Women's Health Issues + Fertility

primary amenorrhea

absence of menses at age 15 years in the presence of normal growth and secondary sex characteristics

primary amenorrhea examples

chromosomal abnormalities (ex: turners syndrome), alterations in the hypothalamic-pituitary-ovarian-uterine axis, anatomic abnormalities (absence of uterus, vagina, and or cervix), endocrine disorders

secondary amenorrhea

absence of menses for more than three cycles of six months in women who previously had a menses

secondary amenorrhea examples

pregnancy, stress, weight loss, strenuous exercise, disorders of the hyothalamic-pituitary-ovarian-uterine axis

tx for amenorrhea

possible hormonal management; progesterone (provera), oral contraceptives, calcium supplement in women with hx of eating disorder or exercise induced amenorrhea

provera

induces menses + stops bleeding

oral contraceptives

regulate cycle

Primary dysmenorrhea

• noticed 6-12 months after menarche; recurrent, crampy, lower abd pain during menses, pain triggered with release

• Seen in late teens, early 20s; declines with age

tx for primary dysmenorrhea

provide adequate relief of pain; heat, massage, exercise, dietary changes, cranberry juice, peaches, watermelon

Med: NSAIDS (1-3 days before onset of menses), OCP (decreases prostaglandin synthesis)

Secondary dysmenorrhea

associated with pelvic pathology/disease; adenomyosis, endometriosis, PID, polyps, fibroids, IUD

secondary dysmenorrhea symptoms

dull lower abd aching pain, radiates to back or thighs, bloating, pelvic fullness

secondary dysmenorrhea onset

may begin with ovulation, start of menses and during menses

secondary dysmenorrhea tx

…

PMS

mildly interferes with some aspects of a woman’s life

PMDD

severe form of PMS in which symptoms of anger, irritability and internal tension are prominent; must have 5 symptoms (1 must be psychological); begins in luteal phase, recurrent, interfere with the woman’s life

PMDD symptoms psychological

anger, anxiety, depression, irritability, sense of being overwhelmed, sensitivity to rejection, social withdrawal

PMDD symptoms behavioral

forgetfulness, fatigue, poor concentration

PMDD symptoms physical

bloating, appetite changes, breast tenderness, headaches, lethargy/fatigue, muscle aches/pain, sleep disturbances, swelling of extremities

PMDD tx

lifestyle changes (diet, vitamins, exercise, decrease tobacco/ETOH/caffeine, counseling, stress management)

Meds (NSAIDS,OCPS, SSRIs)

Endometriosis

tissues similar to the uterine lining grows outside of it

endometriosis symptoms

dysmenorrhea, deep dyspareunia, chronic non-cyclic pain, pelvic heaviness, pain radiating to thighs and rectum, bowel symptoms, abnormal bleeding, infertility/ectopic pregnancies, fluctuates in severity during different periods of her life

endometriosis tx

Pain: NSAIDs

Control: OCPS, hormonal gnRH antagonists

Steroids

Surgical: laparoscopy, hysterectomy, removal of fallopian tubes and ovaries

gold standard for endometriosis (dx + tx)

laparoscopy

what suppresses endometrial growth for endometriosis

pregnancy

Uterine fibroids

benign tumors of the smooth muscle of the uterus

uterine fibroids symptoms

irregular bleeding, abd/pelvic pressure when enlarged or near other organs: bladder, colon; pain, abd enlargement

uterine fibroids diagnosis

pelvic exam, u/s, hysteroscopy

uterine fibroids complications

premature labor, spontaneous abortion, infertility, anemia

uterine fibroids tx

COCs, hormonal IUD, GnRH agonists, Fe supplement, surgery (myomectomy, total hysterectomy)

myomectomy

gets rid of fibroids

total hysterectomy

gets rid of fibroids + uterus

dysfunctional uterine bleeding

d/t hormones

• estrogen secreted never develops

• can occur later in reproductive life d/t low progesterone levels

dysfunctional uterine bleeding risks factors

<20 and >40 (beginning and end of reproductive lives= hormonal imbalance and anovulation), thyroid disorders, PCOS

dysfunctional uterine bleeding tx

hormone therapy (OCPS, Lupron, Synthroid); IUD (NSAIDS); treat cause (surgery)

Polycystic Ovarian Syndrome (PCOS)

one of the most common reproductive tract problems in women <30; irregular cycles (45-90 days), anovulatory cycles, infertility, hyperdrogenicity (hirsutism, acne, alopecia), increased waist to hip ratio, hyperpigmentation (neck, axillae, inguinal areas)

PCOS labs and diagnostics

• FH: FSH ratio (1:2) or (1:3)

• Glucose and insulin: d/t increased glucose + insulin

• dehydroepiandosterone sulfate (DHEAS)

• transvaginal u/s

• TSH

• lipid profile

• HCG: rules out pregnancy

PCOS complications

metabolic syndrome, T2DM: infertility, endometrial cancer, ovarian cancer, CV disease, atherosclerosis, HTN, increased triglycerides

PCOS tx

weight loss/exercise, low dose, low androgenic combination of OCP to restore cyclic menses, insulin-sensitizing agents: metformin, ovulation induction

Bacterial STIs

chlamydia, gonorrhea, syphilis

Viral STIs

HPV, HSV, Hepatitis, HIV

Trichomoniasis symptoms

diffuse, malodorous, yellow-green discharge with vulvar irritation, friable cervix, “strawberry cervix”

Trichomoniasis dx

microscopy of vaginal secretions, swab/PAP; trichomonasis will make “gyrate movement” under microscope

trichomoniasis tx

metronidazole 2g x1 or metronidazole 500 mg BID x7 days

Scabies

Feeds and lays eggs; hatch in 3-4 days (nymphs burrow into the skin and feed-major cause of itching)

• Mites are found in skin folds (between fingers, on the sides of feet, on the writs and genitals, and in bends of elbows)

• Trasnmitted within families and institutions; personal contact

scabies symptoms

itching

scabies diagnosis

visualization of burrows

scabies tx

• Permethrin cream 5% applied to all areas of the body (neck down); washed off after 8-14 hrs OR

• Lindane Cream 1% applied in thin layer to all areas of body (neck down); washed off after 8 hrs

scabies pt educate

not for use immediately after showering/bath, by persons with extensive dermatitis, or pregnant/lactating women

Pediculosis

infested with lice that may be found on the skin, particularly the hair areas (scalp, pubis) and causes intense pruruitus; transmitted through close contact, usually sexual; genital area, axillae, eyelashes, head hair

pediculosis dx

locating nits or adult lice on hair shaft

pediculosis tx

Permethrin cream 1% applied to infected areas; wash off at 8-12 hrs

Vaginitis

inflammation of vagina and possibly the vulva; results in discharge and pain

BV

• Common in women of reproductive age

• pH of vagina alkaline

• Sx: malodor, abnormal vaginal discharge (thin, white-grey, profuse)

• Dx: pH>4.5, +amine or whiff (fish smell), +clue cells

• Tx: intravag (metronizadole gel, clindamycin cream, clindamycin ovules), oral (metronizadole, tinidazole, clindamycin)

Candida

• yeast-like fungal infection of the vagina that results from change in flora

• Predisposing factors: pregnancy abx, diabetes, HIV infections, high carb intake, poor hygeine, hypersensitivity/allergen

• Sx: vulvar pruritus, vaginal discharge, burning, irritation, soreness, dyspareunia, dysuria

• Dx: normal pH, -amine, + KOH (presence of hyphae + yeast building), culture to differentiate type

• Prevent: avoid perfume, bubble baths, bath gel, maxi pads, tampons; change out of wet clothes-athletic gear, bathing suits, wear cotton underwear, no underwear to bed; loose clothing; if treated, take all medications; DON’T DOUCHE

PID

• Most commonly in fallopian tubes, uterus

• most frequent serious infection encountered by women

• risks: ectopic pregnancy, chronic pelvic pain, infertility

• positive CMT (cervical motion tenderness): cervix rocked w/ provider finger to assess for pain

STD implications

• infected newborns

• miscarriage

• ectopic pregnancy

• preterm delivery

• LBW

• birth defects- blindness, deafness, bone deformities, and intellectual disabilities

• stillbirth

• illness in newborn period

• newborn death

Zika Virus

• athropod-borne flavivirus

• sx: low grade fever with maculopapular rash, rathralgia, conjunctivitis

• transmission: semen, mosquito carrying the virus

• associated with neurologic complciations: congenital microcephaly, Guillan Barre syndrome, myelitis, and meningoencephalitis

• Pregnant women shuld avoid traveling

fibrocystic breast changes

sx: single or mutiple, firm, well define, mobile, most upper outer quadrant and axillary tail, bilaterial, dull heavy pain, feelings of fullness, tenderness, begin 1 week before menses, ends 1 week after menses ends

fibrocystic breast changes dx

breast u/s (<35), mammogram (>35), fine needle aspiration (FNA), excision and biopsy

fibrocystic breast changes tx

analgesics, heat, Vit E supplements, diuretics, avoid caffeine, tea, cola, chocolate, supportive bra, OCPs

fibroadenoma

most common benign breast condition; ages 15-25 years

• discrete, single, unilateral mass, Non-tender, round to lobular, typically no change with menses, increase in size with pregnancy; decrease in age

• dx: u/s, mammogram, biopsy

• Tx: observation if young; possible surgical removal

other breast concerns

nipple discharge: physiologic, endocrine, malignancy galactorrhea (elevated prolactin level in morning- caused by thyroid, pituitary, surgery, trauma)

Mammary duct ectasia: inflammation of duct behind nipple; disorder or peri or postmenopausal aged women

risk factors of cancer of the breast

obesity, lack of physical exercise, alc, HR during menopause, early age at first menstruation, having children late or not at all

signs of cancer of the breast

lump in breast, change in breast shape, dimpling of skin, fluid from the nipple, red, scaly patches of skin

cancer of breast management

lumpectomy, simple (total) masectomy, modified radical masectomy, radical masectomy, radiation, chemotherapy, hormonal therapy, breast reconstruction

UTI risks factors

sexual activity, diaphragm use, known structural abnormality/stone, immunosuppression, pregnancy, sickle cell trait/disease

UTI s/sx

urethritis, cystitis, pyleophritis

UTI tx

bactrim, Cipro, Floxin, Macrobid

UTI pt education

finish all meds, OTC pain meds dont cure UTIs, pregnant women may have asymptomatic bacteria, teach proper hygiene and prevention measures (front to back)

Climateric/Peri menopause

ovarian function and hormone production decline; may span 10-15 years

menopause

one full year without menses; average 51.4 (35-60)

Age <40: abnormal menopause

Physical changes menopasue

alteration in menstrual pattern, vasomotor instability, urogenital atrophy due to loss of estrogen, skin changes, thinning of hair, decrease in scalp, pubic, and axillary hair, increased bone loss-osteoporosis

psychological changes

change in mood, libido changes, insomnia

menopause tx

nutrition, aerobic and weight-bearing exercise, contraception, routine health assessment and screening sexual health, hormone replacement therapy (HRT): relief of vaginal symptoms

Infertility

inability of a couple of reproductive age to conceive after 12 months or more of regular coitus without using contraception

female factor infertility

anovualtion, anatomic defects of female reproductive tract

male factors infertility

abnormal spermatogensis, abnormal count, morphology, motility, volume

hx for infertility

couples age, duration of infertility, previous infertility of other rls, frequency of coitus, use of lubricants, mumps, renal disease, radiation therapy, STIs, chronic diseases, major stress/fatigue, recent lack of acute viral or febrile illness, exposure to chemicals, excessive heat

female specific evaluation

PID, previous pregnancies, douching practices, work exposures, alc and drug use, exercise, eating disorders, menstrual cycle length, regularity, VS, height, and weight, HTN, acne, hirsutism, thyromegaly, enlarged lymph nodes, indirect indicators of ovulation

infertility evaulation

semen analysis, ovulation, tubal patency, uterine abnormalities, peritoneal abnormalities, hormonal panels, test for FSH + estrogen

semen analysis normal

2.0 ml or more; sperm count >20 million/ml; 50% mobile with forward progression; 30% normal morphology

Ovulation assessment

Basal Body Temp, detecting LH in urine, mid luteal progesterone contraception

BBT

done in AM; before getting OOB; temp rise .4 ×3 days= ovulation; doesnt predict ovulation

ovulation

24-36 hrs after LH surge

mid luteal phase progesterone contraception

7 days after ovulation (>3.0 ng/ml=ovulation; >10ng/ml=adequate luteal phase support); can give detect information about ovulation and luteal phase defect

assessment of tubal patency hyperosalpingography

x ray study of internal female genital tract; injection of radiopaque dye through cervix; performed 2-5 days after menses; decreases risk of retrograde menstruation and disruption of ovum transport, fertilization, and implantation

tx of infertility

correction of anovulation or poor ovulation

s/sx of anovulation or poor ovulation

irregulary cycles, abnormal BBT, mid-luteal phase serum progesterone <3ng/ml, thyroid, adrenal, prolactin of CNS system disorders, emotional stress, changes in weight, exercise

tx of anovulation or poor ovulation

Clomiphene Citrate (Clomid) for 5 days; ovulation should occur 7-10 days after completing medication, increased 50mg next cycle if unsuccessful, max dose 150mg/day

D/C after 6th cycle

Tx of anatomic abnormalities

impacts fallopian tubes, peritoneum, or uterus

• infertility caused by PID, appendicitis, ectopic pregnancy, endometriosis, previous pelvic or abd surgery

• uterine abnormalitis: congenital deformities and fibroids

• laparoscopy and HSG; tubal reconstruction, lysis of adherence, ablation of endometriosis

tx of inadequate spermatogensis

Eliminate alterations in thermoregulation, intercourse every other day during fertile period, if no improvement: artificial insemination using donor sperm or assisted reproduction

ART

• AT/TDI

• IUI

• IVF/ET

• ZIFT

AT/TDI

artificial insemination or therapeutic donor insemination: donor or partner sperm

IUI

intrauterine insemination: sperm directly put into uterine cavity

IVF/ET

in vitro fertilization with embryo transfer

ZIFT (zygote intrafallopian trasnfer)

fertilization in vitro→put into uterine cavity

final points of infertility

emotional, expensive, ethical questions/cultural significance