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 Answer
Gynecological Health History
The gynecological health history is a comprehensive assessment of a woman's reproductive health, vital for diagnosing conditions, guiding treatment, and providing preventive care. Its components and rationale are as follows:
Menstrual History: Includes age at first period (menarche), frequency, duration, flow, and any associated pain (dysmenorrhea). This information helps identify irregularities, hormonal imbalances, or conditions like endometriosis.
Obstetrical History: Documents all pregnancies, deliveries, and their outcomes. This provides context for reproductive health and potential future risks. It's often recorded using the GTPAL system.
Contraceptive History: Records current and past methods of birth control. This is essential for understanding a patient's reproductive plans, addressing side effects, and recommending new options.
Sexual History: Includes the number of partners, gender of partners, and history of sexually transmitted infections (STIs). This information is crucial for assessing STI risk and providing appropriate screening and counseling.
Pap Smear and HPV History: Details the date and results of previous Pap smears and HPV tests. This helps determine the patient's cervical cancer screening needs and adherence to guidelines.
Gynecological Conditions: Documents any history of conditions like fibroids, cysts, endometriosis, or polycystic ovary syndrome (PCOS). This helps in understanding a patient's risk profile and managing chronic issues.
Surgeries: Records any surgeries related to the reproductive system, such as hysterectomy, oophorectomy, or tubal ligation. This provides context for current symptoms and future health risks.
Breast History: Includes a history of lumps, pain, or breast cancer, which are relevant to a patient's overall health and cancer risk assessment.
The GTPAL System
The GTPAL system is a standardized method for documenting a woman's pregnancy history. Each letter represents a specific component:
G (Gravida): The total number of confirmed pregnancies, regardless of outcome. This includes the current pregnancy.
T (Term): The number of pregnancies delivered at 37 weeks of gestation or later.
P (Preterm): The number of pregnancies delivered between 20 weeks and 36 weeks and 6 days of gestation.
A (Abortions): The number of pregnancies that were lost before 20 weeks of gestation. This includes spontaneous miscarriages and elective abortions.
L (Living): The number of children currently living.
USPSTF Screening Recommendations for G.R.
Based on the USPSTF guidelines for G.R., a 66-year-old female with a history of a hysterectomy for fibroids, the following screenings would be recommended:
Cervical Cancer Screening: None. The USPSTF recommends against cervical cancer screening (Pap smear) in women 65 and older who have had adequate prior screening and are not at high risk for cervical cancer. Given her history of a hysterectomy for benign reasons (fibroids), she likely no longer has a cervix and therefore does not need to be screened.
Breast Cancer Screening: Mammography every two years for women aged 50 to 74. While G.R. is 66, she is within the recommended age group, so this screening is still advised.
Colorectal Cancer Screening: The USPSTF recommends screening for colorectal cancer starting at age 45. For G.R., screening is recommended until age 75. Options include a high-sensitivity fecal occult blood test (FOBT), sigmoidoscopy, or colonoscopy.
Osteoporosis Screening: The USPSTF recommends screening for osteoporosis with bone measurement testing in women aged 65 years and older. Given her age, G.R. should be screened for osteoporosis.
Lung Cancer Screening: The USPSTF recommends annual low-dose computed tomography (LDCT) for patients aged 50 to 80 with a 20 pack-year smoking history who currently smoke or have quit within the past 15 years. Her smoking history is not provided, but this screening should be discussed.
Abdominal Aortic Aneurysm (AAA) Screening: Recommended for men aged 65 to 75 who have ever smoked. Not recommended for G.R. as she is female.
Combined Hormonal Contraception Contraindications
For a 35-year-old woman with a BMI of 40, combined hormonal contraception is contraindicated in several situations. These contraindications are primarily due to the increased risk of blood clots and cardiovascular events. More than four contraindications include:
History of or current Venous Thromboembolism (VTE), such as deep vein thrombosis (DVT) or pulmonary embolism (PE).
History of or current Stroke, Coronary Artery Disease, or other arterial thromboembolic disease.
Certain types of migraines with aura.
Severe uncontrolled hypertension (≥160/100 mmHg).
Known thrombogenic mutations, such as Factor V Leiden.
Smokers over the age of 35. Although she is 35, her BMI of 40 puts her at an even higher risk, making smoking a critical contraindication.
BMI of 40 or higher is an independent risk factor for VTE, which is a significant concern with combined hormonal contraceptives.