Women's Health
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Item MUCINOUS ADENOCARCINOMA LOCATED ON THE RIGHT LABIA(2013-04-12) Carrizales, EnriquePurpose: To present a case report and review of the literature of a patient with a well differentiated mucinous adenocarcinoma located on the right labia. Methods: A 52 year old African American female, gravida 3, para 2, presented to the clinic with a 8 month history of a pea sized mass on her right labia that had increased in size and tenderness. On physical exam the nodule was located at the internal middle third of the labia minora. The nodule was removed superficially and a diagnosis of a mucinous adenocarcinoma was made. Results: The removed mass was an irregular 1.0 x .8 x .5 cm fragment of gray-white soft tissue with an attached 0.6 x 0.4 cm ellipse of pale tan skin and a 2.1 x 1.5 x 0.5 cm aggregate of gelatinous translucent tan and red-tan mucoid material. Pathology revealed that the mass did not have free margins. Pathology of the labial mass biopsy revealed a well-differentiated mucinous adenocarcinoma with coexpression of mammaglobin and GATA-3 most likely of eccrine origin. Considering the coexpression of mammoglobin and GATA-3, the tumor is presenting a phenotype similar to mucinous carcinoma arising from the breast. However, a bilateral mammogram showed no evidence of malignancy. The decision was made to undergo a radical excisional procedure with a sentinel lymph node biopsy on the right side to determine lymphatic spread of the tumor. Conclusions: Sweat gland tumors of the vulva are a rare type of cancer. There is a lack of clear evidence in the literature regarding this condition. Between 1958 to 2009, 12 patients were described receiving treatment. Of the 12 patients five had recurrence of the cancer, three with distant metastatic disease and two with a localized recurrence. The literature states that radical resection of the tumor with clear margins results in the best outcomes. The literature is unclear as to whether adjunct therapy, radiotherapy or chemotherapy, has added benefits. This is particularly true in the case of radiotherapy as current literature suggests that primary sweat gland tumors tend to be resistant to this modality. In view of coexpression of mammaglobin GATA-3 and the absence of any evidence of breast cancer the diagnosis of a primary sweat gland tumor of the vulva was made.Item VENTRAL WALL HERNIATION AFTER CESAREN DELIVERY COMPLICATES FUTURE PREGNANCIES(2013-04-12) Long, AliaPurpose: The purpose of this case report is to present a patient that had a pregnancy with a portion of the uterus in the hernia sac and potential compromise to the fetus. She also developed significant cellulitis and fistulous tracts around her hernia. Hernias large enough to encompass all or a portion of the growing uterus are a rare complication of some pregnancies. Our patient had several complicating issues arise due to her large, ventral wall hernia. Methods: Involved a retrospective chart review of the management of a patient with a ruptured ovarian ectopic pregnancy. A literature review was undertaken for management points. Results: A 24 year old, gravida 3, para 2 was seen for her prenatal care and delivery of her baby. She had had a previous wound infection with her last cesarean that left a large ventral wall hernia on her abdomen. She quickly became pregnant again and the subsequent pregnancy was complicated by a portion of the growing fetus and uterus extending into the hernia sac. She received increased fetal surveillance during her pregnancy. Maternal-fetal medicine consulted throughout her pregnancy. She was also admitted for intravenous antibiotics for cellulitis and fistulous tracts developing from old pocket of infection possibly form her previous abscess pockets. The patient ultimately underwent repeat cesarean and intraoperative hernia repair with mesh placement. Post-operatively she did well. Conclusions: Ventral wall hernias will be seen more commonly as the rate of cesarean rises in the United States. Providers will need to be familiar with a variety of significant complications that may arise in these high-risk pregnancies. The patient outcome will likely be improved with a multispecialty approach to their pregnancy management.Item A CROSS SECTIONAL STUDY OF SEXUAL FUNCTIONING, ATTITUDES AND SATISFACTION OF LAPAROSCOPIC BANDING PATIENTS(2013-04-12) Mamawala, MufaddalPurpose: Sexual functioning and sexual satisfaction problems are well known to negatively impact QOL of obese patients. To date little is understood about sexual functioning of patients following WLS. This study is designed to investigate the sexual functioning, attitudes and satisfaction of post-surgical WLS patients, using a cross-sectional design. Methods: Subjects included 44 women who underwent laparoscopic banding surgery (LBS). Subjects had an average age of 44.95 years (20 - 69), and an average post-surgical weight loss of 56.72 pounds (10 - 154). Patients were stratified into (k=3) groups based on time since surgery, 1-6 months, 7-9 months, and e10 months. Subjects completed a self-report medical history checklist to determine current health status (diabetes, osteoarthritis, hypertension, depression, mental disorders). Self-report surveys included Female Sexual Function Index (FSFI), Body Exposure during Sexual Activities Questionnaire (BSEAQ), and Body Image Quality of Life Inventory (BIQLI). Group scores for each survey were compared using repeated measure ANOVAs. Bivariate Correlation was used between BIQLI, BSEAQ, FSFI, and Weight Loss to evaluation relationships between variables. Percent of subjects meeting criteria for Female Sexual Arousal Disorder (FSAD) was calculated based on published normative values. Subjects were then divided into "no sexual dysfunction" and "sexual dysfunction" based on published normative values. Cross-Tabulation and Fischer's-Exact Test was utilized to compare health status between women with and without sexual dysfunction. Results: There was no difference between time since surgery stratified groups for FSFI, BSEAQ, or BIQLI. There was a significant correlation between BSEAQ and FSFI (r= -0.566, p=.000). No other correlations were significant. In comparison to published normal values, 41% of subjects could be classified as having Female Sexual Arousal Disorder. There was no difference in prevalence of self-reported medical conditions between women with and without sexual dysfunction. Conclusions: A high percentage of post-surgical LBS patients are continuing to experience disturbances in sexual functioning despite a wide range of weight loss or time since surgery. Sexual dysfunction appears strongly related to the extent to which they are focused on a negative body image during sexual activity. These results will contribute to the development of targeted interventions to facilitate improvement in QOL in this population.Item OVARIAN ECTOPIC PREGNANCY: AN UNUSUAL PRESENTATION AND TREATMENT(2013-04-12) Spring-Robbins, ChandraPurpose: The purpose of this case report is to share a case of ovarian ectopic pregnancy and its complicated management. Ovarian ectopic pregnancies are rare, with an incidence of 1/7000 pregnancies. Management needs to consider future childbearing, ovarian preservation and hemodynamic stability. Methods: Involved a retrospective chart review of the management of a patient with a ruptured ovarian ectopic pregnancy. A literature review was undertaken for management points. Results: A 39 year old gravida 2, para 0102 presented to the Emergency Department and was diagnosed with likely hemoperitoneum and possible rupturing ectopic pregnancy. She was taken to the operating room and an ovarian ectopic noted laparoscopically and confirmed by pathologist on frozen section. An ovarian wedge resection performed and patient discharged home. She had persistently elevated human chorionic gonadotropin (hCG) level and was given methotrexate for presumed microscopically remaining chorionic villi. Her hormone level eventually declined to zero. Conclusions: Ovarian ectopic pregnancies are much more rare than those in the fallopian tubes. The management of them can be complicated by desire for ovarian preservation, significant hemoperitoneum if ruptured and persistent chorionic villi if the ovary is left behind.Item LEIOMYOSARCOMA OF THE VAGINA(2013-04-12) Ortiz, ChrisPurpose: To present a case report and review of the literature of a patient with leiomyosarcoma, a rare tumor of the vagina. Methods: A 38-year-old Caucasian female, gravida 7, para 6, presented to the hospital with vaginal bleeding from a mass in the vagina. On physical exam the mass filled the entire upper vagina. A biopsy was performed and showed a partially necrotic spindle cell tumor with atypia. The diagnosis of a leiomyosarcoma was made. Results: An ultrasound of the uterus determined that it measured 10.5 x 5.7 x 8 cm. An MRI was performed and it indicated a very large lobulated mass along the posterior aspect of the uterus. The mass appeared to originate from and partially obscure the cervix; it was well circumscribed and measured 7.5 x 4.7 x 7.3cm. The original assessment was that the patient had a large fibroid uterus with a leiomyosarcoma protruding from the cervix. A mass was detected arising from the mid portion of the right lateral vaginal wall via a 7 mm pedicle. The mass was removed with a wide radical resection. Pathology revealed a leiomyosarcoma with 21 mitotic figures per 10 high-power fields making it an aggressive sarcoma. Radiological imaging including a PET CT scan and MRI revealed no metastatic disease. The patient was presented at Tumor Board and adjuvant therapy including chemotherapy and radiotherapy was considered. Although the literature is unclear as to the benefits of radiotherapy or chemotherapy it was determined that she has had a 50-60% chance of recurrence either locally or distally, particularly in the lungs. The decision was made to give pelvic radiotherapy followed by chemotherapy in the form of Adriamycin. Conclusions: Vaginal leiomyosarcomas are uncommon with approximately 140 cases reported in the literature. This results in a lack of evidence to guide treatment modalities. The literature shows that these cancers tend to reoccur locally and undergo hematogenous metastasis into adjacent organs, specifically the lungs. The primary treatment is wide surgical resection of the tumor with post-operative consideration for radiation and/or chemotherapy. Although, there is no good evidence of the benefits of radiation or chemotherapy, due to the high incidence of local and distant recurrences radiation and/or chemotherapy is usually given.Item FACTORS ASSOCIATED WITH MAMMOGRAPHY UTILIZATION IN UNDERSERVED WOMEN IN SOUTH DALLAS, TX(2013-04-12) Chen, JingPurpose: To explore the association between self-reported mammography history, demographic characteristics, and medical care services. Methods: 430 women, aged 40 years and older, recruited between 2010 and 2012 for a breast cancer prevention program, were surveyed at baseline. Surveys were paper questionnaires administered with help from lay health educators. We tested the association between previous mammogram history of the participants and demographic characteristics, as well as medical care characteristics using chi-square tests and a multivariable logistic regression. Variable selection into the model was performed with a stepwise method. Results: In the univariate analysis, results from the chi-square test indicated that four demographic variables were significantly associated (P < 0.05) with having ever received a mammogram: age, race, family income, and marital status. Seven medical care variables were significantly associated with having ever received a mammogram: (1) health insurance, (2) ever performed a breast self-examination in the last month, (3) ever had a clinical breast examination in the previous year, (4) having a personal doctor, (5) regular check-ups, (6) ever talked to a doctor about breast cancer, and (7) talking to a doctor about receiving a mammogram. In the multivariable logistic analysis, age, marital status, insurance, and talking to doctor on mammogram remained significant: 65-74 years old vs. 40-49 years old (OR = 10.9, 95% CI: 1.4-85.0), 50-64 years old vs. 40-49 years old (OR=1.8, 95%C: 1.1-2.9), ever married vs. never married (OR = 1.8, 95% CI: 1.1-3.1), having health insurance vs. not (OR = 1.8, 95% CI: 1.1-3.0), and having ever talked to a doctor about receiving a mammogram vs. not (OR = 3.2, 95% CI: 1.9-5.2). Conclusions: Being older, married, having health insurance, and ever talked to a doctor about receiving a mammogram were positively associated with past mammography. On the other hand, there is a need to develop specific strategies for promoting mammography among younger, unmarried, or underinsured women. Further study needs to be conducted in a more racially-diverse population to support these findings.Item TARRANT COUNTY INTERCONCEPTION CARE INTERVENTION: FORMATIVE RESEARCH(2013-04-12) Smith, LucyPurpose: The purpose of the formative stage of this interconception intervention is to conduct stakeholder focus groups and individual interviews to guide the development of an intervention for women who have experienced a previous adverse birth or maternal health outcome. Methods: Focus groups and semi-structired interviews with stakeholders were conducted to ascertain their perspective on designing the intervention. Study participants are continually being enrolled because data saturation has not yet been achieved, i.e. the interviews will finish once no new information is being ascertained from the stakeholders. Interviews and focus group recordings were transcribed and will be entered into the NVivo 8 Database for data management and analysis. Results: So far, a total of two focus groups of fifteen people have been conducted, as well as sixteen individual interviews with key stakeholders. The stakeholders come from a variety of backgrounds that play an important role in the target population, such as pregnancy services, early childhood development organizations, UNT Health Science Center School of Public Health, March of Dimes, Fetal Infant Mortality Review (FIMR) and medical providers (JPS, UNTHSC, Cook Children's Hospital). Key recommendations from the perspective of stakeholders have included using community health workers that have had similar experiences as the participants in implementing program components and utilizing home visitations. Many stakeholders also voiced concerns about the fragmentation of health services in Tarrant County and that this intervention should work to connect women to existing services in the community. Interviewees tended to emphasize larger issues related to adverse birth outcomes, such as those related to poverty, which is beyond the scope of this intervention's ability to address. Conclusions: Stakeholder involvement is an essential component for program buy-in, cooperation and collaboration because of their experience with the target population. Through this process we have identified unexpected opportunities to strengthen health and social service agencies' ability to prevent infant mortality through better coordination and communication between organizations. In addition, these interviews have allowed us to identify the best approaches for successfully implementing the multi-year program. The next step in the formative research phase of the project is to conduct in-depth interviews with women who have experienced a previous poor birth outcome.Item ESTABLISHING AN ONSITE HEALTH CLINIC IN A DOMESTIC VIOLENCE SHELTER(2013-04-12) Agbeyegbe, LillianPurpose: Screening for Domestic/Intimate Partner Violence (D/IPV) is a protocol in most health care organizations. However health care providers remain uncomfortable with addressing D/IPV with clients. Also provider-patient trust relationship remains poor and D/IPV victims continue to experience poorer health outcomes than non-victims. Clients in a domestic violence shelter already acknowledge their condition as survivors. Shelter staff and partners are trained to be trauma informed and to meet clients where they are. The purpose of this study was to identify from clients and staff members, the barriers that keep survivors from accessing health care services, and determine priority services for an onsite health clinic. Methods: A review of the literature was used to establish the health consequences for survivors of D/IPV. An IRB approved needs assessment was conducted with clients and direct service staff at a domestic violence agency. The clients were surveyed with a questionnaire and self-reported on barriers to accessing health care, health needs forgone and top three desired services for an onsite health clinic. Staff members were interviewed on health needs observed with clients and barriers preventing clients from accessing health care services. Results: Clients identified insurance, transportation and waiting time as the three top barriers preventing accessing health care services. Staff identified additional barriers as client's state of mind and awareness of healthcare need. Clients reported dental care as the need most ignored, followed by primary care and vision. The top three services reported by clients as the most desired were primary care, women's health and dental care. The most observed health care needs as observed by staff were primary care, medication needs, mental health and women's health. Conclusions: An onsite health clinic can eliminate barriers identified by clients and staff as preventing survivors from accessing health care services. While clients and staff both agree that primary care services is the most needed service in an onsite health clinic, they differ on the next two most pressing services needed. The medication needs identified by staff is however crucial - whatever care a client gets can be negated by their inability to get the needed medication. Mental health services can also influence how best a client responds to other health care services. These can be considered the top three priorities for an onsite health clinic.