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Transcript of Well Woman Care: Overview and Updates Well Woman.pdf · Menopause – may include complementary...

  • WELL WOMAN CARE:

    OVERVIEW AND UPDATES

    2015 PLEASE NOTE THAT THESE SLIDES ARE POSTED ONLY FOR REFERENCE BY WORKSHOP

    PARTICIPANTS. ANY ADDITIONAL USE IS PROHIBITED UNLESS EXPLICIT PERMISSION IS OBTAINED.

    Workshop presenter:

    Hilary Schlinger, CNM, MS

  • WHY MIDWIVES?

    Applying the Midwifery Model to Womens Health

    Approach to Care:

    Education focus

    Individualized attention

    Holistic

    Integrative/complementary

    Non-judgmental

    Cultural sensitivity

    With Women Intimate with intimacy

    Sensitivity to abuse issues

  • WELL EXAM

    General Health Parameters

    Vitals, Physical Exam

    Laboratory Testing

    Based on Symptoms, History, Age

    Other Screening

    Based on Symptoms, History, Family History, Age

    and Personal Decision-making

    Breast Exam

  • WELL EXAM

    The Well-Woman Examination:

    Choosing the proper speculum

    &

    Performing a bimanual exam

  • VAGINAL SPECULUMS

    Graves: Wide, duck-billed

    Pederson: Narrow, straight sides

    Metal or plastic; reusable vs disposable

    Multiple lengths and widths available

  • SELECTING A SPECULUM

    Graves Postpartum

    Multiparous woman

    Known laxity of vaginal musculature

    During procedure, such as IUD insertion

    Pederson (medium width) Routine well-woman exam

    Narrow Pederson Young woman; 1st exam; nave to penetration

    Post-menopausal woman

  • GRAVES SPECULA

  • PEDERSON SPECULA

  • VISUAL EXAMINATION

    Examine the external genitalia for:

    Warts

    Other lesions

    Visible prolapse

    Discharge

    Internal skin color

    Hemorrhoids

    Lichensclerosis

  • INSERTING THE SPECULUM

    Tilt the handle to one side

    Angle downward toward coccyx

    Slowly rotate handle downward during insertion

    Wait to feel a give when beyond the vaginal muscles

    Slowly open by raising upper blade

    Obtain desired specimen(s)

    Remove by reverse of above

  • SUGGESTIONS FOR AN EASIER EXAM

  • INSPECT THE CERVIX BENIGN CHANGES

    Ectropion Endocervical Nabothian

    Polyp Cyst

  • INSPECT THE CERVIX PATHOLOGICAL

    CHANGES

    Cervical cancer

  • OBTAIN PAP AND CULTURES

    Broom, spatula/brush, or broom/brush?

    Broom alone adequate with pre-menopausal women

    due to lower transformation zone

    Some studies support broom/brush combination for

    use in older women with higher TZ

    ThinPrep or SurePath?

    Either can be used for Pap, HPV, and/or CT/GC

    ThinPrep: +Trichomonas

    SurePath higher cell yield, so may be superior for

    menopausal women with scant cellularity

    Check with your lab for acceptable lubricants

  • BIMANUAL EXAMINATION

    Use two lubricated, gloved fingers

    Place fingertips behind cervix

    Place external hand above pubic bone

    Gently lift cervix

    Palpate uterus between hands

    Assess for position, size, shape, firmness,

    mobility, tenderness or pain on palpation

  • BIMANUAL EXAMINATION

    Palpating the uterus

  • UTERINE POSITION

    Anteverted majority of women

  • UTERINE POSITION

    Anteflexed

  • UTERINE POSITION

    Retroverted

  • UTERINE POSITION

    Retroflexed

  • PALPATE THE OVARIES

    Move your internal fingertips to one side, into the adnexal area

    Using your external hand, push gently downward

    Sweep hands toward pubic bone

    Ovary will slip between your fingertips; the ovary is palpated by the internal fingers

    Repeat on the other side

  • PALPATING THE OVARIES

    Position of the ovaries:

  • OTHER FINDINGS: FIBROIDS

    Irregular shape of uterus:

  • OTHER FINDINGS: PID

    Tenderness or Pain on Palpation

    Discharge

    Causative organisms

    Most Common: Chlamydia or Gonorrhea

    Mycoplasma

    BV may contribute

    Treatment

    IM + PO outpatient vs in-hospital txt

  • OTHER LESS COMMON FINDINGS

    Irregularity of shape:

  • PAP THE NEXT GENERATION OF GUIDELINES

    Pap Smears

    Interpretation and Action

  • PAP SMEAR CERVICAL CYTOLOGY

    Screening for cervical cell changes Cancerous changes; abnormal cells

    Inflammation

    Infection

    Bethesda System for reporting of results

    Performed via speculum exam; brush & spatula OR broom OR broom & brush

    Liquid-Based Cytology:

    Not proven to be more accurate, however

    can also be used for HPV + other STIs

  • BETHESDA SYSTEM

    Satisfactory or Unsatisfactory?

    Endocervical component present?

    No cell abnormalities:

    Reported as Negative for Intraepithelial Lesion

    or Malignancy

  • SQUAMOUS CELLS

    Thin, flat cells that form the surface of the

    cervix

    Squamous cell abnormalities

    ASC-US most common abnormal pap result

    LSIL

    HSIL

    ASC-H

    Squamous cell carcinoma

  • SQUAMOUS CELL ABNORMALITIES

    Dysplasia and Cervical Intraepithelial Neoplasm

    (CIN) describe the actual cell changes

    CIN 1 mild dysplasia

    Usually resolves on its own

    CIN 2 moderate dysplasia

    CIN 3 severe dysplasia

  • GLANDULAR CELLS

    Mucus-producing cells found in the endocervical canal

    Glandular cell abnormalities:

    AGCatypical glandular cells

    AISendocervical adenocarcinoma in situ

    Adenocarcinoma

    Glandular cell abnormalities much less common than squamous cell abnormalities

  • PAP SMEAR

    Speculum exam and pap are performed prior to

    a bimanual exam

    Best time for a pap:

    Day 10-20 of cycle;

    When not menstruating;

    Has not douched, used vaginal creams or

    spermicides for 48 hours;

    Has not had a tampon in for 48 hours

  • WHO SHOULD HAVE A PAP?

    ASCCP Updated Guidelines of 2012:

    First pap at age 21 Women younger than 21 should not be screened regardless of risk factors

    Age 21 - 29:

    Screening pap every 3 years; reflex AS-CUS to HPV

    Age 30 - 65 with no history of CIN

    Screening pap + HPV-HR Co-testing every 5 years (preferred ) fewer colposcopies/sl. lower cancer rate

    OR Screening pap every 3 years

  • PAP SMEAR TIMING

    Not Annual Anymore:

    Annual screening for low-risk groups result in twice the rate of colposcopies with only slightly greater cancer risk reduction

    More intensive or alternative screening for:

    Women with HIV

    Women with immunosuppression

    DES-daughters

    Women with a history of CIN 2, CIN 3 or cervical cell carcinoma

  • WHO CAN STOP HAVING PAPS?

    Women whom have had a hysterectomy for

    non-cancerous reasons

    Women aged 65 or more with:

    At least 3 consecutive negative Paps

    OR 2 consecutive cotests in the past 10 years

    And adequate screening with no history of CIN 2+

    for past 20 years

    With most recent screening within past 5 years

  • CIN 2, CIN 3 OR CANCER DIAGNOSIS

    These women remain at risk for persistent or

    recurrent disease for at least 20 years

    Screening for 20 years, even in the event of

    hysterectomy or beyond age 65

  • HPV

    HPV: a group of >150 viruses

    Some types cause warts, including genital warts although those which cause genital warts are NOT those associated with cervical cancer

    Approximately 15 types are referred to as high-risk: i.e. they are more likely to cause cancerous changes in cervical cells

  • HPV TESTING

    Age 21-30: reflex testing for ASC-US

    Age >30: offer HPV-HR cotesting

    regardless of diagnosis every 5 years

    OR reflex testing, either for ASC-US or any

    abnormality on pap, with pap every 3 yrs

    Decision-making will be determined by

    both pap and HPV result

  • NEGATIVE HPV DNA TEST

    Offers better predictive value after 6 years

    than a negative pap does after 3 years

    Rates of CIN 3+ with neg HPV vs neg Pap:

    Pap: 3 yrs: 0.51%; 4 yrs: 0.69%; 5 yrs: 0.83%;

    6 yrs: 0.97%

    HPV: 3 yrs: 0.12%; 4 yrs: 0.19%; 5 yrs:0.25%;

    6 yrs: 0.27%

  • HPV GENOTYPE-SPECIFIC TESTING

    Why do typing?

    Assessing risk

    HPV 16 Highest risk of CIN 3+ of any HR type

    HPV 18 Associated with adenocarcinomas

    HPV High-Risk Other lower risk of future

    CIN3+ than 16 or 18

  • PAP, HPV, OR PAP + HPV?

    20,810 Women followed for up to 10

    years

    Negative Predictive Value for CIN 3 after

    45 months:

    Pap alone 99.47

    HPV DNA 99.76

    Pap + HPV 99.84

  • NEGATIVE PAP WITH POSITIVE HPV

    Occurred in 4% of cases overall

    Cumulative incidence of CIN 3+ 3% after 39 months

    5% after 120 months

    Selected group of HPV 16/18 positive 12% CIN 3+ after 39 months

    21% CIN 3+ after 10 years if HPV 16+

    17% CIN 3+ after 10 years if HPV 18+

    2% CIN 3+ after 10 years non 16/18+

  • NEGATIVE PAP WITH POSITIVE HPV

    Management options i