tpmg cme conference 2015 jeff morrison, do. searched for new patient visits and consults to tpmg...
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Workup for Common Gynecologic Problems
• 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
Menorrhagia (Abnormal uterine bleeding)
• Reproductive Age Females
• 80 ml• A volume of bleeding that interferes with
daily activities• Changing a pad or tampon more that
every two hours
Menorrhagia (Abnormal uterine bleeding)
• Pregnancy, Pregnancy, Pregnancy
• Uterine abnormalities• Ovulatory dysfunction• Cancer• Bleeding disorder• Infection• Endocrine abnormalities• Medication
Menorrhagia (Abnormal uterine bleeding)
• 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
Menorrhagia (Abnormal uterine bleeding)
• 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?
Menorrhagia (Abnormal uterine bleeding)
• Physical Exam
• Ultrasound
• BHCG, CBC, TSH, Chlamydia/Gonorrhea testing
Vaginitis• History is unreliable
• Physical Exam• Ph testing, Wet prep, Culture
• 60% vulvovaginitis• 70% trichomoniasis• 90% bacterial vaginosis
Vaginitis
• No Microscope• Culture for yeast• NAA (nucleic acid amplification) tests for
trichmoniasis, bacterial vaginosis, candida• Culture for candida• Bacterial cultures are unreliable
Vaginitis
• DNA tests for Gonorrhea and Chlamydia• Cytology – unreliable• Confirmation with wet prep• BV – sensitivity 49% vs wet prep• Trichomoniasis – False-positive rate of 4%
Vaginitis
• Non-infectious causes• Atrophy• Lichen sclerosis• Contract dermatitis• Stress Incontinence
Vaginitis
• BV – frequently recurrent (30% within 3 months)
• Partner treatment ineffective• Prolonged antibiotic therapy
Postmenopausal Bleeding• Rule out malignancy• History• Symptoms• Timing• Aggravating Factors• Medications• OTC treatments• Family Hx of breast, colon, and gynecologic cancers• BMI
Postmenopausal Bleeding
• Pelvic US• Endometrial lining is > 4mm• Endometrial changes – diffuse or focal
increased echogenicity (heterogeneity)• Endometrium not adequately visualized
• Endometrial biopsy/sampling
Postmenopausal Bleeding
• 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
Contraception• Many changes
• Permanent vs. Reversible
• Permanent Methods• Vasectomy• Hysteroscopic tubal occlusion (In-office procedure)• Laparoscopic bilateral tubal cauterization
ContraceptionReverisible methods
• Paragard IUD• Mirena IUD• Skyla IUD• Nexplanon implant• Depot Provera• Nuva ring• Ortho Evra patch• OCPs• Natural family planning• Condoms, Diaphragm• Withdrawal
Contraception
• 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 %
Cystocele/Prolapse• 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
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