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G YNECOLOGICAL C ONSIDERATIONS IN T REATING W OMEN WITH P HYSICAL D ISABILITIES

G YNECOLOGICAL C ONSIDERATIONS IN T REATING W OMEN WITH P HYSICAL D ISABILITIES. Developed by the Center for Research On Women with Disabilities, Baylor College of Medicine. OBJECTIVES.

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G YNECOLOGICAL C ONSIDERATIONS IN T REATING W OMEN WITH P HYSICAL D ISABILITIES

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  1. GYNECOLOGICAL CONSIDERATIONS IN TREATING WOMEN WITH PHYSICAL DISABILITIES Developed by the Center for Research On Women with Disabilities, Baylor College of Medicine

  2. OBJECTIVES • • Identify effects of physical disabilities on masking symptoms and creating special concerns in reproductive health. • Describe factors that interfere with diagnosing STD’s in women with physical disabilities. • Select special techniques for conducting pelvic examinations. • List the requirements of the Americans with Disabilities Act (ADA) for medical facilities. • Recognize the symptoms of physical and sexual abuse, and refer women appropriately.

  3. Percentage of Women 22% with Disabilities Compared to Overall Population U.S. Census, 1994.

  4. FINDINGS National Study of Women with Physical Disabilities • 94% sexually active • Equal rates of STDs • 31% denied services • Significantly less likely to receive exams • Barriers significantly discouraging • 62% abused

  5. CASE STUDY Day 1 HISTORY: 24-year-old; Complete T2 SCI; Intermittent catheterization; Previous UTIs & Yeast infections EXAM: Discharge; Frequent leg spasms. TREATMENT: OTC miconazole

  6. CASE STUDY Day 11 COMPLAINTS: Fever; Headache; Sweating EXAM: 160/95; 70 bpm; Bruises; Firm, tender abdomen; Elevated WBC; Few bacteria DIAGNOSIS: Urinary Tract Infection TREATMENT: Oral cotrimoxazole

  7. CASE STUDY Day 15-ICU COMPLAINTS: Fever; Headache; Sweating; Nausea; Flushing; Cold feet EXAM: 210/105; Bowel sounds absent; Firm abdomen; WBC 21K w/97% segs; Staphylococcus epi, E. Coli Klebsiella; BP elevates w/bimanual exam (EXAM STOPPED) DIAGNOSIS: Urosepsis TREATMENT: Nitroprusside drip; ceftazidime

  8. CASE STUDY Day 16-18 TREATMENT: Ampicillin; Clindamycin; Exploratory laparotomy drainage DIAGNOSIS: Acute salpingitis and tubo- ovarian abscess; Cultures grow chlamydia NOTE: Day 18 fever resolves, BP returns to 100/70 mmHg

  9. STDs in women w/SCI Factors Interfering with Diagnosis: • Common symptoms absent or undetected • Findings attributed to more common causes • Nonspecific signs and symptoms unrecognized • Delay in seeking medical attention

  10. AUTONOMIC DYSREFLEXIA Lesion Stimulus

  11. AUTONOMIC DYSREFLEXIA Symptoms • Severe hypertension • Pallor • Piloerection • Sweating

  12. AUTONOMIC DYSREFLEXIA Management • Education / Prevention • Gentle use of speculum • Local anesthetic

  13. AUTONOMIC DYSREFLEXIA Treatment • Remove stimulus • Gentle use of speculum • Local anesthetic • Stop exam • Reposition patient • Loosen clothing • Check bladder / rectum • Administer short acting antihypertensive

  14. THE GYNECOLOGICAL EXAM • • History—menstrual and sexual • • Examination • Breast—inspection and palpation • Pelvic—speculum, bimanual • Rectal • • Screening tests as appropriate • Mammogram • Pap Test • Vaginitis & STD’s • Fecal occult blood • Bone density • • Contraceptive counseling

  15. PATIENT TRANSFERS

  16. EXAM POSITIONS

  17. EXAM POSITIONS

  18. CONTRACEPTION • General • Data scarce • Effects of hormones on disabilities • Oral contraceptives • Thrombotic predisposition • Effect on coagulation markers • Benefits

  19. CONTRACEPTION • Depo-provera and norplant • Irregular bleeding • Decreased bone mass • Barrier methods • Inconvenient • UTI • IUDs • Pelvic inflammatory disease

  20. MENSTRUAL MANAGEMENT • Manual dexterity • Transfer techniques • Pharmaceutical intervention

  21. DISABILITY & MENOPAUSE • Premature osteoporosis

  22. OTHER ISSUES • Decreased tissue turgot & strength • Loss of skin elasticity • Reduced blood supply to skin & soft tissue • Vasomotor instability

  23. ABUSE • High prevalence among women with disabilities • Longer periods of time • More difficulty resolving abusive situations • More likely abuse in medical settings • Excuses for signs of abuse

  24. ABUSE Clues from Medical History • Inconsistent description • Time delay • Accident-prone history • Suicide attempts or depression • Repeated psychosomatic complaints • (Adapted from Salber PR, Taliaferro, E, 1995)

  25. ABUSE Clues from Medical History (cont.) • Alcoholism and/or drug abuse • Injuries during pregnancy • Poor nutrition • Other pregnancy-related problems • Post-traumatic stress syndrome • Disability-related abuse

  26. HOW TO HELP What To Do For Abused Patient • Talk about abuse • Assess degree of danger • Help develop safety plan • Document the incident • Plan for follow-up • Provide resource information

  27. ADA - Examples of Disabilities • Orthopedic, visual, speech and hearing impairments• Cerebral palsy• Epilepsy• Muscular dystrophy• Multiple sclerosis• Cancer• Heart disease • Diabetes• Mental retardation• Psychiatric disability• Specific learning disabilities• Tuberculosis• Past history of drug addiction and/or alcoholism

  28. ADA REQUIREMENTS • Guaranteed services• Equal services• Integrated setting• Facility evaluation• Accessibility modifications• Administrative or eligibility criteria• Practices, policies, and procedures• Providers’ costs

  29. IDEAL PHYSICIAN’S OFFICE • • Hallways and exam room able to accommodate wheelchair • Adjustable-height, extra-wide padded exam table • Platform scale • Staff trained to assist with dressing and to be sensitive to disability issues

  30. GOOD EXAMPLES

  31. EXAM TABLE ADJUSTABLE HEIGHT

  32. PLATFORM SCALE

  33. HOPES & DREAMS

  34. This CME Presentation was developed by the Center for Research on Women with Disabilities Margaret A. Nosek, PhD, Executive Director Department of Physical Medicine and Rehabilitation Baylor College of Medicine Houston, Texas www.bcm.tmc.edu/crowd/ With funding from the Paralyzed Veterans Association, Education and Training Foundation and the National Institute on Disability and Rehabilitation Research

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