1. TPMG CME Conference 2015 Jeff Morrison, DO

2. Searched for New Patient visits and Consults to TPMG Ob/Gyn in 2013 and 2014. 2070 Patient visits Menorrhagia Irregular Menses Vaginitis Postmenopausal bleeding Contraceptive Counseling Cystocele

3. Reproductive Age Females 80 ml A volume of bleeding that interferes with daily activities Changing a pad or tampon more that every two hours

4. Pregnancy, Pregnancy, Pregnancy Uterine abnormalities Ovulatory dysfunction Cancer Bleeding disorder Infection Endocrine abnormalities Medication

5. Perimenopause Anovulation Uterine abnormalities Cancer

6. 53/1000 US women experience difficulties 5,300/100,000 Cervical Cancer – 6/100,000 Breast Cancer – 122/100,000 Colon Cancer – 39/100,000 Influenza Deaths – 1.2/100,000

7. What’s the source? History Is she pregnant? Contraception, sexual activity? Has this happened before? Previous evaluation? Last Pap smear? Hx of abnormal pap smears? Context of bleeding? New medications?

8. Physical Exam Ultrasound BHCG, CBC, TSH, Chlamydia/Gonorrhea testing

9. History is unreliable Physical Exam Ph testing, Wet prep, Culture 60% vulvovaginitis 70% trichomoniasis 90% bacterial vaginosis

10. Vaginal pH BV (>4.5) Trichomoniasis (5-6) Candida (4-4.5)

11. No Microscope Culture for yeast NAA (nucleic acid amplification) tests for trichmoniasis, bacterial vaginosis, candida Culture for candida Bacterial cultures are unreliable

12. DNA tests for Gonorrhea and Chlamydia Cytology – unreliable Confirmation with wet prep BV – sensitivity 49% vs wet prep Trichomoniasis – False-positive rate of 4%

13. Non-infectious causes Atrophy Lichen sclerosis Contract dermatitis Stress Incontinence

14. BV – frequently recurrent (30% within 3 months) Partner treatment ineffective Prolonged antibiotic therapy

15. Rule out malignancy History Symptoms Timing Aggravating Factors Medications OTC treatments Family Hx of breast, colon, and gynecologic cancers BMI

16. Pelvic US Endometrial lining is > 4mm Endometrial changes – diffuse or focal increased echogenicity (heterogeneity) Endometrium not adequately visualized Endometrial biopsy/sampling

17. Persistent bleeding Endometrial biopsy/sampling

18. Cervical cancer Mean age 52.2 years Peaks at 35 – 39, and 60-64 Endometrial cancer Mean Age 61 years >40% women older than 65

19. Many changes Permanent vs. Reversible Permanent Methods Vasectomy Hysteroscopic tubal occlusion (In-office procedure) Laparoscopic bilateral tubal cauterization

20. Paragard IUD Mirena IUD Skyla IUD Nexplanon implant Depot Provera Nuva ring Ortho Evra patch OCPs Natural family planning Condoms, Diaphragm Withdrawal

21. 46% of women discontinue contraception – side effects, partner complaint Nexplanon implant and Progesterone IUD 84,80% continuation rate Copper IUD – 78 % continuation rate Pill, patch, ring – 67 %

22. Asymptomatic – no treatment needed Symptomatic –Pessary –Surgical intervention Apical support – traditional vs. mesh repair Anterior repair – High rate of recurrence without apical support Mesh repair – lower rate of recurrence

23. Poor surgical candidate Le Forte colpoclesis