Common Female Complaints The 3 Ps Dana Davenport, APRN, MSN, FNP-C Family Nurse Practitioner

Objectives Upon completion of this lecture, the nurse will be able to: 1. Discuss common problems woman have effecting their menstrual cycle. 2. Identify common causes of gynecological pain. 3. Discuss recommended treatment for common STDs. 4. Discuss options for preventing pregnancy. 5. Discuss updates related to prevention of cervical cancer.

The 3 P’s Periods Pain Prevention Women seeking care for gynecological needs often present with a complaint associated with their period, a complaint of pain or seeking prevention of pregnancy or cervical cancer.

Periods Amenorrhea Irregular periods Dysfunctional Uterine Bleeding Dysmenorrhea

Amenorrhea Causes Diagnosis Pregnancy Infection PCOS Thyroid Stress, exercise, eating disorder Anatomical, hormonal, Tumor Diagnosis Complete history Pregnancy test Labs: TSH, Prolactin, FSH, LH, Testosterone Page 453 in Williams (Beckmann, et al., 2014) (Hoffman, Schorge, Schaffer, Halvorson, Bradshaw, & Cunningham, 2012)

Irregular Periods Causes Diagnosis Infection PCOS Thyroid Stress, exercise, eating disorder Tumor Diagnosis Obtain complete history Labs: TSH, Prolactin, FSH, LH, Testosterone (Beckmann, et al., 2014) (Hoffman, Schorge, Schaffer, Halvorson, Bradshaw, & Cunningham, 2012)

(Cervical polyps, 2017) (Fibroids, 2015) (Polyps)

Treatment Pregnancy – refer for OB care. Lifestyle changes Medication Treatment of infection PCOS treatment options Lifestyle changes Medication Referral to OBGYN or other surgeon. (Kaunitz, Approach to abnormal uterine bleeding in nonpregnant reproductive-age women, 2016)

Dysfunctional Uterine Bleeding Causes Ovulatory dysfunction Polyp Leiomyoma Malignancy Diagnosis Labs: CBC, Sonography Treatment Medication Surgery Remember to watch for anemia. (The American College of Obstetrics and Gynecologists, 2013)

Dysmenorrhea Primary Symptoms Treatments Cramping Nausea Vomiting Low back pain Headaches Diarrhea Treatments NSAIDs OCPs Diet changes Pain associated with menstruation (Hoffman, Schorge, Schaffer, Halvorson, Bradshaw, & Cunningham, 2012)

Types of Gynecological Pain Lower abdominal pain Ovarian Pain Pelvic Pain Dyspareunia

Causes of pain Gynecological Urological Gastrointestinal UTI Cystitis Infection Ectopic Pregnancy Ovarian cysts Endometriosis Leiomyomas Urological UTI Cystitis Urinary tract stone Gastrointestinal Irritable bowel syndrome Constipation Colitis Diverticular disease (Hoffman, Schorge, Schaffer, Halvorson, Bradshaw, & Cunningham, 2012)

Case Study A 17 year old female presents complaining of dysuria for about one week. Denies increased frequency, odor, hematuria. Patient also denies being sexually active, vaginal discharge or abnormal periods.

Cause of Pain Diagnose Obtain History Physical exam Labs Radiology Sexual history Physical exam Labs Radiology Laparoscopy

Treatment of Pain Treatment of infection Referral to Pain control PCOS treatment options Physical Therapy Referral to ER OBGYN Urologist Gastroenterologist (Barbieri, 2016) (Kaunitz, Approach to abnormal uterine bleeding in nonpregnant reproductive-age women, 2016)

Sexually Transmitted Infections Bacterial Vaginosis Chlamydia Gonorrhea Herpes HPV Syphilis Trichomoniasis

STD Treatment (STD Tx guide , 2015)

Bacterial Vaginosis Signs and symptoms Diagnose Treatment Discharge Itching odor Diagnose exam Wet prep Clue cells pH of >4.5 Treatment Metronidazole 500 mg po bid for 7 days OR Metronidazole gel 0.75%, one applicator full intravaginally, once a day for 5 days Clindamycin cream 2%, one applicator full intravaginally at bedtime for 7 days Will discuss risk factors for getting BV. (Beckmann, et al., 2014) (Center for Disease Control and Prevention, 2010)

Chlamydia Treatment Diagnosis Signs and symptoms Asymptomatic Discharge Vaginal bleeding Dysuria Diagnosis Swab Urine test Treatment Azithromycin 1 g po OR Doxycycline 100 mg po bid for 7 days (Center for Disease Control and Prevention, 2010) (Hoffman, Schorge, Schaffer, Halvorson, Bradshaw, & Cunningham, 2012)

Gonorrhea Treatment Diagnosis Signs and symptoms Asymptomatic Discharge-yellow or green Vaginal bleeding Dysuria Diagnosis Swab Urine test Treatment Ceftriaxone 250 mg IM in a single dose Plus Azithromycin 1 g po in a single dose When treating for gonorrhea it is also recommended to treat for Chlamydia, due to the fact that it is hard to diagnose Chlamydia in the presence of gonorrhea and the high likelihood of having both types of infection. (Beckmann, et al., 2014) (Beckmann, et al., 2014) (Center for Disease Control and Prevention, 2010)

Trichomoniasis Treatment Diagnosis Alternative Signs and symptoms Vulvar itching/burning Discharge- copious odor Dysuria dyspareunia Diagnosis Wet prep Urine test Treatment Metronidazole 2 g po in a single dose Tinidazole 2 g po in a single dose Alternative Metrondazole 500 mg po bid for 7 days. (Beckmann, et al., 2014) (Center for Disease Control and Prevention, 2010)

Prevention Surgical LARCs Injection Pills/Patch/Ring Barrier/Spermicide Withdrawal Fertility awareness (Effectiveness of family planning methods, 2011)

U.S. Medical Eligibility Criteria for Contraceptive Use (Curtis, et al., 2016)

Deciding what contraception is best? 1. What are your contraceptive goals? 2. Do you have any healthcare problems? 3. What are your periods like? 4. Are you currently sexually active with male partner? 5. What have you tried in the past? 6. Are you good at taking pills? 7. Is price an important factor? 8. Do you also need protection from STIs? (Kaunitz, Contraceptive counseling and selection, 2016)

Surgical Men Women Who should use this Vasectomy Tubal ligation Essure Hysterectomy Who should use this Men and women who do not want to conceive. (Braaten & Dutton, 2016)

LARCs IUD Implant Who should use this Copper Mirena – 5 years Skyla – 3 years Implant Nexplanon Who should use this Women who are wanting to wait 3-5 years to have a child. Adolescents People who say “I can’t remember to take a pill.” Discuss Pros and Cons of each method. MEC eligibility chart (Kaunitz, Contraceptive counseling and selection, 2016)

Injection Depo-Provera Who should use this medroxyprogesterone acetate Every 3 months Who should use this Women who do not want to conceive in the near future HTN Adolescents (Kaunitz, Contraceptive counseling and selection, 2016)

Oral Contraceptive Pills Monophasic Biphasic Triphasic Progestin-only Who should use OCPs Women who can remember to take a pill daily. Women who like regular cycles Women with PCOS Women who want to conceive in the near future (Kaunitz, Contraceptive counseling and selection, 2016)

Patch/Ring Patch Ring Who should use Patch/Ring Women who are comfortable with method. Women who like regular cycles Women who want to conceive in the near future (Kaunitz, Contraceptive counseling and selection, 2016)

Barrier/Other Condoms Sponge Cervical cap Diaphragm Calendar method Male Female Sponge Cervical cap Diaphragm Calendar method Who should use this method? Women who can’t or do not want to use hormonal contraception Women who also want STI protection (Kaunitz, Contraceptive counseling and selection, 2016)

Cervical Cancer Prevention HPV vaccine Pap test (The dreaded pap test: Opening up (literally) about my experiences, 2013)

HPV infection HPV risk factors Detection What is Human papillomavirus? HPV and Cancer risks Cervical cancer Head and neck cancer Anal cancer Penile cancer HPV risk factors Unprotected sexual contact Number of sexual partners Age Weakened immune system Damaged skin Personal contact Detection (Mayo Clinic Staff, 2017) (Palefsky & Cranston, 2015)

HPV Vaccinations Recommendations updated in 2016 Boys and girls ages 9-14 receive 2 doses. 1st dose 2 dose 6-12 months after first dose Boys and girls ages 15-26 receive 3 doses. 2nd dose- 1-2 months after first dose 3rd dose – 6 months after first dose (Meites, Kempe, & Markowitz, 2016)

Pap test Current guidelines No screening under age of 21 years Women 21-65 pap screening every 3 years 30-65 years screening pap with HPV Over 65 years with adequate testing no screening (Moyer, 2012)

References Barbieri, R. L. (2016, August 23). Evaluation of acute pain in women. Retrieved March 17, 2017, from Uptodate: https://www.uptodate.com/contents/evaluation-of-acute-pelvic- pain-in-women?source=search_result&search=pelvic%20pain&selectedTitle=1~150 Beckmann, C. R., Ling, F. W., Herbert, W. N., Laube, D. W., Smith, R. P., Casanova, R., et al. (2014). Obstetrics and gynecology, seventh edition. Baltimore: Lippincott Williams & Wilkins. Braaten, K. P., & Dutton, C. (2016, February 7). Overview of female sterilization. Retrieved March 10, 2017, from Uptodate: https://www.uptodate.com/contents/overview-of-female- sterilization?source=search_result&search=permanent%20sterilization&selectedTitle=1~ 150 Center for Disease Control and Prevention. (2010). MMWR 2010;55(No RR-12). Alanta: U.S Department of Health and Human Services. Cervical polyps. (2017, March ). Retrieved March 18, 2017, from University of Florida health: https://ufhealth.org/cervical-polyps Curtis, K. M., Tepper, N. K., Jatlaoui, T. C., Berry-Bibee, E., Horton, L. G., Zapata, L. B., et al. (2016). U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep 2016;65(No. RR-3), 1-104. Effectiveness of family planning methods. (2011). Retrieved March 11, 2017, from www.cdc.gov: https://www.cdc.gov/reproductivehealth/contraception/unintendedpregnancy/pdf/cont raceptive_methods_508.pdf

References Fibroids. (2015, May 12). Retrieved March 15, 2017, from slideshare.net: https://www.slideshare.net/fahadzaq1/fibroids-48053511 Hoffman, B. L., Schorge, J. O., Schaffer, J. I., Halvorson, L. M., Bradshaw, K. D., & Cunningham, F. G. (2012). Williams Gynecology, second edition. McGraw-Hill. Kaunitz, A. M. (2016, 13 October). Approach to abnormal uterine bleeding in nonpregnant reproductive-age women. Retrieved March 11, 2017, from Uptodate: https://www.uptodate.com/contents/approach-to-abnormal-uterine-bleeding-in- nonpregnant-reproductive-age- women?source=search_result&search=irregular%20menses&selectedTitle=1~150 Kaunitz, A. M. (2016, 15 November). Contraceptive counseling and selection. Retrieved March 15, 2017, from Uptodate: https://www.uptodate.com/contents/contraceptive- counseling-and- selection?source=search_result&search=contraception&selectedTitle=1~150 Mayo Clinic Staff. (2017). HPV infection. Retrieved March 10, 2017, from Mayoclinic.org: http://www.mayoclinic.org/diseases-conditions/hpv-infection/symptoms-causes/dxc- 20199064 Meites, E., Kempe, A., & Markowitz, L. (2016, December 16). Use of a 2-dose schedule for human papillomavirus vaccination-updated recommendations of the advisory committee on immunization practices. Retrieved March 16, 2017, from MMWR 2016; 65:1405-1408: http://dx.doi.org/10.15585/mmwr.mm6549a5

References Moyer, V. A. (2012, March). Screening for cervical cancer: U.S. preventive services task force recommendation statement. Retrieved March 10, 2017, from Uspreventiveservicestaskforce.org: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/c ervical-cancer-screening Palefsky, J. M., & Cranston, R. D. (2015, May 10). Virology of human papillomavirus infections and the link to cancer. Retrieved March 10, 2017, from uptodate: https://www.uptodate.com/contents/virology-of-human-papillomavirus-infections- and-the-link-to-cancer?source=search_result&search=HPV&selectedTitle=1~150 Polyps. (n.d.). Retrieved March 15, 2017, from Womens-health-advice.com: http://www.womens-health-advice.com/polyps/ STD Tx guide . (2015). Retrieved March 10, 2017, from Google play: https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&ua ct=8&ved=0ahUKEwjM1fvV7NHSAhWJxYMKHXVaBtcQjRwIBw&url=https%3A%2F%2Fplay. google.com%2Fstore%2Fapps%2Fdetails%3Fid%3Dgov.cdc.stdtxguide&bvm=bv.1493977 26,d.cGc&psig=AFQjCNFA86LGWlX0Y The American College of Obstetrics and Gynecologists. (2013). Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Committee on Gynecologic Practice. The dreaded pap test: Opening up (literally) about my experiences. (2013, October 27). Retrieved March 10, 2017, from Randomdysfunctions.com: https://randomdysfunctions.com/funny-pap-test-stories/