Final 2010 GYN Module 1

N 580a Primary Care of Women: Well Woman and Gynecologic

Care
Fall 2010

TABLE OF CONTENTS
Clinical Information
Clinical Objectives 2-7
Student Responsibilities 8
Sample Patient Report
8
Sample Patient Charting 9-10
Scope of Primary Care Practice in Gynecologic Care
10-12

Didactic Information
Unit 1: Health Promotion and Evaluation in Gynecology 12-13
Unit 2: Human Physiology of the Menstrual Cycle 13-14
Unit 3: Contraceptive Choice, Compliance & Counseling 14-15
Unit 4: Selected Contraceptive Methods 15-17
Unit 5: Emergency Contraception 17
Unit 6: Fertility Awareness Methods 17-18
Unit 7: Sterilization 18
Unit 8: Screening for HIV
19
Unit 9: Pelvic Pain and Masses 19-20
Unit 10: Evaluation and Management of Vaginitis 20-21
Unit 11: Evaluation and Management of STDs 21-22
Unit 12: Pap Smear Management and Gynecologic Cancers 23
Unit 13: Evaluation and Management of Urinary Conditions 24-25
Unit 14: Menstrual Disorders 25-26
Unit 15: Breast Mass/Breast Disease 26-27
Unit 16: The Climacteric 27-29
Unit 17: Sexuality, Contraception & Pregnancy Issues in Adolescence 20-30
Unit 18: Sexuality 39
Unit 19: Gynecologic Care of Lesbian Client 41
Unit 20: Unplanned Pregnancies 42

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Final 2010 GYN Module 2

CLINICAL INFORMATION

Clinical Objectives

This course is the first in a series meant to help you achieve the standards set by the
professional organizations representing nurse-midwives and women’s health nurse
practitioners. Standards for the beginning level of practice expected of graduate nurse-
midwives are outlined in the ACNM Core Competencies. The bolded italics below
denote the 2007 core competencies as outlined by ACNM. Similar standards are set for
Women’s Health Nurse Practitioner Students who are eligible to sit the certification exam
held by the NCC.

A. Upon completion of this course, the student will be able to demonstrate in clinical
practice:

1. Independently manages the care of women seeking contraception and/or

gynecologic services under the supervision of the clinical preceptor.
A. Applies knowledge of well woman and midwifery women’s health nurse
practitioner practice of gynecologic care that includes, but is not limited
to the following:
1. Anatomy and physiology of the reproductive systems, including the
breast, through the life cycle
2. Human sexuality
3. Common screening and diagnostic tests
4. Parameters for differential diagnosis of common uro-gynecologic
problems
5. Management strategies and therapeutics for gynecologic health,
implementation of contraceptive methods, and common uro-
gynecologic problems.
6. Management strategies and therapeutics for sexually transmitted
infection that includes indicated partner evaluation, treatment or
referral
7. Counseling for sexual behaviors that promote health and prevent
disease
8. Counseling for clinical interventions and/or referral for unplanned or
undesired pregnancies, sexual concerns, and infertility.
9. Pharmacokinetics and pharmacotherapeutics of frequently prescribed
medications for contraception and gynecologic care.
10. Manage primary care for non-chronic illness and screen for chronic
illnesses when age appropriate or risk factors are present
B. Applies knowledge of well woman and midwifery/women’s health nurse-
practitioner practice in the preconception period that includes, but is not limited
to, the following

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Final 2010 GYN Module 3

1. Assessment of individuals and family readiness for pregnancy,

including emotional, psychosocial, and sexual factors.

II Perimenopause and Post-Menopause

A. Independently manages, under the supervision of the clinical preceptor, the
care of women during the perimenopause, postmenopausal and aging
period.
B. Applies knowledge of well woman and midwifery/women’s health nurse
practitioner practice in the perimenopause, postmenopause, and aging
periods, that includes, but is not limited to, the following:
1. Effects of menopause on physical, mental, and sexual health.
a. Anatomy and physiology of the systems as affected by the aging
process
b. The effects of the menopause on physical and mental health
c. Nutritional needs of the aging woman
2. Identification of deviations from normal.
3. Counseling and education for health maintenance and health
promotion in the aging woman.
a. Common screening and diagnostic tests to identify the onset of
chronic diseases during the climacteric
4. Initiation or referral for age/risk appropriate periodic health
screening.
5. Management strategies and therapeutics for alleviating the common
discomforts that may accompany the perimenopausal period.
a. Management techniques and therapeutics, including
complementary therapies, for alleviating the common
discomforts in aging women.
b. Pharmacokinetics and pharmacotherapeutics of frequently
prescribed medications and treatments for the
perimenopausal and menopausal woman
.
III. Demonstrate use of midwifery/women’s health nurse practitioner management
framework: principles, skills, and process

NURSE-MIDWIFERY HALLMARKS (Also appropriate for Women’s Health Students)

Midwifery care also meets the standards set by the Hallmarks of Midwifery care outlined
by the 2007 core competencies, which are:
A. Recognition of pregnancy, birth, and menopause as normal physiologic and
developmental processes.
B. Advocacy of non-intervention in the absence of complications
C. Incorporation of scientific evidence into clinical practice
D Promotion of family-centered care
E. Empowerment of women as partners in health care
F. Facilitation of healthy family and interpersonal relationships
G. Promotion of continuity of care

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Final 2010 GYN Module 4

H. Health promotion, disease prevention, and health education

I. Promotion of a public health perspective
J. Care to vulnerable populations
K. Advocacy for informed choice, shared decision-making, and the right to self
determinations
L. Cultural competence
M. Evaluation and incorporation of complementary and alternative therapies
in education and practice
N. Skillful communication, guidance, and counseling
O. Therapeutic value of human presence
P. Collaboration with other members of the health care team.

NURSE-MIDWIFERY AND WOMEN’S HEALTH NURSE PRACTITIONER

FRAMEWORK: SKILLS

The student is able to:

A. Perform all skills in a manner which:

1 Includes the therapeutic value of human presence

2. Demonstrate correct and efficient utilization of hands, instruments, and
equipment.
3. Result in obtaining accurate data which may include the safe completion
of an appropriate procedure/maneuver.
4. Cause the least possible physical and/or psychological discomfort to the
consumer but still is able to obtain the information needed for
management.
5. Reflect ability to make independent judgment and actions.

B. Perform and explain a complete physical exam appropriate to well woman visit:

1. Review of systems
2. Care at an initial or annual visit
3. Gross observation of affect and behavior
4. Head and neck exam
5. Heart and lung exam
6. Breast exam
7. Abdomen and back exam
8. Extremities exam
9. Pelvic exam including:
a. Inspection of vulva
b. Speculum exam
c. Obtain specimens for pap smear, cervical culture, chlamydia test,
wet mount, herpes culture
d. Bimanual exam

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Final 2010 GYN Module 5

e. Assessment of pelvic musculature

f. Rectal exam

C. Perform and explain circumscribed review of systems and aspects of physical

exam appropriate to an interval visit.

D. Perform or obtain appropriate laboratory tests.

E. Perform venipuncture for laboratory tests if appropriate to clinical site.

F. Perform appropriate treatment for problems requiring intervention, for example,

applying Trichloracetic acid for HPV infection.

G. Perform pregnancy sizing when appropriate.

H. Fit, insert, and evaluate contraceptive devices, for example, diaphragm, , IUD,
when appropriate.
I. Demonstrate proper use of microscope.

J. Identify organism/cells from vaginal/cervical discharge.

NURSE-MIDWIFERY AND WOMEN’S HEALTH NURSE PRACTITIONER

FRAMEWORK: PROCESS
1. Investigates by obtaining all necessary data for complete evaluation of the
woman:
A. Reviews previous data when available.
B. Identifies the purpose of the visit for the consumer.
C. Identifies the purpose of the visit for the health care provider.
D. Interviews consumer appropriately, obtaining complete and relevant history
1. Family-medical-surgical
2. Personal-medical-surgical
3. Obstetric-gynecological (including menstrual, sexual, contraceptive).
4. Health habits and lifestyle (including drugs, alcohol, smoking nutrition,
activity/rest medications, stress management).
E. Performs systematic review of systems and appropriate physical examination
of the consumer.
F. Obtains all routine laboratory data
G. Organizes data for preliminary diagnosis and complete database.
1. Clusters data appropriately
2. Identifies tentative diagnosis
3. Identifies missing information
4. Obtains additional data as necessary (includes history, physical,
laboratory, and other data)
H. Validates assumptions
I. Provides an appropriate, organized, prioritized report of client’s status to

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Final 2010 GYN Module 6

consult when appropriate, including pertinent data, statement of the

problems, and plans

2. Makes an accurate identification of problem(s)/diagnosis(es) based upon correct

interpretation of the data:

A. Determines women to be healthy or with indications of disease states

B. Determines woman’s need for health promotion, disease prevention, health
screening or medical treatment
C. Determines patient as pregnant and length of gestation or non-pregnant
D. Determines normalcy/deviations from normal for each system of the body and
mind
E. Utilizes family members as appropriate

3. Anticipates other potential problems/diagnoses based on problems/diagnoses

identification and/or correct interpretation of the data

A. Screens patients for:

1. Common health problems
Anemia and blood dyscrasias
Diabetes
Lung disease
Cardiac disease
Liver disease
Kidney disease
Substance abuse
Infectious disease
Mental health problems
2. Health promotion and disease prevention needs
Need for primary health screens
Immunizations
Pre-conception care
3. Gynecological conditions

4. Evaluates patient need for immediate intervention, and/or physician consultation and
collaborative management, and/or physician referral when there is deviation from
normal.

5. Develops a comprehensive plan of care which is supported by explanation of valid

rationale underlying the decision made and is based on the preceding steps:

A. Identifies possible treatment plans and consequences of each.

B. Provides description of diagnosis, finalizing the plan of management of
potential problems and rational for plan.
C. Informs consumer of options, rationale, risks, sequellae, and limitations of
therapeutic milieu including anticipated procedures (prior to institution of

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Final 2010 GYN Module 7

procedures).
D. Identifies need for appropriate additional lab tests.
E. Plans for subsequent assessment at appropriate intervals.
F. Utilizes appropriate faculty consultation for validation of management plan
G. Selects most appropriate therapeutic plan based on valid rationale

6. Demonstrates maintenance of clinical competency attained in other courses including:

A. Physical assessment
B. Primary care of women

7. Directs/implements the plan of care efficiently and safely

A. Offers appropriate additional lab tests

B. Orders appropriate treatments
C. Performs appropriate procedures
D. Arranges for subsequent assessments at appropriate intervals
E. Obtains appropriate medical consultation or collaboration
F. Records data legibly, concisely, and logically
1. Includes only and all clinically relevant materials in written recording.
2. Uses appropriate amount of time for charting.
3. Uses appropriate medical terminology
4. Is well organized and concise in verbal reporting
5. Includes only and all clinically relevant material in verbal reporting
G. Facilitates entry into and utilization of health care systems.
H. Communicates appropriately with health team members, faculty and peers
I. Develops environment of mutual respect in any professional interaction

8. Evaluates the effectiveness of the care given, recycling appropriately through the
management process of any aspects of care which has been ineffective

A. Predicts expected outcomes of management plan

B. Identifies methods for follow-up evaluation
C. Provides for follow-up evaluation when possible
D. Identifies implications of treatment results for subsequent practice

Student Responsibilities

Students are expected to assume responsibility for their own learning. Students
are expected to share their own concerns regarding their own leaning and to demonstrate
sensitivity to the learning needs of their classmates. This includes sharing experiences in
conferences and actively participating in seminars.

Students are expected to assume responsibility for keeping records accurately

(including clinical evaluation forms), for neither soliciting nor accepting help from others

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Final 2010 GYN Module 8

on examinations, for taking credit for only their own work and for assisting others in
maintaining a high standard of professional ethics.

Sample Patient Report

The student will give report to the preceptor as below before going into see the patient
until such time as the preceptor feels you can see patients somewhat independently. Still
no patient is to leave clinic without first reporting to the preceptor. Otherwise you will be
traveling to the patient’s home to do any needed follow-up.

This is a year old, g p , who presents to clinic for . Her

weight and BP are . Pertinent lab results include: hematocrit
, pregnancy test results are etc . Her cervical (or other) cultures results
were . Her significant surgical history includes .
Her significant medical history includes . Her family history is
significant for .

I am going to find out the following information .

I plan to do:
a complete physical
a pelvic exam
pap smear
GC, CHL culture
other

Sample Patient Charting

More clinical sites are now using electronic records or check lists for charting. SOAP
notes are not as commonly done but very helpful in making sure your data collection is
compete, your clinical reasoning is complete and accurate, and that your management
plan is appropriate. This section gives you an example but SEE THE SEPARATE SOAP
NOTE EXPLANATION FOR FURTHER DETAILS on how to write a SOAP note. If
your site uses a checklist, you may not need to write a S or O however always put your
assessment (diagnosis) and plan somewhere where they are easy to identify.

If you are having organizational difficulties in your thinking process or your charting a
SOAP note is most helpful. Even if your site has electronic charting practicing SOAP
charting will help focus your thinking and help you develop a complete management
plan. So use a blank sheet of paper to get your data, organize yourself by doing a SOAP
note and then enter your visit data into the check list or electronic record.

S. Identifying information (Age, Gravida, Parity, LMP and EDC if pregnant) is

Chief complaint : Experiencing .
Has questions about .

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Final 2010 GYN Module 9

Requests to have a refill on her BCPs etc

Requests routine exam, no problems or complaints, or
questions.
Background history:
This will vary depending on why the woman is coming in to be seen. If
this is a new patient or a woman who is coming in for her annual well
woman checkup, you will need to detail a complete history. Here is a
possible outline
GYN: menarche, cycle regularity, and length
Contraception
UTI/STD/Pap/GYN problems
OB: number/types of deliveries/problems.
Medical history
Allergies
Smoking, alcohol, drug
Significant problems or negative
Include current medications somewhere
Surgical history
Social history: mental health concerns, relationships, occupational
issues etc
Family history

If the patient is here for a problem history, then only the most positive and
negative findings relevant to the problem at hand needs to be included.
Commonly used language is ..”History is significant for….”

O. Vital Signs, WT or BMI as appropriate

Thyroid - neg
Breasts - no masses, SBE taught
Abdomen - neg
Vulva - no lesions
Vagina - clear or neg or white odorless discharge noted etc.
Cervix - clear, or no lesions or erosion or eversion etc.
Uterus - small, firm, mobile, non-tender, anteverted (retroverted) include all 5 of
these descriptors
Adnexa - neg left, neg right, or no masses left and right or no masses and non-
Tender include as outlined here
Rectum - neg, or not examined, or deferred
Extremities - neg
A. Normal gyn exam or
normal physical exam or
normal exam except for the following problems
for eg. Post pill amenorrhea
or polycystic breasts
or whatever you found which is a deviation from normal

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Final 2010 GYN Module 10

Intrauterine pregnancy 6 weeks size, or normal post TAB exam

Note that all problems, whether they are GYN related or not, or something that
another provider is managing such be included
P. Lab tests ordered,
Medications (full prescribing information written)
Counseling re medications given (side effects, duration of treatment)
Nonpharmacologic counseling
Warning signs if conditions worsen and what to do about it
Follow up (when) and venue of follow up (phone, office visit)

Scope of Primary Care Practice in Gynecologic Care

The following table lists problems commonly seen in women’s health practice. The lists
are organized to help students understand which conditions are commonly under the
management of midwives and women’s health practitioners and which are commonly
referred out to other providers.

Note that individual practice parameters vary by type of provider, as well as by the
interest of an individual provider, the prevalence of the problem in the practice, and the
availability of referral resources. In general, nurse midwives and women’s health nurse
practitioners have a narrower scope of practice with medical conditions than adult nurse
practitioners. The following lists are a guide for midwifery practice. See the units below
for details on these conditions. .

Because WHNP students at YSN are jointly prepared as both WHNP and ANPs, they
may have a larger scope of practice in managing some medical conditions and the same
scope of practice in gynecologic, well woman, and contraceptive practice as nurse-
midwives and WHNP. Please consult your Specialty Director if your role in the
management of these conditions is unclear.

Screen/Triage/Refer Manage
Dermatologic Severe acne Mild to moderate acne
Skin cancer
Fungal infections: tinea, candida,
pityriasis rosea
Bacterial infections: impetigo,
folliculitis, furnuncle
Psoriasis, severe eczema Eczema
Contact dermatitis
Lyme Disease
Viral infections: warts, herpes
Infestations
Lichen sclerosis
HEENT Hearing loss, recurrent otitis Otitis externa, media
Conjunctivitis, sty
Cluster headache, ominous Tension headache, migraine
headache headache
Hyper/hypothyroidism, thyroid Environmental allergies
nodule

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Final 2010 GYN Module 11

Respiratory Pneumonia, persistant Common cold, acute bronchitis,

pharyngitis, chronic sinusitis strep throat, influenza, acute
sinusitis
TB Latent TB prophylaxis
Cough, persistent
Severe asthma Mild intermittent asthma to mild
persistent asthma, Initial
treatment of acute asthma
exacerbation
Cardiac Angina/chest pain
Hypertension Mild hypertension requiring life
style management only
Severe hyperlipidemia or multi- Hyperlipidemia requiring lifestyle
risk individuals and those needing
medication management
DVT
Heart murmurs Diagnosis of heart murmurs
Abdominal Most causes of chronic Mild GERD, viral related
abdominal pain, Hepatitis A, B, C vomiting and diarrhea, Initial
treatment of H Pylori with co-
management, GYN abdominal
pain,
Nutritional Bulemina, anorexia Obesity
Muscluoskeletal Osteoarthritis, rheumatoid Mild chronic arthritis
arthritis
Osteoporosis Prevention of osteoporosis
Lumbosacral pain Mild low back pain, strain
Carpal tunnel syndrome
Scoliosis
Gout Costochronditis
Ankle strains, sprains, shoulder,
wrist, knee, joint pain
Fibromylagia
Mental Health Psychosis, Severe depression and Mild depression and anxiety
anxiety
Substance abuse Smoking cessation
Refer to mental health Identify Sexual and Physical
professional as appropriate Abuse
Urinary Complicated pyleonephritis UTI, outpatient pyleonephritis
Renal calculi
Incontinence Conservative management of
incontinence including evaluation
and management of pessaries
Interstitial cystitis
Reproductive Menstrual problems
Polycystic ovary syndrome
HIV HIV testing and counseling
STDs
Vaginitis
Sterilization Contraception. Sterilization
counseling. Contraceptive starts
for OCPs, depo, IUD insertion,
removal, barrier methods, fertility
awareness methods, Problems

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Final 2010 GYN Module 12

with all forms of contraception

Ectopic pregnancy Pregnancy
Chronic pelvic pain Dyspareunia
Severe endometriosis, fibroids Mild fibroids and endometriosis
Tubo-ovarian abscess, Outpatient PID
bartholinitis, toxic shock
Rectocele, cystocele, urinary Initial evaluation, initial
incontinence management of incontinence
GYN cancers: vulva, vagina, Management of abnormal pap
cervix, uterus, ovary smear until time to refer for
colposcopy
Breast mass/discharge, suspected Fibrocystic breasts. Work up of
pituitary tumors breast mass/galactorrhea
Perimenopausal symptoms,
hormone therapy use
Preconception Care
Postmenopausal bleeding after Post menopause bleeding screen
US, endometrial biopsy (if for pathology with US,
trained) demonstrate MD endometrial biopsy if trained
intervention
Infertility Infertility work up – cycle
reasons, lack of pt knowledge re
cycle, lab work, semen analysis
Acute pelvic problems with Stable fibroids note size and
ovarian cysts, fibroids with position of mass or uterine size
symptoms, endometriosis, toxic for non-symptomatic woman,
shock, tubo-ovarian abscess, management of pelvic pain with
Bartholinitis, contraceptive options.
Unplanned pregnancy Counsel for unplanned pregnancy

Breast mass/ discharge and work- Climacteric care; aging, onset of

up/ triage to diagnostic imaging chronic diseases, screening for
and breast surgeon ADL / independence,

Unit 1 Health Promotion & Evaluation in Gynecology

1. Identify major risk factors and screening strategies for family violence,
battering and sexual abuse including rape.
2. Identify ethical considerations in contraception.
3. Identify your own values regarding contraception.
4. Describe what is meant by informed choice, shared decision making and the right
to self-determination
5. Identify methods of counseling for sexual behaviors that promote health and
prevent disease
6. Manage the common screening tests done for
colon cancer
diabetes
thyroid disease
cholesterol screening

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Final 2010 GYN Module 13

7. Describe effective screening techniques for the identification of depression,

anxiety, substance abuse, abuse, violence, and bipolar disorders.
8. Describe common immunizations including their indications, schedules,
contraindications, and side effects that should be given in reproductive health
care settings including vaccines against tetanus, pertussis, measles, mumps,
rubella, varicella, hepatitis B, hepatitis A, pneumococcal, HPV, and influenza.
9. Describe the components of preconception counseling

Unit 1 Readings:
Hatcher chapters 1, 4,5,24
Schuilling Chapter 1
Hackley (2007) Chapter 1 Primary Care
Chapter 2 Immunizations
Chapter 3 Health Screenings
Chapter 7 Violence Against Women

Hackley B (2008) Incorporating Immunization Services into Reproductive Health

Care Journal of Midwifery & Women’s Health; 53( 3):175-187.
http://dx.doi.org/10.1016/j.jmwh.2008.01.002

Zonfrillo N, Hackley B (2008) The Quadrivalent Human Papillomavirus Vaccine:

Potential Factors in Effectiveness. Journal of Midwifery & Women’s Health;
53(3):188-194 http://dx.doi.org/10.1016/j.jmwh.2007.12.015

Smith R, Cokkinides V, Brooks D, Saslow D, Brawley D. (2010) Cancer

screening in the United States, 2010: a review of current American Cancer
Society guidelines and issues in cancer screening CA: a Cancer Journal for
Clinicians. 60:99-119. DOI 10.3322/caac.20063
http://dx.doi.org/10.3322/caac.20063
(sorry I cant get rid of the highlight, it was a reminder to me to put in the article
link)

Recommended Adult Immunization Schedule, 2010. Available at

http://www.cdc.gov/mmwr/PDF/wk/mm5851-Immunization.pdf

Bivalent Human Papillomavirus Vaccine (HPV2, Cervarix) for Use in Females

and Updated HPV Vaccination Recommendations from the ACIP NEW JUNE
2010
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5920a4.htm?s_cid=mm5920a
4_e
Quadrivalent Human Papillomavirus Vaccine (HPV4, Gardasil) for Use in Males
and Guidance from the ACIP. Available at

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Final 2010 GYN Module 14

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5920a5.htm?s_cid=mm5920a
5_e

Berghella V, Buchanan, E, Pereira L,Baxter, J (2010) Preconception

Care
Obstetrical and Gynecological Survey, 65(2):119, DOI:
10.1097/OGX.0b013e3181d0c358
(sorry I cant get rid of the highlight, it was a reminder to me to put in the article
link) http://dx.doi.org/10.1097/OGX.0b013e3181d0c358

Unit 2 Human Physiology of the Menstrual Cycle

1. Define the following and their significance to the menstrual cycle and the
reproductive organs:
Hypothalamus
Pituitary
Prolactin
Inhibin
Menstruation
Follicular/Luteal phases
Ovulation
Proliferative/Secretory phases
Follicles
Corpus luteum
Gonadotropin releasing GnRH
Gonadotropins
Follicle stimulating hormone - FSH
Luteinizing hormone - LH
Ovarian steroids
Estrogen
Estradiol
Estrone
Estriol
Progesterone - progestins, progestogens
Negative feedback system
Basal body temperature
Middleschmerz
Puberty

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Final 2010 GYN Module 15

Menopause
HPO axis
Body fat

Reading: Schuilling & Likus Chapter 5

Hatcher Chapter 2

Unit 3 Contraceptive Choice, Compliance, and Counseling

Content Objectives - The student is able to:

1. Identify factors influencing contraceptive choice and compliance.

3. Identify bioethical considerations with regards to contraception

3. Describe goals for teaching efficacy to clients.

4. Identify the influence of significant other(s) on contraceptive choice and

compliance.

5. Describe ways to assist women in decision-making regarding contraceptive

choice and compliance.

6. Discuss common reasons for discontinuance of contraceptive methods.

Readings:

Hatcher Chapters 3,19, 23 (p594), 27

Unit 4 Selected Contraceptive Methods

1. For the following contraceptive methods:

a. Combined and progestin only oral contraceptives including new products

b. Male and female condoms
c. Cervical cap
d. Depo-Provera
e. Diaphragm
f. Form, suppositories, film
g. IUD – paragard, mirena
h. Sponge
I. Withdrawal

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Final 2010 GYN Module 16

j. Lactational Amenorrhea Method

k. Orthoevra patch
l. Nuvaring
Identify:
a. Mechanisms of action
b. Perfect-use and typical failure rates
c. Absolute and relative contraindications
d. Benefits (including noncontraceptive) and risks
e. Advantages and disadvantages
f. Side effects and complications
g. Pertinent information to be obtained from women by
history, physical, and laboratory assessment
h. Possible drug interactions
I. Appropriate times during the menstrual cycle, post-partum,
and post-abortion for initiation of these methods
j. Instructions for correct use and appropriate anticipatory
guidance
k.. Management of common side effects
l. Appropriate follow-up care

2. For oral contraceptives:

a. Describe the factors to consider when deciding whether to prescribe

combined or progestin-only oral contraceptives
b. Discuss the hormonal etiology of common side effects
c. Discuss the management of common side effects, including switches to
different hormonal formulations
d. Review the formulations of different oral contraceptives, including
relative potency of hormonal components

3. For the diaphragm:

a. Identify the different types of diaphragms

b. Identify the criteria for selection of a particular type of diaphragm
c. Identify the situations in which the diaphragm should be replaced or
refitted
d. Identify criteria for determining the correct fit of the diaphragm
e. Describe how/why diaphragms/fitting rings should be cleaned and
disinfected

4. 5. For the IUD

a. Describe the various IUDs in terms of mechanism of action, effectiveness,

and availability
b. Identify the criteria for selection of the type of IUD
c. Identify the steps in inserting an IUD

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Final 2010 GYN Module 17

d. Identify the techniques used to decrease the chances of uterine perforation

and infection during IUD insertion
e. Identify signs, symptoms and management of a vaso-vagal reaction post-
insertion
f. Identify the management of the major complications from an IUD:
Perforation, pregnancy, and infection
g. Identify methods of locating an IUD when the strings are not visible and
discuss order of implementation
h. Identify reasons of IUD removal and describe the techniques for removal.

Readings

Hatcher Chapters 5-17

US Medical Eligibility Criteria for Contraceptive Use, 2010. Available at

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5904a1.htm?s_cid=rr5904a1_e

WHO Medical Eligibility Criteria 2010 Contraceptive Update Available at

http://www.ippf.org/NR/rdonlyres/D67E0B0E-39C9-4A0A-99E7-
44AD870C5058/0/MedBullEnglishMar2010.pdf

Unit 5 Emergency Contraception

1. Identify for the hormonal methods of emergency contraception

a. Dosages of various hormones (Plan B, oral contraceptives) used as

emergency contraception
b. Mechanism of action
c. Pertinent history, physical, and laboratory information which must be
considered before prescribing hormonal emergency contraception
d. Advantages and disadvantages
e. Patient instructions
f. Common side effects and their management
g. Contraindications
h. Appropriate follow-up

2. Identify for post-coital IUD’s

a. Mechanism of action
b. Pertinent history, physical, and laboratory information which must be
considered before inserting post-coital IUDs
c. Advantages and disadvantages
d. Patient instructions
e. Common side effects and their management

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f. Contraindications
g. Appropriate follow-up

Readings:

Hatcher Chapter 6
Varney p 528

Unit 6 Fertility Awareness Methods

Content Objectives - The student is able to:

1. Differentiate between the different methods of fertility awareness according to the

physiologic basis for the effectiveness of each.

a. Calendar method
b. Basal body temperature method
c. Cervical mucus (ovulation) method
d. Symptom-thermal method
e. Standard day

2. Identify the advantages and disadvantages of fertility awareness methods.

3. Identify the instructions appropriate for users of fertility awareness methods.

4. Identify the population most likely to use these methods effectively.

5. Identify the times in a woman’s reproductive life when it would be difficult to use
the fertility awareness method.

Readings:
Hatcher Chapter 16

Unit 7 Sterilization

Content Objectives - The student is able to:

1. Identify the anatomical structures involved, the advantages/disadvantages of,

failure rates, and complications of the following procedures:
a. Tubal ligation
(1) laparoscopic
(2) laparotomy (abdominal)
(3) vaginal
(4) transcervical (Essure)

18
Final 2010 GYN Module 19

b. Vasectomy

2. Identify the psychosocial/ bioethical implications of sterilization, and the factors

affecting satisfaction now and in the future.

3. Identify the essential components of patient teaching about sterilization, e.g.,

procedures, life situations that influence the appropriateness of the timing and choice.

4. Identify the procedure for reversing sterilization procedures and effectiveness

rates.

5. Describe sterilization abuse and its prevention.

6. Describe the federal laws and regulations regarding sterilization.

Readings: Hatcher Chapter 17

Unit 8 Screening for HIV

Content Objectives

1. Identify the bioethical considerations associated with the diagnosis of HIV

2. Identify components of HIV risk assessment; identify risk factors for HIV
infection.

3. Identify groups of risk for HIV infection, including women for whom testing is
recommended.

4. List factors involved in prevention of HIV infection, including safer-sex for

women.

5. Discuss the options and issues for HIV testing counseling.

Readings: Hatcher Chapter 21

Hackley 2007

Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant

Women in Health-Care Settings MMWR Recommendations and Reports 2006
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm

Unit 9 Pelvic Pain and Masses

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Final 2010 GYN Module 20

1. For common presentations of abdominal pain and pelvic masses, the student is able to
describe the
1. Underlying pathology/etiology, and predisposing factors
2. Subjective symptoms
3. Objective physical findings
4. Laboratory findings
5. Common differential diagnosis including
Ectopic pregnancy
Ovarian cysts
Fibroids
Endometriosis
Toxic shock syndrome
Dyspareunia
Chronic pelvic pain
Bartholinitis

Readings
Hatcher Chapters 20, 21,23
Schuilling Chapter 22, 25

Vercellini, P Viganò‌ P, SomiglianamE Abbiati 1‌ ,23, Giussy Barbara‌1 and Luigi

Fedele 1‌ ,3 (2009) Medical, surgical and alternative treatments for chronic pelvic
pain in women: a descriptive review. Gynecological Endocrinology
25 (4) 208-221 , DOI 10.1080/09513590802530940
http://dx.doi.org/10.1080/09513590802530940

Vercellini P et al (2009) Chronic pelvic pain in women: etiology, pathologenesis,

and diagnostic approach. Gynecological endocrinology 25(3) 149-158.
http://dx.doi.org/10.1080/09513590802549858

2. The student is able to describe the use and accuracy of different urine/serum pregnancy
tests and abdominal/transvaginal sonograms in the evaluation of suspected ectopic
pregnancy and adnexal masses.

Readings
Hatcher Chapter 23

Other Interesting Reading

20
Final 2010 GYN Module 21

Nama V. Manyonda I. Tubal ectopic pregnancy: diagnosis and management. Archives of

Gynecology & Obstetrics. 279(4):443-53, 2009 Apr.
http://dx.doi.org/10.1007/s00404-008-0731-3

Ortiz DD. Chronic pelvic pain in women. American Family Physician.

77(11):1535-42, 2008 Jun 1.
http://www.mdconsult.com/das/journal/view/0/N/20724484?
ja=646576&PAGE=1.html&issn=0002-838X&source=

Unit 10: Evaluation and Management of Vaginitis

The student is able to describe for the following conditions the

1. Underlying pathology/etiology and predisposing factors
2. Subjective symptoms
3. Objective physical findings
4. Differential diagnoses
5. Management with non-pharmacological therapies when
appropriate
6. Management with complimentary and alternative therapies
where appropriate
7. Medications used in the management of these conditions
8. Appropriate level of nurse-midwifery and women’s health nurse
practitioner (independent, collaborative, co-management,
referral) based on the severity of the disease presentation . (See
page 7)
9. Sequelae of the problem
10. Appropriate client teaching
11. Appropriate follow-up
12. Impact of pregnancy on diagnosis and management.
Conditions:
Bacterial vaginosis
Candida vaginitis
Trichmoniasis
Atrophic vaginitis
Lichen scleroses

Readings:

Hackley Chapter 21

Authoritative Recommendations and Primary Sources

CDC. Sexually transmitted diseases - Treatment Guidelines 2006
Available at http://www.cdc.gov/std/treatment/

21
Final 2010 GYN Module 22

Unit 11: Evaluation and Management of STDs

The student is able to describe for the following conditions the

1. Underlying pathology/etiology and predisposing factors
2. Subjective symptoms
3. Objective physical findings
4. Differential diagnosis
5. Management with non-pharmacological therapies when
appropriate
6. Management with complementary and alternative therapies where
appropriate
7. Medications used in the management of these conditions
8. Appropriate level of nurse-midwifery and women’s health nurse
practitioner (independent, collaborative, co-management, referral)
based on the severity of the disease presentation (see page 7)
9. Sequelae of the problem
10. Appropriate client teaching
11. Appropriate follow-up
12. Identify the effectiveness of currently available contraceptive
choices in preventing transmission
13. Distinguish between treatment failures and reinfection and the
management of each
14. Impact of pregnancy on diagnosis and management
15. Identify the population and the schedule and for Gardisil

Conditions:
Chlamydia Herpes
Molluscum contagiosum Condylomata acuminata
Hepatitis A, B, C Pediculosis pubis
Gonorrhea Human Papillima Virus (HPV)
Syphilis
PID

Readings:

Hackley 2007 Chapter 23

Hatcher Chapter21

CDC. Sexually transmitted diseases - Treatment Guidelines 2006

http://www.cdc.gov/std/treatment/

Hackley B (2008) Incorporating Immunization Services into

22
Final 2010 GYN Module 23

Reproductive Health Care Journal of Midwifery & Women’s Health; 53

( 3):175-187.

Zonfrillo N, Hackley B (2008) The Quadrivalent Human

Papillomavirus Vaccine: Potential Factors in Effectiveness. Journal of
Midwifery & Women’s Health; 53(3):188-194.

Authoritative Recommendations and Primary Sources

Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant

Women in Health-Care Settings 2006;55(RR-14):1-17
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm?s_cid=rr5514a1_e

CDC. (2005) Antiretroviral Postexposure Prophylaxis After Sexual, Injection-

Drug Use, or Other Nonoccupational Exposure to HIV in the United States
MMWR Recommendations and Reports. 54(RR-02): 1-20. Available at website:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5402a1.htm

Updated recommended treatment regimens for gonococcal infections and

associated conditions - United States, April 2007, available at
http://www.cdc.gov/std/treatment/2006/updated-regimens.htm

CDC. General information on sexually transmitted infection.

http://www.cdc.gov/std/

Recommended

Lesbian STD Home Page, University of Washington

http://depts.washington.edu/wswstd/Info-SaferSexTips.htm

Good source on information re STD transmission for bisexual and lesbian women.

Online Learning Resources

CDC STD Training http://www.cdc.gov/std/training/onlinetraining.htm
CDC Clinical slides http://www.cdc.gov/std/training/clinicalslides/

Unit 12: Pap smear Management and Gynecologic Cancers

The student is able to describe for the following conditions, the

1. Underlying pathology/etiology, and predisposing factors
2. Subjective symptoms
3. Objective physical findings

23
Final 2010 GYN Module 24

4. Appropriate tests used to evaluate the condition

5. Differential diagnosis
6. Management with non-pharmacological therapies when appropriate
7. Management with complimentary and alternative therapies where
appropriate
8. Classes of medications used in the management of these conditions
9. Appropriate level of nurse-midwifery and women’s health nurse
practitioner (independent, collaborative, co-management, referral) based
on the severity of the disease presentation
10. Sequelae of the problem
11. Appropriate client teaching
12. Appropriate follow-up
Conditions:
Abnormal pap smears (use articles only)
Cervical cancer
Ovarian cancer
Vulvar cancer
Human papilloma virus (HPV)
Endometrial cancer
Readings:
Hatcher Chapter 22 (NOT FOR CERVICAL CANCER>>OUTDATED>SEE
ARTI CLES BELOW)

ACOG Practice Bulletin no. 109: Cervical cytology screening. ACOG Committee
on Practice Bulletins--Gynecology. Obstetrics & Gynecology. 114(6):1409-
20, 2009 Dec http://ovidsp.ovid.com/ovidweb.cgi?
T=JS&NEWS=N&PAGE=toc&SEARCH=00006250-200912000-
00000.kc&LINKTYPE=asBody&LINKPOS=49&D=ovft

ACOG Practice Bulletin No. 99: management of abnormal cervical cytology and
histology. American College of Obstetricians and Gynecologists. Obstetrics &
Gynecology. 112(6):1419-44, 2008 Dec.
http://ovidsp.ovid.com/ovidweb.cgi?T=JS&NEWS=N&PAGE=toc&SEARCH=0
0006250-200812000-00000.kc&LINKTYPE=asBody&LINKPOS=1&D=ovft

ASCCP (2009) Use of HPV genotyping to manage HPV HR positive/cytology

negative women 30 years and older. Available at
http://www.asccp.org/pdfs/consensus/hpv_genotyping_20090320.pdf

Wright T, Massad S, Dunton C, Spitzer M, Wilkinosn E, Solomon D. (ASCCP)

2006 Consensus Guidelines for the management of women with abnormal

24
Final 2010 GYN Module 25

cervical cancer screening tests. AJOG Available at http://www.g-o-

c.org/uploads/asccp_2006_consensus_guidelines.pdf

Wright T, Massad S, Dunton C, Spitzer M, Wilkinosn E, Solomon D.

(ASCCP)2006 2006 consensus guidelines for the management of women with
cervical intraepithelial neoplasis or adenocarcinoma in situ AJOG. Available at
http://download.journals.elsevierhealth.com/pdfs/journals/0002-
9378/PIIS0002937807009337.pdf

Algorithms
1) http://www.asccp.org/pdfs/consensus/algorithms_hist_07.pdf

1) http://www.asccp.org/pdfs/consensus/algorithms_cyto_07.pdf

Look here for other interesting stuff:

Gulati AP. Domchek SM The clinical management of BRCA1 and BRCA2
mutation carriers.
Current Oncology Reports. 10(1):47-53, 2008 Jan.
http://dx.doi.org/10.1007/s11912-008-0008-9

Dann RB. Kelley JL. Zorn KK Strategies for ovarian cancer prevention.
Obstetrics & Gynecology Clinics of North America. 34(4):667-86, viii, 2007 Dec
http://dx.doi.org/10.1016/j.ogc.2007.10.001

Unit 13: Evaluation and Management of Urinary Conditions

A. The student is able to describe for the following problems: the

1. Underlying pathology/etiology and predisposing factors
2. Subjective symptoms
3. Objective physical findings
4. Differential diagnosis
5. Management with non-pharmacological therapies when appropriate
6. Management with complimentary and alternative therapies where
appropriate
7. Medications used in the management of these conditions
8. Appropriate level of nurse-midwifery and women’s health nurse
practitioner (independent, collaborative, co-management, referral)
based on the severity of the disease presentation
9. Sequelae of the problem
10. Appropriate client teaching
11. Appropriate follow-up
Conditions:

25
Final 2010 GYN Module 26

Urinary tract infections: Cystitis, Pylonephritis

Hematuria
Interstitial cystitis

B.Distinguish based on urinanalysis findings the following:

Conditions:
Pyelonephritis
Contaminated specimen
Cystitis
Renal calculi

Readings:
Hackley 2007 Chapter 18 Abdomen: Kidney, Bladder, and Reproductive
Problems p 679-702

Unit 14 Menstrual Disorders

Content Objectives:

1. Describe the differential diagnosis, etiology, screening procedures,

treatments, including pharmacologic, and follow-up for the following:

A. Amenorrhea
B. Dysmenorrhea
C. Oligomenorrhea
D. Menorrhagia
E. Metrorrhagia
F. Menometrorrhagia
G Dysfunctional Uterine Bleeding (DUB)
H. Polycystic Ovarian Syndrome (PCOS) (including genetic role)

3. Describe physical and emotional symptoms associated with premenstrual

syndrome, their possible causes and relief measures

4. Describe the role of the thyroid on menstrual cycling, fertility

Readings:
Hatcher Chapter 20

Morrow C, Naumburg E (2009) Dysmenorrhea Primary Care Clinics in Office

Practice, 1:19-32 doi:10.1016/j.pop.2008.10.004 |
http://dx.doi.org/10.1016/j.pop.2008.10.004

26
Final 2010 GYN Module 27

Glintborg D, Andersen M (2010) An update on the pathogenesis, inflammation,

and metabolism in hirsutism and polycystic ovary syndrome Gynecological
Endocrinology, 26 (4): 281-296 http://dx.doi.org/10.3109/09513590903247873

Schuilling Chapter 19, 20, 21

Unit 15 Breast Mass/Breast Disease

1. Identify components of the medical history pertinent to risk assessment

and symptom assessment for breast disease.

2. Define components for assessment of

A. Palpable mass
Cyst
Solid mass
Vague nodularity
B. Breast pain
C. Nipple discharge
D. Skin or nipple changes
E. The persistently worried woman with a negative work-up

3. Define a step by step workup for a breast mass

A. what tests to order by age or other parameters
B. when to refer
C. follow-up

4. Define components of assessment and counseling for women with a

family history of breast cancer.

Readings:

Hatcher Chapter 22
Schuilling Chapter 13
Hackley 2007 Chapter 19

Nelson H, Tyne K, Nalk A, Bougatsos C, Chan B, Humphrey L. (2009)

Screening for breast cancer: An update for the United States Task Force. Annals
of Internal Medicine. 151:727-737.
http://www.annals.org/content/151/10/727.full.pdf+html

27
Final 2010 GYN Module 28

Unit 16 The Climacteric

Content Objective:

1. Define the following:

A. Menopause
B. Climacteric
C. Perimenopause
D. Postmenopause

2. Identify the average age and normal variations when these life stages
occur.

3. Identify when it is considered safe for a woman to stop using birth control.

4. Describe normal changes and physical exam findings of the following

organs/systems in the perimenopausal woman/postmenopausal women.

A. Skin and subcutaneous tissue

B. Breasts
C. Eyes, hearing
D. Musculo-skeletal system
E. Vulva
F. Vagina
G. Uterus
H. Bladder
I. Skeleton

5. Describe endocrine changes in the perimenopause/postmenopause.

6. Identify common physical signs and changes of the

perimenopausal/postmenopausal period, their prevalence and significance.

7. Identify factors that make a perimenopausal/postmenopausal woman at

risk for the following conditions:

A. Breast CA
B. Endometrial CA
C. Osteoporosis

1) Identify preventive measures and screening procedures for

each of the above conditions.

28
Final 2010 GYN Module 29

2) Discuss appropriate counseling regarding prevention and

screening for the above conditions.
.

8. Discuss the controversies regarding the appropriate indications for and

management of estrogen/progesterone therapy.

9. Identify for both combined and estrogen only hormonal replacement

preparations:
A. Mechanism of action
B. Hormonal content
C. Benefits and risks
D. Contraindications
E. Side effects and complications

10. Discuss alternatives to medical management of perimenopausal

symptoms.

11. Discuss emotional changes and developmental tasks of the

perimenopausal period, including how societal attitudes influence these.

12. Identify counseling needs of perimenopausal/postmenopausal women.

13. Demonstrate understanding of successful aging, health maintenance and

preventive care for women of midlife through senescence.

14. Identify the etiology of general changes occurring from midlife and
demonstrates knowledge of relief measures that can be taken for each of
the following:

Energy levels
Sleep
Weight-obesity, weight loss
Pain
Skin/ looking older

15. Identify issues for women as care providers for family members.

16. Identify issues concerned with sensory loss associated with aging,
including vision, hearing, memory lapse and loss.

17. Identify issues concerned with death and dying for women themselves and
their circle of family and friends.

29
Final 2010 GYN Module 30

Readings:
Varney 2004 Chapter 13

Hatcher Chapter 26

Schuilling Chapter 11

Hackley, B. & Rousseau, ME. (2004) Managing menopausal symptoms

after the Women’s Health Initiative Journal of Midwifery & Women’s
Health.

Takahashi Paul, et. al. (2004) Preventive health care in the elderly
population: a guide for practicing physicians. Mayo Clin Proc 79:416-427
Available at
http://www.mayoclinicproceedings.com/content/79/3/416.full.pdf

Unit 17 Sexuality, Contraception and Pregnancy Issues in Adolescence

Content Objectives - The student is able to:

1. Define adolescence from the perspective of:

A. Physiology
(1) Biological
(2) Puberty
B. Psychology/Cognition

2. Identify the bioethical considerations of teen sexuality

3. Define Tanner’s stages of pubertal development.

4. Describe the major demographic factors related to adolescent sexuality

and pregnancy, including:
A. Average age of first intercourse for female and male adolescents.
B. Percentage of adolescents using contraception at time of first
intercourse.
C. Number of adolescent pregnancies per year in the United States
and the outcomes, including:
(1) Number of live births
(2) Percentage of live births resulting in adoption
(3) Number of therapeutic abortions
D. Percentage of adolescents estimated to be homosexual or bisexual
in the United States.

30
Final 2010 GYN Module 31

5. Discuss developmental factors that are related to timing of first intercourse

and to adolescent pregnancy.

6. Discuss major risk factors for non-healthy states during adolescence,

including:
A. STDs, especially HIV/AIDS
B. Drug and alcohol use/abuse
C. Crime
D. Eating disorders
E. Depression/suicide

7. Identify unique health screening needs of the adolescent.

8. Identify unique counseling needs of the adolescent.

Readings:
Hatcher pp. 232, 285, 286

Schuilling p 25-31

Delisi K. Gold MA. The initial adolescent preventive care visit.

Clinical Obstetrics & Gynecology. 51(2):190-204, 2008 Jun.
http://ovidsp.ovid.com/ovidweb.cgi?
T=JS&NEWS=N&PAGE=fulltext&AN=00003081-200806000-
00004&LSLINK=80&D=ovft

Berlan E, Bravender T (2009) Confidentiality, consent, and caring for the

adolescent patient. Current Opinion in Pediatrics. 21(4) 450-456
http://ovidsp.ovid.com/ovidweb.cgi?T=JS&NEWS=N&PAGE=fulltext&AN=000
08480-200908000-00006&LSLINK=80&D=ovft

Unit 18 Sexuality

Content Objectives - The student is able to:

1. Identify the bioethical considerations innate in women’s sexuality

2 Describe phases of sexual response in women:

3. Discuss sexual response of female genital/reproductive structures:

A. Clitoris
B. Vagina

31
Final 2010 GYN Module 32

C. Uterus
D. Vulva

4. Discuss role of sex hormones on sexual response of women.

5. Discuss effect of alcohol/recreational drugs on human sexual response.

6. Identify the potential causes and treatments for the following sexual
dysfunctions:
A. Dyspareunia
B. Primary and secondary erectile dysfunction
C. Vaginismus
D. Anorgasmia
E. Premature ejaculation
F. Desire phase disorders
G. Excitement phase disorders
H. Female gender role difficulties

7. Discuss sexual psychology of women:

8. Identify possible techniques to help put yourself and a client at ease while
taking a sexual history.

9. Identify your own values and attitudes about sexuality.

10. Identify possible range of sexual activity in humans.

11. Identify changes in sexuality of women associated with life transitions.

12. Discuss the relationship between contraception, contraception and

sexuality.

13. Discuss the relationship between sexuality and sexually transmitted

disease.

Readings:
Amato P (2006) Categories of Female Sexual Dsyfunction Obstetrics and
Gynecologic Clinics of North America 33:527-534.
http://dx.doi.org/10.1016/j.ogc.2006.10.003

Carey J (2006) Disorders of Sexual Desire and Arousal Obstetrics and

Gynecologic Clinics of North America 33:549-564.
http://dx.doi.org/10.1016/j.ogc.2006.10.004

Rosen R (2006) Normal Sexual Response in Women. Obstet Gynecol Clin

N Am 33: 515-526. http://dx.doi.org/10.1016/j.ogc.2006.09.005

32
Final 2010 GYN Module 33

Kingsberg S. (2006) Taking A Sexual History Obstet Gynecol Clin N Am

33: 535-547 http://dx.doi.org/10.1016/j.ogc.2006.09.002

McGloin L (2006) Orgasmic Dysfunction Obstet Gynecol Clin N Am 33:

579-587. http://dx.doi.org/10.1016/j.ogc.2006.09.004

.Stone-Godena T. Vulvar pain syndromes: vestibulodynia Journal of

Midwifery & Women's Health. 51(6):502-9, 2006 Nov-Dec.
http://dx.doi.org/10.1016/j.jmwh.2006.08.010

Schuiling Chapter 14

Unit 19 Gynecologic Care of Lesbian Client

Content Objectives - The student is able to:

1. Define lesbian, with attention to both sexual and political meanings.

2. Appreciate the implications of being a lesbian the closet and a lesbian

coming out.

3. Define homophobia, heterosexism, and heterosexual privilege.

4. Identify implications for the health care of lesbian clients by providers

with homophobic and/or heterosexist attitudes.

5. Discuss difficulties of lesbian health care receivers including:

Fear of coming out
Fear of being found out
Fear of pelvic exam
Contraception

6. Discuss issues of confidentiality for lesbian clients.

7. Identify specific lesbian sexual practices that have implications for the
treatment of the following:
Vaginal infections
Herpes
Gonorrhea, syphilis, chlamydia
HIV

8. Discuss ways of incorporating non-heterosexual approaches to

gynecologic health care into practice.

33
Final 2010 GYN Module 34

9. Identify alternative methods of conception available to lesbians who desire

childbearing.

Readings:
Schuilling Chapter 10

Coker T, Austin S, Schuster M (2010) The health and health care of lesbian, gay,
and bisexual adolescents. Annual Review of Public Health, 31: 457-477.
http://dx.doi.org/10.1146/annurev.publhealth.012809.103636

McDonald C. Anderson B. The view from somewhere: locating lesbian

experience in women's health. Health Care for Women International. 24(8):697-
711, 2003 Sep-Oct. http://search.ebscohost.com/login.aspx?
direct=true&db=c8h&AN=2004021506&site=ehost-live

Brown JP. Tracy JK. Lesbians and cancer: an overlooked health disparity.
Cancer Causes & Control. 19(10):1009-20, 2008 Dec
http://dx.doi.org/10.1007/s10552-008-9176-z

Unit 20 Unplanned Pregnancies

Content Objectives - The student is able to:

1. Describe early clinical signs of pregnancy and methods of dating early

pregnancies.

2. Identify pregnancy tests available, how they work & relative accuracy of
test results.

3. Describe the size and consistency of the uterus:

A. Not-pregnant
B. 6 weeks (post LMP)
C. 8 weeks
D. 10 weeks
E. 12 weeks
F. 14 weeks

4. Identify factors that can cause the size of the uterus to be greater than
dates in the first trimester.

34
Final 2010 GYN Module 35

5. Describe the elements of decisional and supportive counseling for women

with unplanned pregnancies.

6. Identify the psycho-social implications of an unwanted pregnancy.

7. Describe the alternatives available to a woman/couple with an unwanted

pregnancy.

8. Describe medical and surgical procedures for terminations of pregnancies

and length of gestation where these are indicated.
A. Discuss risks and medical hazards of each procedure
B. Discuss advantages and disadvantages of each procedure

10. Describe the use of laminaria or prostaglandins to ripen the cervix.

11. Identify your own feelings toward abortion and how these may influence
your approach to women seeking abortion.

12. Identify signs and symptoms and management plan of the following
abortion complications:
A. Retained products of conception
B. Continuing pregnancy
C. Perforation
D. Endometritis
E. Salpingitis
F. Pelvic inflammatory disease
G. Ectopic pregnancy

14. Describe normal and abnormal pathology report from a TAB.

15. Describe the quantity and character of normal bleeding after first trimester
D & E abortion.

16. Identify when the HCG levels of 1st or 2nd trimester of pregnancy can be
expected to return to normal.

17. Identify when uterine involution should be complete following an

abortion.

18. Identify when, after an abortion, the menses can be expected to return, and
whether the first period will be normal.

19. Identify essential instructions and an anticipatory guidance to be given

after an abortion

Readings:

35
Final 2010 GYN Module 36

Hatcher Chapter 23, 24

Beal M (2007) Update on Medication Abortion Journal of Midwifery &

Women's Health, Volume 52, Issue 1, January-February 2007, Pages 23-
30 http://dx.doi.org/10.1016/j.jmwh.2006.10.006

36