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NGR 6334 Women’s Health for Advanced Practice Nurses Summer 2008 Instructor: Elizabeth Rash PhD, ARNP, FNP-C Assistant Professor College of Nursing

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Presentation on theme: "NGR 6334 Women’s Health for Advanced Practice Nurses Summer 2008 Instructor: Elizabeth Rash PhD, ARNP, FNP-C Assistant Professor College of Nursing"— Presentation transcript:

1 NGR 6334 Women’s Health for Advanced Practice Nurses Summer 2008 Instructor: Elizabeth Rash PhD, ARNP, FNP-C Assistant Professor College of Nursing

2 Menopause ? "Tell me and I forget. Teach me and I remember. Involve me and I learn." Benjamin Franklin

3 42y Lily CC: Experiencing some hot flashes and night sweats x few mos. Menses remain regular. Night sweats cause some sleep disturbance.

4 What else do you want to know? What type of PE do you do? Any diagnostic tests at this time?

5 What do you recommend for her hot flashes and night sweats? Nonpharmacologic? Pharmacologic?

6 Lily decides she will try some of the non- pharmacologic recommendations for now and see how things go.

7 45y Lily returns 3 yrs later CC: Periods are slightly irregular and very heavy. She continues with occasional night sweats & insomnia (mainly before periods).

8 What else do you want to know? –Find a nearby classmate Spend a moment interviewing each other with questions you might ask Lily about her irregular periods, vasomotor symptoms and insomnia Practical Application

9 What type of PE do you do?

10 PE WNL except slightly nodular uterus. –What might this mean? Any diagnostic tests at this time?

11 Labs CBC: wnl UA & U-hCG: neg CMP: wnl TSH: wnl You also did a Pap, TV PUS…pending Were you thinking of any other tests?

12 Reflective response: Reflective response: How will you manage this?

13 Large fibroid How will you manage this? TV PUS

14 Fibroid Mgt Options No action GnRH agonists (ex. Lupron) –Reduces size for other interventions Hysterectomy Myolysis (heat, laser or cryo destruction) Myomectomy (surgical resection) Uterine Artery Embolization ??? Other experimental…

15 What if… TV PUS: hyperechoic endometrial band of of 15mm

16 Endometrial stripe: –Normal postmenopausal 5-8mm –Premenopausal normal up to 13mm Lily’s is 15mm What next?

17 Endometrial Bx Result Result: Category 1 Normal biopsy: endometrium or secretory (progesterone effect or postovulatory)

18 Remember… CC: Periods are slightly irregular and very heavy. Continues with occasional night sweats, insomnia (mainly before periods). How will you now manage her diagnosis of perimenopuasal DUB w/ vasomotor symptoms & insomnia?

19 You choose… Name: Lily Eli Date: 6/7/08 Alesse #3pk Jane Clinician ARNP Fl Low dose 20mcg COC Why low dose COC rather than HRT?

20 Lily asks: –If I am on birth control pills, how will I know when I reach menopause? Reflective response: Reflective response: How will you respond?

21 50y Lily CC: Here for well woman exam. Has not had a period in 13 mos. Having increasing hot flashes. Stopped her Alesse 2 yrs. ago.

22 What else do you want to know? –Find a nearby classmate Spend a moment interviewing each other with questions you might ask Lily about her amenorrhea & vasomotor symptoms Practical Application

23 Additional subjective information Meds: HCTZ 12.5mg prn for swelling; Viactiv Calcium chews 1 qd Also, slight UI with cough or sneeze

24 What PE do you do? Any diagnostic tests for the amenorrhea, hot flashes?

25 Labs: –FSH 55 IU/L –U/A neg

26 Please put away books and notes Put your name and date on a 3x5 card What is the likely meaning of an FSH of 55?

27 How will you now manage her Nonpharmacologically? Pharmacologically?

28 Name: Lily Eli Date: 6/7/09 Effexor XR 35mg/d # 30 Ref x 2 Jane Clinician ARNP Fl What patient education and follow-up will you do?

29 You ordered a DXA scan

30 Please put away books and notes Put your name and date on a 3x5 card What is the diagnosis based on the following DXA result? T score spine -2.2 T score femoral neck -1.1

31 T-Score Interpretation Above -1 SD Normal bone mass -1 to -2.5 SD Low bone mass (osteopenia) Below -2.5 SD Osteoporosis How will you tx Lily’s osteopenia? When will you repeat the DXA scan? Is there anything you can do in the interim to assure she is responding to your tx?

32 Bone Markers Predict Response to Therapy Before Evidence of BMD Changes Urine bone marker: N-terminal telopeptides of type-I collagen (uNTx) Serum may be more accurate –2 consecutive samples (collected anytime between 1 and 12 weeks) –Mean (Μ) 33-35nmol

33 Lily returns 2 yrs. later. She has been on Actonel 35mg/wk On recheck of her DXA: T score spine -3.2 (was -2.2), T score femoral neck -3.5 (was -1.1) What do you ask Lily? How might you manage this?

34 Lily returns stating her UI is worse. What else do you want to know?

35 She says: “Still some urine leakage with cough/sneeze but now urinary frequency especially at night and having hurry calls.” What’s your preliminary diagnosis? What PE would you do? Any diagnostics?

36 Lily opted for a pessary!!! What pt. ed. would you provide?

37 The pessary helped a bit for the stress UI but Lily is still having problems with OAB and urge UI. What would you recommend?

38 Name: Lily Eli Date: 8/7/08 Ditropan XL 5mg/d # 30 Ref x 2 Jane Clinician ARNP Fl What patient ed. do you provide with this Rx?

39 Lily returns with a potted plant. She wants to thank you for the wonderful care you have provided her for many years!

40 Issue Kay was placed on bioidentical compounded hormones (Triest) for peri-menopausal symptoms. She thinks they are making her feel better. You are aware that the research: NAMS, & ACOG do not support the efficacy or safety of “compounded”: bioidenticals over Rx HRT. What do you tell Kay?

41 ????? Next week: HIV and sexual orientation on the Web 2 weeks: in-class final exam. –Please be on time –Remember your PID and Rasberry Scantron


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