Lecture 17

1. Obtain a targeted but thorough gynecologic and obstetrical history.
Observation
Chief complaint
Gynecologic history
•Menstrual history – menarche, last menstrual period, cycle length and characteristics (color, amount, assoc sx)
• Pregnancy history
• Vaginal or pelvic infections – type of infection, treatment, any complications, risk factors
• Gynecologic surgical procedures
• Urologic history – incl. bladder dysfunction, acute or chronic bladder or kidney infections, hematuria, stones
• Pelvic pain – Sx, relation to menstrual cycle or assoc w/ other events
• Vaginal bleeding
• Sexual and contraceptive status – sexually active?, types of relationshps, individual(s) involved, satisfaction/orgasmic, dyspareunia, sexual dysfunction (patient/partner), onset of sexual activity, number of partners
Significant medical history
Medications, allergies, habits
Preventative measures
• Immunizations, incl. HPV vaccine
• Cancer screening – breast, pap smear
• Vitamins, calcium
• Diet, exercise
Family history
• Illness, cause of death – esp. cancers
• Congenital malformation, mental retardation, reproductive wastage
Occupational and vocational history
Social history
Review of systems
• Remember psychiatric – depression, physical abuse, sexual abuse

2. Demonstrate a proper breast and pelvic examination (ICM Pelvic Workshop).
Not on exam.

3. Plot the relative levels of estrogen, progesterone, FSH, and LH during a menstrual cycle.
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Day 1 is the first day of menses, which typically lasts 4-5 days.
Cycles can last from 25-30 days, w/ the luteal phase 14 days, and the follicular phase of varying length.
Follicular phase = proliferative phase. Luteal phase = secretory phases.

4. Counsel a patient about condom effectiveness with regard to sexually transmitted infections.
• Barrier and spermicidal methods provide protection against STIs, but even 100% condom use does not eliminate the risk of any ST.
• Protection against STIs has a beneficial impact on the risk of tubal infertility, ectopic pregnancy, and cervical cancer.
• Types –
• Latex – may cause allergy
• Polyurethane – 4-6 times greater risk of breakage and slippage as compared to latex condoms
• Silicone rubber
• “Natural skin” (lamb’s intestine) condoms do not offer STI protection.
• The typical use failure rate (12%, 18% for adolescents) is much higher than the perfect use failure rate (3%).
• Incorrect and inconsistent use contributes to condom failures, so it’s important to use condoms correctly and consistently.
• Use with a spermicide decreases the failure rate and increases protection against STIs.
• 100% condom use, in actuality, is so uncommon that it is almost a theoretical concept.
• It is important to consistently use condoms to reduce risk and to
• Condoms reduce the risk of infections, and never by 100%.
• No risk reduction for HPV or trichonomas vaginalis
• 29-50% risk reduction for syphilis transmission w/ 100% condom use.
• 50% risk reduction for gonorrhea and Chlamydia w/ 100% condom use.
• W/ 100% condom use there remains a 60% relative risk of herpes, and a 15% relative risk of HIV.

5. Given any pertinent clinical presentation, be able to recognize when a woman is peri-menopausal and describe the pathophysiology of the anatomic and physiologic effects on the bones, heart, breasts, vaginal mucosa, and endometrium.
Menopause = no menstrual period for 12 months in the setting of ovarian failure that comes with age.
Perimenopause = no menstrual period for less than 12 months.
SSX
• Age, 45-52 y/o (average age = 52)
• Low estrogen and inhibiin production leads to FSH and LH >40 miU/ml
• Irregular bleeding patterns secondary to anovulation leading to amenorrhea
• Osteoporosis
• Hot flashes/fushes (vasomotor instability)
• Dryness and atrophy of the urogenital epithelium and vagina
• Sleep disturbances – insomnia
• Mood changes, irritability nervousness
Pathophysiology
• Loss of ova and associated follicles (mainly by atresia) leads to decreased ovarian estrogen secretion
• After menopause, extraglandular (in adipose tissue, bone, muscle, skin, brain) formation of estrone becomes the dominant pathway
• Hot flush – sensation of warmth and heat followed by profuse sweating
• Pathogenesis is unclear – related to pulses of LH secretion
• Estrogen replacement alleviates symptoms
• Triggered in central nervous centers (e.g. the hypothalamus)
• Urogenital atrophy – thinning of vaginal epitheliu, atrophy of the vagina, and symptoms of atrophic vaginitis [burning, dyspareunia (painful sex), vaginal bleeding, loss of uterine support w/ subsequent uterine descensus (slipping/falling out of place)]
• Due to estrogen deficiency. Symptoms relieved by estrogen treatment
• Other – depression, anxiety, fatigue, and irritability
• Relieved w/ estrogen therapy, either directly or by preventing hot flashes (which disrupt sleep)
• Osteoporosis – loss of structural support in trabecular bone, predominantly of the axial skeleton
• Due to estrogen deficiency, which causes increased bone resorption and mobilization of Ca w/ increased urinary or intestinal excretion of Ca.
• Estrogen deficiency may lead to increased sensitivity to PTH in bone.
• Estrogen decreases bone turnover by acting on osteoblasts.
• Cardiovascular effects
• Estrogen in the vasculature leads to decreased binding to inflammatory cells and LDL, increased production of endothelial NO
• Loss of ovarian function leads to decreased HDL cholesterol and increased LDL cholesterol

6. Given any pertinent clinical presentation, be able to recognize when estrogen, alone and in combination with progesterone, is indicated in the management of menopause.
Indications for estrogen treatment
• Osteoporosis (lower the risk of spine and hip fractures esp.)
• Caucasian or Asian race
• Low body weight
• Hypoestrogenism
• Early menopause
• FHx
• Diet low in Ca and vitamin D
• Diet high in caffeine, phosphate, alcohol, and protein
• Cigarette smoking
• Sedentary life style
• Reduced risk of colon cancer
• Indications for estrogen + progesterone treatment – If a woman still has her uterus, she needs to receive progesterone to prevent endometrial hyperplasia and endometrial cancer
Contraindications for estrogen +/— progesterone treatment
• Increased risk of breast cancer, heart attacks, strokes, blood clots w/ E + P therapy
• Estrogen alone, or w/ progesterone, does not prevent cardiovascular disease