Operational Gyn-Field Feminine Hygiene...

My Women's Health clinical assignment was at the Fort Hood, Killeen, TX Women's Health Clinic. Right now there are 2 upcoming deployment iterations preparing to head to Iraq (in September) and to Afghanistan (in December). I had the opportunity to provide care for many of the females going through their SRP's (Soldier Readiness Processing). Most of the females we saw were junior enlisted (E-1 to E-4) and very young (18-24 yrs old). Some of these females needed "SRP PAPs", or "SRP PAP F/U Colpos", or "SRP Birth/Menses Control", or, quite a few for "pre-deployment FTX vaginitis", in a very short period of time left before deployment, in order that they be medically cleared and qualified for mission accomplishment.

After having received our MCM/Bushmaster training (as well as our OB-Gyn classes), understanding how women manage in combat environments is important, both from the perspective of correcting inappropriate and perhaps dangerous practices, and from the perspective of using corrected practices to prevent infections and other potential illnesses. I believe we Providers have a responsibility to educate our female patients as well as make sure that the mostly-male units which these females belonged to here in "Cav Country" (and in other deploying units) understand the need to provide educational training programs about feminine hygiene issues to those commanders and supervisors who operate in field environments.

We were already treating many females for chemical vaginitis caused by the use/overuse of new "feminine hygiene products", such as sprays and douches, soaps and powders which caused irritation of the perineal and vulvar skin-all to "keep me from smelling like a man" they would say. Others suffered from BV and Candida-often from wearing the same sweaty underwear for more than one day, wearing spandex, not wearing cotton breathable underwear, wearing tight fitting uniforms, not cleaning the perineal area appropriately, and not washing/cleaning hands before and after urinating/defecating/changing menstrual pads or tampons. Some issues were pt education related, others were related to deficiencies in unit sanitation measures.

Although resources are available (see A Guide to Female Soldier Readiness for 1 example), including many Health Care Providers in the medical community to assist leaders in maintaining unit readiness, the females we were seeing in the clinic had NO idea of the Do's and Dont's of "field female survival". Preservation of the force is our goal, and opportunity to reach service members at the unit level, with support from the leadership, is a golden one that needed attention here.

Deployed military women have an increased risk for development of vaginitis due to extreme temperatures, primitive sanitation, hygiene and laundry facilities, and unavailable or unacceptable healthcare resources

Prior to unit deployment on an extended field exercise or to a contingency operation, a training session could/should be coordinated for unit females by the Community Health Nurse, Public Health, a representative of the Dept. of OB/GYN, or other experienced health care professionals. They can educate personnel about how to prepare themselves for the field, and how to maintain their health during deployment. They can also expertly answer questions and hold discussions-to decrease the "barracks grapevine" from serving as the "be all/know all" when it comes to Women's Health issues.

Some suggested topics for predeployment briefings are: 1) birth control and sexually transmitted infections (STIs); 2) female hygiene in field settings, to include advice on how to avoid UTIs and yeast infections; 3) female-specific health care services available in theater and ways to obtain these services; 4) guidance on packing sufficient female hygiene products and medications; 5) tips on staying healthy; 6) guidance on nutrition and dietary supplements; 7) sexual assault awareness information and/or training.

According to the comments of the female patients we were seeing, there was little to no information provided to them in their mostly-male units, pertaining to "female field hygiene", thus they were left on their own to maintain their health and readiness in austere environments. We can and must do better than this.

I heard alot of bad stuff about Yaz

I was surprised with the amount of females that came in for contraceptive counseling b/c they heard bad stuff about Yaz. They report they didn't know much about the reasons why Yaz has a lawsuit pending but it had to be bad, some did state they heard it caused kidney problems and possibly clots. Many stated that they loved Yaz and had no problem taken the medication but were extremely concerned about the pending litigation against Yaz. The following is from the attorneys that are bringing forward the lawsuit:

Recently, women who have suffered from Yasmin problems have been increasingly coming forward to report their injuries. Serious side effects of Yaz including blood clots, stroke, and heart attack along with gall bladder disease and pancreatitis have been linked with women using the birth control. Consumer groups and some members of the medical community are questioning Yaz side effects and the increased risk for blood clots and strokes. Yaz, Yasmin andOcella are considered “fourth generation” combination birth control pills. They contain a newer type of synthetic progestin called drospirenone. This contraceptive is one of the most popular contraceptives and has been heavily marketed to women throughout the United States promoting its use in treating premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD).

Yaz problems including stroke, blood clots, DVT and pulmonary embolism have been reported. Side effects of Yaz may result due to changes in your blood clotting system. Some people associate the higher risk of developing blood clots, strokes, and heart attacks with the type of synthetic progestin in Yaz birth control called drospirenone. Side effects should be immediately evaluated by a doctor because complications can cause serious injuries and be life-threatening. Currently neither the FDA or the manufacturer has issued a Yaz recall and it remains one of the most popular birth control pills.

My preceptor and I could not find any evidence in the literature that stated patients taken Yaz were at an increased risk for any of the SE stated above as compared to other contraceptives....After explaining to the patients the risk involved in staying on Yaz or changing to another contraceptive they all chose to stay on their current contraceptive.... Your thoughts are welcomed

IUD issues

Difficult insertion:

30 yo, G2/T 2, P2, A, 0, L 2, cesarean section for both births presents to WHNP after two unsuccessful attempts at IUD placement. Pt relates history of abnormal PAP smears, laser cone and cold knife procedures, suspected stenoic os. The patient underwent two attempts at IUD placement via two different clinicians both of which were unsuccessful despite attempts at sequential dilation. Management options of the patient include attempted placement in the clinic post intravaginal Cytotech 200mg x 2, or placement in outpatient surgery. Patient elects outpatient surgery option due to concerns about further discomforts expected without anesthesia.

Post insertion cramping and bleeding:

35 you G3/T 2, P 1, A 0, L3. Patient presents 6 days after initial IUD placement with complaints of bleeding (now stopped) and abdominal pain and cramping which is rated by the patient at 7/10. The patient denies fever chills, other signs/symptoms of infection. To this point abdominal pain has not been responsive to NSAID therapy. On physical exam the vault and os are free of blood. Strings to the copper IUD are evident at approximately 3 cm in length. There is no cervical motion tenderness, but the patient’s abdomen is tender to palpation. An ultrasound was performed that demonstrated the presence of the IUD inside the uterus. The patient was discharged with a 5 day supply of Percocet and instructed again concerning signs and symptoms of infection. The patient was also instructed to schedule a routine appointment in approximately 3 months.

Observations:

IUD placement is a common procedure but not best for every patient. Based on the first patient’s past history of Laser cone and cold knife procedures primary care providers would probably have be justified in referring the patient to the WHNP or obstetrician. Additionally, it is necessary to educate patient thoroughly concerning what symptoms to expect post insertion. Bleeding and cramping may persist for some time post insertion and patients need a warning in advance while at the same time being instructed concerning signs of complication e.g. infection, insertion though of the IUD through the wall of the uterus.

But my Pregnancy Test Was Negative!

An AD 35yo G3P3 African American female arrived to the office for placement of the Mirena IUD. She'd been on OCPs for the past two years for managment of dysmenorrhea and decided she wanted to have some time off of the pills to "let my hormones get normal" and "to get ready to maybe have one more baby before I'm too old." She felt that an IUD offered a quicker pause for the cause in her fertility plan since the last time she was on OCP it took her "a year" to get pregnant. Although she was advised to continue her OCP until successful placement of the IUD or at least protected intercourse until placement, she'd stopped her OCPs in early May and had one short, scant period in mid May.
She'd obtained her negative Hcg test the afternoon prior to the visit and was excited to have the IUD placed. However, as we reviewed her history of recent coital encounters, we learned that she'd had unprotected intercourse for the past three days.
We informed her that she was no longer a candidate for IUD placement in the event that she was actually already in the process of conceiving. To which she responded, "But my pregnancy test was negative and I had my period last month."
She overassumed the use of OCPs for mere management of dysmenorrhea and somehow failed to realize its additional "anti-contraceptive" benefits! So this is someone of a GYN/OB combo I recon. But the take home is...ensure that clients understand both the intent of the prescription of OCPs for a specific GYN issue but also ensure that they thoroughly understand the full range of physiologic consequences especially it's influence on fertility while consuming.

Gyn sickcall - Fibroids, fibroids and more fibroids

Twas the name of the day for me, twas more than I could handle!

3 clients, same history . Client A: 38 y/o AA female with history of fibroids with symptoms (pelvic fullness, intense pain, and menometrorrhagia). S/P Tubal ligation x 16 years ago. Motrin and heat packs for relief – little good. Do a pelvic exam, bimanual exam, check for recent pap, if none present, do one. Maybe/maybe not order U/S now, assess CBC for anemia (palms of hand, skin, cap refill, oral mucosa and subconjunctival mucosa). Client B: 26 y/o WF, AD, nulliparous and celibate (virgin), asymptomatic, with significant family history (mother and aunts hysterectomy age 34 d/t recurrent fibroids), Client C: 45 y/o WF symptomatic abnormal uterine bleeding x 6 months, metromenorrhagia, microcytic anemia, history of tubal ligation >6 years with worsening symptoms after. NO RECENT CERVICAL/VAGINAL EXAM/PAP WITHIN LAST 2 YEARS, but there was a recent U/S order and result showing >12cm mass on the uterus. Whoever ordered the U/S did not do an exam.

For the asymptomatic pt we offered her 2 options: try a COC to try to suppress/ control the ovaries hormonal production (nuvaring) or wait another 3 months to revisit U/S to assess growth, if she did not want to start the BC measures. For the other 2 patients, treatment were similar. We scheduled them for endometrial biopsy, possible date for hysterectomy (assessed anesthesia and intubation status – sleep apnea, obesity, asthma, response to anesthesia etc) and my preceptor talked to them about starting Lupron till the date of surgery as a temp quick fix measure with f/u.


With these patients, I learnt that some providers tend to shy away from doing pelvic exam on the patients for whatever reason. Doesn’t do them much good, especially the ones that say, but I had one 2 years ago and “they” said I was fine, I think or I am not ready for one today, can I reschedule! Or I am only here to review the results of my U/S and Labs. We heard all these “reasons” today. So he says to me: Never be afraid to “get in there” and “do it.” You are not doing them any good! Eventually, it going to be done, but it may be too late! If it is a vaginal complaint, look at the vagina (inside not outside)!

Do the RECTOVAGINAL EXAM!

Recurring Themes During the Post-Menopausal Well Woman Exam

During my clinical experience the majority of the patients I saw for well women exams were post menopausal women. There seemed to be four reoccurring themes I would encounter when seeing these patients.
1.) Stenotic Os. The first issue was the stenotic os, particularly in nulliparous women. When obtaining a pap specimen from the stenotic os, it can be difficult to insert the brush or spatula into the os and lead to inadequate collection of endocervical cells from the SCJ or transformation zone. It is important to note on the report if the os was stenotic or not.
2.) Atrophic Vagina. The second issue was the atrophic vagina. The physical findings were similar from patient to patient. Friable tissue, scant and thin vaginal fluid, lack of rugae on the vaginal mucosa, and collapsing of the vaginal walls. Patients may or may not be symptomatic. It is important to be gentle with the pelvic exam and a smaller speculum may be needed as the tissue bleeds easily and is not as pliable.
3.) Small Uterus and Ovaries. The third issue was difficulty with palpating the uterus and ovaries. This is an expected finding because after menopause and as women age, these organs atrophies. You may need to palpate deeper when doing the bimanual which could be uncomfortable for some women. The point to remember is that an easily palpable uterus or ovary in a postmenopausal woman should raise your index of suspicion that something may not be right.
4.) Menopausal symptoms. The 4th and most complex issue was the vasomotor symptoms associated with menopause. The common complaints were insomnia, hot flashes, night sweats, irritability, and vaginal dryness. Some women were perimenopausal and some had 10 years + since menopause. What was common among most of these women, was that these symptoms were really affecting their quality of life. They also expressed feelings of isolation, because family, friends, coworkers did not understand how uncomfortable this time could be. It is important for FNPs to be understanding, reassuring, and knowledgeable about current therapies for menopausal vasomotor symptoms. Treatment can be complex and the options are numerous. These patients have usually been doing their own research about the options available and will ask questions that you cannot imagine. Having a good up to date resource about current therapies, myths, and facts regarding menopause is a must have in the family practice setting.

To bleed or not to bleed

19 y/o G1P1 with 16 week old son being seen for IUD removal this visit. This pt had the Mirena IUD placed six weeks after giving birth with normal vaginal exam. In giving instruction with this birth control method, women are warned of spotting or break through bleeding between periods within the first six months then probable amenorrhea. This pt had little complications other than the annoyance of amenorrhea within 6 wks of placement. Pt states that not having a period felt unnatural for her and felt more comfort in having a regular cycle. Although most women I know would feel this is a worth while side-effect, it is very important to educate your pt that this is a possibility and if this is not what she would feel comfortable with then perhaps the paraguard or an alternate form of birthcontrol may be more suitable. We don't really discuss cost readily within the military system but having a patient maintain an IUD less than 6 months is an unnecessary expense to the military healthcare system. It would be more advantageous for the pt to utilize more cost effective measures better suited to her preference.