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

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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

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 Women’s 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; naïve 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:

AGC—atypical glandular cells

AIS—endocervical 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 include:

Repeat pap and HPV in 1 year; OR

Immediate HPV 16/18 assay, if available

Cotesting in one year:

If positive on either test: Refer for colposcopy

If negative: Return to routine screening

16/18 genotyping

If 16/18 positive: refer for colposcopy

If 16/18 negative: Repeat pap + HPV in 1 year

NEGATIVE PAP WITH POSITIVE HPV

ASC-US CYTOLOGY RESULTS ASC-US: perform HPV testing

HPV Negative: Continue routine screening per

age-specific guideline

HPV Positive: Refer for colposcopy

YOUNG WOMEN AND HPV

2007 survey: 24.5% of those aged 14-19 were

positive for HPV, and 17.6% positive for high-

risk HPV

44.8% of women aged 20-24 tested positive for

HPV; 28% positive for high-risk HPV

Conclusion: adolescents and young women

acquire HPV efficiently

YOUNG WOMEN AND HPV

Young women are also very efficient at clearing

the infection

Median duration of HPV infection in one study

was 8 months

70% no longer infected by 12 months

81% no longer infected by 24 months

0.1% rate of cervical cancer in adolescents

(~1/1,000,000)

YOUNG WOMEN

Young women (age 21-24) with ASC-US or LSIL:

Reflex HPV for ASC-US only; OR

Repeat cytology in 12 months (preferred)

If negative, ASC-US or LSIL, repeat pap again in 12

months

If negative, return to routine screening

If ASC-US or higher, rec. colposcopy

If HSIL, recommend colposcopy

YOUNG WOMEN 21-24

DECISION-MAKING TREE

ASC-H: Recommend colposcopy

No CIN 2 or 3: repeat pap @ 6 & 12 mo OR

HPV DNA testing at 12 months

If any pap abnormality or + HPV, repeat

colposcopy

If negative, return to routine screening

DECISION-MAKING TREE

LSIL: Recommend colposcopy

No CIN 2 or 3: repeat pap @ 6 & 12 mo OR HPV

DNA testing at 12 months

If any pap abnormality or + HPV, repeat colposcopy

If negative, return to routine screening

CIN 2 or 3: Diagnostic excisional procedure

DECISION-MAKING TREE

HSIL:

Immediate Loop Electrosurgical Excision (LEEP) or

Colposcopy with endocervical assessment

If no CIN 2 or 3, either observation with

colposcopy and pap at 6 & 12 months OR

diagnostic excisional procedure

ABNORMAL PAP IN PREGNANCY

ASC-US & HPV+ or LSIL – 2 options: Colposcopy without endocervical sample

No CIN 2 or 3: Postpartum follow-up

CIN 2 or 3: consider least-invasive excisional procedure

Defer colposcopy until at least 6 wks postpartum

HSIL or ASC-H: Colposcopy without endocervical sample

(as above)

DIAGNOSTIC PROCEDURES

Biopsy

Endocervical Sampling

Endometrial Sampling

LEEP – Loop Electrosurgical Excision Procedure

Cone Biopsy

Cryotherapy (freezing)

Laser treatment

Differential Diagnosis of Vaginal Infections

VAGINITIS

Inflammation of the vagina

A change in microbial balance:

Use of antibiotics

Change in hormones due to pregnancy, breastfeeding or menopause

Douching

Spermicide or lubricant use

Sexual intercourse

Infection

COMMON VAGINAL INFECTIONS

Yeast - Candida

Bacterial Vaginosis (BV)

Trichomonas

Less common:

Ureaplasma or Mycoplasma infection

DIAGNOSIS OF VAGINAL INFECTIONS

Discharge – appearance Normal: White, creamy

Yeast: White, curdy

BV: Thin, white/gray, adherent

Trich: yellow/green, frothy

pH Normal: 3.8-4.2

Yeast: <4.5

BV & Trich: >4.5

DIAGNOSIS OF VAGINAL INFECTIONS

Amine Odor (KOH “whiff test”) Normal: absent

Yeast: absent

BV & Trich: fishy

Microscopy Normal: epithelial cells, lactobacilli

BV: clue cells; no WBCs & no lactobacilli

Trich: trichomonads; WBCs

Yeast: w/KOH: hyphae, buds

EPITHELIAL CELLS

LACTOBACILLI

RED AND WHITE BLOOD CELLS

YEAST

YEAST

BV – CLUE CELL

BV – CLUE CELL

TRICHOMONAS

TRICHOMONAS

OVERVIEW

CONTRACEPTION

CONTRACEPTION

Hormonal Contraceptives:

Progestin-only:

Implantable – Mirena & Skyla IUD, Nexplanon

Injectable – DepoProvera

POP - “Mini Pill”

Combined Estrogen & Progestin:

COC – “The Pill”

Nuva Ring

Evra Patch

CONTRACEPTION

Non-Hormonal:

Barrier Methods:

Diaphragm

FemCap

Condoms – Male and Female

Withdrawl

Spermicides

Copper IUD (Paragard)

Natural Family Planning

Lactation Amenorrhea

“MORNING AFTER”

Progestin-only

Plan B

RX vs pharmacist-prescribed vs OTC

Progesterone Receptor Modulator

Ulipristal: ella

Limited availability at this time

Paragard (copper IUD) insertion

Highest efficacy – within 5 days of sexual intercourse

CONTRACEPTIVE EFFECTIVENESS

BRANCHING OUT – AREAS OF EXPERTISE

Menopause – may include complementary

therapies or Bio-HRT

Transgender care – may include hormone

therapy

Herbal consultations for specific health issues

Adrenal fatigue, Hypothyroidism, Chronic fatigue

Adolescent and teen health