Women’s Health Part 2

1. Women’s Health Part 2

2. Infertility • Definition: Unprotected sexual intercourse for 1 year without conception. • 1 year length relates to rate of fertile couples: 50% in 3 months, 75% in 9 months 90% in 1 year will get pregnant

3. Infertility cont. • Causes: Inadequate sperm, lack of ovulation, tubal damage, uterine pathology, cervical abnormalities,vaginal factors, luteal phase defect, recurrent fetal loss. • 10-20% are unknown causes • Contributing factors: Aging, reduced frequency of intercourse, timing, use of lubricants/spermicidal, douching, exposures to environmental, occupational hazards, excessive weight loss, stress

4. Diagnostic Test’s • Males: Medical history and physical, sperm counts, evaluation of fluids. • Females: Medical history and physical, serum pregnancy test, pap smear, pelvic exam, vaginal/cervical cultures for any infections, cycle day 3 FSH/LH/TSH labs, Hysterosalpingogram, Hysteroscopy, Laparoscopic surgery

5. Treatment • Treatment depends upon cause! • 3 month trial in office • Provera Challenge • Check for UPT • Provera x 10 days to produce menses • CD 1 or 3-7 or 5-7 take Clomid 50-100mg 1 po x 5 days • CD 10,12, 14, 16 have intercourse • CD 32-35 will have menses if not check UPT • If menses= repeat cycle 2 more times, then refer to fertility specialist

6. Breast Health/BSE • Regular self-exams will help you come familiar with what is normal for your breasts. • You will be able to recognizes changes promptly and bring it to the attention of your health care provider. • Monthly Self-Breast Exams will ease your mind and is good breast health. • Regular clinical exams and mammograms are also recommended

7. When to do the Self-Breast Examination • Establish a regular time each month to do your exam. • If you are still menstruating, a few days after your period when your breasts are not sore, around the 4th day. • Women who no longer menstruate, should pick the same time every month to do the exam

8. Nonmodifiable Risk Factors for Br.Ca • Female Gender • Advanced Age • (Race/Ethnicity) Older white women have slightly greater incidence • Personal history/family history of breast cancer • Menarche before age of 12 • Menopause after age 55

9. Modifiable Risk Factors • Excessive Alcohol (2-5 drinks daily) • Cigarette Smoking • Nulliparity • First born after age 30 • No breast-feeding • Oral Contraceptive use • Prolonged PMP HRT • Obesity • Sedentary lifestyle

10. Non Risk Factors • Deodorant Use • Under wire Bras • Spontaneous or Induced Abortions • Breast Implants • Oral Contraceptives use is a minimal risk and temporary with risk returning to baseline 10 years after discontinuing use.

11. Abnormal Findings • Dimpling, puckering, irritation, discoloration or bulging of the skin. • A change in a nipple, discharge, pain, or an inverted nipple. • Redness, soreness, rash or swelling. • Unusual lumps or thickening of the breast tissue

13. Diagnostic Imaging Options Mammography • Detects calcifications, densities, and architectural distortions. • Lower sensitivity in younger woman • Inability to differentiate between solid and cystic masses.

14. Diagnostic Imaging Options Ultrasound • Differentiating between solid and cystic masses • Inability to identify calcifications MRI • Identifying tissue with increased blood supply (tumor) • Expensive, limited specificity, false-positive results

15. Breast Screening RecommendationsACOG, ACS Self-Breast Exams Monthly beginning at age 20 Clinical Breast Exams Every 3 years age 20-40 Yearly after age 40 or 35 at risk Mammography Every 1-2 years older than 39, higher risk, start earlier

16. Breast Health Recommendations • Minimize caffeine intake • Regular exercise, at least 2 hours a week • Supportive bra during strenuous exercise • Low Fat Diet • Manage Stress • Mammogram starting at age 40 every 1-2 years

17. Breast Cancer • Less than 20% of breast lumps are malignant or need treatment. • Upper outer quadrant (Axillary Tail of Spence) has about 50% of cancers • Early detection and treatment remains the best for improving both quality of life and survival

18. Breast Cancer Statistics Age risk for breast cancer • From birth to age 39: 1 out of 231 (<0.5%) • Age 40-59: 1 in 25 (4% risk) • Age 60-70: 1 in 15 (7% risk) • Age 80 and above: 1 in 7 (14.3% risk)

19. Local Surgery:radical modified radical/simple Mastectomy Lumpectomy Radiation Therapy Systemic Chemotherapy Hormonal therapy Combo of above Bone marrow transplant Treatment

20. Care of Post-op Mastectomy • Position patient in semi-fowlers with arm elevated • Wound care: JP suction, check for bleeding, swelling, temperature • Monitor circulation of arm • AVOID BP’s on affected side • TCDB/pain management/comfort care

21. Care of Post-op Mastectomy Patient Teaching • Encourages arm exercises • Emotional Support (groups) • Reconstruction options • Avoid constrictive clothing • No BP’s or injections on affected side • Report symptoms of: edema, redness, breakdown of scar tissue, mass/lump in other breast

22. Cancer Risk’s • Cervical • Uterine • Ovarian

23. Cancer Risk’s Cervical • HPV types 16,18 • Multiple pregnancies • Early age of sexual intercourse • Obesity with diet low in veggies/fruits • Low socioeconomic • History of STD’s/multiple partners

24. Cancer’s cont. • Preventable • Gardasil Vaccine • Currently for ages 9-26 • 3 dose intervals: Now, 2 months, 4 months

25. Cancer Risk’s cont. Uterine • African American ethnicity • Obesity • Never been pregnant • Middle age to elderly (>55 yrs.old) • Diabetes • Breast,Colon,Ovarian cancer • ERT

26. Cancer Risk’s cont. Ovarian • Start menses before age 12 • Late Menopause (older than 55 yr) • Infertility/Infertility drugs • No children/1st after age 30 • Family history of cancer • Personal history of breast cancer

27. Cancer Risk’s • Health Maintenance • Annual check-ups • Get concerns looked at ASAP • DUB/Abd. bloating/Masses/lumps • Treatment may be medication or surgery

28. Urinary Incontinence • Stress Incontinence: Sudden loss of urine from intra-abdominal pressure without detrusor muscle contraction (sneezing, coughing, laughing) • Urge Incontinence: Loss of urine with strong desire to void as bladder contracts, result of detrusor instability. Strain to empty bladder, but emptying is incomplete

29. Urinary Incontinence • Mixed Incontinence: Symptoms of both stress and urge incontinence with one being more bothersome. • Overflow Incontinence: Involuntary loss of urine associated with over-distention of the bladder from and underactive or contractile detrusor or outlet obstruction. In men results from benign prostatic hyperasia

30. Treatment Kegels exercises Biofeedback Pelvic stimulation Urodynamics for further evaluation. Prolapsed: Pessary or surgery Consult Medications Estrogen Vaginal creams Anticholinergics Surgery Bladder Neck Sling (TVT) Urinary Incontinence cont.

31. Benign Disorders • Fibroids: consisting of muscle tissue that grows in or on the wall of the uterus • Polyp: Single or multiple fingers of soft uterine tissue that dangle from the uterine wall • Adhesions: Areas of scar tissue • Cysts: Fluid-filled sac Can cause dysfunctional uterine bleeding Do pelvic ultrasound Decide how to treat (surgery or not?)

32. Pelvic Organ Prolapse • Cystocele: bladder drops into vagina • Rectocele: Rectum bulges into vagina • Enterocele: Small Intestine bulges into vag. • Uterine Prolapse: Uterine drops into vagina • Vaginal Vault Prolapse: Uterus removed, walls of vaginal fall into themselves

33. Nonsurgical Treatment Help ease the symptoms of the prolapse if it is mild: • Wearing a Pessary to help support the organ • Doing Kegal exercises to strengthen the pelvic floor muscles • Kegel: Contract your pelvic floor muscle as if to stop the urine stream. 10 times a couple times a day

34. Surgical Intervention • Cystocele: Anterior Repair (sutures) • Rectocele/Enterocele: Posterior repair (sutures) • Uterine Prolapse: Hysterectomy • Vaginal Vault Prolapse: Suspension

35. Monitor: Fluids, Vitals, Dressing check TCDB: Q2 hrs. Foley: Check color and record drainage Pain management Prevent DVT’s: TEDS, leg exercises q 1 hr., early ambulation Emotional support Discharge teaching: No heavy lifting, nothing in vaginal for 6 weeks, driving for 2-3 weeks, check s/s for infection F/U in Office Post-op Care

36. Hormones Estrogen: Secreted by the ovaries • Protects against heart disease, stroke, osteoporosis, dementia, and memory disorders. • Improves thickness and elasticity of skin, vaginal and bladder walls • Improves brain function, body balance and coordination

37. Hormones cont. • Progesterone secreted by ovaries • Progesterone prepares the uterus for pregnancy. • Protects against uterine, breast cancers, osteoporosis, fibrocystic breast disease and ovarian cysts

38. Hormones cont. • Testosterone secreted by testes, ovaries, and adrenal gland. • Affects energy levels, muscle mass, strength, endurance, fat development, exercise tolerance and mood. • Protects against heart attacks, strokes, HTN, obesity, and arthritis

39. Hormones cont. • Thyroid secreted by thyroid gland • Regulates blood circulation, body temperature, metabolism and brain function • Protects against heart attacks and strokes, improves brain metabolism. Helps prevent memory problems

40. Symptoms can last as long as 7-10 years Hot Flashes Night Sweats Vaginal Dryness Mood Swings Forgetfulness H/A Changes in Menstrual cycle Urinary Problems Decreased Libido Perimenopause

41. Perimenopausal What to do? • Help with Symptoms • Soy-rich diet • Hormonal therapy ERT/HRT • Dress layers • Vaginal creams • Vitamin D and Calcium • Diet and exercise (Kegels) • FSH Levels > then 8 into 40 range

42. Oral Contraceptives HRT ERT with no uterus Most common symptoms treated are: Hot flashes, Night Sweats, and Vaginal Dryness Drug Therapy

43. Low Dose Oral Contraceptives • Estrogen and Progestin • Help with: regulate periods, improve sleep and mood swings • Will continue to have uterine bleeding even after menopause which can make it difficult to determine whether menopause is reached.

44. Pros Effectively manages symptoms Protect against Osteoporosis May reduce risk of colon cancer Cons Does not protect against heart disease Slightly increases the risk of heart attack, strokes, blood clot, and slight increase in breast cancer ERT/HRT

45. HRT • Alleviates hot flashes, night sweats, and vaginal dryness symptoms • Prevents bone loss • Improves cholesterol levels • Good candidate if you do not have a history of or high risk factors for breast cancer, bloods clots, stroke, or heart disease

46. HRT • Cyclic HT: Estrogen for 25 days, add Progesterone on last 10-14 days, then 3-6 days of no therapy • Continuous-cyclic HT: Estrogen every day, Progesterone on last 10-14 days, • Continuous-combined: Estrogen and Progesterone every day • Intermittent-combined: Estrogen every day, Progesterone add three days on, three days off

47. HRT • Combined Estrogen/Progesterone • Oral (Premphase/Prempro) • Transdermal (Climara Pro) Twice weekly • Progestogen Only • Oral (Provera, Prometrium)

48. ERT • Estrogen only without a uterus. • Oral Pills (Premarin) • Transdermal Patches (Climera) Once weekly • Vaginal Creams (Estrace)

49. Menopause Cessation of menses over a 12 month period Considered a transition of biological and cultural event. Natural or Surgical Menstrual periods stop occurring because the ovaries no longer produce the hormones progesterone and estrogen. (90% of bodies total production) Median age is 51

50. Menopause • It frees women from periods • No pregnancy/contraceptive concerns • Fewer child care responsibilities • Increased opportunities to pursue other goals • More leisure time/community involvement • Some have few to no symptoms