Focusing on women’s health

 

Name and describe the components and rationale of the gynecological health history.
Define and describe each component of the GTPAL system used to document pregnancy history.
Following the guidelines of the United States Preventive Service Taskforce (USPSTF) what screening recommendations would you do to G.R. a 66-year-old female patient who visits you at the office for the first time (last visit to her PCP 5 years ago) with only positive health history of hysterectomy 10 years ago due to fibroids.
A 35-year-old women with a BMI of 40 comes in asking about combined hormonal contraception’s. You explain the contraindications for hormonal contraception include (name more than 4 contraindications).

Sample Solution

Let’s cover gynecological health history, the GTPAL system, USPSTF screening recommendations, and contraindications for combined hormonal contraception.

Components and Rationale of Gynecological Health History:

A comprehensive gynecological health history is essential for assessing a woman’s reproductive health and identifying potential risks. Key components include:

  1. Menstrual History: This includes the age of menarche (first period), cycle length, duration of flow, amount of bleeding, any irregularities (e.g., spotting, heavy bleeding), and any associated symptoms (e.g., pain, cramping). Rationale: Provides insights into ovulatory function and potential hormonal imbalances.

  2. Obstetrical History: This includes information about all pregnancies, including the number of pregnancies, live births, miscarriages, abortions (elective or spontaneous), and any complications during pregnancy, labor, or delivery. Rationale: Helps identify risk factors for future pregnancies and assess reproductive health history.

  3. Contraceptive History: This includes the types of contraception used in the past and present, including effectiveness, side effects, and reasons for discontinuation. Rationale: Helps understand contraceptive needs and identify potential risks or contraindications.

  4. Sexual History: This includes information about sexual activity, number of partners, history of sexually transmitted infections (STIs), and any concerns about sexual function or satisfaction. Rationale: Identifies risk factors for STIs and allows for appropriate screening and counseling.

  5. Gynecological Surgeries and Procedures: This includes any surgeries or procedures related to the reproductive organs, such as hysterectomy, oophorectomy, tubal ligation, or biopsies. Rationale: Provides information about potential anatomical or functional changes that may affect reproductive health.

  6. Symptoms: Any current gynecological symptoms, such as pelvic pain, vaginal discharge, abnormal bleeding, or vulvar itching, should be thoroughly explored. Rationale: Helps identify potential underlying conditions requiring further evaluation.

  7. Family History: A family history of gynecological cancers (e.g., breast, ovarian, uterine) or other reproductive health conditions is important. Rationale: Identifies potential genetic predispositions to certain conditions.

GTPAL System:

GTPAL is an acronym used to summarize a woman’s obstetrical history:

  • G (Gravida): The total number of pregnancies, including current pregnancy, regardless of outcome.
  • T (Term): The number of pregnancies delivered at term (generally 37 weeks or later).
  • P (Preterm): The number of pregnancies delivered preterm (before 37 weeks).
  • A (Abortions): The number of pregnancies ending in abortion (spontaneous or elective) before 20 weeks.
  • L (Living): The number of children currently living.

USPSTF Screening Recommendations for G.R. (66-year-old with hysterectomy):

Since G.R. has a history of a hysterectomy due to fibroids, some standard screening recommendations do not apply to her. Specifically, she would no longer need cervical cancer screening (Pap tests) or screening for uterine cancer (endometrial biopsy). However, other USPSTF recommendations still apply, including:

  • Breast Cancer Screening: The USPSTF recommends mammography every two years for women aged 50 to 74. Since G.R. is 66, this would be appropriate. (Note: The USPSTF recently updated their breast cancer screening recommendations and now recommend screening every 2 years starting at age 40. It’s important to be familiar with the most up-to-date guidelines.)
  • Colorectal Cancer Screening: The USPSTF recommends screening for colorectal cancer starting at age 45 and continuing until age 75. Given her age, this is applicable. There are various screening methods available (e.g., colonoscopy, fecal occult blood testing), and the choice should be made in consultation with her healthcare provider.
  • Osteoporosis Screening: The USPSTF recommends screening for osteoporosis in women aged 65 and older. This is relevant for G.R.
  • Cardiovascular Disease Screening: Assessment and management of cardiovascular risk factors, such as blood pressure, cholesterol, and diabetes, are important.
  • Depression Screening: Screening for depression is recommended for all adults.
  • Obesity Screening and Counseling: Given her age and previous health history, BMI assessment and counseling may be relevant.

It’s important to note that these are general recommendations, and individual risk factors may warrant additional screening or interventions. A shared decision-making approach, where the patient and provider discuss the benefits and risks of screening, is crucial.

Contraindications for Combined Hormonal Contraceptives:

Combined hormonal contraceptives (CHCs) contain both estrogen and progestin. There are several contraindications to their use, including:

  1. History of thromboembolic events: (e.g., deep vein thrombosis, pulmonary embolism) or a known hypercoagulable state.
  2. History of stroke or heart attack.
  3. Certain types of migraine headaches (especially with aura).
  4. Uncontrolled hypertension.
  5. Active liver disease.
  6. Known or suspected breast cancer or other estrogen-sensitive cancers.
  7. Undiagnosed abnormal genital bleeding.
  8. Pregnancy or suspected pregnancy.
  9. Smoking (especially in women over 35).
  10. BMI of 35 or greater (relative contraindication – risk/benefit assessment is crucial). While a BMI of 40 is not an absolute contraindication, it is a significant relative contraindication. The increased risk of VTE (venous thromboembolism) with obesity is further compounded by the use of CHCs. A thorough discussion about risks and benefits is essential. Other contraceptive options should be considered and discussed.

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