1 Women’s health NURS

2 Women’s health Objectives: Class participants will be able to address, diagnose and treat the common following concerns in primary care: Breast & Cervical CA screening Breast concerns Pelvic pain & PID Vaginitis STD Screening – Taking a Sexual History Contraception

3 Breast CA Screening American Cancer SocietyWomen ages 40 to 44 should have the choice to start annual breast cancer screening with mammograms (x-rays of the breast) if they wish to do so. Women age 45 to 54 should get mammograms every year. Women 55 and older should switch to mammograms every 2 years, or can continue yearly screening. Screening should continue as long as a woman is in good health and is expected to live 10 more years or longer. All women should be familiar with the known benefits, limitations, and potential harms linked to breast cancer screening. They also should know how their breasts normally look and feel and report any breast changes to a health care provider right away. Some women – because of their family history, a genetic tendency, or certain other factors – should be screened with MRIs along with mammograms. (The number of women who fall into this category is very small.) Talk with a health care provider about your risk for breast cancer and the best screening plan for you.

4 Screening for Breast Cancer Using Film Mammography - USPSTFTitle Screening for Breast Cancer Using Film Mammography - USPSTF Population Women aged years Women aged years Women aged ≥75 years Recommendation Individualize decision to begin biennial screening according to the patient's circumstances and values. Grade: C Screen every 2 years. Grade: B No recommendation. Grade: I (Insufficient Evidence) Risk Assessment This recommendation applies to women aged ≥40 years who are not at increased risk by virtue of a known genetic mutation or history of chest radiation. Increasing age is the most important risk factor for most women. Screening Tests Standardization of film mammography has led to improved quality. Refer patients to facilities certified under the Mammography Quality Standards Act (MQSA), listed athttp://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMQSA/mqsa.cfm. Timing of Screening Evidence indicates that biennial screening is optimal. A biennial schedule preserves most of the benefit of annual screening and cuts the harms nearly in half. A longer interval may reduce the benefit. Benefits of Benefits and Harms There is convincing evidence that screening with film mammography reduces breast cancer mortality, with a greater absolute reduction for women aged 50 to 74 years than for younger women.Harms of screening include psychological harms, additional medical visits, imaging, and biopsies in women without cancer, inconvenience due to false-positive screening results, harms of unnecessary treatment, and radiation exposure. Harms seem moderate for each age group. False-positive results are a greater concern for younger women; treatment of cancer that would not become clinically apparent during a woman's life (overdiagnosis) is an increasing problem as women age. Rationale for No Recommendation (I Statement) Among women 75 years or older, evidence of benefit is lacking Other Relevant USPSTF Recommendations The USPSTF has made recommendations on mammography screening for breast cancer, screening for ovarian cancer, and chemoprevention of breast cancer. These recommendations can be found at www.uspreventiveservicestaskforce.org. 

5 Cervical CA Screening American Cancer SocietyCervical cancer testing should start at age 21. Women under age 21 should not be tested. Women between the ages of 21 and 29 should have a Pap test done every 3 years. HPV testing should not be used in this age group unless it’s needed after an abnormal Pap test result. Women between the ages of 30 and 65 should have a Pap test plus an HPV test (called “co-testing”) done every 5 years. This is the preferred approach, but it’s OK to have a Pap test alone every 3 years. Women over age 65 who have had regular cervical cancer testing in the past 10 years with normal results should not be tested for cervical cancer. Once testing is stopped, it should not be started again. Women with a history of a serious cervical pre-cancer should continue to be tested for at least 20 years after that diagnosis, even if testing goes past age 65. A woman who has had her uterus and cervix removed (a total hysterectomy) for reasons not related to cervical cancer and who has no history of cervical cancer or serious pre-cancer should not be tested. All women who have been vaccinated against HPV should still follow the screening recommendations for their age groups. Some women – because of their health history (HIV infection, organ transplant, DES exposure, etc.) – may need a different screening schedule for cervical cancer. Talk to a health care provider about your history.

6 Title Screening for Cervical Cancer - USPSTF Population Women ages 21 to 65 Women ages 30 to 65 Women younger than age 21 Women older than age 65 who have had adequate prior screening and are not high risk Women after hysterectomy with removal of the cervix and with no history of high-grade precancer or cervical cancer Women younger than age 30 Recommendation Screen with cytology (Pap smear) every 3 years. Grade: A Screen with cytology every 3 years or co-testing (cytology/HPV testing) every 5 years. Grade: A Do not screen. Grade: D Do not screen with HPV testing (alone or with cytology) Grade: D Risk Assessment Human papillomavirus (HPV) infection is associated with nearly all cases of cervical cancer. Other factors that put a woman at increased risk of cervical cancer include HIV infection, a compromised immune system, in utero exposure to diethylstilbestrol, and previous treatment of a high-grade precancerous lesion or cervical cancer. Screening Tests Screening women ages 21 to 65 years every 3 years with cytology provides a reasonable balance between benefits and harms.Screening with cytology more often than every 3 years confers little additional benefit, with large increases in harms. HPV testing combined with cytology (co-testing) every 5 years in women ages 30 to 65 years offers a comparable balance of benefits and harms, and is therefore a reasonable alternative for women in this age group who would prefer to extend the screening interval. Timing of Screening Screening earlier than age 21 years, regardless of sexual history, leads to more harms than benefits. Clinicians and patients should base the decision to end screening on whether the patient meets the criteria for adequate prior testing and appropriate follow-up, per established guidelines. Interventions Screening aims to identify high-grade precancerous cervical lesions to prevent development of cervical cancer and early-stage asymptomatic invasive cervical cancer.High-grade lesions may be treated with ablative and excisional therapies, including cryotherapy, laser ablation, loop excision, and cold knife conization. Early-stage cervical cancer may be treated with surgery (hysterectomy) or chemoradiation. Benefits of Benefits and Harms The benefits of screening with cytology every 3 years substantially outweigh the harms. The benefits of screening with co-testing (cytology/HPV testing) every 5 years outweigh the harms. The harms of screening earlier than age 21 years outweigh the benefits. The benefits of screening after age 65 years do not outweigh the potential harms. The harms of screening after hysterectomy outweigh the benefits. The potential harms of screening with HPV testing (alone or with cytology) outweigh the potential benefits. Other Relevant USPSTF Recommendations The USPSTF has made recommendations on screening for breast cancer and ovarian cancer, as well as genetic risk assessment and BRCA mutation testing for breast and ovarian cancer susceptibility. These recommendations are available athttp://www.uspreventiveservicestaskforce.org/. 

7 Palpable breast massesEpidemiology 16% of women have breast problems over a 10 year period Most breast symptoms are benign, but breast CA is the most commonly diagnosed CA and a leading cause of CA-related death in US women Breast masses, nipple discharge or inflammatory skin changes require immediate evaluation Breast masses are a common complaint; require detailed history to determine odds of malignancy

8 Palpable breast massesRisk Factors for Breast CA Demographics Advanced age Overweight or obesity (particularly in postmenopausal women) White race or Ashkenazi Jewish descent Medical history BRCA1 or BRCA2 mutation First-degree relative with breast or ovarian cancer History of atypical hyperplasia or lobular carcinoma in situ One prior breast biopsy (regardless of results) Personal history of breast or ovarian cancer Medications and diet Alcohol consumption (more than one drink per day) Current or prior use of hormone therapy or oral contraceptives Reproductive history Menarche before 12 years of age Menopause after 55 years of age Nulliparity or age older than 35 years at first delivery Other High breast density on mammography Prior thoracic radiation exposure

9 Palpable breast massesCharacteristics of Masses Benign Mass: Discrete margins with NO skin changes Smooth, soft to firm, mobile Dominant Mass (concerning for CA): three-dimensional lesion distinct from surrounding tissues Asymmetric relative to the other breast Hard, immobile, fixed to surrounding tissue Poorly defined margins

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11 American College of Radiologyclassification of findings on mammogram

12 breast Pain Epidemiology Mastalgia accounts for up to 66% of visitsMastalgia has NOT been shown to be a risk factor for breast CA Asses the quality, duration, location and radiation of pain Assess aggravating activities Cyclic Pain: related to menstrual cycle, bilateral, diffuse, radiates to axillae, most commonly during luteal phase prior to menses (increased hormones, increased water content) Noncyclic Pain: not related to menstrual cycle, and may be unilateral or focal

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14 Nipple discharge Epidemiology Benign in 97% of casesAsk about characteristics: color, number of ducts involved, if it is associated with amass, and if unilateral or bilateral Pathologic: discharge that is unilateral, bloody, serous, clear, or associated with a mass. Most common sources of pathologic d/c: intraductal papilloma, duct ectasia, carcinoma, infection. Physiologic: discharge that is bilateral, involves multiple ducts, is associated with nipple stimulation or breast compression

15 Nipple discharge Antihypertensive agentsMedications that may cause nipple discharge: Antihypertensive agents Methyldopa, reserpine, verapamil Gastrointestinal agents Cimetidine (Tagamet), metoclopramide (Reglan) Hormones Estrogen, oral contraceptives Opiates Codeine, heroin, methadone, morphine Psychotropic agents Antipsychotics, monoamine oxidase inhibitors, neuroleptics, selective serotonin reuptake inhibitors, tricyclic antidepressants

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17 Pelvic pain EpidemiologySymptoms often non-specific; a diagnostic challenge Differential: UTI, pyelonephritis, kidney stone, mittleschmerz, endometriosis, ovarian cyst, uterine fibroid, diverticulitis, Urgent considerations: Ectopic pregnancy Ruptured ovarian cyst Ovarian torsion Appendicitis Pelvic inflammatory disease (PID)

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23 Recommended Parenteral Regimen ACefotetan 2 g IV every 12 hours OR Cefoxitin 2 g IV every 6 hours PLUS Doxycycline 100 mg orally or IV every 12 hours Recommended Parenteral Regimen B Clindamycin 900 mg IV every 8 hours PLUS Gentamicin loading dose IV or IM (2 mg/kg of body weight), followed by a maintenance dose (1.5 mg/kg) every 8 hours. Single daily dosing (3–5 mg/kg) can be substituted. Outpatient Rx for Mild-Moderate Disease Ceftriaxone 250 mg IM in a single dose PLUS Doxycycline 100 mg orally twice a day for 14 days WITH or WITHOUT Metronidazole 500 mg orally twice a day for 14 days OR Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally administered concurrently in a single dose Other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime)

24 vaginitis EpidemiologyA spectrum of conditions that cause vaginal and/or vulvar symptoms of itching, burning, irritation, odor and vaginal discharge One of the most common reasons women seek medical advice Most common infectious causes: Bacterial Vaginosis Vulvovaginal Candidiasis Trichomoniasis

25 vaginitis EpidemiologyIn review of studies from of symptomatic women: BV diagnosed in 22-55% Vulvovaginal candidiasis in 17-39% Trichomoniasis in 4-35% 30% remained undiagnosed after clinical evaluation

26 vaginitis Key Symptoms: A lack of itching makes candidiasis unlikelyA lack of perceived odor makes BV unlikely Inflammatory signs more common with candidiasis Fishy odor on exam is predictive of BV

27 vaginitis Bacterial VaginosisMost prevalent cause of vaginal discharge or malodor Occurs in up to 30% OF WOMEN When normal Lactobacillus species in the vagina are replaced with anaerobic bacteria More than 50% are asymptomatic Odor more prevalent after IC when vaginal alkalinity increases (also during menses) Associated with late miscarriages, premature rupture of membranes, and preterm birth Also linked with increased risk for HIV infection

28 vaginitis • Thin, homogenous vaginal dischargeBV Diagnosis: In clinical practice, bacterial vaginosis is diagnosed by the presence of three out of four Amsel criteria31: • Thin, homogenous vaginal discharge • Vaginal pH greater than 4.5 • Positive whiff test (fishy amine odor when 10 percent potassium hydroxide solution is added) • At least 20 percent clue cells (vaginal epithelial cells with borders obscured by adherent coccobacilli on wet- mount preparation or Gram stain)

29 vaginitis • Thin, homogenous vaginal dischargeBV Diagnosis: In clinical practice, bacterial vaginosis is diagnosed by the presence of three out of four Amsel criteria31: • Thin, homogenous vaginal discharge • Vaginal pH greater than 4.5 • Positive whiff test (fishy amine odor when 10 percent potassium hydroxide solution is added) • At least 20 percent clue cells (vaginal epithelial cells with borders obscured by adherent coccobacilli on wet- mount preparation or Gram stain)

30 BV Click link below: Best instructional vaginal microscopy video!

31 vaginitis BV Treatment:A Cochrane review of 24 randomized controlled trials (RCTs) showed that clindamycin and metronidazole (Flagyl) are equally effective, achieving clinical cure in 91 and 92 percent of cases, respectively, after two to three weeks of treatment.33 Six RCTs showed topical and oral antibiotic preparations to be equally effective. One disadvantage of oral regimens is a longer duration of treatment.33 Intravaginal clindamycin cream is preferred in case of allergy or intolerance to metronidazole. Metronidazole in a single 2-g dose has the lowest effectiveness for treating bacterial vaginosis and is no longer recommended. Metronidazole, 500 mg twice daily for one week, is effective for treating bacterial vaginosis and trichomoniasis. Although lactobacillus probiotics are safe, there is no conclusive evidence that they are superior to or enhance the effectiveness of antibiotics in the treatment of bacterial vaginosis or prevent its recurrence.34 Treatment of sex partners and follow-up visits if symptoms are resolved are not recommended.

32 vaginitis Recurrent BV:Most relapses of bacterial vaginosis occur within the first year and strongly correlate with new sex partners. Reported recurrence rates are 15 to 30 percent within three months. One RCT on persistent bacterial vaginosis indicated that metronidazole gel 0.75% (Metrogel), used twice weekly for six months after initial treatment, effectively maintained a clinical cure for six months.

33 vaginitis Trichomoniais DiagnosisSymptoms and signs of trichomoniasis are not specific, and diagnosis by microscopy is more reliable. Features suggestive of trichomoniasis are trichomonads seen with saline, leukocytes more numerous than epithelial cells, positive whiff test, and vaginal pH greater than 5. The wet-mount preparation is an inexpensive and quick test with variable sensitivity of 58 to 82 percent,40 and is influenced by the experience of the examiner and the number of parasites in the vaginal fluid sample Click here to see motile trichomonads . Click here for close up! Adding examination of the spun urine specimen can increase the detection rate of Trichomonas vaginalis from 73 to 85 percent.41

34 vaginitis Trichomoniais TreatmentA single 2-g dose of metronidazole is adequate but can cause dyspepsia and metallic taste Metronidazole 500 mg BID for seven days will treat bacterial vaginosis and Trichomoniasis and is better tolerated Metronidazole in a dosage of 2 to 4 g daily for seven to 14 days is recommended for metronidazole-resistant strains. The parasitologic cure rate of intravaginal nitroimidazole creams is an unacceptably low 50 percent Sex partners should be treated simultaneously. To reduce recurrence, partners should avoid resuming sexual intercourse until both have completed treatment and are asymptomatic.

35 vaginitis Vulvoginal Candidias Diagnosis:symptoms such as pruritus, vaginal soreness, dyspareunia, and vaginal discharge are common, but not specific Most patients can be diagnosed by microscopic examination of vaginal secretions with a 10% potassium hydroxide solution (sensitivity, 65 to 85 percent). Vaginal pH is usually normal (4.0 to 4.5). Vaginal culture should be considered in recurrently symptomatic women with negative microscopy and a normal pH.

36 Yeast on Microscrope

37 vaginitis Non-infectious VaginitisIrritant contact dermatitis OR allergic contact dermatitis May be associated with use of feminine hygiene products or contraceptive materials, among many other causes Atrophic vaginitis can manifest clinically with symptoms of vaginal dryness, itching, discharge, irritation, and dyspareunia. It affects 10 to 40 percent of women who have conditions associated with estrogen deficiency Diagnosis is based on history and physical findings, supplemented by vaginal pH levels, vaginal wet-mount preparation (to exclude superimposed infection), and, rarely, culture or cytology. Both systemic and topical estrogen treatments are effective in relieving symptoms. Topical vaginal estrogen is preferred because of the low systemic absorption and reduced risk of adverse effects compared with oral therapy. Estrogen-containing creams, pessaries, intravaginal tablets, and the estradiol vaginal ring appear equally effective for the symptoms of atrophic vaginitis

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44 Taking a sexual historyA sexual history needs to be taken during a patient’s initial visit, during routine preventive exams, and when you see signs of sexually transmitted diseases (STDs). The dialogue lends itself to the opportunity for risk- reduction counseling and sharing information about behaviors that may place your patient at risk of contracting STDs. A sexual history allows you to identify those individuals at risk for STDs, including HIV, and to identify appropriate anatomical sites for certain STD tests.

45 Taking a sexual historySome patients may not be comfortable talking about their sexual history, sex partners, or sexual practices. Try to put patients at ease and let them know that taking a sexual history is an important part of a regular medical exam or physical history.

46 Taking a sexual historySample Dialogue: I am going to ask you a few questions about your sexual health and sexual practices. I understand that these questions are very personal, but they are important for your overall health. Just so you know, I ask these questions to all of my adult patients, regardless of age, gender, or marital status. These questions are as important as the questions about other areas of your physical and mental health. Like the rest of our visits, this information is kept in strict confidence. Do you have any questions before we get started?

47 Taking a sexual historyThe five “P”s stand for: Partners Practices Protection from STDs Past history of STDs Prevention of pregnancy

48 CDC’s STD & HIV Screening RecsAll adults and adolescents from ages 13 to 64 should be tested at least once for HIV. Annual chlamydia screening of all sexually active women younger than 25 years, as well as older women with risk factors such as new or multiple sex partners, or a sex partner who has a sexually transmitted infection Annual gonorrhea screening for all sexually active women younger than 25 years, as well as older women with risk factors such as new or multiple sex partners, or a sex partner who has a sexually transmitted infection. Syphilis, HIV, chlamydia, and hepatitis B screening for all pregnant women, and gonorrhea screening for at-risk pregnant women starting early in pregnancy, with repeat testing as needed, to protect the health of mothers and their infants. Screening at least once a year for syphilis, chlamydia, and gonorrhea for all sexually active gay, bisexual, and other men who have sex with men (MSM). MSM who have multiple or anonymous partners should be screened more frequently for STDs (i.e., at 3-to-6 month intervals). Anyone who has unsafe sex or shares injection drug equipment should get tested for HIV at least once a year. Sexually active gay and bisexual men may benefit from more frequent testing (e.g., every 3 to 6 months).

49 Easy STD screening panelBlood test for HIV/RPR Urine for GC/CT dna amplfication

50 Other STD tests (not for routine screening)HSV – must unroof and culture vesicle in viral medium HPV – visual or PAP test (HPV DNA)

51 The source for STD screening and treatmentCDC’s STD Treatment Guidelines Last major publication was 2015 Updates in 2012 focused on gonorrhea resistance to oral meds Check this site frequently for updates

52 CDC STD Treatment APP! http://www.cdc.gov/std/std-tx-app.htm Get it!Includes: Diagnosis and treatment of 21 STDs and sexual assault. Access to the full STD Treatment Guidelines. "A Guide to Taking a Sexual History."

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54 Emergency contraception guide There are two types of emergency contraception (EC): 1. Emergency contraceptive pills (ECPs) a. Plan B One-Step, Next Choice One Dose, and My Way consist of one pill that the instructions state must be taken with 3 days (72 hours). b. Levonorgestrel Tablets consist of two pills. Although the instructions state that the first one must be taken within 3 days (72 hours) and another must be taken 12 hours later, both pills can be taken at the same time within four days (96 hours) after unprotected sex. c. ella consists of one pill that must be taken within 5 days (120 hours). Research has shown that the pills in a and b above are equally effective when taken on the first-fourth days after unprotected sex and are ineffective thereafter. ella is equally effective when on the first-fifth days. 2. Emergency insertion of a copper T intrauterine device (IUD) within 5 days (120 hours)

55 Emergency contraception guideHow effective are ECPs? Plan B One-Step, Next Choice One Dose, My Way and Levonorgestrel Tablets: 7 out of 8 women who would have gotten pregnant will not become pregnant after taking these pills. ella: 6 or 7 out of every 100 women who would have gotten pregnant will not become pregnant after taking ella. What are the side effects of ECPs? headache, nausea, abdominal pain, menstrual pain, tiredness, dizziness

56 Emergency contraception guideCan I use ECPs if I am pregnant? Women who are pregnant or suspect they are pregnant should not use ECPs. This is because they are ineffective; ECPs will not cause any adverse effects on an existing pregnancy. Emergency contraceptive pills prevent pregnancy and are different from medications which cause abortions. How does the copper T IUD work as emergency contraception? The copper T IUD is a method of emergency contraception when it is inserted within five days of unprotected intercourse. The copper T IUD is a T-shaped device that is put into the uterus by a health care provider. It prevents sperm from reaching the egg, from fertilizing the egg, and may prevent the egg from attaching in the uterus. It does not stop the ovaries from making an egg each month. One advantage is that it can remain in place for up to ten years as a women’s regular contraception. After the IUD is taken out, you can get pregnant.

57 Emergency contraception guideMajor disadvantage to Emergency Contraception: No protection from STDs. Concern patients may take more risks when pregnancy less of a concern.