The Health Care of Women in Military Settings

Operational Obstetrics & Gynecology

The Health Care of Women in Military Settings

2nd Edition

NAVMEDPUB 6300-2B

Table of ContentsPage 1

Table of Contents

Introduction...... 1

Routine Gynecologic Care...... 3

Pap Smears...... 7

Birth Control Pills...... 17

Other Contraceptive Methods...... 25

Bleeding...... 34

Vaginal Discharge and Itching...... 39

Human Papilloma Virus...... 44

The Vulva...... 46

Problems with Menstruation...... 56

Abdominal and Pelvic Pain...... 59

Problems with Urination...... 67

Breast Problems...... 71

Menopause...... 77

Sexual Assault...... 81

Normal Pregnancy...... 87

Abnormal Pregnancy...... 96

Normal Labor and Delivery...... 105

Problems During Labor and Delivery...... 116

Care of the Newborn...... 125

Medical Support of Women in Field Environments...... 129

The Prisoner of War Experience...... 138

Appendix: Phone Numbers for OB-GYN Consultation...... 140

IntroductionPage 1

Introduction to the 2nd Edition

When it was written in 1992, Operational Obstetrics & Gynecology was based primarily on my own personal experiences and perspectives, and focused on the needs of the sea-going population.

In writing the 2nd Edition, I have tried to incorporate several changes:

• I’ve expanded the applicability of the manual to the other areas of military operations (Air, Sea and Land).
• I’ve added several chapters not covered in the 1st Edition.
• I’ve solicited and incorporated changes and additions from operationally experienced medical providers from the Army, Navy, Marine Corps, Air Force and Coast Guard.

<small></small>Military Medicine

Providing health care in military settings is similar, in some ways, to civilian settings and in some ways different.

In civilian settings, the primary responsibility is to the patient, with secondary concerns from the insurance company, employer and family. In military settings, the primary responsibility is to the Command.

In most cases, the interests of the Command and the interests of the patient are the same, particularly in a garrison setting. In a deployed setting, divergence of interest may occasionally arise, creating challenges for the military health care provider.

Military medicine also differs from civilian medicine in three other fundamental ways:

• Medical providers are isolated.
• Medical resources are limited.
• Operational circumstances may influence the provision of medical care.

It is because of these differences that clinical problems in an operational setting may be treated differently than the same clinical problem in a civilian setting. The principles of treatment are the same: the application of treatment may be different.

Women’s Health Care

For the most part, women's health care needs are the same as men's health care needs. Women develop coughs, colds, stomach upsets, contusions, abrasions, and fractures. They need preventative care and immunizations.

However, some of their health care needs are different:

• Womenhave some unique gynecologic and obstetric needs.
• Women may have different vulnerabilities to certain diseases or injuries.
• Women may use health care services differently than men.

Women in the Military

Military women are a unique group.

They are a generally young, healthy population, pre-screened for most common, chronic diseases. They are, for the most part, physically fit and engage in regular exercise.

Women in the military are, as a group, younger than their male counterparts, are of lower rank, sustain more stress fractures, and utilize health care services twice as often. Even after excluding female-specific reasons (OB, GYN), they still use health care services more often. In this regard, they are similar to civilian women who also use health care services more often. In most studies, like their civilian counterparts, although they use health care services more often, they are generally less satisfied with those services than men.

Women in the military come from many backgrounds. Among Navy recruits, nearly half have been victims of physical domestic abuse prior to entry into the service, a figure similar to their male counterparts.

As a group, women have:

• More self-reported chronic conditions and all acute conditions except injuries
• Higher illness rates
• More days of illness and disability
• 10% more acute conditions, particularly infections, respiratory problems and digestive conditions
• Poorer vision
• Poorer dental status
• Better hearing
• More genitourinary problems
• Less chronic illness leading to death
• Lower death rates

About one-third of the OB-GYN health care visits made by military women are for routine care. Most of the remaining visits are for:

• STD diagnosis and treatment
• Menstrual abnormalities
• Vaginitis
• Urinary tract problems
• Pregnancy-related problems

Purpose of this Manual

This manual is designed to assist those who treat women with gynecologic problems and offer guidance for the continuing care of these women, particularly in isolated settings where gynecologic consultation is not readily available.

The manual is not all-inclusive and is not intended to replace good clinical judgment nor in-depth textbooks, which should be consulted whenever appropriate.

As in most areas of medicine, there may be more than one way to deal with any particular gynecologic problem. For simplicity, one basic approach is usually given here. There are often other approaches that will give very good or superior results.

CAPT Michael John Hughey, MC, USNR

Code 02SPO

Special Projects Officer for the Assistant Chief,

Operational Medicine and Fleet Support

Bureau of Medicine and Surgery

Department of the Navy

2300 E Street NW

Washington, DC

20372-5300

Routine Gynecologic ExamPage 1

Routine Gynecologic Care

Annual Exam

Once a year, a full gynecologic exam is indicated in women of childbearing years.

This is an excellent opportunity for routine health screening and patient counseling. The amount of detail and the content of the exam will depend on many factors, but a typical, routine, examination is illustrated here.

Many health care providers find it useful to utilize a standard form for recording information about this exam. An example is found in the back of this manual.

Chief Complaint

This is the reason for the visit.

It might be for a routine GYN visit, or to refill birth control pills, or because of a troublesome vaginal discharge. The Chief Complaint can almost always be stated in one sentence or less.

"What brings you to see me today?

Medical History

Ask how the patient has been since her last examination.

This is an opportunity for you to get a current medical status report. You might ask:

"Have you had any problems?"

"How are you feeling today?"

For patients not previously seen or for whom you have no medical records, you should note any previous significant medical or surgical illness, and allergies.

"Have you every been hospitalized for any medical illness?"

"Have you ever had any surgery?

"Are you allergic to any medicine?

Medications

Ask her to identify medications she takes regularly.

This will provide additional insight into her current health status and may identify areas of her medical history she has forgotten.

"Are you taking any medication on a regular basis?"

Menstrual History

Record menstrual data.

Age of onset of menses (menarche), the regularity (or irregularity) of menses, their frequency, duration, heaviness and any associated symptoms, such as cramps, bloating or headaches. Note the first day of the last menstrual period.

LMP______

Menarche age______

Menses are regular/irregular

Menses Q_____ days x ______days.

Pregnancy History

Determine the number and nature of pregnancies.

Gravida (G) means the total number of pregnancies. Para (P) means the number of children born. Abortions (AB) means the number of spontaneous or induced abortions.

G______

P______

AB_____

Contraception

Inquire as to the method currently used for contraception. This may provoke an answer that opens the door to a discussion of sexual issues that may be troubling to her.

Nutrition

Assess the general nutritional status.

This can be done visually and with noting her height and weight. For women with a normal, balanced diet, nutritional supplements are probably not necessary, but most people have difficulty maintaining a normal balanced diet. For those, a daily multivitamin can be very helpful in making up for any nutritional deficiencies. Additional iron is particularly helpful for women in maintaining a positive iron balance. Otherwise, the steady loss of iron through menstruation can lead to some degree of anemia.

For women anticipating a pregnancy, Folic acid 400 mg PO daily is recommended by the Center for Disease Control to reduce the risk of birth defect related to the spine.

I sometimes will ask:

"Are you eating a normal, balanced diet?"

"Do you normally take a vitamin pill?"

Exercise

Regular exercise is important for physical and psychological reasons.

Women who exercise regularly will generally experience less trouble with cardiovascular disease, bone loss (osteoporosis), weight control, and depression.

To be most effective, the exercise should be strenuous enough to cause sweating, last at least 20 minutes, and occur several times a week. Lesser amounts of exercise may also be beneficial.

"Do you get a chance to exercise regularly?"

As a group, women are more likely to sustain minor athletic injuries, for reasons that may include level of training or fitness, degree of experience with exercise, architectural construction of the pelvis and lower limbs, and possibly hormonal effects.

It is important to try to avoid athletic injuries while continuing to exercise. Try not to perform the same exercise two days in a row...give the body 48 hours to recover.

If a certain exercise causes pain, either modify it or discontinue it so that the pain does not persist. Gradually increase the duration and intensity of training and avoid sudden large increases that may lead to overuse injuries.

Mood

Depression is a common clinical problem affecting twice as many women as men. Talking with the patient will give you a reasonable assessment of her mood.

Depression is diagnosed whenever a depressed mood or loss of interest/pleasure is associated with at least four other symptoms, consistently over a two-week period. (DSM-IV)

• Depressed mood most of the day, most days
• Marked loss of interest in normal activities most of the day, most days
• >5% change in body weight in 1 month when not intentionally trying to modify body weight
• Insomnia or too much sleep most nights
• Psychomotor agitation or depression most of the time
• Marked fatigue nearly every day
• Feeling worthless or inappropriately guilty most of the time
• Diminished ability to think or make decisions most days
• Recurring thoughts of death or suicide

Physical Exam

While some physicians perform each of these evaluations at every routine gynecologic visit, some perform only those which focus on specific issues for the specific patient.

Weight

Weigh the patient.

Make an assessment of how her weight fits with standards for good health. Too much and too little weight are both problems.

Compare the weight with previous weights to assess the trend.

Blood Pressure

Measure the blood pressure and the other vital signs.

Particularly among older women, elevated blood pressure is a common problem and one that may be effectively controlled or treated. Uncontrolled elevated blood pressure is associated with a number of serious medical consequences.

Face and Eyes

Look in her eyes.

Watch they eyes for symmetry, proportion, focus, white sclerae, and movement. Look for any facial muscle weakness appearing as a droop or asymmetry.

Eye movements should be coordinated. The ability to read a sentence with each eye suggests intact ophthalmic, neurologic and higher brain function.

Facial muscles should have symmetry.

Ears

Look in her ears.

While not always necessary, a quick look in the ears will confirm pearly-white drums, the absence of fluid behind the drum, clean canals and the absence of pain while pulling on the external ear to straighten the canal.

Thyroid

Check the thyroid gland.

Many gynecologists routinely feel the thyroid for enlargement, tenderness or lumps, which might suggest a thyroid nodule.

Lungs

Listen for wheezes suggesting asthma, diminished breath sounds, or fine crackles, suggesting pneumonia or heart failure. Some apparently abnormal sounds will clear if the patient coughs.

Heart

Listen. Note the regularity of the rhythm, and the presence of any abnormal sounds such as clicks or murmurs.

Breasts

Check for any lumps, masses, tenderness, nipple discharge, or skin changes such as dimpling, retraction or crusting.

Abdomen

Palpate the abdomen.

It should be soft, and non-tender, with no masses. The liver may be just barely palpable below the rib cage and should not be tender.

Pelvic Examination

Evaluate the pelvis systematically.

Visually inspect the vulva, vagina and cervix. Obtain specimens for a Pap smear and any cultures that may be indicated.

Then feel the pelvis by application of a "bimanual exam." For a normal examination:

• External genitalia are of normal appearance. There is no enlargement of the Bartholin or Skene glands.
• Urethra and bladder are non-tender.
• Vagina is clean, without lesions or discharge
• Cervix is smooth, without lesions. Motion of the cervix causes no pain.
• Uterus is normal size, shape, and contour. It is non-tender
• The adnexa (tubes and ovaries) are neither tender nor enlarged.

Pap Smear

Obtain a Pap smear annually. Sometimes, a Pap is repeated more often, particularly if there have been abnormalities on prior Pap smears.

Cultures

Cultures can sometimes be helpful in determining the cause for vaginal or vulvar symptoms such as pain, burning or itching.

Bacterial cultures for Strept, E. coli and other pathogens may then indicate a course of treatment.

Some physicians routinely culture for gonorrhea and/or chlamydia on all of their patients at each routine visit. Whether this is wise for you depends on the frequency with which these STDs are found in your population.

Rectal

While some physicians routinely perform a rectal exam on all patients, others perform a rectal only on selected individuals in certain clinical circumstances, such as after age 50.

Routine screening with sigmoidoscopy every 5 years after age 50 is recommended by many physicians.

After the rectal exam, the small particles of stool left on the examining glove can be evaluated for the presence of occult blood. This is most useful after the age of 50.

Urine

Some physicians routinely check the urine at each routine visit. Others check the urine only for specific indications.

A clean urine specimen can be evaluated for the presence of:

• Color
• Character
• Leukocytes
• nitrite
• Urobilinogen
• Protein
• pH
• Blood
• Specific Gravity
• Ketones
• Bilirubin
• Glucose

Wet Mount

Vaginal discharge can be evaluated using a "wet mount."

A small amount of discharge is mixed with 10% potassium hydroxide (KOH), placed on a glass slide and covered with a coverslip. The KOH dissolves cell membranes, making it easier to see yeast organisms under the microscope.

Another small amount of discharge is mixed with a drop of normal saline, placed on a glass slide and examined under the microscope. With saline, active trichomonad organisms can be seen moving and "clue cells," indicating bacterial vaginosis can be seen.

Mammography

Mammography is a useful method of evaluating the breasts for the possible presence of early malignancy.

While not 100% accurate, it is probably around 80% accurate, particularly in detecting the very small, early malignancies not appreciated by physical examination.

Recommendations for frequency of mammograms, but the following general guidelines can be followed:

• Women with a disquieting symptom (eg bloody nipple discharge) or physical finding may benefit from an indicated mammogram
• Women with no significant high risk factors will probably benefit from routine mammogram screening every other year, from age 40 to 50, and annually after age 50.
• Women with a strong family history of breast cancer or other significant high risk factor may benefit from more frequent mammogram screening, and starting at a younger age.

Breast Self-examination

An important part of patient education is to see that she feels confident in her skills at self-breast examination. If not, you can teach her the proper techniques. I sometimes inquire:

"Are you examining your breasts regularly?"

Immunizations

In the civilian population, adult immunizations generally include:

• dt (Tetanus) every 10 years
• Measles booster once if born in 1957 or thereafter
• Influenza for the high risk group (Yearly>65, those with significant medical risks and their close contacts)
• Pneumococcus once after age 65 or in any high risk group
• Hepatitis B for high risk groups

In military populations, immunizations are directed by the Armed Forces Immunizations Program, and augmented by the addition of anthrax immunization.

Counseling

Counseling may be brief or lengthy.

It may be focused on the problems presented during the examination, or may be global, such as diet, exercise, or other healthy life-styles.

Patients often feel this is the most important part of the visit. Take your time and sit down while talking to the patient. You need not be a master of "bed side manner" for the patient to appreciate this time. Just be honest, direct, and pleasant.

Plan

Before leaving, the patient should understand any future plans.

Laboratory requisitions or consultation requests can be given. Patient hand-outs can be provided. Plans might include:

• Mammography
• Laboratory tests
• Consultations
• Patient information brochures

It is routine to indicate when the patient should return to the office (RTO) or return to the clinic (RTC).

"RTO in ______months."

Pap SmearsPage 1

Pap Smears

The Cervix

The cervix is located at the top of the vagina. It is the opening to the uterus and is composed of dense connective tissue. It has very little smooth muscle in it, compared to the rest of the uterus, which is almost entirely smooth muscle.