. some medications may help older women by improving their UI symptoms. considerations must be paid addressed when prescribing medications in older women. Women with Disabilities often logically associated— that is, UI is a significant cause of disabilities, and disabilities make UI more serious. lower back disabilities and balance impairment. Women with urge UI are more likely than continent women to have poorer lower extremity physical functioning. comorbid conditions (e.g., diabetes mellitus, chronic pulmonary disease, stroke, and Parkinson's disease) may cause UI in frail elder women. Women with disabilities such as spine problems may not be able to perform a pelvic muscle contraction, or have the ability to control their bladder or urine system. Although some medications may improve symptoms of UI for older and disabled women, a number of considerations- older women who have renal/hepatic impairment, there are many prohibitions. For older women who take multiple medications, drug interactions are difficult to avoid. higher risk of experiencing retention, so post-void residual evaluation prior to and potentially after prescription needs to be careful considered. In frail older women, antimuscarinic agents can exacerbate cognitive impairment. For older women with dementia or with decreasing sensation, prompted voiding aimed at increasing toileting more usefulness for control and management of UI, considering the low effectiveness and problematic side-effect profiles of medications. Cultures may influence women's perception of UI. Non-white women (i.e., black, Arab, Asian, and Hispanic) often believe UI is a negative outcome from childbirth or prior sexual experience and blame themselves for its development. Women in this situation may hesitate to discuss UI, out of a concern that they may be perceived as unclean. In addition, cultural divides may exist regarding who is willing to seek medical help for UI. In one study, women who were Jewish were relatively more likely, Christian, Muslim, Buddhist, and Hindu did not seek medical, felt embarrassed and believed UI was a normal part of aging. Taiwan have been shown to be less likely to seek help for their UI compared with women in Western cultures. this condition is distressing and affects their health-related quality of life but some women do not find UI to be of enough bother to warrant medical intervention. Instead, they may select simple self-care management strategies, such as placing a pad or tissue in their underwear to catch urine loss. degree of diagnostic testing and management strategies should always be determined in conjunction with the individual woman, based on her unique experience. she is the expert in understanding the degree of bother from her symptoms. Identifying the most bothersome aspect offers a starting point from which to prioritize efforts to sort out the complex etiology that will inform step-by-step management.

cervical cancer- schuilling

fourth most common female malignancy in terms of both incidence and mortality. second most commonly diagnosed cancer and the third most common cause of death among women who live in low-resource countries- low-resource country and being economically disadvantaged significantly increase a woman's risks of both developing cervical cancer and dying from it. decreased by more than 50% over the past 30 years, mainly due to implementation of screening protocols. more likely for a woman to be diagnosed with cervical precancer than with invasive cervical cance. Women who are Hispanic or African American are more likely to be diagnosed with the disease and are more likely to die of it compared to white women. may not have access to adequate screening or treatments for early precancerous cervical lesions. HPV is now recognized as the most important causative agent in cervical carcinogenesis. most common STI worldwide. all women who are sexually active will be infected at some point with this virus, with many experiencing repeated infections. spread by skin-to-skin genital contact without intercourse. highest prevalence seen in women younger than 25 years. condoms reduce but do not eliminate the risk of transmission. 80% to 90% of infections are transient, sometimes causing only mild cytologic abnormalities, and they usually become undetectable within 1 to 2 years. A successful immune response results in viral control or clearance. 2% will develop cervical carcinoma. persistent infection with highrisk HPV is the most significant risk factor for the development of invasive cervical cancer. 150 genotypically distinct variants of HPV have been identified, approximately 40 of which will infect the epithelium of the skin or mucous membranes of the genital area. Types 6 and 11 are responsible for 90% to 100% of genital warts (condylomata acuminata) and low-grade cervical changes such as mild dysplasia. Lesions due to low-risk HPV infections have a higher likelihood of regression and rarely progress to cancer. 20% to 50% of people infected with low-risk viruses have coinfection with high-risk HPV types. High-risk HPV types are known to cause persistent infection that leads to highgrade cervical changes such as moderate or severe dysplasia and neoplasia. At the same time, these strains are frequently found to be the etiologic factor in minor lesions and mild dysplasia. Types 16 and 18 are found in 70% of cervical cancer cases and are also found in other types of anogenital cancers. HPV types are differentiated by molecular methods according to genetic sequencing found on the outer capsid protein, L1. HPV infections begin developing when there is a break in the basal epithelium, and the virus remains latent in this region. major difference between lowand high-risk HPV types is that after infection is established, the low-risk HPV types are maintained as extra-chromosomal DNA episomes, while the highrisk HPV genomes become integrated into the host cells' DNA in malignant lesions. Integration of the viral genome into the host cell genome is considered a hallmark of malignant transformation. Highrisk HPV produces viral protein products (E6, E7) that bind and inactivate the host's tumor suppressor genes p53 and pRb . The inactivation of these genes blocks apoptosis (programmed cell death) and induces chromosomal abnormalities. Premalignant changes can represent a spectrum of cervical abnormalities, which are referred to as squamous intraepithelial lesions (SIL) or cervical intraepithelial neoplasia (CIN). These early lesions, which form a continuum that is divided into low-grade or high-grade SIL or CIN 1, 2, and 3, reflect the increasingly abnormal changes that occur in the cervical epithelium. Over time, the premalignant lesions can persist, regress, or progress to invasive malignancy. CIN 1 often regresses spontaneously, whereas CIN 2 and 3 are more likely to persist or progress. 30% to 70% will develop invasive carcinoma over a period of 10 to 12 years. long natural history of this disease provides an opportunity to screen women for premalignant lesions, thereby preventing the lesions from evolving into cervical cancer. most common type of cervical cancer is squamous cell carcinoma (SCC), which accounts for 80% to 90% of all cervical cancers. SCC arises from the squamous cells that cover the ectocervix, and HPV 16 has been implicated as the type most commonly associated with SCC. Adenocarcinoma, the second most common cervical cancer type, accounts for 10% to 12% of cervical cancer cases. It most often arises from the columnar epithelium— a group of mucus-producing glandular cells— located in the endocervix and has been associated most commonly with HPV 18, followed by HPV 16. mixed- adenoscuamous carcinomas or mixed carcinomas. risk factors Early age at first intercourse (age 18 years or younger) is a risk factor for HPV: It is believed the younger-developing cervix is at a greater risk of being infected because of the normal physiologic process called squamous metaplasia. squamous metaplasia occurs at the squamo-columnar junction, or transformation zone, where the more fragile columnar epithelial cells are replaced with hardier squamous epithelial cells. metaplasia may arise throughout the reproductive years, it is most active during adolescence and first pregnancy. Indeed, first-time pregnancies that occur in women younger than 17 years are associated with twice the risk of cervical cancer compared to women who develop cervical cancer later in life- more vulnerable to carcinogenic agents such as HPV. The age of greatest risk, however, is midlife, when the majority of cervical cancer diagnoses are made. An estimated 15% cases are diagnosed after 65 years of age, with most occurring in women who have not participated in regular screening. multiple sexual partners or having a partner with multiple sex partners increases the risk of multiple exposures to HPV. Cofactors, such as smoking, are thought to play a contributing role Smoking Among women infected with HPV, current and former smokers have approximately two to three times the incidence of high-grade cervical intraepithelial lesions or invasive cancer. Smoking exposes the body to many carcinogens that affect more than just the lungs, as carcinogens are absorbed by the lungs and carried in the bloodstream, thereby traveling throughout the body. damage the DNA in cervical cells. Smoking may also impair the immune response, thereby interfering with the body's ability to clear the HPV. Patients who are immunocompromised from HIV, AIDS, or other causes (e.g., medications) have an increased prevalence and persistence of HPV infection. A precancerous lesion may develop more quickly into an invasive cancer if a woman is immunocompromised. risk of cervical cancer doubles after 5 years of combined oral contraceptive (COC) use, but returns to normal about 10 years following discontinuation of oral contraceptives. intrauterine device (even if for less than a year) appear to have a lower risk of developing cervical cancer. estrogenic effect of COCs may prevent the ectopy of the cervix from receding into the cervical canal, leaving the vulnerable area exposed. less likely to use barrier protection, thereby increasing their risk of contracting HPV. do not warrant discontinuing COC use in the case of an abnormal Pap test. high parity Having had three or more full-term pregnancies has been associated with an increased risk for cervical cancer genetic whose mother or sisters have had cervical cancer are more likely to develop the disease. inherited condition that makes some women more susceptible to HPV. Nutritional Status Diets low in fruits and vegetables potential contributing factors in the development of cervical cancer. Low levels of vitamins C and E, folate, and carotenoids have been linked to cervical cancer. poverty Many women with a lower socioeconomic status or living in developing countries continue to lack ready access to adequate screening and treatment Daughters of women who took diethylstilbestrol (DES) are 40 times more likely to develop clear cell adenocarcinoma (CCA) of the vagina and cervix than women who were not exposed to DES in utero. Clear cell adenocarcinoma is a rare form of vaginal and cervical cancer. The average age of women diagnosed with DESrelated cervical cancer is 19 years. removed from the market in 1971, so women who were exposed at age 19 years (or younger) are less likely to receive a diagnosis infectious agents the pathogenesis of cervical cancer remains unclear. Nevertheless, HSV-2 and Chlamydia trachomatis infections are known to be associated with a chronic inflammatory response and micro-ulceration of the cervical epithelium. Such an inflammatory response is associated with the generation of free radicals, which are thought to play important roles in the initiation and progression of cancers. Free radicals directly damage DNA and DNA repair proteins and inhibit apoptosis, allowing the development of genetic instability presentation: usually asymptomatic. As many as 20% of patients who have invasive cervical cancer are asymptomatic, the most commonly noted are abnormal vaginal bleeding, such as postmenopausal bleeding, irregular menses, heavy menstrual flow, painless heavy menstrual bleeding, or postcoital bleeding. An abnormal vaginal discharge that is odiferous, watery, purulent, or mucoid may also be present. Late symptoms that suggest metastatic spread include bladder outlet obstruction, constipation, back pain, pelvic pain, pain during intercourse, and leg swelling assessment: history- abnormal vaginal bleeding (intermenstrual or postcoital bleeding), unusual vaginal discharge, or dyspareunia Sexual history— age at first intercourse, number of sexual partners in the past 6 months, number of lifetime partners, and presence of lesions in sexual partners Contraceptive history, including use of barrier methods HPV and other STIs in the woman and her partners Immunosuppression, including HIV infection Prior history of cancer or cancer therapy (e.g., radiation, chemotherapy, surgery) In utero DES exposure Date and result of the most recent Pap test Prior abnormal cervical cytology Menstrual history, including the date of the last menstrual period Pregnancy history History of tobacco, drug, or alcohol use Family history of cervical cancer HPV immunization status PE: thorough pelvic, abdominal, inguinal lymph node, and rectal examination. As the disease progresses, the cervix may appear abnormal, with gross erosion, ulcers, or a mass that bleeds easily on contact. In the late stages, an extensive, irregular, cauliflower-like growth may develop. The cervix may be hard and indurated, and its mobility may be restricted or lost. As the tumor enlarges, it grows by extending upward into the endometrial cavity, downward into the vagina, and laterally to the pelvic wall. It can invade the bladder and rectum directly. bimanual examination can detect a mass or bleeding from tumor erosion. Common sites for distant metastasis include the pelvic lymph nodes, liver, lungs, and bones Metastasis to the liver may lead to findings of hepatomegaly. Leg edema is suggestive of tumor obstruction of the lymph or vascular systems. The triad findings of leg edema, pain, and hydronephrosis are indicative of spread to the pelvic wall. diagnostics: routine Pap testing for precancerous lesions that has led to a dramatic decline in mortality rate from cervical cancer is now being balanced against data showing that 9 of 10 abnormal Pap tests will revert to normal even without treatment. immune responses will resolve approximately 90% of HPV infections. new guidelines- guidelines recommend that screening for cervical cancer start at age 21 years. The evidence suggests that women younger than 21 years have a high likelihood of spontaneous clearance of abnormal cells and, therefore, are at low risk for developing cervical cancer. Screening should start at age 21 years with a routine Pap test and continue at 3-year intervals until the age of 29 years. Between the ages of 30 years and 65 years, cotesting (Pap test with HPV DNA testing) should be performed every 5 years. Cotesting is important because it has a lower false-negative rate and therefore there is less possibility of missing an abnormality. Women older than 65 years who have never had precancerous changes, who have never been diagnosed with cervical cancer, or who have had removal of the cervix and uterus with no evidence of precancerous or cancerous changes do not require further screening for cervical cancer. Women who are 65 years and older and who are at high risk for cervical cancer, such as those who were exposed to diethylstilbestrol in utero, have an immunosuppressed status, are positive for HIV, or have a history of organ transplant, should discuss alternative interval testing with their clinicians. It is important for clinicians to appreciate that while guidelines can be helpful, they are not meant to replace sound clinical judgment that is based on an individualized assessment of a woman's risk profile, her subjective concerns, and assessment findings. Bethesda Categories of Epithelial Cell Abnormalities ASC-US Atypical squamous cells of undetermined significance. This term is used when the squamous cells do not appear completely normal but it is not possible to determine the cause of the abnormal cells. An estimated 10- 20% of women with ASC-UC may have CIN 2 or 3. An estimated 1 in 1,000 women with ASC-UC may have invasive cancer. ASC-H Atypical squamous cells— cannot exclude HSIL. LSIL Low-grade squamous intraepithelial neoplasia. Encompasses: HPV transient infection CIN 1 (mild dysplasia): Lesion involves the initial one-third of the epithelial layer HSIL High-grade squamous intraepithelial neoplasia. Encompasses: HPV persistent infection CIN 2 (moderate dysplasia): Lesion involves one-third to less than two-thirds of the epithelial layer CIN 3 (severe dysplasia, carcinoma in situ): Lesion involves twothirds of the epithelial layer to full thickness Squamous carcinoma Malignant cells penetrate the basement membrane of the cervical epithelium and infiltrate the stromal tissue (supporting tissue). In advanced cases, cancer may spread to adjacent organs such as the bladder or rectum, or to distant sites in the body via the bloodstream and lymphatic channels. cervical cytology results dequacy of Specimen Satisfactory for evaluation (note presence or absence of endocervical or transformation zone components and any other qualifiers such as inflammation, or blood on os present) Unsatisfactory for evaluation (specify reason) General Categorization (Optional) Negative for intraepithelial lesion or malignancy Epithelial cell abnormality: specify whether squamous or glandular cells b Other (e.g., endometrial cells in a woman age 45 or older) Interpretation/Result a Non-neoplastic cellular findings (optional to report) Non-neoplastic variations : Squamous metaplasia Keratotic changes Tubal metaplasia Atrophy Pregnancy associated changes Reactive cellular changes associated with: Inflammation Lymphocytic (follicular cervicitis) Radiation IUD Glandular status post hysterectomy Organisms Trichommonas vaginalis Fungal organisms with a form or structure that looks like Candida spp. Change in flora (e.g. consistent with bacterial vaginosis) Bacteria that have a form consistent with Actinomyces spp. Cellular changes consistent with herpes simplex virus Cellular changes consistent with cytomegalovirus Other Such as endometrial cells in a woman age 45 or older. Other findings Epithelial Cell Abnormalities: Squamous cell ASC are divided into two categories: ASC-US: Atypical squamous cells of undetermined significance ASC-H: Cannot exclude high-grade squamous intraepithelial lesion LSIL Refers to cervical cancer precursors encompassing human papillomavirus, mild dysplasia, and CIN 1 HSIL Refers to cervical cancer precursors encompassing moderate and severe dysplasia, carcinoma in situ, and CIN 2 and CIN 3 Includes identification of features consistent with invasion Squamous cell carcinoma Glandular cell Atypical Specify endocervical, endometrial, glandular cells, or NOS Atypical Specify if specimen is either endocervical cells or glandular cells favoring neoplastic disease Endocervical AIS Adenocarcinoma Identify if endocervical, endometrial, extrauterine, or NOS Other Malignant Neoplasms (List Is Not Comprehensive) Endometrial cells in a woman 45 years or older additional testing to r/o other diff based on s/s: STI testing. Chlamydia and gonorrhea are commonly encountered STIs that may produce symptoms similar to those of cervical cancer. test for HPV, chlamydia, and gonorrhea when a woman presents with a vaginal discharge that has not resolved. Wet mount preparation. Women who have vulvovaginal candidiasis, bacterial vaginosis, or trichomoniasis can present with a variety of symptoms referral for colposcopic examination with a biopsy of the abnormal area Endocervical curettage. A curette is inserted into the endocervical canal to remove tissue when the transformation zone is not visible. This procedure is aided by colposcopy Cone biopsy. In this procedure, a cone-shaped tissue extending from the exocervix to the endocervical canal (including the transformation zone) is removed. The loop electrosurgical technique (LEEP) uses a wire hook heated by an electrical current to remove the tissue. A cold-knife biopsy uses either a surgical scalpel or laser to remove tissue under anesthesia differentials: must be ruled out prior to diagnosing cancer- Cervicitis: noninfectious related to trauma or chemical irritation; infectious related to STIs such as chlamydia, Neisseria gonorrhoeae , HSV, and Trichomonas Vaginitis Granulomatous (rare) or cervical polyps Pelvic inflammatory disease Symptoms highly suggestive of cervical cancer may rarely be due to Paget's disease, vaginal cancer, endometrial carcinoma, or primary myeloma. mgmt: three recombinant vaccines (bivalent [2vHPV], quadrivalent [4vHPV], and 9-valent [9vHPV]) use non-infectious virus-like particles prepared from the L1 capsid protein from the HPV types for which the vaccines provide coverage. HPV 16 and 18, which together are responsible for an estimated 66% of cervical cancer cases; the 9vHPV vaccine offers coverage for five additional oncogenic HPV types that are collectively responsible for an additional 15% of cervical cancer cases. 9vHPV vaccine has the potential of increasing the rate of prevention of cervical cancer from approximately 70% to 90% GlaxoSmithKline/bivalent HPV recombinant vaccine (Cervarix) HPV types 16, 18 Adjuvant: Aluminum hydroxide Protects against precancer and cancer of the cervix Merck/quadrivalent HPV recombinant vaccine (Gardasil in the United States; Silgard in some other countries) HPV types 6, 11, 16, 18 Adjuvant: Amorphous aluminum hydroxyphosphate sulfate Protects against precancer and cancer of the cervix, vulva, and vagina Protects against anal precancer and cancer Protects against genital warts Merck/9-valent HPV (Gardasil 9) HPV types 6, 11, 16, 18, 31, 33, 45, 52, 58 Adjuvant: Amorphous aluminum hydroxyphosphate sulfate Protects against precancer and cancer of the cervix, vulva, and vagina Protects against anal precancer and cancer Protects against genital warts side effects most commonly reported have been pain, swelling and redness at the injection site, and systemic symptoms of headache and fever. Rare adverse reactions found to be causally related to HPV vaccines include syncope (which can happen with any injected vaccine) and anaphylaxis. guidelines emphasize having women sit or lie down during vaccine administration and remain supine for 15 minutes post injection so that they can be observed to minimize injury from potential syncope. Ongoing studies of all three HPV vaccines are exploring the safety of their use during pregnancy and case reports of rare adverse events begin HPV immunization for women at 11 or 12 years (or 9 years, if deemed necessary) and to follow a 3-dose schedule at 0, 1 to 2 months, and 6 months. period for women to be immunized spans from age 13 to 26 years. Women who already have abnormal cervical cytology results are still candidates for the vaccine, as it does not treat current disease, but will provide protection from infections from other HPV types. use any available HPV vaccine to protect women against HPV 16 and 18, and advises completion of the series even if one formulation needs to be substituted for another due to availability issues. If the vaccination series schedule is interrupted, the woman does not need to restart it from the first dose One important caveat is that women who have a history of immediate hypersensitivity to yeast should not receive the 4-valent or 9-valent HPV series. Likewise, prefilled syringes of 2-valent vaccine are contraindicated for women who have a history of anaphylactic response to latex HPV vaccine is currently contraindicated during pregnancy, but may be given to women who are breastfeeding. inadvertently received a first dose during pregnancy may be reassured that there is no evidence from clinical trials or through interim analysis of 5 years of pregnancy registry data that suggests the immunization increases the risk of adverse outcomes. Preventive measures should include educating women that the risk of infection can be decreased by delaying the onset of sexual activity, decreasing the number of sexual partners, using condoms consistently, and eliminating tobacco use. treatment: Treatment of precancerous lesions and CIS (stage 0; Tis, N0, M0) includes cryosurgery or laser ablation to kill abnormal cells. Loop electrosurgical excision or cold-knife conization can be used for definitive treatment in women with early-stage IA1 (T1a1, N0, M0) who want to preserve fertility. lifelong surveillance at regular intervals. The clinician determines the timing and frequency of follow-up based on Pap test results and colposcopy examinations Hysterectomy is a choice for stage IA1 cancers and some stage 0 disease if cone biopsy reveals positive margins. For cervical cancer stages IA2 (T1a2, N0, M), IB (T1b, N0M), and sometimes IIA (T2a, N0, M), a radical hysterectomy removing the uterus, parametria and uterosacral ligaments, upper part of the vagina, and sometimes lymph nodes is indicated. Postoperative complications associated with any pelvic surgery can include new onset urinary incontinence, pelvic pain, and dyspareunia. emotional support for issues such as loss of fertility; possible need for a catheter, as voiding can be difficult with the disruption of nerves; and concerns regarding sexuality. clitoral area is not disturbed and that their ability to have sexual relations and achieve orgasm will remain intact women with IA2, IB, or IIA cervical cancer who want to preserve fertility and have lesions smaller than 2 cm. A trachelectomy removes the cervix and upper part of the vagina while preserving the body of the uterus. stage IA2, IB, or IIA cancer include bypassing surgery and choosing external-beam pelvic radiation plus internal brachytherapy. When biopsies have positive margins, chemotherapy is added to the radiation therapy. Advanced-stage cervical cancers— that is, IIB (T2b, N0 M0), III (T3, N0, M0), or IVA (T4, N0, M0)—are usually not treated with surgery. Instead, external pelvic radiation with internal. brachytherapy is combined with chemotherapy. Special attention is given to imaging studies (MRI, PET scan) to ascertain possible metastasis. The treatment of stage IVB (any T, any N, M1) cervical cancer is primarily palliative, because cure is not possible. Palliative radiation may be used to control bleeding, pelvic pain, or urinary or bowel obstruction from pelvic disease. Women with recurrent cervical cancer are candidates for total pelvic exenteration, which extends the removal of organs and tissues from the radical hysterectomy to include pelvic lymph node dissection and, depending on spread, removal of the bladder, vagina, rectum, and part of the colon. Emotional and physical recovery needs are extensive when such surgery is performed, as the woman must learn to manage urostomy and colostomy sites and may have difficulty with edema in the legs from removal of lymph nodes. A new vagina may be surgically constructed and if desired, a woman can resume a satisfactory sex life. Adding chemotherapy as an adjunct has been shown to boost positive response to radiation. The use of platinum compounds is standard treatment, followed by plant alkaloids and topoisomerase inhibitors. Adding bevacizumab— a monoclonal antibody that inhibits angiogenesis and slows the growth of new blood vessels supplying cancer cells— First-line single agents include cisplatin, carboplatin, and paclitaxel. First-line combination therapies include cisplatin/paclitaxel/bevacizumab; cisplatin/paclitaxel; topotecan/paclitaxel/bevacizumab; carboplatin/paclitaxel; cisplatin/topotecan; topotecan/paclitaxel; and cisplatin/gemcitabine educate- same sex females should be vaccinated Adolescents should receive HPV vaccination with other routine tetanus- diphtheria- acellular pertussis and meningococcal vaccines, and clinicians need to strongly recommend the vaccine to their young patients' parents for cancer prevention Women who have received the full HPV immunization series need encouragement to continue to comply with screening. Education and reeducation regarding the screening protocols, along with phone or letter reminders, are important to integrate into practice. When discussing an abnormal Pap test with women, clinicians need to be aware that precancerous lesions are often associated with a diagnosis of cancer. Clarifying misperceptions and education regarding the treatment protocols for early lesions can alleviate stress. educate women on the association between HPV infection and cervical cancer and review STI prevention strategies and safe sex practices. Young women need to understand the importance of delaying the risk of HPV exposure through delaying the onset of sexual activity, decreasing the number of sexual partners, using condoms to decrease risk, and eliminating use of tobacco products. pregnancy most women are diagnosed in stage I. No treatment is warranted for preinvasive lesions of the cervix during pregnancy, although expert colposcopy is recommended to exclude the possibility of invasive cervical cancer. Treatment of invasive cervical cancer depends on the stage of the cancer and the gestational age at diagnosis. Most experts advocate a cesarean birth at fetal viability with concurrent radical hysterectomy and pelvic node dissection. mgmt of ca during pregnancy- requires a multidisciplinary approach.

endometrial ca schuilling

majority of cancers affecting the uterine corpus are adenocarcinomas affecting the endometrium Carcinoma of the endometrium is the most prevalent gynecologic malignancy. increased incidence observed in high-resource countries is due to the larger number of women who are obese and physically inactive in such areas. Both obesity and physical inactivity are risk factors for endometrial cancer incidence of endometrial cancer is higher in white women than in black women, but the mortality rate in black women is nearly twice as high as that in white women. A major factor explaining the increased mortality rate in black women is the significant occurrence of higher-grade and more aggressive histologies in this population. 95% survival rate being associated with localized tumors, a 67% rate with regional tumor, and a 16% rate with distant spread. avg age of dx 63yrs. most common cause of death among women diagnosed with endometrial cancer is cardiovascular disease. This outcome most likely reflects the high probability of curative treatment for endometrial cancer, as well as the prevalence of cardiac disease. two types: Type I, or estrogen-dependent endometrial cancer, is the most common and is diagnosed in more than 75% of cases- excess of endogenous or exogenous estrogen, unopposed by progesterone. Long-term unopposed estrogen exposure allows for continued endometrial growth as well as the development of hyperplasia with or without atypia. tumors are usually low grade and have a favorable prognosis. Histologic types include endometrioid adenocarcinomas (most cases); adenosquamous tumors, contain elements of both glandular and squamous epithelium; and other rare variants such as ciliated carcinoma. These types of well-differentiated tumors usually limit their spread to the surface of the endometrium Type II endometrial cancer accounts for approximately 10% of cases and was traditionally thought to be estrogen independent, as the endometrium is generally atrophic or has polyps with this type of disease. estrogen may play some role in polyps' development, neoplasms consist of poorly differentiated prognostic cell types (such as papillary serous or clear cell tumors), higher-grade tumors, and are more aggressive, 4% of type II cancers are uterine carcinosarcomas (CS), also known as malignant mixed mesodermal tumors or malignant mixed Müllerian tumors, both sarcomas and endometrial carcinomas. linked to a genetic predisposition to develop this disease. 10% diagnosed prior to age 50 years who have the autosomal dominant syndrome known as Lynch syndrome (hereditary nonpolyposis colorectal cancer). Lynch syndrome- heritable mutations in a germline typically affecting mismatch repair genes— MLH1 , MAH1 , PMA1 , or MSH6. also associated with an increased risk of developing colon and ovarian cancer , 61% risk of developing endometrial cancer by age 70 years, with most cases appearing by age 50. Cowden disease (multiple hamartoma syndrome) autosomal dominant disorder that involves germline mutations of the tumor suppressing the phosphatase and tensin homolog ( PTEN ) gene and is associated with increased risk for endometrial, breast, and thyroid cancer. BRCA genes- it is unknown whether the mutation itself or prophylactic treatment for the mutation (tamoxifen) increases risk. exact cause of endometrial cancer is unknown, the current understanding of risk factors helps to identify women at risk for type I endometrial cancer due to estrogen excess. Risk factors associated with exogenous sources of estrogen include the following: estrogen therapy for 5 or more years, added progesterone for at least 10days/mth mitigates risk. limit ET use for menopausal women to lowest effective dose, shortest duration. tamoxifen- Nolvadex; used for chemoprevention of breast ca. selective estrogen receptor modulator- suppresses growth in breast tissues but stimulates growth of endometrial lining. Raloxifene- another SERM not associated with risk. risk factors a/w endogenous sources of estrogen: early menarche before 12, more years endometrium exposed to estrogen. late menopause after 52, increased duration of exposure infertility, nulliparity, during preg- hormonal shift toward progesterone; removal of premalignant cells, pregnancy; protective immunity-mediated effect, multi parity- reduced risk. obesity BMI >25 and even greater if >27. young and diagnosed with endometrial cancer are very likely to be obese, be nulliparous, and have type I well-differentiated histology. obeses- higher endogenous estrogen from increased adipose tissue. chronic anovulation common cause of infertility. PCOS common cause; excess androgens and elevated LH normal or low FSH, elevated free estrogen. T2DM and HTN a/w obesity or not a/w obesity increased risk high fat diet lead to obesity, fatty foods may also directly effect estrogen metabolism ovarian ca, certain tumors (granulosa theca cell tumors) produce estrogen other risks for endometrial ca- increased age, smoking (for type II cancers), sedentary lifestyle, history of pelvic radiation to treat another cancer, and endometrial hyperplasia. clinical presentation: occurs most frequently in women who are postmenopausal. The average age at diagnosis 63 years, with 15% of woman being diagnosed before age 50 and 5% before age 40. Younger women usually have specific risk factors such as morbid obesity, chronic anovulation, and heredity syndromes. The most common symptom— 90% of women— is abnormal uterine bleeding. menstruating, this symptom can take the form of bleeding between periods or excessive, prolonged menstrual flow. postmenopausal, any bleeding is considered abnormal and should be evaluated. Advanced symptoms include pelvic pain, abdominal distention with or without pain, bloating, change in bowel or bladder pattern, and change in appetite. History assist the clinician in identifying women at high risk for endometrial cancer include the character of the bleeding, the pattern of the flow, and the number of pads used when bleeding occurs. accompanying problems (e.g., dyspareunia, pain, bladder or bowel problems); experiencing any unusual vaginal discharge or if she has ever been diagnosed with an STI. menstrual history and inquire if the woman is taking any hormones. possibility of pregnancy and whether she has experienced any symptoms of pregnancy (e.g., missed period, breast tenderness, or nausea and vomiting). previously been pregnant- obtain a pregnancy history in addition to medical and family histories. has a personal or family history of breast, ovarian, or colon cancer. experienced infertility problems or if she has a history of PCOS physical examination thorough abdominal, inguinal lymph node, pelvic, vaginal, and rectal examination. Abnormal bleeding from the genital tract can occur from the vagina, cervix, uterus, or fallopian tubes. Inspect the external genitalia for lesions or atrophic vaginitis, cause of the bleeding. Perform a vaginal examination to determine whether the bleeding is caused by vaginal or cervical infection. amount, color, consistency, and odor of the vaginal discharge; cervix friable or has an unusual discharge; and examine the patient for cervical polyps. Perform a bimanual examination. Palpate the cervix, normally feels smooth, firm, evenly rounded, and mobile. cervical motion tenderness. palpate the uterus, ovaries, and inguinal lymph nodes. Note uterine size and contour. Endometrial cancer seldom causes much uterine enlargement, and any increase in size usually occurs slowly. Uterine fibroids usually feel firm and may make the uterus asymmetrical. Note any enlargement of the ovaries and lymph nodes. rectal examination to identify lesions or other abnormalities. Metastatic spread of endometrial cancer occurs in a characteristic pattern, commonly to the pelvic and para-aortic nodes. Common sites for distant metastasis include the lungs, inguinal and supraclavicular lymph nodes, liver, bones, brain, and vagina dx testing: atypical glandular cells in postmenopausal women is suggestive of uterine malignancy and requires further investigation as does any postmenopausal bleeding. f/u with endometrial bx or transvaginal US Transvaginal ultrasound adjunctive means of evaluation for endometrial hyperplasia as well as polyps, myomas, and structural abnormalities of the uterus. edometrial thickness of 4 mm or less indicates that biopsy can be deferred. rare cases of type II endometrial cancer present with endometrial thickness of 3 mm or less, ongoing symptoms of bleeding require biopsy. Persistent bleeding in the face of a negative biopsy also requires further investigation.premenopausal, the value of imaging is questionable, as the measurement of endometrial thickness is irrelevant. decision to biopsy based on the clinical presentation and symptoms. Endometrial Biopsy- office procedure that is now the primary method for histologic sampling of the endometrium. obtained through the use of an endometrial suction catheter that is inserted through the cervix into the uterine cavity. detects 80% to 90% of endometrial cancers if an adequate tissue sample is obtained. result fails to provide sufficient diagnostic information or if abnormal bleeding persists, a dilation and curettage (D & C) with a hysteroscopy is recommended Dilation and curettage gold standard for assessing uterine bleeding and diagnosing endometrial cancer. If endometrial biopsy findings are inadequate or negative with ongoing symptoms of bleeding, or if the endometrial thickness as assessed by transvaginal ultrasound is greater than 4 mm, or if a high degree of suspicion exists, the patient needs a D & C under anesthesia to exclude malignancy Hysteroscopy in the office setting to directly visualize the uterine cavity. tiny telescope is introduced through the cervix into the uterus. filling the uterus with saline, the practitioner can visualize and biopsy suspicious areas. not required in conjunction with the D & C, recommended because it provides the best opportunity to examine the endometrium and confirm premalignant endometrial lesions. Elevated CA-125 levels are associated with some endometrial cancers. Extremely high levels are suggestive of metastasis beyond the uterus. Evaluation of CA-125 is another assessment option for women who are poor surgical candidates referral: diagnosed with endometrial cancer who require surgical staging. Exceptions would be women who are poor surgical candidates who require assessment of potential metastasis sites with imaging (CT, MRI, PET/CT). decisions made preoperatively are complex and best suited to physicians with advanced expertise in endometrial carcinoma. A referral to a gynecologic oncologist; comprehensive evaluation of the need for preoperative imaging (CT, MRI, PET/CT), extent of comprehensive staging or debulking, and best treatment options The differential diagnoses for genital bleeding - Bleeding from the lower genital tract can occur from the vagina (carcinoma, lacerations, trauma, infections, or atrophic changes with age) or the cervix (cervicitis, STIs, polyps, or cervical carcinoma). from the uterus (carcinoma, fibroids, polyps, pregnancy, or dysfunctional uterine bleeding) or the fallopian tubes (pelvic inflammatory disease [PID], ectopic pregnancy). hormone replacement therapy may experience breakthrough bleeding. mgmt: prevention-several factors are a/w decreased incdence of endometrial ca: Combined oral contraceptives. The risk is increased by the presence of unopposed estrogen. COC instead of an estrogen-only contraceptive prevents the proliferative effect of estrogen, decreasing the risk of developing abnormal endometrial hyperplasia. both risk and duration related, and it remains increased for years after stopping use of unopposed estrogen; ameliorated by adding progestins in the correct dose and duration, use of depot medroxyprogesterone acetate and use of a levonorgestrel-releasing IUD Physical activity; modifies the risk of endometrial cancer by reducing obesity, a known risk factor for endometrial cancer Low-fat diet- consumption of a diet low in saturated fats and high in fruit and vegetable intake is associated with a reduced risk of developing endometrial cancer controlling other risk factors: PCOS need appropriate treatment to avoid the effect of unopposed estrogen on the uterus. menopausal and have an intact uterus should avoid using unopposed estrogen to relieve menopausal symptoms. history of breast or ovarian cancer or hereditary nonpolyposis colorectal cancer need to be closely monitored for endometrial cancer. women with or at increased risk for HNPCC should be offered annual testing for endometrial cancer with endometrial biopsy beginning at the age of 35 years. counseled about preventive measures such as the option of prophylactic hysterectomy with bilateral salpingo-oophorectomy at the completion of childbearing definitive tx: depends primarily on the type and stage of the disease, the level of differentiation, the woman's overall health, and her personal preferences. options for endometrial cancer include surgery, radiation therapy, chemotherapy, hormonal therapy, and biologic therapy. Chemotherapy may be used in recurrent or advanced cases of endometrial cancer. surgery: Comprehensive surgical staging through total abdominal hysterectomy with bilateral salpingo-oophorectomy and peritoneal washing for cytology. some surgeons choose selective lymph node sampling versus full dissection. multiple-site sampling has been associated with improved survival rates and complete pelvic and para-aortic lymphadenectomy remains the standard. localized disease are usually cured with surgery alone. myometrial invasion are usually treated with a combination of surgery and adjuvant radiation therapy. Careful staging guides therapy staging: FIGO's surgical staging system is used for surgical staging of endometrial cancer. Less favorable prognosis findings include hormone receptor status— progesterone receptor site levels greater than 100 are associated with 93% disease-free survival rate at 3 years as opposed to a 36% rate if these levels are less than 100; myometrial invasion; vascular invasion; presence of aneuploidy; oncogene (mutated gene) expression, and the fraction of cells in S- phase— the percentage of cells in a tumor that are in the phase of the cell cycle when DNA is synthesized radiation: may be given externally (external-beam radiation), via an intracavitary method (brachytherapy), or both. Vaginal brachytherapy has less gastrointestinal (GI) toxicity and is better tolerated by most women- Diarrhea and fatigue are common side effects of radiation therapy. Pelvic radiation may also cause vaginal stenosis (narrowing of the vagina from scar tissue), which may make vaginal intercourse painful. vaginal dilator or having vaginal intercourse several times per week can help prevent scar tissue formation. Use of vaginal lubricants may also be helpful Chemotherapy has been shown to improve outcomes for women with advanced endometrial cancer. The most common agents used for treatment include paclitaxel, carboplatin, doxorubicin, and cisplatin. The combination of paclitaxel, doxorubicin, and cisplatin has been shown to significantly improve response rates with advanced or recurrent endometrial cancer, although neurotoxicity is a significant problem for many patients; paclitaxel in conjunction with carboplatin is less toxic and is an alternative regimen. hormone therapy: not candidates for surgery or radiation, or who have advanced disease and are poor candidates or unwilling to undergo more aggressive treatment, may opt for hormonal therapy. most commonly used for this purpose are progestational drugs such as medroxyprogesterone (Provera) and megestrol (Megace). Response to hormones reflects the presence and level of hormone receptors and the degree of tumor differentiation. Other hormone therapy options include tamoxifen and aromatase inhibitors, which block the use of estrogen in fat tissue FIGO staging: I - Tumor confined to the corpus uteri IA - Endometrial only or less than 50% invasion through the myometrium IB - Invasion equal to or more than 50% of the myometrium II Growing into the supporting connection tissue of the cervix (stroma) III Invasion beyond the uterus and cervix; not in the pelvis IIIA Spread to serosa of the corpus uteri and/or fallopian tubes or ovaries (adnexal) IIIB Vaginal and/or parametrial involvement IIIC1 Metastases to pelvic and/or apra-aortic lymph nodes IIIC2 Spread to pelvic and aorta lymph nodes IV Invasion into the bladder or rectum, lymph nodes in groin and/or distant organs IVA Invasion into the bladder and/or bowel mucosa and/or distant metastases IVB Spread to distant lymph nodes, the upper abdomen, the omentum or organs (bones, lungs) Follow-Up specific schedule of follow-up visits after surgery, chemotherapy, or radiation therapy. scheduled every 3 to 6 months during the first 2 years, then every 6 months for 3 years, and then annually. Most endometrial cancer recurrences are found within the first 3 years. An examination of the abdomen and inguinal lymph nodes, along with speculum and rectovaginal examinations, should be done at each follow-up visit. focus on symptoms that might indicate cancer recurrence, most discovered during evaluation of symptomatic patients. symptoms or physical examination results suggest recurrent cancer, imaging tests such as a CT scan, ultrasound, CA125 blood test, or biopsies should be ordered. no symptoms or physical examination abnormalities are identified, routine blood tests and imaging tests are not recommended. keep in mind that the greatest risk of death in endometrial cancer survivors is associated with noncancer causes- consume a healthy diet and adopt healthy lifestyle behaviors. educate on the early symptoms of endometrial cancer and encouraged to report any postmenopausal bleeding promptly. Young women need to understand the relationship between high BMI and the risk for endometrial cancer. Clinicians need to keep in mind that most endometrial cancer survivors die due to noncancer causes. Encouraging weight loss and healthy diet and lifestyle behaviors. Special Considerations Women of childbearing age may be devastated at the loss of fertility upon receiving a diagnosis of endometrial cancer. candidates for more conservative, fertility-sparing treatment options. Women who have grade 1, well-differentiated endometrioid endometrial carcinoma without myometrial invasion or metastasis may want to discuss these options with a specialist. After careful evaluation and consideration of the risk, these woman may choose a hormonal treatment with a progestin or a gonadotropin-releasing hormone agonist. Most experts continue to recommend surgical management immediately following completion of childbearing. Other women might be interested in ovarian preservation. The ovaries are potential sites for occult metastatic disease and the ongoing production of estrogen is a risk factor for reoccurrence. need to have a conversation with a specialist to make informed treatment decisions regarding the potential for ovarian preservation. women who are premenopausal require evaluation for quality of life issues following surgical treatment for early-stage endometrial cancer. New evidence suggests that estrogen therapy to treat menopausal symptoms might be a viable option for these women despite the conventional wisdom that exogenous estrogen is a potential risk factor for reoccurrence. American College of Obstetricians and Gynecologists has determined that estrogen therapy to manage menopausal symptoms is a reasonable option given appropriate counseling and monitoring.

eriksen article- tx of osteopenia

majority of osteoporotic fractures happen in individuals with BMD t-scores in the osteopenic range (−2, 5< t-score <−1). Generally, osteopenia has to be associated with either low energy fracture(s) or very high risk for future fracture as assessed with risk calculators like FRAX to warrant specific osteoporosis therapy. Vertebral fractures are now conveniently assessed using lateral x-rays from DXA machines. antiresorptive treatments (mainly hormone replacement therapy and SERMS in younger and bisphosphonates or Denosumab in older women) are the treatments of choice in this group of patients,—only rarely is anabolic therapy indicated. patients are considered having low bone mass (osteopenic), when their BMD t-score of the spine or hip lies between −1 and −2,5. Although fracture risk increases with decreases in BMD, the vast majority of osteoporotic fractures occur in osteopenic patients. Forty to 50% of all subsequent fractures occur within 3 to 5 years after a first fracture, and the presence of such fractures demands rapid intervention with specific osteoporosis drugs to reduce the risk of a subsequent fracture. Hip, vertebral, and nonhip, nonvertebral fractures were each associated with approximately one third of deaths. The major causes of death were related to cardiovascular and respiratory comorbidities. While hip and other nonvertebral fractures are clinically obvious, the detection of vertebral fractures constitutes a significant problem. Morphometric vertebral fractures are the most frequent fractures in women and men older than 50 years. strong predictor of future vertebral, nonvertebral, and hip fracture risk. Clinical vertebral fractures are characterized by back pain lasting for 2-3 months, depending on fracture severity, but they represent only a small subgroup of all vertebral fractures. morphometric vertebral fractures therefore remain undiagnosed, which results in many patients developing severe osteoporosis with multiple fractures and chronic pain, before effective treatment is instituted. when clinical suspicion, e.g. significant height loss, increasing kyphosis, protruding abdomen, rib-iliac crest distance of less than 2 cm, and acute or chronic back pain, is raised, a spine x-ray is performed. But even when lateral x-rays of the spine are available, vertebral fractures are often missed. detection of prevalent fractures is very important when making decisions on treatment in osteopenic women. This has been further facilitated by accessory software for DXA scanners yielding lateral x-rays of the spine, which permit assessment of vertebral fracture status. Advantages are: low radiation dose, the availability of semiautomatic image analysis tools to assist in measuring vertebral shapes of the individual vertebrae, its plan-parallel projection, and its high negative predictive value. The disadvantage is the inability to study upper thoracic vertebrae, but only a minority of fractures are found there. aspects of osteoporosis and fracture risk are clinically recognizable (such as age, gender, and body weight), even before a first fracture has occurred. WHO developed the Fracture Risk Assessment (FRAX) tool (www.shef.ac.uk./FRAX). It is an internet based clinical tool for calculation of fracture risk in the individual patient based on assessment of significant risk factors for osteoporotic fracture. The FRAX algorithm is based on large-scale prospective population-based studies which isolated the following risk factors as significant determinants of fracture risk: age, gender, body weight and body mass index, a history of fracture, hip fracture in parents, current smoking, excessive alcohol intake, rheumatoid arthritis, glucocorticoid use, and other forms of secondary osteoporosis. FRAX based ten year risks of 20% or higher for all osteoporotic fractures and 3% or higher for hip fracture are considered reasonable intervention thresholds. In patients with BMD-based osteoporosis or presenting with a clinical fracture or both, diagnostic evaluation is necessary to exclude secondary osteoporosis. Such evaluations should include hematologic parameters (Hb, WBC), serum 25-(OH)D3, calcium, creatinine, thyroid-stimulating hormone, parathyroid hormone (PTH), serum/urine electrophoresis and testosterone. other serum measurements such as plasma cortisol, tests for celiac disease and selected other evaluations looking for secondary causes are indicated pharmacotherapy: therapies for the prevention and treatment of osteoporosis affect bone remodeling by either inhibiting bone resorption (antiresorptive or anti-activation drugs) or enhancing bone formation (anabolic regimens). Despite the advances in pharmacotherapy the majority of patients with osteopenia and osteoporosis are not treated [50], and for patients who initiate therapy, adherence to therapy is commonly below 50% at 1 to 2 years Antiresorptive (anti-activation) drugs Estrogen receptors have been demonstrated on both osteoblasts and osteoclasts. Estrogen replacement therapy (ERT) or combined estrogen/progestin therapy (HRT) reduces bone turnover by about 50% and improves bone balance at each invidual BMU in postmenopausal women. current recommendations support restricting the use of estrogen in most women to 5 years in the perimenopausal period to reduce hot flushes and other postmenopausal symptoms, and regular mammography should be performed. Selective estrogen receptor modulators (SERMs) are non-steroidal synthetic agents, which exert estrogen-like properties on the bone and cardiovascular systems, but estrogen antagonistic actions in the breast and, in some cases, the endometrium. developed both for breast cancer prevention and for osteoporosis, raloxifene, is now approved in many countries for the treatment of osteoporosis. tamoxifen, the risk of invasive breast cancer was decreased by 72%. hot flashes and other menopausal symptoms may recur on raloxifene. raloxifene, increases the risk of deep venous thrombosis three-fold. Raloxifene was as effective as tamoxifen in reducing the risk of invasive breast cancer and carried a lower risk of thromboembolic events and cataracts, but a non-statistically significant higher risk of non-invasive breast cancer. The risk of other cancers, fractures, ischemic heart disease, and stroke was similar for both drugs. Androgen replacement therapy in males In hypogonadal males low testosterone levels result in a high turnover state in bone leading to bone loss and increased risk of fracture. Testosterone replacement therapy in hypogonadism will increase circulating estradiol levels and thereby reduce bone turnover and increase BMD. hypogonadism, usually defined as total testosterone levels below 8 nmol/l and hypogonadal symptoms. regular controls of prostate specific antigen (PSA) and digitial rectal exploration before and after institution of therapy is still warranted. Calcitonin Both injectable and intranasal administration of calcitonin results either stabilization of BMD or small increases in spine BMD (1-3%) and reductions in bone turnover as reflected in decreased levels of bone markers. Nasal calcitonin is generally well tolerated, with occasional rhinitis. Headache, flushing, nausea, and diarrhoea have been reported more commonly with subcutaneous, than with intranasal calcitonin. considered a second- or third-line agent for osteoporosis treatment. biophasphonates: potent inhibitors of bone resorption and reduce the risk of osteoporotic fractures when administered orally or by intravenous infusion. alendronate, risedronate, ibandronate, and zoledronic acid. Once adsorbed onto bone surfaces, the mechanism of action is based on two actions: 1) tight binding to hydroxyapatite crystals in bone; 2) inhibition of important metabolic pathways in osteoclasts after incorporation during resorption of bisphosphonate coated bone. The main side effect of oral bisphosphonates is gastrointestinal (GI) intolerance- Most reported GI symptoms have been non-ulcer dyspepsia. rare reports of severe esophagitis in patients taking oral bisphosphonates. subject to significant scrutiny: 1) osteonecrosis of the jaw (ONJ) 2) atypical femoral fractures. In oncology only iv. Bisphosphonates are used with doses exceeding the doses used in osteoporosis by a factor of 10-12, and ONJ has been reported in an estimated 1-2% of cancer patients receiving higher doses of predominately intravenous bisphosphonates for patients with malignancies (myeloma and breast ca). estimated the risk in osteoporosis to e between 1/10,000 and 1/100,000. transverse fractures of the femoral shaft in patients on long term treatment with alendronate. usually preceded by longstanding pain in the affected hip and most fractures happen without fall-related trauma. Bilateral fractures may occur, and on x-rays, signs of periosteal reaction and diffuse or focal cortical thickening are usually seen. general consensus is that the benefit of significant reduction of all hip fractures after bisphosphonate treatment far outweighs the small risk of an atypical fracture. Parathyroid hormone Continuous excessive secretion of parathyroid hormone (PTH) (e.g. primary hyperparathyroidism) causes bone catabolism, characterized by cortical bone loss in particular. exogenously administered intermittent PTH leading to a peak of excess PTH for about 3 h is anabolic due to stimulation of osteoblastic bone formation and increased skeletal remodeling activity. Teriparatide increases cancellous bone volume, restores trabecular bone architecture and increases cortical thickness. It also leads to periosteal new bone formation and increases cross-sectional area, potentially increasing cortical bone strength. may be responsible for the pronounced reduction of non-vertebral fractures by up to 80% in patients treated for more than 18 months. associated with nausea, and headache. asymptomatic mild hypercalcemia, a side effect frequently. There is an enhanced effect on bone mass when PTH is sequentially followed by antiresorptives like alendronate or estrogen. If some kind of antiresorptive treatment is not given, bone mass will return to baseline within 2 years after discontinuation of PTH. PTH is currently used most commonly in adults with severe osteoporosis,—many of whom have had fractures while on other antiosteoporotic agents or have had intolerance to bisphosphonates, and will rarely have indications in osteopenic patients. Denusomab, a specific recombinant humanized monoclonal antibody against RANKL, is the most effective suppressor of bone resorption yet developed. It reduces bone turnover by over 95%. inhibition of osteoclastic bone resorption. BMD increases seen are more pronounced than with other antiresorptives. no increase in the risk of cancer, infection, cardiovascular disease, delayed fracture healing, or hypocalcemia. In the osteoporosis trials with Denosumab there were no cases of osteonecrosis of the jaw. In the oncology trials with Denosumab, however, the risk of ONJ was found to be similar to that of Zoledronic acid. Daily intake of strontium ranelate has been shown to reduce the risk of vertebral and nonvertebral fractures in postmenopausal women with osteoporosis or a prevalent vertebral fracture or both. summary: increasing array of effective treatments is at our disposal, to protect patients with osteopenia against fractures. While there is general consensus on treating osteopenic individuals with prevalent low energy fractures, the treatment of osteopenia without fracture is still debatable. pharmacotherapy should be instituted if an osteopenic patients has prevalent fractures or suffers new fractures, be it clinical or asymptomatic. significant accumulation of several significant risk factors, for example as indicated by the FRAX tool may constitute an indication for pharmacotherapy. without such risk factors should be counselled on a "bone friendly" lifestyle with nutritional modifications, regular exercise, moderation in alcohol use and If possible smoking cessation. In patients with low vitamin D levels, Ca + D supplementation may also be indicated. Amino-bisphosphonates, taken orally or intravenously, remain the dominant treatment modalities for osteoporosis. reduce fracture risk in osteoporotic as well as osteopenic individuals. 10 years with 90% suppression of bone turnover is safe. Denosumab constitutes a future alternative to bisphosphonates. younger postmenopausal women with osteopenia, estrogen or estrogen/progestin still has a place as a short term (up to 5 years) treatment, especially in women with menopausal symptoms. SERMs should be considered in younger postmenopausal women, especially those at increased risk of breast cancer. males with low testosterone levels, testosterone substitution is indicated as it improves skeletal integrity. We still need long term controlled studies on this treatment, but the risk of prostate cancer does not seem to be as big as previously anticipated. Teriparatide, would currently rarely be considered in women or men with cheaper anabolics available, however, initial therapy with anabolics to bring osteopenic patients out of the risk zone followed by an antiresorptive would probably be the ideal treatment.

managment of HT side effects:

schuilling: Fluid retention: Decrease salt intake; maintain adequate water intake; exercise; use an herbal diuretic or mild prescription diuretic Bloating: Change to low-dose transdermal estrogen; lower the progestogen dose to a level that still protects the uterus; change the progestogen or try micronized progesterone Breast tenderness: Lower the estrogen dose; change the estrogen; decrease salt intake; change the progestogen; decrease caffeine and chocolate consumption Headaches: Change to transdermal estrogen; lower the estrogen and/or progestogen dose; change to a CC-EPT regimen; ensure adequate water intake; decrease salt, caffeine, and alcohol use Mood changes: Lower the progestogen dose; change to a CC-EPT regimen; ensure adequate water intake; restrict salt, caffeine, and alcohol consumption Nausea: Take hormones with meals; change the estrogen; change to transdermal estrogen; lower the estrogen or progestogen dose

absolute contraindications to estrogen therapy

schuilling: Known or suspected cancer of the breast Known or suspected estrogendependent neoplasia History of uterine or ovarian cancer History of coronary heart disease or stroke History of biliary tract disorder Undiagnosed, abnormal genital bleeding History of or active thrombophlebitis or thromboembolic disorders adverse effects: Uterine bleeding Breast tenderness Nausea Abdominal bloating Fluid retention in extremities Headache Dizziness Hair loss

Chapter 26: (polyps, fibroids, endometriosis and adenomyosis) schuilling

polyps: within the endocervical canal or endometrium are focal hyperplastic protrusions of epithelial tissue with a vascular core, not true neoplasia. both hormonal and chronic inflammatory stimuli may play a role in their formation. Although typically benign, they do have malignant potential. Cervical polyps occur in as many as 10% of women, but fewer than 1% of those polyps are malignant. single or multiple in number, and typically are less than 3 cm in diameter, but can be larger. Usually lobular or pear shaped, their stalk arises from the cervical canal and may be either short or long. flesh colored to reddish-purple if vascular congestion, often asymptomatic and incidentally diagnosed on routine speculum examination. If symptoms- postcoital or intermenstrual bleeding. Differential diagnosis includes endometrial polyps, cervical carcinoma, and cervical leiomyomata, all of which also may protrude through the cervical os. 10% will have concomitant endometrial pathology (e.g., atypia, cancer, or polyps) evaluation of the endometrium should be considered whenever women present with irregular bleeding. women need to chose btw oberservation and removal for histology. cytology, HPV testing, and colposcopy are important aids to rule out high risk for dysplasia or malignancy. If the polyp is asymptomatic and the woman prefers the option of observation, she should be asked to report irregular or postcoital bleeding. If a woman with cervical polyps experiences symptoms (e.g., irregular or postcoital bleeding, increased discharge) or has an atypical polyp (e.g., larger than 3 cm, necrotic, friable, irregular color), removal for histology is indicated, if the polyp is removed, recurrence is not uncommon. Endometrial polyps are similar to cervical polyps in that they are a hyperplastic overgrowth of the endometrial glandular and stromal cells with a vascular core. They are also most often asymptomatic, can be single or multiple in number, and are a common cause of abnormal vaginal bleeding, typically smaller than 10 mm in size, and approximately 25% of smaller ones resolve spontaneously. Endometrial polyps are most common in women 30 to 50 years of age, does not appear to change after menopause. Because they are often asymptomatic, their incidence is unknown. One-third of women of any age who are evaluated for infertility have endometrial polyps, but causation is not established and age may be a factor. symptoms most typically report abnormal (e.g., intermenstrual or postmenopausal) bleeding. Malignant transformation uncommon, but similar risk factors with endometrial cancer, including increasing age, obesity, hypertension, and use of selective estrogen receptor modulators that stimulate the endometrium (e.g., tamoxifen). unexpected bleeding in women with these risk factors should raise the level of concern. most commonly identified and evaluated using transvaginal ultrasound. In menstruating women, optimally done when the endometrium is thinnest (in the early follicular phase, cycle days 4- 6) to improve detection of polyps smaller than 10 mm. color or power Doppler and contrast with or without 3-D imaging may improve visualization. ambiguous- repeat imaging at a more optimal cycle time or referral may be warranted. Saline infusion sonohysterogram is often used to facilitate visualization during ultrasound, and hysteroscopy (i.e., placement of a thin telescopic tube through the cervix and into the uterine canal) for identification and biopsy. For asymptomatic endometrial polyps identified incidentally on ultrasound imaging, conservative management, such as repeat imaging to establish stability, is an appropriate option. Gonadotropin-releasing hormone (GnRH) agonists are sometimes used to shrink large polyps prior to hysteroscopic resection, levonorgestrel intrauterine system (LNG-IUS) does not have a role in treatment but may prevent endometrial polyp formation in high-risk women, such as those using tamoxifen. abnormal bleeding, blind biopsy is inadequate; hysteroscopic polypectomy is the removal method of choice. Pregnancy is a contraindication to removal of either cervical or endometrial polyps. Unless there is an urgent indication, removal should be deferred or performed only by a specialist. Malignancy risk increases with aging; postmenopausal women with atypical polyps and/or vaginal bleeding warrant a thorough endometrial evaluation (e.g., imaging and guided biopsy or polypectomy). uterine fibroids: (myomas/leimyomatas) bengin growths arise from smooth muscle of the uterus. classified based on the uterine layer most involved in their location: Subserosal fibroids arise on the external surface of the uterus, intramural or myometrial fibroids lie completely within the myometrium, and submucosal fibroids make contact with the endometrium. if pedunculated, they are vulnerable to torsion, necrosis, or prolapse through the cervical canal, where they can be confused with cervical polyps. range in size from microscopic to large tumors weighing several pounds. Multiple fibroids are common, single may occur. majority of women have fibroids present in their uterus by menopause, but only approximately 25% become symptomatic. most common indication for hysterectomy in the United States. Heredity and cumulative exposure to estrogen both play roles in fibroid growth. Symptomatic fibroids are more common in the decade prior to menopause, in obese and primiparous women, and in women with African ancestry; they are uncommon after menopause. fibroids can impede fertility in some women, depending on their size and location (e.g., via blockage of sperm migration or of implantation due to the decreased blood supply and hypoestrogenic environment of the fibroids themselves). they may be a manifestation of the type of myometrial stem cell stimulation and hyperproliferation normally seen in a pregnant uterus. The cells of fibroids also display disorganization of collagen fibrils very similar to that seen in keloids, suggesting a potential common etiology, which is supported by the more common occurrence of both keloids and fibroids in women of African ancestry. It is surprisingly unclear why fibroids, which result from highly hormone-sensitive cellular hyperproliferation, so rarely involve malignancy (less than 1%). fibroids are asymptomatic and identified incidentally at ultrasound or pathology. Women who have symptoms typically report heavy or irregular menses, dysmenorrhea, pelvic pressure or pain, dyspareunia, or change in urine or bowel control. associated pregnancy-related problems, including infertility and pregnancy loss. When women report pain, it is often dull, crampy, and mild to moderate, but pain may become acute if torsion or necrosis occurs. Women with very enlarged fibroids may report an increase in abdominal girth, and occasionally incorrectly assume they are pregnant. Fibroids (subserosal, intramural, or submucosal), can occasionally involve the cervix or protrude through the cervical canal, being visible or palpable as a mass on pelvic examination. suggestive of uterine fibroids (e.g., abnormal uterine bleeding, pelvic pain or pressure) include a detailed menstrual and bleeding history, and clear descriptors of related pain or pressure, helping to define any cyclic relationship. any difficulty achieving or maintaining pregnancy and any personal or family history of uterine fibroids or keloid formation. fibroids are firm to palpation and nontender. Whether or not they are palpable will depend on their location and size. The uterus may be palpable abdominally if the fibroids are very large. On bimanual examination, the uterus may feel normal, smoothly enlarged, or irregular. Rectal examination may facilitate the identification of posterior fibroids. pedunculated subserosal fibroid may be confused with a firm adnexal mass. Guarding or rebound tenderness can indicate irritation of the peritoneum related to torsion. Definitive diagnosis of fibroids is usually made by ultrasound. In perimenopausal and postmenopausal women, endometrial cancer should be ruled out even if fibroids are identified, as they may be a concomitant condition. Any woman who reports frequent, heavy bleeding should have a hematocrit to evaluate the extent of blood loss. differentials- part of the diff for abnormal uterine bleeding. similar symptoms of pelvic pain and pressure with endometriosis and adenomyosis as well as non-uterine conditions, such as ascites; disorders of the gastrointestinal tract (e.g., constipation, irritable bowel syndrome) or urinary tract (e.g., bladder diverticula, benign tumors); other gynecologic abnormalities (e.g., benign adnexal tumors); and neoplasia at any abdominal or pelvic location. management: No effective strategies for prevention or early intervention for fibroids have been identified, and conversion to malignancy is rare. asymptomatic uterine fibroids are managed expectantly. When fibroids become symptomatic, treatment options include medical therapies, surgery (minimally invasive procedures or hysterectomy), uterine artery embolization, and magnetic resonance imaging (MRI)-guided focused ultrasound. decisions about the timing and type of treatment are based on the number, size, and location of fibroids; the type and severity of symptoms; the woman's age and proximity to menopause; future childbearing plans; and preference regarding uterine preservation. No available medical treatments make fibroids disappear. current medical options modify sx/shrink fibroids temporarily: Progestogens- Heavy bleeding- Reduce fibroid associated endometrial hyperplasia, Intrauterine system may improve dysmenorrhea also but is contraindicated with submucosal fibroids or an irregularly shaped endometrial cavity Gonadotropinreleasing hormone agonist- Used to shrink fibroid prior to fertility treatment or surgery, May control heavy bleeding- Only approved for short term (3 months) due to adverse-effect profile, Fibroids can regrow quickly after treatment Selective estrogen reuptake modulators- Shrink fibroid volume- Off label use, May increase cancer risk in other cells Selective progesterone receptor modulators- Shrink fibroid volume- Off label use, May increase cancer risk in other cells Aromatase inhibitors- Shrink fibroid volume- Off label use, limited data, and high adverseeffect profile Combined oral contraceptives- May improve periodic bleeding control and/or dysmenorrhea- No evidence they enhance fibroid growth; not contraindicated for women with fibroids Nonsteroidal antiinflammatory drugs- May improve periodic bleeding control and/or dysmenorrhea- Rare but serious risks include gastrointestinal bleeding, acute renal failure, and congestive heart failure chiefly desires control of fibroid-related heavy bleeding, oral progestogens, an LNG-IUS, or a short-term GnRH agonist may be sufficient. LNG-IUS may improve dysmenorrhea as well. The LNG-IUS is contraindicated for women who have fibroids that are submucosal, distort the uterine cavity, or are large (total uterine size greater than 12 cm). Leuprolide, a GnRH agonist, is approved by the U.S. Food and Drug Administration (FDA) as a medical treatment to shrink fibroids temporarily (e.g., preoperatively or prior to attempting to become pregnant), and may temporarily control bleeding. concerns for women using GnRH agonists include vasomotor symptoms and decreases in bone density, so only short-term treatment is approved. The effect of a GnRH agonist is temporary: Fibroids will begin to regrow within months of discontinuation, and surgery or pregnancy attempts should ensue as soon as therapy is completed to maximize the benefits. may choose surgery- if pedunculated fibroid (risk torsion), sx poorly controlled by medical tx, or fibroid obstruct other tx- ca or fertility interventions. Hysterectomy is a definitive option for women who have severe symptoms, are distant from menopause, and feel they have completed childbearing. Myomectomy, in contrast, preserves the uterus, and can be performed laparoscopically, abdominally, or hysteroscopically depending on fibroid quantity, size, and location. can be performed in conjunction with a cesarean birth if indicated. Myomectomy does not prevent the growth of new lesions, however, and women choosing this option should be aware that they may require future procedures if symptomatic fibroids recur. nonmedical, minimally invasive treatments are currently available. FDA-approved procedures of uterine artery embolization (UAE) and MRI-guided focal ultrasonography ablation. UAE- guided injection of embolic particles to obstruct vascular supply of the fibroid(s), more likely to have additional surgical treatment for fibroids within 5 years. MRI-guided, focused highfrequency ultrasound therapy is a thermoablative option for inducing fibroid necrosis. Fertility outcomes after these uterus-sparing procedures have not been well studied. gonadotropin-releasing hormone agonists: Leuprolide (Lupron)- Endometriosis and uterine fibroids- Intramuscular injection- 3.75 mg monthly or 11.25 mg every 3 months Nafarelin (Synarel)- Endometriosis- Nasal spray, 200 mcg per spray- 400- 800 mcg per day 400 mcg: One spray in one nostril in the morning and one spray in the other nostril in the evening 800 mcg: One spray in each nostril twice a day Goserelin (Zoladex)- Endometriosis- Subcutaneous injection in the upper abdomen- 3.6 mg monthly chronic subacute condition, emergencies can occur. Torsion, which can cause acute, severe abdominal pain and necrosis, is a surgical emergency requiring immediate referral. Acute hemorrhage may also occur. women with symptomatic, not improved with medical mgmt or attemting pregnancy w/ crit of infertility = referral for gyn or specialist intervention. most have normal pregnancy, but close observation is indicated in pregnancy, as women with fibroids have a higher risk of poor pregnancy outcomes, including infertility, failed implantation, spontaneous abortion, preterm labor, placental abruption, malpresentation, cesarean birth, peripartum hysterectomy, and postpartum hemorrhage. maybe associated with advanced maternal age. Pre-pregnancy, fibroidectomy may be considered in women with fibroids that appear to be impairing fertility and for submucosal fibroids. 70% of fibroids grow during pregnancy. need to re-evaluate during pregnancy. prior myomectomy have a small increased risk of uterine rupture in labor, and should be carefully counseled and monitored. Perimenopausal and Postmenopausal Women- After menopause, the spontaneous decrease in hormone production typically results in reduction in fibroid size and resolution of symptoms. Exogenous hormone therapy after menopause is not contraindicated for women with fibroids if that treatment is otherwise warranted. perimenopausal or postmenopausal and present with enlarging fibroids, hysterectomy is indicated. Myomectomy, especially via power morcellation, is contraindicated, risk of occult cancers of the uterine corpus increases with aging. Influences of Culture- Abnormal, irregular bleeding can cause significant social and sexual difficulties for women from cultures that have activity taboos related to menstrual bleeding. potential need for surgery may be problematic for women who prefer to avoid allopathic medicine. Fertility preservation may be of primary importance for women from some cultures and may warrant special consideration in treatment planning. concerns may also play a role in assessment and treatment including endometriosis, adenomyosis, and ovarian cysts. Endometriosis & Adenomyosis: Endometriosis is the presence of endometrial glands and stroma outside of the uterus. Adenomyosis includes the presence of similarly atypical diffuse or localized endometrial cells within the myometrium and is a variant of endometriosis. endometrial implants have been identified in diverse sites, including the ovaries, anterior and posterior cul-de-sac, posterior broad ligaments, uterosacral ligaments, fallopian tubes, sigmoid colon, appendix, and round ligaments. outside the uterus- less commonly; in other genital organs (e.g., vagina, vulva, cervix, perineum), the urinary tract, inguinal canals, elsewhere in the gastrointestinal tract, the respiratory system and diaphragm, the pericardium, surgical scars, and the umbilicus. may have cyclic or noncyclic pain that severely impairs their quality of life and are also at increased risk for infertility and poor pregnancy outcomes. 10% of women, can be very burdensome, is present in more than 80% of women with chronic pelvic pain, 50% of women with infertility, and 50% of adolescents with dysmenorrhea. Adenomyosis has been identified in 20% to 30% of pathology specimens at hysterectomy. Risk factors for endometriosis include genetic factors (sevenfold risk increase in women with symptomatic first-degree relatives), Caucasian race, early menarche, short menstrual cycles, and active ovarian function (symptoms are uncommon in premenarche and after menopause). more likely to have other pain syndromes (e.g., interstitial cystitis, fibromyalgia) and other autoimmune conditions (e.g., thyroid dysfunction, asthma), suggesting this condition may involve both underlying alterations in immune surveillance and central sensitization. hereditary, environmental, immunologic, mechanical, and hormonal. varied phenotypes of endometriosis, which include adenomyosis; the often asymptomatic superficial implants seen incidentally on the peritoneum at surgery; severely pain-evoking, deep infiltrating endometriosis; and endometriomas (cyst-like structures, usually in ovaries, contain endemetrial tissue and blood). proposed mechanisms of development: Implantation of otherwise normal retrograde menstruation (observed as early as neonatally), which becomes activated in girls and women with genetic or environmentally mediated susceptibility Spontaneous metaplasia of coelomic epithelium (the lining cells of body cavities) or mesenchymal stem cells Atypical differentiation of epithelial cells; triggers may include endogenous or exogenous biochemical or immunologic factors Mechanical spread, as during surgery (e.g., adenomyosis or the implants identified in abdominal surgical or episiotomy scars) Distant seeding of endometrial or stem cells via the lymphatic or circulatory system Dysregulation of organogenesis (especially of the uterine wall) in embryonic females (hereditary or environmentally mediated endocrine disruptors) biochemically atypical endometrial cells, whether they are intrauterine or ectopic. Ectopic endometrial implants appear to function independently from the ovaries, producing their own endogenous estrogen de novo from cholesterol conversion, but lacking progesterone receptors to balance this estrogen activity. increased density and variation in typology of nerve cells in the endometrium and myometrium of women with endometriosis suggest potential mechanisms for related pain intensity. abnormalities in central pain sensitivity processing, suggested by the increased incidence of coexisting syndromes such as anxiety and depression, migraine headaches, fibromyalgia, bladder pain syndrome, and irritable bowel syndrome. endometrial implants may be seen incidentally during surgery performed on asymptomatic women. On the other hand, women may present with severe to debilitating dysmenorrhea, dyspareunia, dyschezia, dysuria, or chronic or intermittent dull, throbbing, or sharp pelvic, abdominal or back pain, and can experience associated infertility. adenomyosis may have menorrhagia as well as dysmenorrhea, dyspareunia, and pelvic pain. Endometriomas may result in acute pain episodes. extrapelvic endometriosis should be included in the differential diagnosis whenever women report cyclic symptoms in any organ. history of chronic pelvic pain discriptors and pain scale. location and character of any dyspareunia should be assessed, along with menstrual cycle patterns, associated symptoms (e.g., dysmenorrhea, nausea and vomiting, diarrhea), fertility history, and family history of endometriosis. Discovery of the effects of this condition on quality of life and response to treatments may help with the differential diagnosis. abdominal and pelvic examination, including a rectal examination, are indicated. When pelvic pain is present, begin with a gentle single-digit vaginal examination to map foci of pain, rather than with a speculum examination. adenomyosis may have a diffusely enlarged, boggy, and/or tender uterus, which may be asymmetrical, but lacking the firm nodularity of fibroids. endometriosis may exhibit condition-specific signs such as pain or nodules at palpation of the posterior fornix or rectovaginal septum, tenderness or induration of the uterosacral ligaments, a tender non-mobile uterus, and a tender enlarged adnexal mass (consistent with endometrioma). Palpation of the vaginal side walls and ancillary pelvic floor muscles may aid in differentiation of endometriosis from pelvic-floor myalgias. Occasionally, endometrial implants are seen on the cervix or vaginal walls during speculum examination, appearing as nonblanching red or brownish/blackish areas or firm nodules. Asymptomatic lesions do not require treatment, although biopsy for histology is appropriate if the diagnosis is unclear. There are no specific laboratory tests for endometriosis; irregular, heavy, or irregular bleeding may warrant endometrial biopsy and testing for anemia. Transvaginal ultrasound is a relatively low-cost technology that can play a role in ruling out other diagnoses and that may identify endometriomas, adenomyosis, and, occasionally, deeply infiltrating endometriosis in the bladder, uterosacral ligaments, rectum, or rectovaginal septum. Transrectal ultrasound may identify bowel involvement and aid in surgical planning. MRI may be useful if other uterine abnormalities are suspected. Endometriosis and adenomyosis are really diagnoses of histology and require surgical biopsy for confirmation. differentials- Other gynecologic and nongynecologic causes of chronic pelvic pain include bladder pain syndromes, irritable bowel syndrome, pelvic-floor muscle myalgias, and other gynecologic anatomic abnormalities (e.g., uterine fibroids, ovarian cysts, hydrosalpinx). symptom management and maintenance of desired fertility. Ovulation suppression is a primary target of medical therapy, with the goal being to eliminate or reduce ectopic endometrial activity. agents shown to decrease reported pain for endometriosis: type-agent-regimen-AR-consideration Combined oral contraceptives- Pill, vaginal ring, transdermal patch -Cyclic or continuous (continuous may be more effective for pain management); no data to define optimal oral dosage- Minimal, compared to other agents (mood swings, low increased clot risk)- Long-term safety is well documented Inexpensive Limited data on pain management but appear comparable to other methods No data to support fertility preservation Progestins- Oral (norethindrone, megestrol, or medroxyprogesterone acetate) Intramuscular injection (DMPA) Implant (etonogestrel rod) LNG-IUS- Continuous (implant or LNG-IUS), longacting (injection every 3 months), or shortacting (daily oral) agents Medroxyprogesterone acetate and norethindrone acetate are FDA approved for endometriosis treatment- Irregular menstrual bleeding, breast tenderness, fluid retention, weight gain, and depression or mood instability- Pain reduction of typically 70- 100% Decreased bone mineral density with long-term DMPA use LNG-IUS may be optimal for adenomyosis or postsurgical suppression due to low adverse effects GnRHa- Depot injectable with quicker onset (leuprolide, goserelin) Nasal spray (nafarelin) Norethindrone acetate is FDA approved only as add-back therapy- Combine with addback estrogen and/or progestogen, tibolone, bisphosphonates, or selective estrogen receptor modulators to limit bone loss and hot flashes- Hypoestrogenic symptoms (bone loss, vaginal atrophy, vasomotor symptoms- Pain reduction as high as 100%, with 50% recurrence post discontinuation Decreases size of endometriomas Significantly more expensive than other treatments, with no evidence of superior outcomes Backup nonhormonal contraception recommended Approval of an oral agent is pending; may decrease bone loss Synthetic androgenic hormones- Ethisterone (Danazol)- Oral daily- Hyperandrogenic and hypoestrogenic: Weight gain, muscle cramps, decreased breast size, acne, hirsutism, hot flashes, mood changes, depression, permanently lower voice- Pain relief similar to GnRHa but less well tolerated Concomitant use of effective contraception is imperative due to risks of virilization of female fetus. insufficient evidence to support the use of acupuncture and other alternative or herbal treatments pain symptoms that do improve with such treatments may recur when the medical therapy is discontinued. Additional medications directed at pain control, including neurotransmitter modulators and opioids, are used for chronic pelvic pain associated with endometriosis. They may improve a woman's quality of life if used judiciously, but play no role in control of the disease or fertility preservation. surgery reserved for treatment for women with debilitating symptoms and poor response or intolerance to medical therapy. Surgical options include laparoscopic conservative management (e.g., removal of endometrial implants, focal areas of adenomyosis, endometriomas, and distorting adhesions), and definitive surgery (e.g., complete hysterectomy with bilateral salpingo-oophorectomy). Laparoscopic removal of implants and adhesions is effective for pain management and resolution of symptomatic endometriomas, may decrease ovarian reserve. Excision is recommended over ablation to allow for histologic diagnosis. Following conservative surgery, medical suppression is often restarted, as pelvic pain symptoms may recur in as many as 40% . Repeat procedures increase risks of postoperative adhesions and damage to ovarian reserve. Endometriomas larger than 4 cm are typically removed, even if asymptomatic, associated with ovarian cancers. severe pain, but wish to preserve their fertility and have not responded to other treatments, presacral neurectomy (excision of the portion of the superior hypogastric plexus that provides sympathetic innervation to the uterus). done infrequently, but provides better long-term pain control when compared to laparoscopic procedures alone. The definitive surgery for endometriosis is hysterectomy with salpingo-oophorectomy. likely to choose hysterectomy if they do not desire a future pregnancy and have resistant symptoms that are severely impacting their quality of life. pain persists after definitive surgery in as many as 15%, may increase again over time in as many as 5%. ovarian preservation have the benefit of bone preservation and positive cardiovascular effects, but increase their risk of persistent or recurrent symptoms. use of add-back estrogen post oophorectomy appears to have minimal effects on the risk of persistent or recurrent symptoms. isolated adenomyosis, women may choose to undergo complete hysterectomy with ovarian preservation. This procedure is typically curative. Endometrial ablation for superficial disease, UAE, and excision of localized disease may also be effective aromatase inhibitors AIs-AIs should be reserved for severely affected women. In premenopausal women, AIs may induce ovulation and should be used with ovarian suppression. Adolescents Endometriosis should be considered in the differential diagnosis of even premenarcheal girls with chronic pelvic pain. more common in girls with imperforate hymen or other obstructive Müllerian anomalies. When combined oral contraceptives are recommended to young adolescents as the first-line treatment, some families may object, assuming this use may be a license to sexual activity. open discussion with the adolescent and her family to review concerns, treatment safety profiles, and the expected potential benefits of endometriosis treatment (e.g., improved quality of life, prevention of central sensitization by good pain management, but no clear role in preventing infertility). Diagrams to demonstrate anatomy and physiology, along with handouts that can be reviewed at home, may be particularly helpful. Unsuccessful symptom management using medications alone indicates a need for referral for potential surgery at any age Women with Infertility Distortion of anatomy, inflammation, abnormal tubal transit, progesterone resistance, and implantation defects may all be involved. not universal agreement on the indications for surgical evaluation and therapy during infertility treatment. Age, duration of infertility, family history, pelvic pain, and stage of endometriosis should be taken into account. infertility and endometriosis, treatment may include expectant management after laparoscopy, superovulation (with gonadotropins) and intrauterine insemination, or in vitro fertilization. GnRH agonists to suppress endometriotic activity for 3 to 6 months prior to in vitro fertilization may improve outcomes. Pregnant Women etiology is unclear, women with either endometriosis or adenomyosis have increased risks when they do achieve pregnancy; late miscarriage, preterm birth, fetal growth restriction, and antepartum hemorrhage. may be related to progesterone resistance and/or the increased risk of subclinical atherosclerosis, a condition that is also associated with endometriosis. Older Women In postmenopausal women, while symptom resolution is typical, endometriosis-related problems may sometimes persist. women with endometriosis-associated infertility may have early-onset menopause, especially obese women, continue to have active symptoms after menopause, even in the absence of hormone therapy; use of hormone therapy or tamoxifen has been implicated in symptom recurrence after menopause for some women; (less than 1%) but increased risk of malignant transformation of endometrial implants, especially on the ovaries. For symptomatic women with a history of endometriosis who request hormone therapy, use of combined estrogen and progestin or AIs have been suggested

12. List at least four diseases for which ERT/HRT may increase a women's risk. For each, describe the theoretical mechanism behind this increased risk.

Hormone Therapy Position Statement (article) Systemic HT may worsen or provoke stress incontinence. A large RCT reported an increased risk of kidney stones with HT. coronary heart disease: women who initiate HT more than 10 years beyond menopause are at increased risk for CHD, and those women who initiate HT- within 10 years of menopause tend to have a lower risk of CHD. stroke: EPT and ET trials demonstrated an increased risk of ischemic stroke and no effect on the risk of hemorrhagic stroke. excess stroke risk dissipated rapidly after discontinuation of HT. venous thrombo: Data from both observational studies and RCTs consistently demonstrate an increased risk of VTE with oral HT. The baseline risk of VTE also increased relative to body mass index (BMI). For obese women (BMI, >30 kg/m2), the baseline risk was almost threefold greater. At any BMI, the risk of VTE doubled with HT and returned to baseline soon after HT discontinuation. Women with a previous history of VTE, obese women, or women who possess a factor V Leiden mutation are at increased risk of VTE with HT use. endometrial ca: Unopposed systemic ET in postmenopausal women with an intact uterus is associated with increased endometrial cancer risk related to the ET dose and duration of use. In general, HT is not recommended in women with a history of endometrial cancer. Progestogen alone could be considered for the management of vasomotor symptoms but no long-term data are available. breast ca: Diagnosis of breast cancer increases with EPT use beyond 3 to 5 years. EPT and, to a lesser extent, ET increase breast cell proliferation, breast pain, and mammographic density, and EPT may impede the diagnostic interpretation of mammograms, therein delaying the diagnosis of breast cancer. the absolute risk of events in younger women is lower than that for older women. HT use in breast cancer survivors may be associated with an increased risk of recurrence. ovarian ca: large volume of observational trial data that points to an association between HT and increased ovarian cancer risk, particularly with long-term use. ET was associated with a higher risk of ovarian cancer than EPT. Women at increased risk of ovarian cancer (eg, those with a family history or a BRCA mutation) should be counseled about this potential association. lung ca: Mortality from lung cancer was increased in current smokers in both treatment and placebo groups compared with nonsmokers and former smokers. findings underscore the need to encourage the cessation of smoking and possibly to increase surveillance in older smokers who are current or past users of EPT. mood: Progestogens in EPT may worsen mood in some women, possibly in those with a history of premenstrual syndrome, premenstrual depressive disorder, or clinical depression. ET might, in some circumstances, augment the antidepressant effects of selective serotonin reuptake inhibitors. HT might have a positive effect on mood and behavior, HT is not an antidepressant and should not be considered as such. Evidence is insufficient to support HT use in the treatment of depression. cognition: HT does not improve memory or other cognitive abilities and that EPT is harmful for memory. available data do not adequately address whether HT used soon after menopause increases or decreases the rate of cognitive decline or later dementia risk. In the absence of more definitive findings, HT cannot be recommended at any age for preventing or treating cognitive aging or dementia.

10. Complete the following: Symptoms and Physiologic Mechanism by which HT Relieves Symptoms a. Hot Flashes b. Urinary Tract Changes c. Mucosa Changes d. Affective Symptomes (insomnia, mood swings, loss of libido) & Cognitive symptoms (inability to concentrate, memory loss)

schuilling: Symptoms usually begin in the perimenopausal period and then gradually increase in severity during the early postmenopausal period, reaching a peak in the first 2 years after the final menstrual period. The symptoms women report most frequently are vasomotor in nature, including hot flashes, hot flushes, and sweats. Most symptomatic women will experience symptoms on average for as long as 5 years after menopause, and approximately one-third of women will experience these symptoms for 10 years or more a. schuilling: The only FDA-approved prescription therapy for treating hot flashes in women who are at high risk for, or who have been diagnosed with, breast cancer is paroxetine. experienced as an intense heat sensation and may or may not be followed by sweating, which can be profuse. They are characterized by a measurable increase in skin temperature and conductance, which is followed by a decrease in core body temperature. Hot flushes are similar to hot flashes but include a flushing over the face and upper chest, most likely due to peripheral vascular dilation. Vasomotor symptoms that occur during the night are termed night sweats. Hot flashes occur concurrently with a surge in LH levels. Although the relationship between LH secretion and body temperature change is not well understood, the same mechanisms that trigger the hypothalamic event that causes the temperature increase also stimulate GnRH secretion and cause LH elevation. Postmenopausal women are more sensitive to core temperature changes because their thermoneutral zone— the range of internally recognized normal core body temperature— narrows. when core temperature rises, they feel overly hot; conversely, when it falls, they feel overly chilled. women who are overweight or obese are more likely to experience hot flashes than women of normal weight. Hormone Therapy Position Statement (article) b. Local ET may benefit some women with overactive bladder. One RCT found that an estradiol ring had a clinical benefit equivalent to that of oxybutynin among women with overactive bladder. No HT product has government approval for any urinary health indication. c. ET is the most effective treatment of moderate to severe symptoms of vulvar and vaginal atrophy (eg, vaginal dryness, dyspareunia, and atrophic vaginitis). d. Vasomotor symptoms: ET is the most effective treatment of moderate to severe symptoms of vulvar and vaginal atrophy (eg, vaginal dryness, dyspareunia, and atrophic vaginitis). ET with or without a progestogen is the most effective treatment of menopause-related vasomotor symptoms and their potential consequences, such as diminished sleep quality, irritability, difficulty concentrating, and subsequently reduced quality of life (QOL). sexual function: A significant effect of ET on sexual interest, arousal, and orgasmic response independent from its role in treating menopausal symptoms is not supported by current evidence. Low-dose local ET may improve sexual satisfaction by improving lubrication and increasing blood flow and sensation in vaginal tissues. schuilling: Some sleep changes are related to normal aging, such as reduced time in sleep stages 3 (early deep sleep) and 4 (deep sleep and relaxation), more periods of brief arousal, and an overall decreased need for sleep, ranging from 6 to 9 hours among women. Hot flashes and sweats can further interrupt sleep. Poor sleep is associated with somatic, mood, and cognitive symptoms as well as performance deficits. Women experiencing poor sleep may demonstrate an inability to concentrate, lethargy, fatigue, difficulty performing tasks, and a lack of motivation. Additionally, poor sleep has been linked to some chronic illnesses, such as cardiac disease and depression. Urogenital changes leading to atrophy affect all women, may cause vaginal dryness and dyspareunia, and can predispose women to urinary tract infections. The risk of urinary incontinence increases with age, but this condition is never considered normal. Low estrogen has been suggested as a factor contributing to the increased prevalence of urinary incontinence among women of menopausal age. decreases in serum estradiol levels have not been shown to cause or worsen symptoms of urinary incontinence in women transitioning through menopause. Many normal changes of aging can also affect sexual function in women, such as longer time to achieve vaginal lubrication and production of fewer vaginal secretions overall; reduced vaginal elasticity, pigment, rugation, and number of superficial epithelial cells, leading to increased petechiae and bleeding following minor trauma (including sexual activity); reduced lactobacilli populations, which increase pH and the risk of infection; and atrophy of adipose and collagen tissue in the vulva. Women may also experience lowered libido, lessened sexual activity, problems with their partner's sexual performance, or relationship problems that make them less interested in sex. higher levels of perceived stress and negative attitudes toward menopause and aging are more likely to experience more severe symptoms. lifestyle modifications to maintain or achieve an optimal body mass index (BMI) of 18.5 to 24.9 kg/m 2 as well as a waist circumference less than 35 inches. In addition, obesity is associated with osteoarthritis, cholecystic disease, and urinary incontinence, as well as with cancers such as breast, endometrial, and colorectal. BMI greater than 27 kg/m as well as gaining body fat during midlife is associated with a greater frequency of hot flashes, night sweats, and soreness or 2 stiffness in the back, shoulders, and neck.

osteoporosis article

Screening Recommendations The US Preventive Services Task Force recommends osteoporosis screening for all women aged > 65 years and for younger women who have a fracture risk greater than or equivalent to that for a 65-year-old Caucasian woman with no additional risk factors National Osteoporosis Foundation guidelines suggest diagnostic assessment with BMD in women aged > 65 years and men aged 70 years, regardless of clinical risk factors Other risk factors include a history of previous fractures, family history of osteoporosis or fragility fractures, estrogen deficiency in women, cigarette smoking, excessive alcohol use or caffeine consumption, physical immobility and lack of exercise, vitamin D deficiency, and low dietary calcium intake Secondary causes of osteoporosis include medication use, particularly glucocorticoids, antiseizure medications, heparin, lithium, proton pump inhibitors, or opioids. Endocrine conditions, such as Cushing's syndrome, hyperparathyroidism, hyperthyroidism, and diabetes, as well as other medical conditions, such as malabsorption, rheumatoid arthritis, or malignancies, can all affect bone. following should be considered for treatment: A hip or vertebral fracture, either clinical or asymptomatic. A T score on BMD testing of -2.5 at the femoral neck, total hip, or lumbar spine. Low bone mass (T score between -1 and -2.5 at the femoral neck or lumbar spine) and a 10-year probability of hip fracture of 3%, or a 10-year probability of a major osteoporosis-related fracture of 20% based on Fracture Risk Assessment Tool score (FRAX). When the balance between bone resorption and bone formation is altered, if there is more breakdown than replacement, bone loss occurs. This typically occurs in postmenopausal women and with many of the secondary causes of osteoporosis noted earlier. It follows, then, that to alter the bone remodeling cycle and improve bone density only 2 avenues are possible: either slow or stop bone resorption, or enhance bone formation. non pharm: Clinicians should stress avoidance of risky physical behaviors that put the patient at risk for injury. Along with the recommendations for regular weightbearing (walking, stair-climbing) and muscle-strengthening exercises (weight-training, yoga), cessation of smoking, decreased consumption of alcohol, and calcium and vitamin D supplementation are recommended for the general population. A fall risk assessment should include checking for a personal history of falling, muscle weakness, gait disorders, and balance and visual deficits. Clinicians should always check for use of central nervous system depressants such as sleep aids, opioids and muscle relaxants, or medications causing dehydration. Timing of therapy is critical, with earlier therapy designed to alter the progressive loss of bone and decrease the risk of fracture. Medications that inhibit bone resorption (antiresorptives) include bisphosphonates (BPs), denosumab, raloxifene, and calcitonin. Estrogen also inhibits bone resorption but will not be described in detail here. Medications designed to enhance bone formation (anabolic agents) primarily include teriparatide (TPT). secondary fracture prevention: appropriate screening in those at risk, osteoporosis can be identified, successfully diagnosed, and treated, both to prevent the first fracture and to decrease the risk of subsequent fractures. Such fracture liaison services (FLS) are developing in the US and around the world. More FLS programs are needed to meet the National Bone Health Alliance goal of decreasing the fragility fracture rate 20% by 2020. FLS objectives are to provide ongoing risk assessments and ensure patients receive the appropriate diagnosis, treatment, support, and follow-up care. These models have been shown to decrease the risk of second fracture by as much as 40% conclusion: The overall adverse outcomes from osteoporotic fractures are increased morbidity, mortality, and cost and continue to be a large public health burden. Aging populations worldwide are changing the epidemiology of osteoporosis. Understanding the epidemiology of osteoporosis and fractures can help predict fractures in those at greatest risk. Continued research and data collection regarding the epidemiology of fracture incidence is key to the development of affordable strategies to identify and treat those at risk. Understanding bone remodeling and how current therapies affect remodeling allows for a rational approach to pharmacologic intervention, with a predictable end-point of reducing the fracture rate. As newer antiresorptive and anabolic agents are developed, further decreases in fracture rate should be anticipated. In addition, models of care such as the FLS concept should be implemented nationally to screen, diagnose, and provide earlier treatment for those with fragility fractures and risk of further fracture.

III. Identify deviations from normal in puberty and menarche. A. Define precocious puberty. B. Identify possible pathologic and nonpathologic causes of precocious puberty and how to differentiate them. C. Identify causes of delay puberty or menarche. D. Identify how to determine abnormal vs. normal pubertal delay. E. Identify the differential diagnosis of delayed puberty.

carefully assess whether the advent of adrenarche prior to thelarche is a normal variation or whether it is due to androgen excess or estrogen deficiency. have not reached puberty by the age of 13 or who have not had menarche by the age of 15 should be evaluated by a clinician to assess for the pubertal delay. (i got this from a text in the HSC library under FNP books- CURRENT Diagnosis & Treatment: Obstetrics & Gynecology, 11e Alan H. DeCherney, Lauren Nathan, Neri Laufer, Ashley S. Roman) A. Sexual precocity is the onset of sexual maturation at any age that is 2.5 standard deviations earlier than the normal age for that population, being usually before the age of 8 years. B. It may be classified as central, or GnRH-dependent, precocious puberty (true precocious puberty), or peripheral, or GnRH-independent, precocious puberty (pseudoprecocious puberty). exogenous, endogenous estrogen, and Mccune-Albright Syndrome. The diagnosis of GnRH-dependent precocity requires demonstration of pubertal gonadotropin secretion. The diagnostic evaluation required to document early pubertal development and differentiate central from peripheral causes includes the determination of serum LH, FSH, and estradiol levels, and a GnRH stimulation test. In patients with GnRH-dependent precocious puberty, the results of these tests will be in the normal pubertal range. Sonography may aid in the evaluation of the ovaries and adrenal glands. Uterine size and endometrial thickness are estrogen dependent and serve as a good bioassay to determine the length of time and magnitude of estrogen exposure. Ovarian cysts and tumors are also visible. Sonography of the adrenal glands is less sensitive than abdominal CT and MRI. Skeletal imaging to document skeletal age and a bone scan may identify areas of fibrous dysplasia in patients with MAS. Brain MRI is indicated in patients with sexual precocity or with neurologic signs. C. may be due to heredity, it is important to rule out other factors that may be impacting the young woman's health, such as poor nutrition or eating disorders, involvement in sports/athletics, or genetic and medical conditions (i got this from a text in the HSC library under FNP books- CURRENT Diagnosis & Treatment: Obstetrics & Gynecology, 11e Alan H. DeCherney, Lauren Nathan, Neri Laufer, Ashley S. Roman) Delayed sexual development has been defined as the absence of normal pubertal events at an age 2.5 standard deviations later than the mean. The absence of thelarche by age 14 years or the absence of menarche by age 16 years is an indication for investigation. Classification can be based on the gonadotropic level: eugonadotropic, hypogonadotropic, or hypergonadotropic primary amenorrhea. D. Determination of gonadal function can be accomplished by obtaining a medical history and performing a detailed physical examination, supplemented by selected laboratory studies. Historical information should center around previous growth and pubertal development. Linear and velocity growth charts as well as a pubertal development chart clarify previous growth patterns and are useful in subsequent follow-up. Knowledge of previous medical disorders may immediately identify the cause of aberrant puberty. Physical examination must include height and weight assessments and a careful search for somatic anomalies. Staging of pubertal development by Tanner criteria is most important in the determination of gonadal function. Presence of breast development signifies prior gonadal function. Imaging studies such as pelvic sonogram and CT and MRI are required for confirmation of congenital absence of the vagina and uterus. Absence of pubic hair is suggestive of the androgen insensitivity syndrome. Karyotype will identify the 46,XY cell line in patients with testicular feminization syndrome. Patients with complete pubertal development and well-formed female configuration ("pear shape") display evidence of continued estrogen production, and normal müllerian systems probably have inappropriate positive feedback and thus chronic anovulation. Progesterone challenge in such patients is helpful. A withdrawal bleed signifies a normal müllerian system and acceptable estrogen production. Serum gonadotropin assays are performed for further elucidation. Elevated FSH levels suggest gonadal failure. Karyotype determination is crucial in diagnosing the various etiologies of gonadal failure. The presence of a Y chromosome in either group dictates gonadal removal. Low FSH levels suggest interference with hypothalamic-pituitary maturation and gonadotropin release. Skull films and prolactin assays must be obtained for all patients to rule out the presence of pituitary or hypothalamic tumors. Appropriate endocrine evaluation identifies the occasional patient with hypothyroidism or congenital adrenal hyperplasia and the rare patient with Cushing's syndrome. Diagnosis of Kallmann's syndrome is suspected in hypogonadotropic patients who have an associated anosmia, and the diagnosis is confirmed by GnRH challenge tests. *The presumed diagnosis of constitutional delay is made by exclusion of all other causes and by the typical GnRH release patterns after GnRH challenge. E. Delayed Menarche with Eugonadotropic Function: Patients with functioning gonads and delayed sexual maturation usually consult a physician while they are in their mid-teens because of amenorrhea. Most have well-formed female configuration with adequately developed breasts. congenital anomalies androgen insensitivity Delayed Puberty with Hypogonadotropic (Hypothalamic) Dysfunction: low to normal levels of gonadotropins (FSH, LH), similar to prepubertal state. Kallmann's syndrome braintumer hyperprolactinemia eating disorders Delayed Puberty with Hypergonadotropic Dysfunction: Gonadal Failure Gonadal failure is characterized by high levels of gonadotropins (FSH, LH), similar to the menopausal state. The common pathway of all ovarian failure disorders is the prominent deficiency of estrogen and the essential need for estrogen-containing replacement therapy in order to achieve normal development and prevent late consequences of estrogen deprivation. most common cause is Turner's syndrome-sex chromosomal aberration of 45,X monosomy mosaicism-a 46,XX line may have ovarian failure even though they have a normal chromosome complement and 2 intact sex chromosomes (46,XX).

11. List at least three diseases that ERT/HRT may prevent. For each, describe the theoretical mechanism of prevention.

Hormone Therapy Position Statement (article) Two studies reported a decreased risk of recurrent urinary tract infection through the use of intravaginal estrogen. Only ET administered by the vaginal route has been shown to be effective for this purpose. RCT evidence that standard-dose HT reduces postmenopausal osteoporotic fractures, including hip, spine, and all nonspine fractures, even in women without osteoporosis. Low doses are effective in maintaining or improving bone mineral density. No HT product currently has government approval for the treatment of osteoporosis. Many systemic HT products, however, have government approval for the prevention of postmenopausal osteoporosis. coronary heart disease: Most observational studies (primarily composed of women who began HT around the time of menopause) support the potential benefits of systemic HT in reducing the risk of CHD. ET may reduce CHD risk (coronary revascularization and composite outcomes including myocardial infarction [MI] and coronary death) when initiated in younger and more recently postmenopausal women without a uterus. ET initiated by recently postmenopausal women may slow the development of calcified atherosclerotic plaque. DM2: Large RCTs demonstrate that HT reduces the diagnosis of new onset type 2 diabetes mellitus (T2DM), although no HT product has government approval to prevent T2DM. inadequate evidence to recommend HT for the sole or primary indication of the prevention of T2DM in perimenopausal or postmenopausal women.

9. State three routes of estrogen administration.

Hormone Therapy Position Statement (article) lower doses typically used when initiating systemic ET are 0.3 mg to 0.45 mg oral CE, 0.5 mg oral micronized 17A-estradiol, and 0.014 mg to 0.0375 mg transdermal 17A-estradiol patch. Low-dose formulations of estradiol are available in approved topical gels, creams, and sprays. Lower HT doses generally have fewer adverse effects, such as breast tenderness and uterine bleeding, and may have a more favorable benefit-risk ratio. transdermal therapy, there is no significant increase in triglycerides, C-reactive protein, or sex hormoneYbinding globulin and little effect on blood pressure. With cutaneous therapies, caution should be exercised to avoid inadvertent transfer to children and animals.

8. List three progesterones that are commonly used in HT.

Hormone Therapy Position Statement (article) starting at the lowest effective doses of 1.5 mg medroxyprogesterone acetate, 0.1 mg norethindrone acetate, 0.5 mg drospirenone, or 100 mg micronized progesterone. Oral progestogens, combined with systemic estrogen, and combined progestogen-estrogen matrix patches have demonstrated endometrial protection and are government approved. A progestin-containing intrauterine system and a vaginal progesterone cream are government approved for use in premenopausal women.

1. Define Menopause

schuilling: thought of as the closure of reproductive capability. Nurse researchers, in particular, have demonstrated that menopause is a normal developmental stage in women's lives. Some women will need HT to increase their quality of life, but this practice is no longer standard treatment for all women during midlife. defined as the point in time in which there has been a cessation of menstruation for at least 12 consecutive months. Menopause occurs in response to normal physiologic changes in the hypothalamic- pituitary- ovarian axis. The early postmenopausal period refers to the first 5 years following menopause when hormonal fluctuations often continue to occur. The late postmenopausal period refers to 6 years after the final menstrual period through the remaining life span. This phase is marked by increasing genitourinary symptoms due to the reduced estrogen levels. A woman is born with approximately 1.2 million ovarian follicles. Throughout her life, fewer than 500 of these follicles are used during ovulation; most are lost through atresia until menopause, when approximately 1,000 follicles remain. more rapid decline noted with increasing age.

VI. Identify the psychological and developmental tasks of adolescence.

traditional developmental task of adolescence is to develop a sense of identity and autonomy before progressing toward adulthood. role of peers tends to increase in importance, and it is normal to observe a distancing from parents and other adults as the adolescent tries to find her own identity, separate from that of her parents during this time. The interaction between an adolescent's behavior and role performance may either promote or confuse her sense of identity, depending on the social context in which it occurs. Through a process of trial and experimentation, individuals develop their own set of values and beliefs as well as a sense of themselves as they formalize or commit to their own identity. Initiation of sexual activity, pregnancy, childbearing, and parenting are all gendered roles and experiences that differ in their effects on any one individual adolescent based on the social, cultural, and historical definition that is associated with these behaviors and roles, as well as peers' and family's perceptions of these events. Reasoning changes as a child grows to adolescence. As a girl goes through adolescence, her cognitive development expands from being a very concrete thinker to gaining the ability to think abstractly, reason more effectively, problem solve, and involve herself in planning for her future

Potential Indications for Use of Emergency Contraception

• Lack of contraceptive use during coitus • Mechanical failure of male condom (breakage, slippage, or leakage) • Dislodgment, breakage, or incorrect use of diaphragm, cervical cap, or female condom • Failure of spermicide tablet or film to melt before intercourse • Error in practicing withdrawal (coitus interruptus) • Missed combined oral contraceptives (any 2 consecutive pills) • Missed progestin-only oral contraceptive (1 or more) • Expulsion or partial expulsion of an IUD • Exposure to potential teratogen (such as isotretinoin or thalidomide while not using effective contraception) • Late injection of injectable contraceptive (>2 wk late of a progestin-only formulation such as depot medroxyprogesterone acetate) * • 2 or more days late starting new vaginal ring or patch cycle • Rape

IX. Identify challenges for the practitioner in teaching healthy behaviors, including pregnancy and STD prevention, to adolescents.

As the adolescent grows older, education, experience, and role models continue to impact brain development. By late adolescence, the prefrontal cortex is more developed, which enables the adolescent to have better abilities at planning, strategizing, and thinking before acting. Thus the older adolescent has a better ability to control her impulses. The enhanced understanding and recognition of the development of the brain that occurs during adolescence has pushed clinicians to pay more attention to how adolescents act and react and why earlier in adolescence it is more difficult for the individual to make sound judgments. This is particularly important as clinicians teach adolescents about preventive health measures such as wearing helmets during activities where there is a risk of a blow to the head (e.g., skiing or snowboarding). chap 4: The USPSTF found little evidence to support the effectiveness of brief, individual counseling sessions in the primary care setting and no evidence supporting abstinence-only education. In contrast, strong evidence suggests that moderateto high-intensity counseling, delivered in multiple individual or group sessions (with a total duration of 2 or more hours), results in a statistically significant reduction in STIs. (i got this from a text in the HSC library under FNP books- CURRENT Diagnosis & Treatment: Obstetrics & Gynecology, 11e Alan H. DeCherney, Lauren Nathan, Neri Laufer, Ashley S. Roman) Questions about high-risk behaviors, including sexual behavior and sexually transmitted diseases (STDs), should be asked privately without the presence of the accompanying adult. The American College of Obstetricians and Gynecologists recommends that adolescents should have their first visit to a gynecologist for health guidance, general physical screening, and the provision of preventive health care services at age 13-15 years. It is reasonable to observe even those who are not sexually active in each stage of adolescence: early adolescence, ages 13-15; middle adolescence, ages 15-17; and late adolescence, ages 17-19. Unfortunately, many adolescents do not seek health care until after first intercourse. In the United States, the median age of first sexual intercourse is 16.5 years, but as many as 7% of adolescents report their first vaginal intercourse before 13 years of age.