Chapter 9 Primary Care in Gynecology

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Chapter 9Primary Care in Gynecology

• - Novaks Gynecology page 199230

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Primary Care in Gynecology

• Early diagnosis and treatment of medical
  illnesses can have a major impact on a womans
  health and is a key component of primary care.
• Although timely referral is important for complex
  and advanced disorders, the gynecologist
  initially may treat many conditions

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Primary Care in Gynecology

• Respiratory Infections
• Sinusitis
• Otitis Media
• Bronchitis
• Pneumonia
• Cardiovascular Disease
• Hypertension
• Cholesterol
• Endocrinologic Disease
• Diabetes Mellitus
• Thyroid Disease

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Respiratory Infection

• Sinusitis
• Otitis Media
• Bronchitis
• Pneumonia

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Respiratory Infection Sinusitis

• Etiology
• Infection begin with a viral agent in
  the nose or nasopharynx that
• cause inflammation that
  blocks the draining ostia.
• Viral agents impede the sweeping motion of
  cilia in the sinus and,
• in combination with
  the edema from inflammation,
• lead to superinfection
  with bacteria
• Bacterial agents S.pyogenes, S.pneumoniae, H.
  influenzae,
• Staphylococcus
  aureus
• a-hemolytic
  streptococcus species
• G(-) organism usually limited to
  compromised hosts in
• intensive
  care units
• chronic disease polymicrobial with
  mixed infections consisting
• of
  aerobic and anaerobic organisms.

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Respiratory Infection Sinusitis

• Factors to contributing the development of sinus
  disease
• atmospheric pollutants, allergy, tobacco
  smoke, skeletal deformities,
• dental conditions, barotrauma from scuba
  diving, airline travel,
• neoplasm,
• chronic sinusitis
• systemic disease (connective tissue
  syndrome), malnutrition
• Clinical finding
• 1) maxillary toothache
• 2) poor response to nasal decongestants
• 3) abnormal transillumination
• 4) a colored nasal discharge established by
  history
• 5) a colored nasal discharge on examination
• - 4 the likelihood of sinusitis?
• - none the likelihood of sinusitis ?

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Respiratory Infection Sinusitis

• Diagnosis
• self-diagnosed headache, dental pain,
  postnasal drainage,
• halitosis,
  dyspepsia
• Imaging studies
• not when initial episodes , but when
  persistent infections occur

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Respiratory Infection Sinusitis

• Treatment
• Broad antibiotic therapy
• cover common aerobes and anaerobes
• patient with acute pain purulent
  discharge
• Systemic decongestants pseudoephedrine
• Topical decongestants
• lt 3days d/t rebound vasodilation and
  worsening of symptoms
• Mucolytic agents (guaifenesin)
• help thin sinus secretions and promote
  drainage
• Antihistamins
• avoided in acute sinusitis d/t drying effects
  may lead to thickened secretions and poor
  drainage of the sinuses.
• Symptomatic therapies facial hot packs and
  analgesics

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Respiratory Infection Sinusitis

• Chronic sunusitis
• from repeated infection with inadequate
  drainage
• Sx recurrent pain in the malar area or chronic
  postnasal drip
• associated with chronic cough
  and laryngitis with intermittent
• acute infection
• Treatment
• - directed at the underlying etiology
• allergy control or aggressive management
  of infections
• - Resistant cases CT
• - Endoscopic surgery polyp remove
• Complication (- untreated sinus-)
• orbital cellulitis leading to orbital
  abscess, subperiosteal abscess
• formation of the facial bones,
  cavernous sinus thrombosis, acute
• meningitis, brain dural abscess
  (rare)

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Respiratory Infection Otitis Media

• Serous otitis media
• Cause
• 2nd to a concurrent viral infection of the
  upper respiratory tract
• Diagnosis
• reveals fluid behind the tympanic membrane
• Treatment
• symptomatic Tx with antihistamines,
  decongestants, glucorticoids
• but, little data exist supporting use of
  these medications

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Respiratory Infection Otitis Media

• Acute otitis media
• Cause
• bacterial infection - Streptococcus
  pneumoniae, H. influenzae
• Sx .
• acute purulent otorrhea, fever, hearing loss,
  leukocytosis
• P. Ex
• red, bulging or perforated membrane
• Treatment
• Broad-spectrum antibiotics
• - amoxicillin-clavulanic acid, cefuroxime,
  trimithoprim-sulfamethoxazole
• antihistamines in treatment of otitis
  media is unclear

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Respiratory Infection Bronchitis

• Acute bronchitis
• inflammatory condition of the
  tracheobronchial tree
• Causes
• - viral infection and occurring in
  winter
• common cold viruses(rhinovirus and
  coronavirus), adenovirus,
• influenza virus, Mucoplasma
  pneumoniae (nonviral pathoen)
• - bacterial infections less common and
  2nd pathogens
• Sx
• coughning sputum (prolonged in
  cigarette smokers) m/c Sx

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Respiratory Infection Bronchitis

• Diagnosis
• P.Ex
• Auscultation coarse rhonchi (rales not
  usually not auscultated )
• signs of consolidation
  and alveolar involvement absent.
• chest x-ray to detect the presence of
  parenchymal disease
• sputum culture
• Treatment
• symptomatic relief uncomplictated cases
• antibiotics for patients who have chest
  radiographic findings
• consistent with pneumonia
• atitussives (containing either dextromethorphan
  or codeine)
• coughing (most aggravating
  symptom)
• expectorants efficacy not been proved

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Respiratory Infection Bronchitis

• Chronic bronchitis
• defined as the presence of a productive
  cough with excessive
• secretions for 3months in a year for 2
  consecutive years
• Prevalence estimated to be 10-20 of the adult
  population
• Classified as a form of chronic obstructive
  disease (COPD)
• Causes
• chronic infection and environmental
  pathogens found in dust
• Sx
• cardinal manifestation incessant
  cough,-usually in the morning ,
• 
  with expectoration of sputum

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Sinusitis Otitis media
bronchtis
Pneumonia
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Respiratory Infection Pneumonia

• Definition
• Inflammation of the distal lung that includes
  terminal airways, alveolar spaces and the
  interstitium
• Causes
• Viral , bacterial, aspiration pneumonia
• Aspiration pneumonia
• cause depressed awareness commonly
  associated with use of
• drugs, alcohol or anesthesia
  
• viral pneumonia
• multiple infection
• - influenza A or B, parainfluenza,
  respiratory syncytial virus
• spread by aerosolization
  associated with coughing,
• sneezing, conversation
• intubation time short, requiring only
  13days prior to the
• acute onset of fever, chills,
  headache, fatigue and myalgia

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Respiratory Infection Pneumonia

• pneumonia develops in only 1 of patients who
  have a viral syndrome
• - mortality rates
• 30 in immunocompromised individuals
  and the elderly
• Staphylococcal pneumoniae (2nd bacterial
  pneumonia)
• arising from a previous viral infection,
  extremely lethal
• vaccination influenza, pneumococcal pneumonia
• amantadine used to treat individual who have
  not been vaccinated
• (in epidemics)
• Treatment supportive care antipyretics and
  fluids

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Respiratory Infection Pneumonia

• Bacterial pneumonia
• Classification Nosocomial or community acquired
• - determine the prognosis and choice of
  antibiotic therapy
• Risk factors
• chronic cardiopulmonary diseases, alcoholism,
  DM, renal failure, malignancy, malnutrition
• Signs and Symptoms
• depending on the infecting organism and the
  patients immune status

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Respiratory Infection Pneumonia

• Laboratory studies
• Gram stain, sputum blood culture
• sputum collection neutrophil gt
  25/LPF
• 
  epithelial cell lt 10/LPF
• ELISA ( indirect serologic test)
• or direct fluorescent antibody staining
  of organisms in the sputum
• Lesionella pneumoniae
• cold agglutinin c appropriate clinical symptoms
• Mycoplasma pneumoniae

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Respiratory Infection Pneumonia
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Respiratory Infection Pneumonia

• Vaccination
• Peumococcal vaccination
• - Indication
• 65, heart, lung disease,
  alcoholism, renal failure, DM, HIV
• infection, cancer
• - repeat vaccination
• recommended 5years after the 1st dose
  in high risk group
• influenza vaccination
• - Indication
• 50years, serious long term health
  problems like heart disease,
• lung disease, kidney disease, DM,
  immunosuppression 2nd to
• long-term steroid or cancer therapy,
  3rd trimester of pregnancy
• during the flu season and anyone
  coming into close contact with
• people at risk of serious influenza
  (physicians, nurses, family
• members) best time Octobermid
  November

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Respiratory Infection Pneumonia

• poor prognosis factor
• involvement gt2 lobes, respiratory rate
  gt30breaths/minute on arrival in the health care
  center, severe hypoxemia (lt60mmHg breathing room
  air), hypoalbuminemia and septicemia
• Complication ARDS (mortality rate 5070)

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Cardiovascular Disease

• Hypertesion
• Hyperlipidemia

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Cardiovascular Disease
Risk factors
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Cardiovascular DiseaseHypertension

• Epidemiology
• -In U.S. 15 of the population between the
  ages of 18 and 74 years
• Incidence
• increases with age and varies with
  race
• gt50 years female gt male
• African Americans gt Whites twice
• Geographic variations higher
  prevalence of hypertension and
• stroke in the southeastern United
  States regardless of race
• Definition
• blood pressure levels 140/90 when measured
  on two separate
• occasions

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Cardiovascular DiseaseHypertension

• Primary or essential hypertension gt95, cause
  unknown
• Secondary hypertension lt5
• Diagnosis
• - Hx and P.Ex
• presence of prior elevated readings,
  previous use of antihypertensive
• agents, a family history of death from
  cardiovascular disease prior to
• age 55, excessive alcohol and sodium use
• ? lifestyle modification is increasingly
  important in the therapy of
• hypertension
• - Laboratory evaluations
• rule out reversible causes of hypertension
  (secondary hypertension)
• UA, CBC, S/E, Cr, fasting glucose, total
  cholesterol, HDL cholesterol,
• EKG

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Cardiovascular DiseaseHypertension

• Measurement of Blood Pressure
• ltProtocols for measurementgt
• - patient should be allowed to rest for
  5minutes in a seated position and the right arm
  used for measurements
• (for unknown reason, the right arm has
  higher readings)
• - cuff should be applied 20mm above the bend of
  the elbow and the arm
• positioned parallel to the floor
• - The cuff should be inflated to 30mmHg above
  the disappearance of
• the brachial pulse or 220 mmHg
• - the cuff should be deflated slowly at a rate
  2mmHg/sec
• cuff size important
• cuff hypertension small cuffs used for
  obese patients
• Diastolic reading
• - Phase IV Korotkoffs sounds
  (muffled sound)
• - Phase V complete disappearance

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Cardiovascular DiseaseHypertension

• Diagnosis and management are based on the
  classification of blood pressure readings

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Cardiovascular DiseaseHypertension
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Cardiovascular DiseaseHypertension

• Treatment
• - General guidelines in assessing individuals
  for therapy

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Cardiovascular DiseaseHypertension
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Cardiovascular DiseaseHypertension

• Choice of drugs
• migraine headache ß-blockers or CCB
• DM ACEi
• MI ß-blockers
• African Americans diuretics CCB
• Monitoring Therapy
• Lifestyle modification (slightly elevated BP)
• - Interval 12 week
• With other disease (i.e.cardiovascular or renal)
• - lifestyle modification alone is
  successful
• close monitoring - interval
  36month
• - lifestyle modification is unsuccessful
  medication

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Cardiovascular DiseaseHyperlipidemia

• Cholesterol esterized form with various
  proteins and glycerides that
• chrarcterize the stage of
  metabolism
• Important lipid particles in cholesterol
  metabolism
• Chylomicrons
• large lipoprotein particles - dietary
  triglycerides cholesterol
• secreted in the intestinal lumen,
  absorbed in the lymph, and then
• passed into general circulation
• adhered to binding sites on the
  capillary wall and are metabolized
• for energy production. (in adipose
  tissue and skeletal muscle )
• Lipoprotein Particle
• consisted three major component
• - core consists of nonpolar lipids
  (triglycerides cholesterol ester)
• - surface coat of phospholipids made of
  apoproteins structural
• proteins
• Apoprotein attached to all lipoprotein
  particles have specific receptors and demarcate
  the stage of cholesterol metabolism

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Cardiovascular DiseaseHyperlipidemia

• Lipoprotein classes
• determined by the separation of lipids in an
  electrophoretic field
• Prehepatic metabolites CM and Remnants
• Posthepatic metabolites VLDL , IDL, LDL., HDL
• Metabolism

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Cardiovascular DiseaseHyperlipidemia

• Hyperlipoproteinemia
• TGchoesterol gt 51
• - predominant fractions are chylomicrons and
  VLDL
• TG cholesterol lt 51
• - problem of VLDL and LDL fraction
• Initial classification

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Cardiovascular DiseaseHyperlipidemia

• Laboratory testing
• multiple environmental causes of variation in
  cholesterol measurements
• lt major sources of variation gt
• - diet, obesity, smoking, ethanol intake,
  effects of exercise
• - clinical conditions
• hypothyroidism, DM, acute or recent MI,
  recent weight changes
• - other
• fasting state, position while the sample is
  drawn, use and duration of
• venous occlusion . Anticoagulant and storage
  and shipping conditions

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Cardiovascular DiseaseHyperlipidemia

• Intraperson variation
• Age and sex
• lt 50years, in women lower lipid values
  than men
• gt 50 years, women lipid value increase d/t
  exogenous oral conjugated estrogens
• Seasional variation
• Diet and obesity
• Alcohol and cigarette smoking
• moderate (defined as approximately 2ounces
  of absolute alcohol/day)
• sustained alcohol intake is noted to HDL ?
  LDL ?, TG ?
• - this effect is negated with higher
  quantities
• Smoking LDL cholesterol and TG ?, HDL
  cholesterol ?
• (critical number 1520 /
  day)
• Exercise TG and LDL? HDL?
• Caffeine mixed effect on lipoprotein
  measurements, avoid in the 12hours prior to blood
  collection
• Blood sample collected in the morning
  after a 12-hour fast

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Cardiovascular DiseaseHyperlipidemia

• Disease States and Medication Effects
• - Diuretics, propranolol TG?, HDL cholesterol?
• (esp. Diuretics total cholesterol ?)
• - DM TG LDL? HDL cholesterol?
• - Pregnancy
• total serum cholesterol ?in 1st trimester,
  continuous increases of all
• fractions in 2nd3rd trimester
• - Hypothyroidism total cholesterol and LDL
  cholesterol ?

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Cardiovascular DiseaseHyperlipidemia

• Management
• Once hyperlipidemia is confirmed on at least two
  separate occasions, 2nd causes should be
  diagnosed or excluded by taking a detailed
  medical and drug history, measuring Scr, fasting
  glucose level, performing thyroid, LFT
• obese patients diet and weight loss (1st)
• Exercise and cigarette cessation

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Figure 9.4 Treatment decisions based on the LDL
cholesterol level
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Cardiovascular DiseaseHyperlipidemia
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Endocrinologic DiseaseDiabetes Mellitus

• Definition
• chronic disorder of altered carbohydrate,
  protein and fat metabolism from deficiency in the
  secretion or function of insulin
• defined by either fasting hyperglycemia or
  elevated plasma glucose levels after an oral
  glucose tolerance test (OGTT)
• Risk factors
• - age gt45years
• - adiposity or obesity
• - a family history of diabets
• - Race and ethnicity
• - Hypertension (140/90)
• - HDL cholesterol 35mg/dL with or without a
  TG level 250mg/dL
• - History of gestational diabetes or delivery
  of baby gt9 pound

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Endocrinologic DiseaseDiabetes Mellitus

• Classification
• Type 1 DM
• The major metabolic disturbance of type
  1 diabetes is the absence of insulin
• from destruction of ß cells in the
  pancreas
• Type 2 DM
• heterogeneous form of disbetes that
  commonly occurs in older age groups
• (gt40 years) and is more frequently noted
  to have familial tendency than type 1
• diabetes.
• type 1 an absence of insulin
  type 2 resulting in insulin resistance

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Endocrinologic DiseaseDiabetes Mellitus

• Diagnosis
• 1. FBG (fasting blood glucose) 126mg/dL
• 2. Random blood glucose 200mg/dL with classic
  signs and symptoms
• of diabetes
• (polydipsia, polyuria, polyphagia and
  weight loss)
• 3. 2-hour OGTT (fasting sample, 60 and 120
  minute samples) after a
• 75g load of glucose
• ? 2-hour OGTT should not be performed if
  the first two criteria are
• present.
• Diagnostic criteria for imparied glucose
  intolerance (IGT)testing
• 110mg/dLFRGlt126mg/dL

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Endocrinologic DiseaseDiabetes Mellitus

• Indication of DM testing
• - Age 45years (repeat at 3-year intervals)
• - Classic signs and symptoms of diabetes
• (i.e. polyuria, polydipsia, polyphagia and
  weight loss)
• - Ethnic groups at high risk
• (Pacific Islanders, Native Americans, Africal
  Americans, Hispanic Americans, Asian Americans)
• - Obesity
• - First-degree relative with diabetes
• - Gestational diabetes or birth of a baby over 9
  pound
• - Hypertension ( 140/90)
• - HDL cholesterol levels35mg/dL or triglyceride
  level 250mg/dL
• - Impaired glucose tolerance based on previous
  testing

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Endocrinologic DiseaseDiabetes Mellitus
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Endocrinologic DiseaseDiabetes Mellitus

• Treatment

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Endocrinologic DiseaseDiabetes Mellitus

• Complication
• Acute complication
• - Diabetic ketoacidosis (DKA)
• - Nonketotic hyperosmolar diabetic coma
  (NKHC)
• - Hypoglycemia
• - Lactoacidosis
• Chronic complication
• - Macroangiopathy accelerated
  atherosclerosis (CHD, MI, CVA)
• - Microangiopathy retinopathy,
  nephropathy, neuropathy
• - Other infection, skin lesion

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Endocrinologic DiseaseThyroid Disease

• Thyroid disorders are more common in women and
  some families, although the exact inheritance is
  unknown.
• In geriatric populations, the incidence ?5
• Thyroid function tests may be misleading in women
  receiving exogenous sources of estrogen because
  of altered binding characteristics (i.e. hormonal
  replacement therapy, pregnancy)
• Hypothyroidism
• Hyperthyoidism
• Thyroid Nodules and cancer

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Endocrinologic Disease Hypothyroidism

• Incidence
• - overt hypothyroidism 2 of women, and at
  least an additional 5
• develop
  subclinical hypothyroidism
• ( subclinical hypothyroidism defined as an
  elevated serum TSH concentration with a normal
  serum free T4 level)

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Endocrinologic Disease Hypothyroidism

• Causes
• - Autoimmune thyroiditis (Hashimotos
  thyroiditis)
• - incidence increases with age
• - associated with other endocrine (e.g. type
  1DM, primary ovarian failure, adrenal
  insufficiency and hypoparathyroidism) and
  nonendocrine disorders (e.g. vitiligo and
  pernicious anemia)
• - Familial predisposition
• ( specific genetics or environmental
  trigger is unknown)
• - Iatrogenic cause after surgical removal or
  radioactive iodine therapy for hyperthyroidism
  of thyroid cancer
• - Secondary to pituitary or hypothalamic
  diseases from TSH or
• TRH deficiency

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Endocrinologic Disease Hypothyroidism

• Clinical Features
• - Fatigue, lethargy, cold intolerance,
  nightmares, dry skim, hair loss,
• constipation, periorbital carotene
  deposition (causing a yellow
• discoloration), carpal tunnel syndrome and
  weight gain(lt510kg)
• menstrual dysfunction (menorrhagia or
  amenorrhea
• - Infertility (d/t anovulation)
• exogenous thyroid hormone is not useful
  for women who are
• anovulatory and euthyroid
• - Neuropsychiatric symptoms
• depression, irritability, impaired memory
  and dementia in the elderly
• - Not cause of premenstrual syndrome (PMS),
  but worsening PMS may
• be a subtle manifestation of hypothyroidism
• - Precocious or delayed puberty

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Endocrinologic Disease Hypothyroidism

• Diagnosis
• confirmed with laboratory studies
• - Serum TSH?, s-T4 or free T4 index ?,
• - Autoimmune thyroiditis
• confirmed by the presence of serum
  antithyroid peroxidase (antimicrosomal)
  antibodies
• Central hypothyroidism
• low or low-normal serum free T4 with either
  a low or inappropriately
• normal serum TSH concentration

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Endocrinologic Disease Hypothyroidism

• Treatment
• - L-thyroxine(T4), levothyroxine (Synthroid
  of Levothroid)
• absorption may be poor when taken in
  combination with aluminum hydroxide (common in
  antacids), cholestyramine, ferrous sulfate or
  sucralfate because of binding or chelation
• - Normal daily dosage 0.10.15mg
• (maintain TSH levels within the normal
  range)

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Endocrinologic DiseaseHyperthyroidism

• Incidence
• affects 2 of women during their lifetimes
  most often during their childbearing years
• Graves disease represents the most common
  disorder
• Causes
• - Graves disease
• - Transient thyrotoxicosis
• result of unregulated grandular release of
  thyroid hormone in
• postparum (painless, silent or
  lymphocytic) thyroiditis and
• subacute (painful) thyroiditis
• - Other
• hCG-secreting choriocarcinoma,
  TSH-secreting pituitary adenoma,
• and struma ovarii
• - Factitious ingestion or iatrogenic
  overprescribing

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Endocrinologic DiseaseHyperthyroidism

• Clinical feature
• - Fatigue, diarrhea, heat intolerance,
  palpitations, dyspnea, nervousness,
• and weight loss.
• (In young patients paradoxical weight gain
  from an increased appetite)
• - Vomiting in pregnant women- confused with
  hyperemesis gravidarum
• - P/Ex ) Tachycardia, lid lag, tremor, proximal
  m. weakness and warm, moist skin
• - Dramatic physical change ophthalmologic and
  lid retraction , periorbital edema and proptosis,
  1/3 of women
• - In elderly adults symptoms are often more
  subtle with presentations
• of unexplained weight loss, atrial
  fibrillation or new-onset angina
• pectoris
• - Menstrual abnormalities
• regular menses, light flow, anovulatory
  menses and associated infertility

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Endocrinologic DiseaseHyperthyroidism

• - Goiter in younger women (m/c) c Graves
  disease
• - Toxic nodular goiter is associated with
  nonhomogeneous glandular enlargement while in
  subacute thyroiditis the gland is tender, hard
  and enlarged
• Diagnosis
• - Total and free T4 and T3 ?
• (measured by radioimmune assayRIA)
• - in thyrotoxicosis , S-TSH concentrations
  undetectable
• - Radioiodine uptake scans
• useful in the differential diagnosis of
  established hyperthyroidism
• Thyroiditis and medication-induced
  thyrotoxicosis
• glandular radioisotope concentration?

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Endocrinologic DiseaseHyperthyroidism

• Treatment
• Antithyroid medication
• PTU ( 50300mg q68hours) or
  methimazole(1030mg/day)
• relapse rate 50 over a lifetime
• - minor side effects fever, rash or
  arthralgias
• - major toxicity (lt1) hepatitis,
  vasculitis, agranulocytosis
• Radioiodine
• Surgical resection
• Iodine-131
• permanent cure of hyperthyroidism in
  7080of patients
• ß-blocker (propranolol)
• control of sympathomimetic symptoms
  (tachycardia), peripheral
• conversion of T4?T3

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Endocrinologic DiseaseHyperthyroidism

• Thyroid storm
• started immediately PTU, ß-blockers,
  glucocorticoids
• and high-dose iodine preparations (SSKI or
  intravenous
• sodium sodium iodide)

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Endocrinologic DiseaseThyroid Nodule and Cancer

• Incidence common and found on P.Ex in 5 of
  patients
• Character
• most nodules- asymptomatic and benign
• - Malignant tendency
• irradiation in childhood,
• Diagnosis
• - TFT? FNA?thyroid scan
• - Biopsy provides a diagnosis in 95 of
  cases
• Malignanacy
• - Papillary thyroid carcinoma (m/c)
• 75 of cases associated cervical lymph node
  metastasis, usually cured
• - Aplastic tumors
• poor prognosis and progress rapidly despite
  therapy
• Treatment
• Radioiodine therapy or surgical ablation