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.

LEEP/Implanon

23 y/o G0P0, WF, here for LEEP and Implanon. Colpo results showed CinIII, so patient is having her 1st LEEP. In part this procedure has been chosen due to the nature of her colpo results, but also taking into consideration that she may wish to have children later, so preserving her cervix is important. She is premedicated with toradol and Xanax. Local anesthetic to the cervix is administered. A "tophat" sample is removed from her cervix and sent for evaluation. The cervix is then cauterized and then Monsell's solution applied. The patient tolerated the procedure well. It took about 30 minutes. What I took home from this was that I need to prepare my patients for what they are about to experience. I need them to understand their risks and benefits. I can now better describe what they can expect. I was surprised by the amount of tissue removed. The provider doing the surgery said that the cervix recovers quite well, showing some sign, but not to the extent it appeared as I watched the procedure performed.
The implant was actually done first, and it took about 10 minutes, from applying the local to removing the introducer and bandaging the site. It was simple quick and relatively painless. I could see some bruising beginning, and little bleeding.

I chose this case because it helped me in understanding the two procedures that I will eventually be describing to my patients. It also helped me to keep the different procedures for managing dysplasia straight in my own head.

49 y/o with Cystocele

One interesting case I observed in clinic was a 49 y/o BF with C/C of urinary incontinence and feeling of fullness in her vaginal area. She had been seen the weekend before in ER because seeing her bladder upon bearing down had startled her ad she was not sure what it was. Margaret a G5P5A0 was pleasant and in no pain. The obstetrician and I took her Hx and initiated a pelvic exam. All of her children had been SVD’s. Her urinary incontinence symptoms had progressively gotten worse. She goes through multiple pads in a day and it was starting to cause her to change plans, stay home more. Pelvic exam revealed intact vaginal vault, no masses. When we had Margaret bear down you could see the bladder descend to the opening of the vagina. OB provider explained a cystocele is mild (grade 1) when the bladder droops only a short way into the vagina. With more severe (grade 2) cystocele, the bladder sinks far enough to reach the opening of the vagina. The most advanced (grade 3) cystocele occurs when the bladder bulges out through the opening of the vagina. Something I would not have thought of the OB took the speculum apart and with one half was able to introduce into vaginal vault, yet see the upper and lateral walls much more clearly. Margaret was a grade 2. He discussed use of a pessiary which is a plastic support piece placed in the vagina that provides support to the adjacent pelvic organs. Performing kegel exercises to help strengthen area, decrease heavy lifting and straining. He also discussed surgical options but wanted to give her some time doing more conservative measures first.
Once she had left we discussed the impact of decreased estrogen level on post menopausal women and its effect on musculature. The one option I brought up was referral for pelvic muscle PT evaluation. I was told they were not in that area. I mentioned you could go through HBA/tricare to help find one in the area or I provided contact: kendra.harrington@amedd.army.mil, 202-782-5716. He felt like that was a valid point and would forward to head nurse to research for future patient referral.

Rhythm Method = Motherhood

One interesting patient I saw was a 35 year old black female G0P0 with a history of fibroids, metrorrhagia, and pelvic pain associated with her menses. The patient’s last pap smear and well woman exam by a civilian provider was in 2009 with normal results/findings (per patient). It was noted that this patient’s menstrual cycle ranged anywhere from 16 to 26 days with spotting in between periods. The patient had no medical records (to include labs, previous abdominal U/S) available to look at as she was typically followed off base by her primary care provider. The patient stated that she was told 2 years ago she had a fibroid the size of a grapefruit on the right side of her uterus. No other information was known (i.e. fibroid characteristics, or even possible surgical plan that fell through). Also, the patient stated that she was married and has not been using any form of birth control for the past 5 years other than the rhythm method. The patient stated that she had been previously worked up for fertility several years ago and was told that she should be able to conceive children. The patient denied having any knowledge pertaining to her husband’s fertility status. The patient vehemently denied wanting to have children at this time. The patient was alert and in no acute distress. The patient had an athletic build and noted that she works out 4-5 times weekly. The physical exam and ROS was unremarkable except for metrorrhagia, pelvic pain, and the rubbery 4-5 cm mass evidenced with a bimanual exam to the right uterine adnexa. Also, of note was a slightly enlarged liver 2cm below the right costal margins with exhalation and even greater excursion with inhalation. The patient was counseled regarding birth control and informed that there was a strong possibility that the fibroid(s) may be keeping her from getting pregnant, or that her husband may suffer from infertility. The patient was offered a monophasic COC (LoOvral) to help with her metrorrhagia and spotting in between menses as well as to provide a form of contraception. The patient was extensively counseled as to her risks of getting pregnant if she was only using the rhythm method. No risk factors other than age were identified with regards to OCP’s. The patient was instructed to have a CMP drawn. Also, she was given a referral for a repeat abdominal U/S as well as a consult surgery. Lastly, the patient was instructed to f/u with her pcm regarding her liver function test, U/S results, and a BP check in 4 weeks time.

mastodynia

17 year old hispanic female with complaints of bilateral breast pain and tenderness since May 2010. She has been on Yaz for two years to help her dysmenorrhea. The patient denied nipple discharge, swelling, or the presence of any rashes. She denied excessive caffeine or chocolate intake. She also denied being sexually active. An ultrasound performed on June 14th did not reveal any underlying pathology/abnormalities. During the physical exam, her breasts were very sensitive to light touch. Other than that, the exam was completey normal. The only recommendation that my preceptor and myself could offer was to try changing her birth control to a progesterone only pill. The patient still wished to be on some sort of birth control because of her dysmenorrhea. The estrogen content in the Yaz could have possibly been the culprit in ther breast discomfort. We offered the patient the option to try Norethindrone, which is a progesterone only pill and does not affect the breasts like the estrogen containing pills do. The patient agreed to try this birth control option with the understanding that she had to take it the same time every day. Additional instructions that were given to this patient that might provide relief included taking naprosyn, wearing a well-fitted, sports bra, and starting vit E supplementation. The patient was aware to follow up within 3 weeks or sooner if the discomfort continues.

greg bellanca

19 year old G0P0 presented to colposcopy clinic after PAPs in October 09 and May 10 both showed ASCUS. According to the ASCCP guidelines, a woman under the age of 20 with an ASCUS pap should have cytology repeated in 12 months. If repeat PAP at 12 months continues to show ASCUS, the cytology would again be repeated at 12 months. Only on a third ASCUS (24 months out from the original) would the patient be referred for colpo.

Unfortunately, the reason for repeat PAP at 7 mo and referral for colpo outside of guidelines was not documented in the record. Possible reasons included provider unfamiliarity with guidelines, the patient’s military status (shore vs sea duty), limited access to care, previous history not documented in record, increased risk factors. The patient is AD female on shore rotation for another 2 years, so pending sea duty rotation was not an issue as far as access to care. No history of STI, no other hx of abnormal PAP, completed Guardasil vaccine series, sexually active with 1 partner in last 12 months and 3 lifetime partners.

The WHNP discussed the lack of necessity to perform colpo at this point, but patient stated that it was not easy to get an appointment and she had already taken time off from work, so rather than wait a year and perhaps have to return, she elected to have the colposcopy performed.

Take home message for me with this patient was that it is imperative to know the current guidelines for PAP follow-up, and if going outside of those guidelines, document, document, document. It would have likely saved the patient from an unnecessary procedure, saved the provider a lot of time, and preserved the faith that the patient had in the referring provider.

The following website has the algorithms for cytology according to American Society for Colposcopy and Cervical Pathology. http://www.asccp.org/consensus.shtml

22 year old WWE

I had a couple of cases that I though of presenting, but thought that this one was, by far, the most eye-brow raising. I saw a 22 year old dependent spouse with a history of hpv who was in the clinic for a wwe and pap smear. While I was reviewing her intake form, I found it significant that she was HSV positive, had a history of gonnorhea, chlamydia, and sexual abuse. Based on her overall background, one would obviously assume that there were some significant psycho-social issues in this patient's life. This suspission was confirmed when she requested STI testing, including HIV. When I inquired about why she felt it necessary to have this testing (in my history taking I asked about monogamy with her husband) she replied that she hasn't had sex with her husband for over 6 months because last November he confessed tha he wanted to be a woman, and had felt that way most of his life. The patient stated that, in light of this, she wasn't entirely confident that her husband hadn't been experimenting with sexually with other men. We ordered all of the requested tests. After the appointment, I reflected on her prior history of sexual trauma, and wondered what part that played in her choice of a man with such confusion about his sexuality.

42yo G3P2A1 Caucasian female presents for annual well woman examination, required prior to deployment to Afghanistan. Patient reports “twisting” left lower quadrant pain since 2003. Adenxal tenderness noted on left side during bimanual. PMH: No hx of STDs; Breast cancer (right)-estrogen/progesterone related in 2006; endometriosis diagnosed while having bilateral tubal ligation performed in 2003. Had pelvic US performed in 2009, ovarian cysts, less than 3cm in size identified; LGSIL in 1990 (no other abnormal paps reported) lumpectomy performed 2006. Family history: Mom with history of uterine cancer. Patient currently followed by breast care center. Patient is due to deploy in August. Patient’s previous US report did not indicate repeat recommendations. Differentials: PCOS, endometriosis, uterine cancer. A pelvic US was ordered and a referral to Oncology was ordered. An oncologist has not followed the patient since 2006 and for further evaluation/recommendations as it relates to her symptoms. The challenge for this case is how to manage the patient’s current problem as it relates to the time constraints involved with the deployment.

First Well Woman Nightmare!

We saw a healthy 21 y/o G0P0 today for her first ever well-woman exam. So the game plan was I would do the H&PE, except for the pap/bimanual exam.  The pt. absolutely denied any h/o sexual experimentation as she "wants to wait to get married" and also denied any h/o abuse.  She'd only tried to use a tampon once and stopped because it was too uncomfortable. She also was a bit histrionic and so although I'd already done a "first" well woman exam successfully on another patient recently, I was glad the midwife was taking this on. Well, the CNM explained the procedure and also let her know that if the pt. asked her to stop, then we'd have to reschedule the appt. for another day.  The midwife was able to insert one finger, w/the pt. c/o stinging, and stiffening her body up (her hymen was still partially intact). But she was unable to advance the speculum further than 1" without the pt grimacing. She once again inserted her finger, and then inserted the speculum the same distance w/the same result. The CNM then asked her, "Do you want me stop", and the pt. said yes, and so the CNM withdrew and terminated the PE. The pt. then asked "well how much more did you have to go" and indicated she preferred to get this over and done with if it there hadn't been that much more to insert.  As a novice practitioner, I would have handled this differently, and I would've been wrong to do so. I would not have terminated the exam completely at the point the CNM did and kept the speculum in for a third and final try to see if I could further work w/her to "get it over and done with".  It takes the sophisticated practitioner to look at the big picture here. Yeah, it would've been over and done with, but now this young lady would have been scarred with a less than ideal experience. It would have been this big traumatic event that would she would carry on through all her GYN appt's, and maybe even her sexual and OB experiences.  I would have done her a disservice, esp. since it's not urgent for her to have the pap since she has a very low risk for STIs/HPV as a virgin. We told her to reschedule in 6 weeks and in the meantime, the CNM instructed her on daily use of a tampon to get her accustomed to the feel of a foreign object in her vagina (although I wonder, does one consider having her return instead in 6 months, or just wait till next year? I mean how important is it if you are not sexually active, or are we assuming that every pt. is lying?? I know it is important to make sure that anatomy is intact, but in the grand scheme of life, how soon is now?). It was a very valuable lesson for me today, that you have to keep the overall person in mind (esp. w/her being a histrionic) and think of their long term health over a "short term gain". 

OCP, Cellulitis and Hernia...Oh My!

34 yo female G2 P2 seen for post-partum visit c/o redness to nipples and questions about OCP. Pt with hx of PCOS, post-partum depression with 1st child, (L) inguinal hernia that developed during pregnancy, and newborn with GERD and milk allergies. She also developed cellulitis to (R) knee from apparent bug bite after delivery. Treated with abx, worsened and required overnight stay in ER to I&D abcess. Given PO Augmentin and receives weekly debridement and dressing changes. Due to baby's milk allergies, transitioning new baby to Neocate formula (Rx) and is pumping to supplement. Noticed cracked, red nipples and was concerned with yeast infection. Stated baby had white covering to tongue that had easily wiped off but was starting to become more difficult to wipe off. Also had questions about OCP d/t hx of PCOS. Had hx of taking Trinesa (tricyclic OCP) with good result. After explanation of different types of OCP (specifically Yaz/Yasmin), decided to stay with previous tricyclic. Other meds prescribed: Diflucan and Newman's Cream for poss. yeast infection and breast redness. Other areas addressed: hernia (rechecked in clinic and continued to be followed by surgery), PPD (addressed and confirmed that even though high stress now, she saw that stress was near ending b/c baby would be transitioned to formula within a week or two and crazy breast pumping/feeding schedule would stop and trips to Dr/ER would be slowing down as her knee continued to get better).

Do your whole interview, not part of it.

23 y/o active duty E-5 fell and broke her wrist in Afghanistan while on a convoy. Went to see the Dr and was medevac'd out of theater to Norfolk to have pins placed. She seen a FNP on a routine visit while recovering and a family history was done. Mother had died of breast cancer at 29 y/o and grandmother at 32 y/o. Testing was done and she was positive for BRCA 1. So she was sent to Bethesda to be seen at the breast care clinic. While there they determined she needed a pap smear. Pap was done and they found an adnexal mass. Turned out to be cysts on both ovaries and they were scheduling a hysterectomy on a 23 y/o with no kids. She had her exam prior to deployment and was told to get her pap when they got back as they didn't have the time since she was on a short notice deployment. Moral of the story is do a full exam and take the time to take care of our patients as earlier intervention might have had a different outcome.

Prescription/treatment quaqmire

This is an interesting case because it was a telecon during my rotation. The provider had seen a 16 y/o Hispanic female patient in March and completed PAP, pelvic and cultures. Patient had positive GC culture. Provider called patient, notified her of results and ordered antibiotics for her to pick up at the MTF pharmacy. Provider keeps a personal log to ensure patients pick up prescriptions when positive cultures involved. Patient never picked up rx so she called her and found that patient had lost her ID card and unable to get on base or pick up her medications. Provider asked patient if she was still having sex and patient stated she was but her boyfriend had been treated. Provider discussed with patient that both required treatment at the same time otherwise the infection could reoccur in treated partner. Patient then asked for civilian prescription to be called into network pharmacy. Provider did so but patient called back stating the pharmacy never received order. Provider called CVS and pharmacist stated they had order and it was good. She had to leave multiple telephone messages before patient called back and stated the pharmacist told her the order was not active. Provider put patient, pharmacist and herself on conference call eventually because patient kept calling clinic stating there was no active prescription at the place she requested. Provider thought that this case was now resolved. Patient then called clinic a few weeks later stating her father has her insurance card and she cannot get it from him. She did not want to tell him why she needed it. Provider directed patient to contact her local health dept to obtain free or low cost treatment if she was unable to get on base or use her insurance card or cash at local pharmacy to pick up her medications. Patient stated she would contact the local health dept. Two weeks later patient called again to say she got a new military ID card and wanted to make sure the antibiotic prescription at the MTF was still available/active because her mother would drive her to the clinic. The patient had still not picked up the prescription at the MTF by the time my clinical rotation was complete.

In this instance could the provider have contacted her parents? Called the front gate to sponsor her on base? I do not know if she had a driver’s license/car and I am not sure if she lived in DC, VA or MD or the distance she had to travel to get to MTF. The metro station is a few miles away from this location. I never looked up her address so unsure what state law applies to the situation. It boggled my mind that so many hours and effort had been expended and the patient had still not received treatment by mid-June after a diagnosis in March.

Atrophic Vaginitis

This patient was a 56 year old black female who came in for her annual well woman exam but upon questioning, revealed that she has noticed a vaginal odor for the past few weeks. The patient had a hysterectomy with ovaries left intact. The patient reports no itching or burning sensation along with the odor. On physical exam, no discharge was noted, but the patient's vaginal mucosa was inflamed and erythematous. We performed a wet smear, which was negative for yeast and BV. We diagnosed the patient with atrophic vaginitis and prescribed premarin cream. The interesting thing about this case for me was that my preceptor knew what the diagnosis was before we even did the wet smear. This was interesting because based on the patient's symptoms, I would not have thought of this. But apparently, this is a very common diagnosis in menopausal age patients. The other thing I had to do was educate this patient about the use of local hormones, since she was very concerned about the side effects of systemic hormones that she has heard so much about.