• Focusing on women's health:
o Name and describe the components and rationale of the gynecological health history.
o 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).
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Focusing on women's health
Full Answer Section
- Obstetric History:
- GTPAL:
- G: Gravidity (total number of pregnancies, including current pregnancy)
- T: Term births (number of pregnancies delivered at 37 weeks or more)
- P: Preterm births (number of pregnancies delivered between 20 and 36 weeks)
- A: Abortions/Miscarriages (number of pregnancies ending before 20 weeks)
- L: Living children
- History of Pregnancies: Details of each pregnancy, including complications, delivery method, and infant outcomes.
- GTPAL:
- Sexual History:
- Sexual activity: Frequency and type of sexual activity.
- Number of sexual partners: Past and present.
- Use of contraception: Type of contraception used and any problems encountered.
- History of sexually transmitted infections (STIs): Previous diagnoses and treatments.
- Gynecologic History:
- Previous gynecologic surgeries: Hysterectomy, tubal ligation, etc.
- History of gynecologic conditions: Endometriosis, ovarian cysts, pelvic inflammatory disease (PID), etc.
- Pap smears and HPV testing: Results and dates of previous screenings.
- Breast health: Breast self-exams, mammograms, breast biopsies.
- Medical and Surgical History:
- Chronic medical conditions: Diabetes, hypertension, asthma, etc.
- Surgeries: Previous surgeries outside of gynecology.
- Family History:
- Family history of gynecologic cancers: Breast cancer, ovarian cancer, cervical cancer.
- Family history of other relevant conditions: Diabetes, heart disease, etc.
- Psychosocial History:
- Lifestyle factors: Smoking, alcohol use, drug use.
- Occupational history: Exposure to potential occupational hazards.
- Socioeconomic factors: Income, housing, access to healthcare.
- Mental health: History of depression, anxiety, or other mental health conditions.
Rationale:
A comprehensive gynecological health history provides valuable information about a woman's reproductive health, risk factors for gynecologic conditions, and overall health status. This information helps healthcare providers:
- Identify risk factors for gynecologic cancers and other health problems.
- Provide appropriate screening and preventive care.
- Develop individualized treatment plans.
- Build a strong rapport and trust with the patient.
USPSTF Screening Recommendations for a 66-year-old Female with Hysterectomy
Based on USPSTF guidelines, for a 66-year-old female with a history of hysterectomy due to fibroids, the following screening recommendations would apply:
- No routine mammography: The USPSTF recommends against routine mammography screening for women aged 75 and older due to the low risk of benefit and potential for harm.
- No routine screening for osteoporosis: The USPSTF recommends against routine screening for osteoporosis in women aged 65 and older who are not at increased risk.
- Consider screening for colorectal cancer: The USPSTF recommends screening for colorectal cancer in adults aged 76-85 years, depending on life expectancy and prior screening history. Since this patient is 66, colorectal cancer screening would be recommended.
- Consider screening for cardiovascular disease: The USPSTF recommends screening for cardiovascular disease in women aged 55 and older.
- Assess for depression: The USPSTF recommends screening for depression in adults.
Contraindications for Combined Hormonal Contraception
Combined hormonal contraceptives (CHCs), which contain both estrogen and progestin, are contraindicated in women with:
- Current or history of venous thromboembolism (VTE): Deep vein thrombosis (DVT), pulmonary embolism.
- History of cerebrovascular accident (stroke) or myocardial infarction (heart attack).
- Known or suspected breast cancer.
- Liver tumors (benign or malignant).
- Undiagnosed abnormal vaginal bleeding.
- Pregnancy or suspected pregnancy.
- Severe hypertension.
- Severe liver disease.
- Major surgery with prolonged immobilization.
- Smoking heavily (more than 15 cigarettes per day) and aged 35 years or older.
Sample Answer
Components of a Gynecological Health History
- Menstrual History:
- Menarche: Age of onset of menstruation.
- Cycle Length: Duration of the menstrual cycle (average number of days between periods).
- Cycle Regularity: Consistency of cycle length.
- Menstrual Flow: Amount and duration of bleeding.
- Dysmenorrhea: Presence and characteristics of menstrual cramps.
- Last Menstrual Period (LMP): Date of the first day of the last menstrual period.
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