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Gyne Review

new note 1/25/11: vitamin A important for ovarian lining function, give women with cysts etc fish oil as it contains A, D and good omegas.

Windstar speaking
final from ov cysts to ?

helpful new book available:
New Essential Guide to Lesbian Conception, Pregnancy and Birth, Stephanie Brill

ADNEXAL MASSES
very common
can cause torsion, can rupture
concerns for fertility
rupture-->adhesions-->infert
so send for US
if 4cm followup with US in 6 weeks
most cysts shrink, 70% resolve, so follow it
if over 8cm refer to ob gyn for surgical consult, laparoscopy
two things that increase risks with cyst or mass: vigorous exercise, penetrative sex

TERATOMA
mc solid mass in young wmn
these also can rupture-->peritonitis

FIBROIDS
lumpy on bimanual, menorrhagia if submucosal or mb ASx
send for US
if ASx management is conservative: watch
repeat bimanual or US in 6 mo, document size, texture
make sure fibroids are stable
Tx: reduce estrogen dominance, eat flax meal and broccoli (supp DIM)
Tx: lifestyle: stop smoking, exercise
advise that fibroids will prob disappear at menopause
no HRT or they might grow right back
if menorrhagia ck for anemia: capillary refill, mucus membranes, HGB 5-7-->hosp for transfusn
if menorrhagia: do bimanual and speculum exam to see where blood is coming from
if submucosal fibroid causing menorrhagia, 64% decr preg rate, 69% decr live birth rate
submucosal worst, may block os or tubes, intramural and subserosal may distort cavity
inhibiting implantation or pressing on fetus causing prematurity, etc
Tx: marina is option (stays for 5 years)
Tx: hysteroscopy, snip it off

PMS vs PMDD
know the difference
PMS criteria: 1 affective and/or 1 somatic sx plus additional criteria
PMDD: 5 affective and at least one has * in list
occur at least 5 days before menses and remit by day 4
sx don't recur until day 13 of cycle
sx present in absence of pharma, drug/alc use
cause identifiable dysfx in social/work life
DX: keep 2 mo PMS diary
Tx: lots of science-based natural medicine options to tx

CONTRACEPTION
insure success: take a full hx and PE-->individualize prescription
don't let patient decide for you
no femcap for homeless teen
pt must be able to use it-->compliance

HORMONAL (OCP)
benefits: lowers risk of ov & endom ca, cysts, regulate cycle, less anemia
bennies: less PID dt progestin in pill makes mucus plug thicker, less ectopic preg
bennies: improved acne, B9 breast dz, reduced CRC, improved bone health
bennies: slows progression of RA (new in lit)
risks: hypercoagulability-->DVT, embolism, stroke, MI, elevated fibrinogen and CRP
risks: breast CA, dysplasia, cervical CA
risks: lupus (new in literature)

IUD
marina has progestin, protects some vs PID
useful: for fibroids if not distorting cavity
best for: monogamous woman who may want to get preg in future with pard who is STI free
CI: avoid marina if breast CA, if left in and recurrent-->100% metastatic
CI: (paragard fine with breast CA)
CI: fibroids distorting cavity
CI: high risk sexual behavior (mult pards), risk of GC/Chlam, AIDS
CI: unexplained vaginal bleeding (must Dx first, CI w/ endom or cx ca)
CI: purulent discharge, GC, Clam, PID
*if BV use good aseptic technique
SO: use condoms for protection with new partner until STI status known
*if IUD removed to get preg wait 1-3 cycles (3 is optimal) to let leukocytosis of area subside

CONDOMS
her favorite condom:
polyurethane (nonlatex), thinner, both partners like it better, stronger
can use oil based lube
female condom not much used
male condom has highest effective percentage: 2% failure rate

FAMILY PLANNING METHOD
must be comfortable with body
1) mucus change--looking for spinbark/eggwhite mucus
2) basal body temp
3) feel for location of cx, during ov it moves up, vaginal elongates, moves down during menses
CI if irreg cycle, uncomfortable with body or with interpretation of sx
CI: infx esp chronic vaginitis

CHRONIC PELVIC PAIN
Defined: over 6 mo, noncyclical, located in pelvis
(if cyclical: PMS, PMDD, dysmenorrhea, endometriosis)
DDX: GI, GU, musculoskeletal, circulatory
Carnett's sign press on point it hurts most while pt is supine, pt lifts legs
if + pain gets worse with effort, if pain same or less then more likely visceral
WORRY IF: weight loss, postmenopausal vaginal bleed, hematochezia (crc), post coital bleeding (cx), perimenopausal irreg bleed (all red flags)
IF CHILD: do abdominal exam, avoid pelvic if not sexually active, can tx for primary dysmenorrhea and see if it helps, can order US that is not transvaginal

INFERTILITY
DDX: both partners, males almost as commonly at fault
DDX: ov dysfx is #1 esp PCOS is 75%, hypothyroid, endometriosis (its own category)
immunological mechanisms of endometriosis (new research)
(AI thyroid dz is mc cause of thyroid dz, affects endometriosis and infert)
other ov factors: hypothalamic anox (dt stress)
tubal factors: GC/Chlam-->scarring even w/o PID
DDX: age
HX: previous pregnancies, sexual frequency, interview both separately and together

MENOPAUSE
defined: no menses x 1 year
two types of perimenopause: early and late
early: cycles change, get shorter, then lengthen
late: skipping cycles
important to check: bone density, breast health, cardiovascular health
BREAST (mammogram)
HEART (lipid profile, CRP, homosycteine, fibrinogen)
BONE (dexa scan)
(endometrial thickness only if bleeding)
ALSO: FFT (free T3, T4, TSH), and Salivary Cortisol
what about HRT?: "talk her out of it"
oral vs transdermal: transdermal better for local
systemic: transdermal better for the heart, don't get inflam/pro-coag marker increase
also protects gall bladder (OCPs can cause gall bladder dz)
good for bone
patches and gels instead of oral
even bioidentical estradiol causes same abn changes and premarin
oral-->breast CA danger

next Thurs test have 3 hours
she's "here to hang out with us"

Comments

( 2 comments — Leave a comment )
neptunia67
Nov. 30th, 2009 09:46 pm (UTC)
CONTRACEPTION
insure success: take a full hx and PE-->individualize prescription
don't let patient decide for you


Really? The doc feels that on this topic, doctor knows better than patient?

Sorry I missed your call. I was on the table at the chiropractor getting heat and "shock" treatment (that's not what it is but I can never remember what it's called) when the phone rang. I figured you were in class by the time I listened to your voicemail, about 30 minutes later.
liveonearth
Nov. 30th, 2009 11:25 pm (UTC)
The thing about women and contraceptive is that women decide that they want something specific because their friend is on it, or because they've seen it advertised, but for sure the doc understands the risks and benefits of the various types of contraception more than the lay person. I am sad to report that all those years I spent on BC pills--because docs prescribed them---if I had known then what I know now I would have changed things a whole lot earlier. But what the heck, one can only know so much about things, and the answers are NOT all on the internet. And frankly the majority of mainstream docs are not well versed on this. We happen to have a teacher here who is really on top of the science in the world of gyne. I am grateful for her.

Uh oh. Hope the shock treatment went well. I want to hear more about this. =-]
( 2 comments — Leave a comment )

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