Women's Health

WOMEN'S HEALTH

Knowledge

Students should be able to define, describe and discuss:

The pathophysiology, clinical findings and diagnosis of menopause

Treatment options for menopausal symptoms

Risks and benefits of hormonal and alternative therapies

SSRIs, gabapentin, catapres, black cohosh, soy products

The pathophysiology, risk factors, causes and diagnosis of osteoporosis

Treatment options for osteoporosis

Calcium, vitamin D, estrogen, raloxifen, alendronate, calcitonin

Differences in clinical presentation, diagnosis and treatment of heart disease in women compared to men

Differential diagnosis and diagnostic evaluation of a breast mass

Risk factors and screening guidelines for breast cancer

Pathophysiology of and screening guidelines for cervical cancer

Management of abnormal pap smears

Physiology of bladder control

The pathophysiology, clinical findings, types and diagnosis of urinary incontinence

Treatment options for urinary incontinence

Pharmacologic – estrogen, alpha agonists and antagonists, cholinergics, anti-cholinergics, anti-spasmodics, calcium channel blockers

Physiotherapy – Kegel exercises, biofeedback, timed voiding

Surgery

Skills

Students should demonstrate specific skills, including:

History-Taking Skills:

Students should be able to obtain, document, and present a medical history for an annual health maintenance examination on a woman and determine appropriate evaluation and therapy for a woman with

Menopausal symptoms

Osteoporosis

Suspected coronary artery disease

A breast mass

Urinary incontinence

Physical Exam Skills:

Students should be able to perform a breast exam

Students should be able to perform a pelvic exam, including a pap smear and be familiar with special maneuvers indicated for a patient with incontinence (cough test; bulbocavernosis reflex, clitoral-sacral reflex)

Differential Diagnosis:

Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings on a woman with

menopausal symptoms

Irregular menstrual cycles

mood swings, anxiety, irritability

insomnia

hot flashes

vaginal mucosal atrophy and irritation

potential osteopenia/osteoporosis

age

thin body habitus

tobacco or alcohol use

Caucasian or Asian race

Sedentary life style

Lack of sun exposure

Family history

Symptoms suggestive of coronary artery disease

Chest pain (classic or atypical)

Epigastric pain

Dyspnea

fatigue

A breast mass

Urinary incontinence

Loss of urine with increased intra-abdominal pressure -- exercise, cough, laughter

Loss of urine preceded by a strong urge to void, whether bladder is full or not – ‘Overactive bladder”

Urine loss associated with over distention of the bladder – diabetic neuropathy, spinal cord injury, multiple sclerosis

Incontinence associated with delirium, infection, atrophic vaginitis, drugs, stool impaction, or psychiatric illness

Incontinence associated with recurrent UTIs, pelvic prolapse, previous pelvic surgery or radiation

Laboratory Interpretation:

Students should know the indications for, limitations of and understand the results of

An FSH (follicle stimulating hormone) level

A bone mineral density test

Exercise stress testing including nuclear stress imaging

Mammography and breast ultrasonography

A pap smear

Basic and Advanced Procedure Skills:

Students should be able to perform a pap smear

Management Skills:

Students should be able to outline an appropriate, cost-effective evaluation and treatment plan for patients experiencing menopausal symptoms that includes consideration of symptom severity, co-morbid conditions such as hypertension, coronary artery disease, osteoporosis, clotting disorders, family history, and patient preferences.

Students should be able to recommend an appropriate cost-effective evaluation and treatment plan for patients with osteoporosis that includes consideration of co-morbid conditions such as GERD, peptic ulcer disease, breast cancer, thrombophilias, family history, patient preferences, and indications for endocrinology consultation.

Students should be able to develop an appropriate cost-effective evaluation and treatment plan for patients with cardiac symptoms that includes consideration of cardiovascular risk factors, likelihood of gastrointestinal, musculoskeletal, psychiatric or pulmonary pathology as etiologic cause of symptoms, patient preferences, and need for consultation from a cardiologist

Students should be able to develop an appropriate evaluation and treatment plan for patients with a breast mass that includes consideration of patient risk factors and indications for referral to a surgeon

Students should be able to determine when to obtain consultation from a gynecologist for a patient with an abnormal pap smear

Students should be able to outline an appropriate evaluation and treatment plan for patients with symptoms of urinary incontinence that considers the type of incontinence, severity of symptoms, and indications for referral to a urologist or urogynecologist.

Attitudes and Professional Behaviors

Students should be able to:

recognize the importance of patient preferences when selecting among diagnostic and therapeutic options

appreciate the impact the patients illness and symptoms have on a patient’s quality of life and well-being

Resources

Clerkship Seminar, “Women’s Health”, S. Hingle, MD

Internal Medicine Clerkship Guide, Paauw, et al, Mosby 2003, pp. 499-520

Articles

Postmenopausal Hormone Replacement Therapy for Primary Prevention of Chronic Conditions: Recommendations and Rationale, US Preventive Services Task Force Guidelines from Guide to Clinical Preventive Services, August 1, 2002

Nonhormonal Pharmacologic and Complementary Treatment of Menopause, Thiedke, Clinics in Family Practice, Volume 4, Number 1, March 2002
National Institutes of Health Consensus Development Conference Statement: Osteoporosis Prevention, Diagnosis and Therapy, Volume 17, Number 1, 2001

Screening for Cervical Cancer: Recommendations and Rationale, US Preventive Services Task Force Guidelines from Guide to Clinical Preventive Services, January 2003

Cardiovascular Disease in Postmenopausal Women: Myths and Reality, Lewis et al, American Journal of Cardiology, June 20, 2002

Books

Breast Health and Common Breast Problems: A Practical Approach, 2004,
Pamela Ganschaw, editor, ACP Women’s Health Series

Coronary Artery Disease in Women, 1999, Pamela Charney, editor, ACP Women’s Health Series

Osteoporosis An Evidence Based Guide to Prevention and Management, 2002, Cummings et al., ACP Women’s Health Series

Presentations

Alternatives to Menopausal Hormone Therapy for Treatment of Hot Flashes - Susan Hingle, MD

Cancer Screening - Robert Robinson, MD

Evaluation and Management of the Breast Mass - Gary Dunnington, MD

Hormone Replacement Therapy - Susan Hingle, MD

Nutrition and Osteoporosis - Amy Olson, RD, CDE

Osteoporosis - Richard Pamenter, PhD

Urinary Incontinence - Susan Hingle, MD

Women and Heart Disease - Susan Hingle, MD

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