WWE:

HPI:

Pelvic pain
BCM
Menses
Pap
Breast

GU ROS: Denies vaginal discharge or abnormal bleeding. No vaginal pruritis or pain.

PHQ9

ROS:
General: no recent wt changes. no f/c. energy adequate.
HEENT: no sore throat
MSK: no breast masses or nodules, no extremities weakness
CV: no CP or palpitations.
Pulm: no cough / wheeze.
GI: no n/v, no diarrhea, no melena, good appetite
Skin: denies any rash

PMHx:
PCP:
Social: TED, home, partner violence, depression
Rx:

OBhx: GPs
Gynhx:
- STI hx
- pap hx
- menses:
- mammogram hx:
BCM:


PE:
General: NAD, afebrile.
HEENT: thyroid nonttp
CV: rrr w/o murmrurs. no heave
Pulm: ctab w/o wrr. good effort and good air movement.
Abdo: soft, nonttp. no palpable masses.
Skin: no rash noted on trunk, extremities.


Breast: b/l exam non-tender and no palpable masses, no discharge, no rash, dimpling, or skin retraction. b/l axillae w/o LAD or masses.

Pelvic: nl external F genitalia. uterus firm w/o palpable nodules, size nl. adnexae mobile, nontender.

SSE: vaginal wall w/o lesions or lacerations. no blood in vaginal vault. cervical os w/o notable lesions or discharge. no foul odor.

AP
#. WWE:
- w/o acute complaints today.
- social: low risk profile
- breast + pelvic exam: benign
- PHQ9:
- BCM:
- Pap hx:
- Breast hx:
>

* lipid panel / A1C / BP / TSH
* non-preg uterus = small pear


- OBGyn counseling : BCM, CV risk management,

------------
Mammogram:
- start 40-50 yo if pt requests; "co-decision"
- 50-75 yo; screen q2 yrs.
- ACOG: q1yr screen at 40 yo
- Fhx:
- BRCA testing:

Pap:
- start at 21 yo; low risk women: q3 yrs if <30 yo .
- co-test w/ HPV at 30 yo - extent to q5 yrs.
- dc Pap screen at 65 yo or TAH if benign hx.
- Pap App: pap and colpo recommendations

CRC:
- iFOBT q1yr; colonoscopy q10 yrs.

DEXA-scan:
- >65 yo F or RF groups (chronic CS use)
- possibly for >75 yo M as well.

HIV: screen everyone
STI screen: GC/CT/RPR/HIV --- ?trichomonas.
- high risk women screen q1yr.
- <24 yo + sexually active: chlamydia q1yr
- teen-65 yo: HIV screen
> if plan on pregnancy, start PNV 400-800 mcg ppx.

------------

Routine Care plans

#. Abnormal Uterine Bleed = Meno/metrorrhagia
- if >35 yo, EMB r/o malignancy
- TVUS: polyps, fibroids, adenomyosis
- start use of cycle calendar
* depo-provera
* provera (PO medroxyprogesterone) 10mg PO 14d/mo.
* progestin mini-pill : continuous w/ some 5-7 d breaks; menses during the break. progestin to maintain endometrium

#. Fibroids
- incidence increase w/ age (>40 yo); RFs: nullip, obese, fhx, black, HTN
- associated w/: menorrhagia, pelvic pain, infertility, pregnancy loss
- note that menorrhagia is associated w/ fibroids, but no good evidence that it directly causes it.
- most w/o sx and incidental findings
- if asymptomatic = expectant management
- myomectomy preserves future pregnancy.
- fibroids typically arise during pregnancy, then regress after menopause.
- fibroids is the MC indication for hysterectomies (30%)
- w/u: TVUS (also MRI, sonohysterogrpahy)
- tx: hysterectomy, myomectomy. uterine aa embolization, myolysis, medical therapy.

#. Pelvic Pain
- ddx: infectious: vaginitis / PID
- ddx: anatomical: endometriosis / adenomyosis
- ddx: physiologic: regular cramping
> cyclical
> infectious
> r/o GI
> rx so far

#. Dysmenorrhea

#. Dysfunctional Uterine Bleed

#. Breast pain

#. PCOS
- Px; hirsutism, irregular menses, central obesity

#. Infections GU
- BV: metronidazole 500mg BID x7d; or 2g x1.
- Trichomonas
- Candida VV: diflucan x1
- GC/CT

#. BCM
- Sexual activity: low risk , LMP: ,
- UPT neg
- No hx breast CA.
> counseled on risks; including breakthrough bleeding, elevated BPs
> pt must use alternative BCM (condom or abstinence) for 2 weeks after starting as may still become pregnant.
> pt declined STI panel
> RTC 3 mo; earlier if w/ migraine HA, breakthrough bleeding, or other side-effects.


- AAFP Contraception overview
- OCPs standard: : Sprintec course, advised of breakthrough bleeding in first 3-5 mo which typically resolves thereafter.
- side benefits : regulated menses, decreased dysmenorrhea, less PMS.

- OCPs longer interval: - Skipping menses : goaskalice : essentially can do this by taking monophasic (multiphase more difficult) OCPs and skip the placebo week; do it back to back, when wants menses, just no pills for 1 week then return to it. The longer go without menses, the heavier the menses.
- OCPs c/i: migraine w/ aura, major surgery w/ prolonged immobilization, hepatocellular CA/adenoma or cirrhosis, HTN (>160/>100), DM w/ cx or DM >20 years, m/l CV Res, breastfeeding women <6 wk PP. VTE/DVT hx. c/i in women >35 yo who smoke, hx VTE/CAD/CVA/PAD (estrogen cause clot; can use progestin instead).
- women w/ seizures: use OCPs w/ >30mcg estrogen only if on AEDs, they reduce OCP efficacy so need higher normal dose.


- Nexplanon : progesterone (etonogestril) inhibit ovulation. use for 3 months, may change if continues to have abnormal bleeding. Can have irregular or prolonged menses or amenorrhea; 1/10 quit nexplanon due to this. Nexplanon can be used to reduce dysmenorrhea.
- Nexplanon c/i:

- IUD :
- IUD c/i: pt denies anatomic abnormalities (including leiomyomas), GC/CT, untreated cervical CA.

- Depo; only depo associated w/ wt gain consistently. For most, can have spotting in between menses, some stop having menses after few cycles.
- Depo good for sickle cell disease pt (actually reduces painful crises). Depo is associated w/ bone thinning, but reverses when DC so actually not need to reduce use.

- Emergency contraception: nausea common (sx tx).
- BREAST CA c/i ALL hormonal contraceptives.

Menstrual Suppresion : guidelines

Mirena cause CVA risk? No, no estrogen does not inc risk.

Adverse side-effects of BCM; AAFP “Managing Adverse Effects of Hormonal Contraceptives”
- MC complaints: wt gain (depo : 10lb / 36 mo), HA (c/i migraine w/ aura, can cause new or worse HA), breast tenderness, breakthrough bleed (common first few months, usually resolves, all OCP formulations similar), mood (no actual evidence for this), sex (inconsistent evidence), skin ∆s (acne! can appear or worsen. can watch for 6mo for improvement).
- Most sx diminish w/ time as continue using same method; reassure that sx resolve by 3-5mo.
- HA: switching OCPs nor anything else will make difference.
- Nexplanon breakthrough bleed first incidence try 5d ethinyl estradiol, will shorten duration.
- Avoid OCPs postpartum 2/2 increased hyper-coagulability (Cochrane review actually no evidence for “breast milk quantity or quality” changes).
- All OCPs have same risk of side-effects.
- OCP use common to have breakthrough bleed in first 5 mo.
- Progestin only pills can worsen acne; may switch to OCP.
- Breakthrough bleeding in continuous contraception usually resolved with 3-4d hormone-free interval.
- Progestin only and low dose estrogen has higher chance of breakthrough bleeding.
- Persistent sx can try changing OCP.