The Menopausal Patient

History: HPI: Menstrual: menarche, LMP, frequency / regularity of periods, duration of periods, heavy / light, bleeding between periods Menopause sx: hot flashes, chills, irritability / mood swings, vaginal dryness Osteoporosis: Previous f ! "a#ing $a/vit%! Urogyn: esp if big &' h ( incontinence )when laughing / coughing / anytime / urge / etc* ( itching / burning / discomfort when urinating ( prolapse: bulges on standing / coughing General GYN stuff: vaginal discharge / discomfort / pelvic pain / masses GYN +istory: PAP history: most recent, any abnormal! Breast history: previous mammograms! ,'-! .ny other /01 issues in the past! OB +istory: pregnancies, deliveries, miscarriages, abortions, ectopics, complications Sexual history: se ually active, with whom, pain with intercourse Birth ontrol: if smo#ing and 2 34, no &$Ps .ny history of ,"5s! PMHx: .ny other medical conditions! Medications! .llergies! SurgHx: previous surgeries! !a"ily Hx: previous h of cancer in family! #reast $ o%arian $ olore tal especially So Hx: lives with whom, safe at home drugs / alcohol / tobacco

Physi

al exa": 6,: /eneral appearance: "hyroid $6: Pulm: 'reast: Pelvic:

&ounseling $ pre%entati%e: Menopause s : onsi'er H(T )HI: points to ma#e if it comes up ( )HI did show an increased ris# of #reast an er* heart 'isease* stro+es* #loo' lots in women on combined hormone replacement ( 7omen on combined hormone replacement had lo,er rates of hip fra tures and olore tal an er, however

"he absolute numbers of patients getting diseases were small in both groups: for instance, 38 / 9:,::: patients on hormone therapy got breast cancer, while 3: / 9:,::: patients on placebo got breast cancer; ( "he patients in this trial were older< many had already gone through menopause, so it=s not e actly the same as how it=s used in clinical practice, but it=s the closest thing we=ve got right now; ( 5f we decide to use +>", we=ll use the loweest dose possible for the shortest amount of time to get you through the symptoms; Osteoporosis ris+: consider getting %-?. / bisphosphonates )if pathologic f of hip or vertebrae, other f and "@ score @9;: to @A;4, or " score B @A;4*; ,hould be ta#ing 9:::@94:: mg $a daily no matter what< if osteoporotic, 8:: 5C vit% too; /et an en'o"etrial #iopsy if concerned )constant bleeding / lots of anovulatory cycles / etc* PAP smears: 7omen age 3: and older who have had three onse uti%e negati%e er%i al cytology test results may be screened on e e%ery three years with either the Pap or liquid@based cytology; 7omen with certain ris+ fa tors may need more frequent screening, including those who have +56, are immunosuppressed, were e posed to diethylstilbestrol )%-,* in utero, and have been treated for cervical intraepithelial neoplasia )$51* A, $51 3, or cervical cancer; Breast: "a""ogra" ,hould have yearly "a""ogra" starting at age -. and continuing as long as the woman is in good health 5f strong D+ breast cancer )mother or sister*, "a""ogra" s reening / yrs earlier than youngest fa"ily "e"#er0s 'iagnosis or 1. years if family member was premenopausal;

Pu#ertal patient
History: GYN +istory: Menstrual: menarche, LMP, frequency, regularity, duration of periods, heavy / light * bleeding between /eneral /01: ( 6aginal discharge / itching / discomfort! ( Pain / itching / burning / discomfort when urinating! ( .bdominal / pelvic pain, masses, fullness; .ny other /01 issues in the past! Sexual history: se ually active, with whom, pain with intercourse .ny history of ,"5s! 'irth control! ,ometimes / always! ,afe in relationship! OB +istory: pregnancies, deliveries, miscarriages, abortions, ectopics, complications PMHx: .ny other medical conditions! %M, +"1, M5, lung dE, stro#e, cancer; Medications! .llergies! SurgHx: previous surgeries! !a"ily Hx: previous h of cancer in family! #reast $ o%arian $ olore tal especially; &ther dEs! So ial Hx: Lives with whom! ,afe at home! "obacco / alcohol / drugs! Physi al exa": 6,: /eneral appearance: $6: Pulm: Pelvic:

&ounseling $ pre%entati%e: Birth ontrol: /o from what she #nows / has been using .s#: history of blood clots! $ondoms: 94F failure rate, but protect against ,"%s 'irth control pills: 8F real life failure rate< decrease ovarian / endometrial cancer, etc; $an get nausea, h/a, brea#through bleeding, wt gain ( -strogen and progesterone; +ave to remember to ta#e every day ( Progesterone only: have to ta#e at same time every day, higher failure rate ( 'leeding every month, every 3 months, or continuous dosing )more brea#through bleeding* ( +ow to start: Starting on 'ay 1 of cycle: least li#ely to ovulate during cycle Sun'ay start: bac#up for G days, leaves ne t wee#end free; Anyti"e start is actually fine: Hust bac#up method for G days

%epo: Progesterone; ,hot in arm every 3 months; $an cause irregular bleeding, especially at beginning, which bothers some people more than others; .lso decreased bone density )reversible*; can cause depression, wt gain, hair loss, h/a; $an lead to amenorrhea; May ta#e I@98mo for fertility to return; 5mplanon: 3 years, progestin implant, most women have lighter periods )some none at all*, really effective but can have irregular / unpredictable light bleeding 5C%s: Longer term, very effective ( Mirena: ; 4 years; Lighter or no periods; ( Paragard: copper; 9: years; $an cause irregular bleeding; Less common stuff: patch )not if overwt or high thromboembolism ris#*, nuvaring )3 w#s in, 9 w# out, or 3mo in with changes, 9 w# out, :;8F failure rate* -mergency contraception @ Plan ' )progestin only* within GAh; 1eed > if B 98, &"$ if 2 98; ST2 testing: /onorrhea / chlamydia: swabs or urine if no pelvic e am ,yphillis, +56: blood test +,6 swab if lesions $onsider Gar'asil for females 99@9A, or 93@AI who didn=t get doses previously )Jprotects against +P6; ,ome types of +P6 cause genital warts, and some types can cause changes in your cervi that down the road can lead to cancer; "his vaccine helps protect against both warts and cervical cancerK* PAP smears: ,tart at age 13 regar'less of sexual history* et 4

Breast exa" Intro'u tion: wash hands, get drape ready, as# about ,'-, everything can be done at home Inspe tion )L positions* @ e pose both breasts, can use wall mirror at home ,eated normally +ands on hips, shrug shoulder forward Leaning forward .rms above head Palpation @ seate' Lymph nodes )supra/infraclavicular* Palpate from clavicle to tail )a illa*, donMt lose contact, wor# in strips, 3 degrees of pressure ,upport breast with hand to palpate top of breast 1ipple / areola . illary nodes @ deep central, lateral, medial, pectoral, subscapular >epeat with other breast Palpation @ laying, arm behind head ,ame steps as above 5f discharge, identify quadrant by stripping / palpation towards nipple $an have pt turn to side for lateral aspect of breast )rap up: >egular, monthly sbe, use mirrors )wall / hand*; 1e t sbe 9 mo, ne t clinical e am at annual /yn visit Pel%i exa" 5 6xternal exa" 7 Position, assist, drape, give s"all "irror, use light, wash hands / put on glo%es 8'ou#le glo%e on dominant hand*, alert pt verbally 7 Palpate )L* 9 Mons pu#is / area of hairline 9 Inguinal nodes 9 :a#ia "a;ora < "inora 9 $hec# S+ene0s N Bartholin0s glands 7 6isually e amine )L* 9 >etract prepu e N e amine litoris 9 Urethra 9 Introitus 9 Perineu"* anus 7 $hec# for prolapse @ as# pt to #ear 'o,n 5 Spe ulu" e am 7 5ntro: ,ar" speculum, show to pt, alert pt before each move 7 %o the speculum e am, tighten screw, Pap smear / swabs if indicated 7 >emove slowly while holding bills open 5 Bi"anual exa" 7 .lert pt, use lubricant 7 Palpate %agina, then er%ix 7 Cse second hand to palpate fun'us, then a'nexa 5 (e to%aginal exa" 7 Ta+e off outer glo%e* use lu#e, alert pt, then "i''le finger in rectum, forefinger in vagina; 7 (epeat #i"anual e am )uterus / adne a* 7 Palpate posterior re tal ,all, then s,eep rectovaginal septum

7 %o he"o ult test for blood )rap up: as# pt to get dressed, will tal# in a bit;