OB/PEDS EXAM 1

Stage 1 of menstrual cycle

period or menstrual phase

Stage 2 of menstrual cycle

Follicular phase, ovary and follicle prepare for release of egg (ovumm)

Stage 3 of menstrual cycle

Ovulation phase; 14 days prior to the next period, egg is expelled from follicle due to estrogen and LH increase

Stage 4 of menstrual cycle

Luteal phase, increase in estrogen propels egg toward uterus, follicle becomes corpus luteum & releases progesterone, uterine wall thickens to prepare for pregnancy, egg is reabsorbed if not fertilized in 24hr, corpus luteum degenerates, estrogen and progesterone decrease and trigger next cycle

Onset and volume of period

12.4 years, q 28 days for 8 days or less, 80mL

How much of folic acid is recommended for women to take per day and why

400mcg/day to prevent neural tube defects if pregnant

Omega-3 fatty acid benefits

Regulate hormones, improve egg quality, & maintain a healthy uterine lining

Coitus interruptus

“Withdrawal” method or “pulling out” method of contraception

Calendar days method of contraception

Record 6 cycles, the start of the fertile period- subtract 18 days from shortest cycle, subtract 11 days from the longest cycle: resulted days are fertile days so NO SEX

Temp taking contraception

Take in AM immediately, 1st day that your temp drops or elevates is the 1st fertile day & lasts 3 days (immediately before ovulation temps will slightly drop, when ovulation occurs, temp slightly elevates and stays for 3 days)

Cervical mucus method of contraception (Billings method)

Thin & slippery, will stretch between fingers during ovulation and is sperm friendly- fertile for 3 days after this appears

Condoms

Use water soluble lubricant w/ latex condoms or polyurethane condoms (both types protect against STIs)

Spermicide

(Jelly or films) Insert 15min before sex, effective for 1hr, but leave in for 6hrs after sex

Diaphragm contraception

Replaced q 2yrs or 20% weight change (book says 10lbs), after abdominal surgery, or after pregnancy

Cervical cap contraception

Similar to diaphragm but do not need fitted, place up to 6hrs prior to sex, and leave in 6hrs after sex

Contraceptive sponge

Contains spermicide

1 size

moisten w/ water prior to sex

leave in for 6hrs after sex

Combined oral contraception

Estrogen AND progesterone

suppresses ovulation, thickens mucus (not sperm friendly), alters uterine lining (makes it harder for implantation to occur)

effectiveness decreases when taking meds affecting liver enzymes

Benefits of combined oral contraception

Highly effective

decreased blood loss & iron deficiency anemia

regulates cycle & decreases painful periods

protects against cancers

improves acne

decreases ovarian cysts

Disadvantages of combined oral contraception

No STI protection

increased risk for blood clots, stroke, MI, HTN, gall bladder disease & liver tumor

exacerbates conditions affected by fluid retention (migraines, epilepsy, asthma, kidney & heart disease)

Adverse effects:

• headache, nausea, fatigue

• tender breasts, breakthrough bleeding

• fluid retention

• increased appetite, depression, oily skin, hirsutism (abnormal hair growth)

Contraindications of combined oral contraceptives

Patient history of: blood clots, stroke, MI, CAD, cirrhosis of liver, liver tumor, uncontrolled HTN, diabetes w/ vascular involvement, breast/estrogen related cancers, pregnancy, breastfeeding, <6 weeks postpartum, smoking & >35 years old

Progestin only pill

Does NOT contain estrogen

use other form of birth control for 1st month

safe while breastfeeding

decreased effectiveness if taking meds affecting liver enzymes

Contraindications for Progestin only pill

Bariatric surgery

lupus

severe cirrhosis or liver tumors

current/past breast cancer

Plan B / Morning after pill

Active drug: Levonorgestrel

take within 72hr after sex

severe nausea common

Transdermal Patch Contraception

Contains estrogen and progesterone, thickens cervical mucous

avoids liver metabolism

apply to dry SQ areas

replace 1x week except week 4 for period cycle

Injectable Progestins

Active drug: medroxyprogesterone

IM or SQ q 11-13 weeks

increase Ca+ intake and weight baring exercise bc increase risk of osteoporosis, do NOT massage site after IM injection

Adverse effects & Contraindications of Injectable Progestins

Adverse effects:

• osteoporosis

• weight gain, depression, headache

• amenorrhea, breakthrough bleeding

Contraindications:

• breast cancer

• CV disease

• poor liver function

• unexplained vaginal bleeding

• do not use longer than 2 years

• can increase diabetes risk

Vaginal Ring

Remove after 3 weeks

leave out for 7 days

reinsert

can remove temporarily for 3-4hrs then replace

Implantable Progestin

Suppresses ovulation & thickens cervical mucous

increases risk for ectopic pregnancy

can be left for 3yrs

CONTRAINDICATION: unexplained vaginal bleeding

IUD

Chemically active “T” shaped device that damages sperm

can be left for 3-5yrs (copper IUD 3-10yrs & contains no hormones)

monitor string monthly

Pap smear, pregnancy test, and cervical culture MUST be negative before placed

Transcervical Sterilization or “Essure”

No longer FDA approved, use birth control for 3mo after

Tubal Ligation

Cut, burn, or block tubes; permanent

Vasectomy

Permanent surgical procedure that cuts or seals tubes carrying sperm, effective after 20 ejaculations after procedure; scrotal support/ ice after

Erectile dysfunction

Occurs when there is an imbalance in contraction & relaxation of smooth muscles in penis; inability to achieve or maintain an erection

Organic Erectile Dysfunction

Gradual decrease in function bc of diabetes, meds, or vascular disease

Risk factors for Erectile Dysfunction

Trauma, surgery, HTN, chronic neuro issues, endocrine disorders, obesity, substance misuse, smoking/alcohol, meds

Pharmacological interventions for Erectile Dysfunction

CV workup first, Phosphodiesterase (PDE-5) inhibitors, Vasodilators

Phosphodiesterase (PDE-5) Inhibitors

Sildenafil & Tadalafil

Avoid nitrates, alcohol, and grapefruit!

S/a: heartburn, headache, flushing, priapism (continued erection)

Vasodilators

Alprostadil (injection or penile suppository)

Papaverine

Phentolamine

*may cause discomfort & HTN

Dysmenorrhea

Painful menstruation

Interventions:

heating pad, massage, effleurage, pelvic rock, low fat diet w/ natural diuretics (ex. Watermelon), aromatherapy, meditation, NSAIDs, oral contraceptives

PMS

Premenstrual syndrome

imbalance between estrogen and progesterone, can cause psychological, physical, or behavioral manifestations

Interventions: oral contraceptives, NSAIDs, spironolactone

Avoid large amounts of caffeine

PMDD

Premenstrual dystrophic disorder

severe form of PMS, caused by unexpected serotonin response to estrogen levels

Interventions: oral contraceptives, NSAIDs, SSRIs, spironolactone, check for SI

Avoid large amounts of caffeine

Amenorrhea

Absence of period

Causes: genetics (ex turner syndrome), pituitary conditions, increased BMI, decreased body fat, breastfeeding, menopause, PCOS, eating disorders, sports, pregnancy

Interventions: hormonal contraceptives

Menorrhagia

Excessive menstrual bleeding

Metrorrhagia

Bleeding between menstrual periods

Menometrorrhagia

Bleeding between periods and excessive bleeding during the period

Interventions for abnormal bleeding

Birth control

TXA- transemic acid (decreases clot breakdown — more likely to clot your blood (to stop bleeding) but increases risk for blood clot

Menopause

No period for at least 12 months (age 41-59)

Menopause symptoms

Hot flashes

mood swings

weight gain

hair loss

irregular periods, breast tenderness

shrinking labia, increased vaginal pH, incontinence

joint pain, osteoporosis, decreased skin elasticity

painful sex (dyspareunia)

migraines, forgetfulness

Labs: estrogen & progesterone DECREASE, LDL increases, HDL decreases

Menopause interventions

Use water soluble lubricant for sex

increase Vit.E and Vit. B6 bc they help decrease hot flashes

exercise, hydration & balanced diet (decrease calories & fat intake, increase fiber and whole grains)

encourage routine health screenings

If you have a uterus and are on estrogen you should:

must be on progesterone additionally

How does metformin increase fertility

It decreases androgen hormones (male hormones) and increases female hormones which increase fertility

Semen analysis instructions

Leave at room temp, abstain from sex for 2-5 days

Infertile couple

One who has not become pregnant after at least 12 months of unprotected sex

___% of the time, infertility is related to the male

40%

Pelvic exam asseses for

Tilted uterus

Postcoital test

Evaluates sexual techniques (positions, etc.)

Hysterosalpingography

Uses dye to check inside uterus and see if fallopian tubes are open

Hysteroscopy

Same as hysterosalpingography but without dye

Laparoscopy

Most invasive, inflate abdomen surgically to see what’s in there

Clomiphene Citrate and Letrozole

Medications used to increase fertility by increasing egg production (stimulate the ovary to produce follicles)

What meds are used to increase fertility

Clomiphene citrate

Letrozole

Metformin

Thyroid meds

Antimicrobial meds (for STIs)

Intrauterine insemination

Insert sperm into female

In vitro fertilization-embryo transfer

Put sperm and egg in Petri dish and let grow

Gamete intrafallopian transfer

Insert sperm and egg separately into fallopian tube hoping they conceive

Donor oocyte

Egg donation

Donor embryo

IVF (Petri dish) already fertilized donation

Gestational carrier

A woman who carries a baby for another couple using IVF; carrier has NO genetic tie to the baby

Surrogate

Uses own egg and IS the baby’s mother

Therapeutic donor insemination

Donated sperm used to inseminate female

PMOS/PCOS

Polyendocrine metabolic ovarian syndrome

chronic

hormonal imbalances

insulin resistance

ovarian dysfunction

In PMOS, there are high levels of ______Which can exacerbate insulin resistance and contribute to metabolic abnormalities

Androgens (testosterone)

Women with PMOS tend to accumulate more _______ which is linked to increased metabolic risk

Fat around their waist

Women with PMOS have a lower BMR, meaning

They burn fewer calories at rest

PMOS increases the risk of developing

Metabolic syndrome

diabetes

cardiovascular problems related to cholesterol

PMOS findings

Obesity

insulin resistance

glucose intolerance

irregular periods

hirsutism

infertility

multiple small cysts

PMOS lab findings

Pelvic exam/ ultrasound for ovarian cysts

Increased testosterone & LH, decreased FSH

A1C elevated

To determine a diagnosis of PMOS, two of the following must be present

Hyperandrogenism, chronic anovulation (ovaries don’t release an egg for a long time leading to irregular periods), ovarian cysts

Erectile Dysfunction Tests

Glycosylated hemoglobin (DM), lipid panel, total testosterone, TSH, penile Doppler ultrasonography, nocturnal penile tumescence test

Penile Doppler ultrasonography

Determines blood flow to penis

Nocturnal penile tumescence test

Sleep study that detects changes in the penis circumference

Which 4 STIs must be reported to CDC

Syphilis, Gonorrhea, Chlamydia, and HIV

If you have herpes and have a positive blood test with no lesions

You can have a vaginal delivery

HPV vaccinations

1st dose: 11-12yrs (can start at age 9)

2nd dose: 6-12mo after 1st dose

3rd dose: IF you are 9-14 and received the first 2 doses less than 5 months apart; IF you’re 15-26 a started doses later; IF you have a weakened immune system

It is NOT recommended for those older than 26

The (9-valent Gardsail 9) HPV vaccine protects against

9 type that can cause cancer and genital warts

(Types: 6,11,16,18,31,33,45,52,58)

6 & 11 cause genital warts

Those affected with ______ will always test positive in the blood even if there are no active lesions

Herpes (HSV)

Herpes findings

Lesions

tender lymph nodes

pain and itching

dysuria

lesions eventually rupture, ulcerate & encrust within 2 weeks

after lesions - may report malaise, muscle aches, and mild fever

Labs/diagnostics for Herpes

Viral culture obtained from sample fluid from lesions

Virologic testing: NAAT assays

Pharmacological interventions for Herpes

Analgesics

Antivirals: Acyclovir, Valacyclovir, Famciclovir

Warm sitz bath

Increase fluid intake

Reevaluate in 2 weeks

HPV

Infects epithelial cells & can lead to cancer

Most common STI

Diagnosed if lesions in genital area, if no lesions - only way to diagnose is Pap smear

Colposcopy

HPV findings

Lesions/bumps in genital area (might not itch or hurt), genital warts, vaginal discharge, dyspareunia (painful sex), bleeding after sex

HPV interventions

Topical agents applied by provider (Trichloroacetic acid/ TCA, bichloroacetic acid/ BCA & Podophyllin) or applied by patient (Podofilox, Imiquimod, Sinecatechins)

Surgical removal or laser therapy

Syphilis

Primary: chancre sore

Secondary: generalized symptoms & rash on palms & soles of feet

Latent: no signs

Tertiary: most serious- organ failure 1-20 years later

Deadly to fetus if not treated before birth

Syphilis testing

Nontreponemal (VDRL, RPR), Treponemal, Microscopic

Syphilis treatment

Antibiotics (Benzathine penicillin single dose if duration of condition is known, if duration is unknown, pt may require 3 injections at 1 week intervals)

Repeat RPR test in 6-12 months, HIV retesting in 3 months

What symptoms should you report to the provider after syphilis treatment

Headache

fever

tachycardia, and

myalgia

could indicate Jarisch-Herxheimer reaction

Chlamydia

Bacterial infection causing inflammatory response

Chlamydia Female Symptoms

gray-white or yellowish discharge

dysuria

urinary frequency

bleeding between menstrual period or bleeding after sex

itching

Chlamydia Male Symptoms

Penile discharge (watery or mucus)

dysuria

urinary frequency

testicular edema or pain

Chlamydia & Gonorrhea testing

Swab culture of discharge, urine culture specimen

Gonorrhea Pharmacological Interventions

Antibiotics (Azithromycin, Ceftriaxone)

Retest 3mo after treatment