GYN- Vulvovaginal disorders & Cervical screening

What is the most prevalent and most important homofermentative anaerobic microbe in the vaginal ecosystem?

Lactobacillus acidophilus spp

What is the pH of the vagina in premenopausal women?

4.0-4.5

What can all vaginitis infections increase the risk of?

STI and PID

What are the primary vaginitis infections in order of prevalence?

BV, candidiasis, trichomoniasis, PID

What is inflammation of the vagina?

Vaginitis

What vaginal disorders are associated with increased vaginal pH?

BV, atrophic vagnitis, trichomoniasis, desquamative inflammatory vagnitis

What are causes of vaginitis?

Infx, hormonal imbalance / hypoestrogenic state, contact / allergic rxn, desquamative, pH imbalance

What ssx are associated with vaginitis?

Pruritus, burning, irritation, excoriations, discharge, vaginal soreness, dyspareunia, erythema, edema

What is the diagnostic workup for vaginitis?

Often clinical dx; culture and wet prep, pH strip testing

What is the MCC of vagintiis in women of childbearing age?

Bacterial vaginosis (BV)

What causes BV?

Gardnerella vaginalis and other anaerobes

What are the MC risk factors associated with bacterial vaginosis (BV)?

New or multiple sexual partners, sharing sex toys between females, lack of condom use, douching, smoking (inc vaginal pH & dec estrogen), recent abx

Is BV considered a sexually transmitted infection?

No

The following sx are associated with what condition?

• MC ASX

• homogenous discharge - thin, milky, grayish, pools at introitus & adheres to vaginal walls (spilled milk appearance)

• pH > 4.5

• +/- fish like odor from amine release

• *does not cause vaginal pain/dypareunia unlike other vagnitis infections

BV

How is BV diagnosed?

Pelvic exam (MC a clinical dx)

pH strip (neutral - basic),

Culture & wet prep (clue cells) followed w/ 10% KOH prep (+whiff test- fish odor)

Large absence of PMN leukocytes on microscopy, no inc in parabasal cells

What is the first line treatment for BV?

Metronidazole (PO or gel) or Clindamycin cream

What must be avoided while taking metronidazole PO to avoid disulfiram-like reaction?

EtOH

What is the second line tx for BV?

Clindamycin (PO or intravaginally) or Tinidazole

What is the treatment for BV in pregnancy?

Metronidazole

What are other recommendations for BV?

Boric acid suppository if pH imbalance, probiotics, pelvic rest, vulvar hygiene

What is the 2nd MCC of vaginitis?

Candida vulvovaginitis

What is the MCC of candida vuvlovaginitis?

C. albicans

What atypical strains can cause candida vulvovaginitis and do not respond to typical anti fungal therapy (MC in immunosuppression or DM)?

Glabrata and tropicalis

What are RF for candida vulvovaginitis?

Luteal phase, abx use, DM/immunosuppression, inc estrogen, PV contraception

The following sx are associated with what condition?

• Asx

• white, clumpy discharge - “cottage cheese”

• normal pH

• vulvar edema, pruritus, excoriations

• dysuria, dyspareunia

• vulvar rash- erythematous, irregular discrete borders ± white discoloration and satellite lesions

Candida vulvovaginitis

What is the diagnosis for candida vulvovaginitis?

Usually clinical dx;

Culture & wet prep - 10% KOH (budding yeast and hyphae)

Swartz lamkin fungal stain (c. albicans stains blue)

microscopy negative up to 50% of time

Does a negative culture r/o candida vulvovaginitis?

No, negative in 50% of cases

*empiric therapy is used

What are treatment options for candida vulvovaginitis?

OTC intravaginal agents, prescription topical therapy, PO fluconazole

What OTC intravaginal agent is preferred in pregnant patients with a yeast infection?

Miconazole 2% cream 5g PV x 7 days

What are treatment options for atypical strains of candida vulvovaginitis?

Trial butoconazole nitrate first, then echinocandins (most effective)

What pregnancy category is fluconazole?

C

What conditions is an increase in parabasal cells common in?

Atrophic vaginitis and desquamative inflammatory vaginitis

What conditions is a large number of PMN leukocytes characteristic of?

Desquamative inflammatory vaginitis, trichomoniasis, atrophic vaginitis w/ infx

What is an STI caused by a protozoan flagellate / parasite that only survives in the vagina, cervix, skene’s ducts and urethra?

Trichomonas vaginitis

The following sx are associated with what condition?

• Asx- can have prolonged carriers status & be found incidentally

• Thin, bubbly, pale green or gray vaginal discharge that is foul smelling → copious & frothy

• pH usually 5-6

• vaginal erythema

• cervicitis- strawberry cervix (petechiae of cervix / vaginal wall)

Trichomonas vaginitis

What is the diagnosis for trichomonas vaginitis ?

Clinical, pap,

Culture & wet prep saline- pear shaped organism w/ small tail (looks like short & fat sperm), undulates & rapid moving, many WBC/PMNs seen

Rapid antigen test

What is the treatment for trichomonas vaginitis?

Metronidazole (PO preferred), abstinence x 24 hrs after completion of med

5-nitroimidazole allergy → refer for desensitization

± TOC

What trichomonas vaginitis treatment is preferred in pregnant women?

Metronidazole (can defer in asx women until 37 wks)

What is important to remember with trichomonas vaginitis?

Test & treat partners!

What is a thinning of vaginal tissue d/t decreased genital flow associated with hypoestrogenic states?

Atrophic vaginitis

When is atrophic vaginitis MC?

Perimenopause & menopause (dramatic drop in estrogen)

What are RF for atrophic vaginitis?

Menopause (natural or induced), postpartum, breastfeeding, hyperprolactinemia, smoking, nulliparity, cessation of coital activity, vaginal surgery

The following sx are seen with what condition?

• thinning of vaginal/vulvar tissue

• dyspareunia, pelvic pressure, vaginal bulge, organ prolapse

• dryness- dec secretions from 3-4 g/4 hrs → 1.7 g/4 hrs

• thin yellow colored discharge

• lower urinary tract sx- frequency, incontinence, burning

• vaginal/vulvar bleeding

• pH > 4.7 (usually 5.5-6.8)

Atrophic vaginitis

What symptoms are associated with thinning of vaginal/vulvar tissue seen with atrophic vaginitis?

dec pubic hair; dryness, loss of elasticity & rugae

loss of labia majora turgor, fusion of labia minora

shortening / narrowing of vaginal canal flattening of cervix, cervical stenosis

How is atrophic vaginitis diagnosed?

Usually clinical; vaginal pH > 4.7 (MC 5.5-6.8)

Parabasal cells on pap/bx

Cervical cytology - atrophy & nuclear enlargement

Elevated FSH & dec estradiol

What is the treatment for atrophic vaginitis?

Vaginal lubricants, moisturizers, topical estrogen (preferred; CEE, estradiol cream, vaginal tablets or ring), systemic estrogen

How is topical estrogen dosed for atrophic vaginitis?

Initiation: daily x 1-2 weeks

Maintenance: 2-3x/week

insert after intercourse or at bedtime

What is an ascending infection of the upper reproductive tract (endometrium, fallopian tubes, ovaries)?

Pelvic inflammatory disease (PID)

What is the MCC of pelvic inflammatory disease (PID)?

Mix of n. gonorrhoeae and chlamydia

What are RF for PID?

15-19 y/o, unprotected sex, multiple partners, prior PID, nulliparity, IUD insertion

What sx are seen in PID?

Pelvic pain, dyspareunia, dysuria, purulent cervical discharge, N, V, fever, +/- bleeding

What complications can be caused by scarring or adhesion from PID?

Tubo-ovarian abscess, chronic pelvic pain, ectopic pregnancy, infertility, Fitz-hugh Curtis syndrome

What condition?

• complication of PID-

• perihepatitis (inflammation of liver capsule) → fibrosis, scarring, peritoneal involvement

• RUQ pain, radiates to right shoulder

• normal LFTS, parenchyma not involved

• Violin string adhesions ot anterior liver surface

Fitz-Hugh curtis syndrome

What is the dx workup for PID?

Pelvic exam- purulent cervical dc, tenderness, chandelier’s sign

HCG, UA, cultures, labs

U/S (not normally needed), culdocentesis (drain pus from peritoneal space), laparoscopy

What is chandelier’s sign?

Cervical motion tenderness (CMT) to palpation so severe that they jump off the table as if reaching for the chandelier

*indicates PID

When is there a low threshold for the diagnosis of PID?

Sexually active young women with combo of lower abdominal, adnexal and cervical motion tenderness

*should receive empiric treatment

The following diagnostic criteria is for what condition?

• must have abdominal/pelvic tenderness, CMT, adnexal tenderness

• plus 1+ of the following:

  • + GS for G- intracellular diplococci (gonorrhea)

  • Fever > 38°

  • N, V, HA, malaise, or weakness

  • WBC > 10,000 (leukocytosis / left shift)

  • Pus on culdocentesis or laparoscopy

PID

What is the inpatient treatment for moderate severity PID?

IV doxy + 2nd gen ceph (cefoxitin or cefotetan) + metro OR

Clinda + gentamicin OR

Ampicillin/sulbactam + doxy

What should you do if a patient with PID has an IUD?

Remove it

What is the treatment for severe PID or uncertain diagnosis?

Hospitalization, bed rest, NPO ± NG suction, IVF, IV abx

What is the recommended regimen for mild-mod PID (she has 2 different slides on it idek bro)?

Ceftriaxone + doxy or azithro + metro

OR

Cefoxitin and probenecid + doxy + metro

What condition is an inflammatory effect of skin/mucosa secondary to contact with an irritant or allergen?

Vulvovaginal contact dermatitis

What condition?

• can mimic infx related vulvovaginitis

• burning, itching, erythema, +/- blisters

• +/- scant dc

• well demarcated rash that outlines placement of irritant / allergen

Vulvovaginal contact dermatitis

What is the diagnostic workup for vulvovaginal contact dermatitis?

Clinical dx is key, +/- vulvar/vaginal bx and allergen testing

What is the treatment for vulvovaginal contact dermatitis?

Short term TCS, avoid irritants, cotton underwear instead of synthetics

What is a chronic inflammatory skin disorder that can lead to thinning of skin, changes in pigmentation, scarring, permanent loss of architecture (micro/macroscopic levels)?

Lichen sclerosis

Where does lichen sclerosus MC affect?

Anogenital region

Who is lichen sclerosis MC in?

Girls pre-menarche and PM women

What condition?

• chronic vulvar pruritus (hallmark) → excoriations, lichenification, secondary insomnia

• hypopigmented atrophic papules that coalesce into plaques MC on labia minora & majora

• introitus- yellow, waxy appearance

• Pruritus ani, painful defecation, anal issues, rectal bleeding

• can be asx and have white scarring and loss of architecture

Lichen sclerosis

How to dx lichen sclerosis?

Clinical, confirm w/ vulvar bx

What is the treatment for lichen sclerosis?

TCS- clobetasol or tacrolimus

Intralesional steroid injection for thickened plaques

What is a collection fluid and/or pus in bartholin’s gland MC caused by E. coli, staph, or n. gonorrhea?

Bartholin’s cyst

What is the dx for bartholins cyst?

CBC and I&D w/ culture

What is the treatment for bartholin’s cyst?

mild-mod: warm compress, sitz bath, analgesic, ± abx (doxy or clinda +/- metro)

painful and fluctuant: I&D w/ word catheter and abx

surgery if > 2cm

What is a cyst full of white cottage cheese like substance, lipids and skin cells, malodorous?

Epidermal inclusion cysts

What cyst is caused by the epidermal layer pushing into the dermis with the outer capsule formed by infundibular portal of a hair follicle?

Inclusion cyst

What is the gold standard for cervical cancer screening?

Pap smear

What is a Pap smear?

Looks microscopically at a collection of cells from the surface of cervix to SCREEN atypical cell changes

*NOT diagnostic, does not confirm or r/p precancerous/cancerous cells

What are the PAP smear screening guidelines for < 21 y/o?

No screening (ASCUS, LSIL, HPV tend to clear on own in this age range)

What are the PAP smear screening guidelines for 21-29 y/o?

Pap or pap w/ reflex HPV testing

If negative, repeat in 3 years

What are the PAP smear screening guidelines for 25 y/o?

Consider primary HPV testing +/- pap

When should Pap smears be initiated?

Age 21 despite sexual activity

What are the PAP smear screening guidelines for ages 30-64?

Pap + HPV every 5 years (preferred)

Pap w/ reflex HPV or pap alone every 3 years

Primary HPV every 5 years (if pt can’t afford pap)

What are the PAP smear screening guidelines for ages ≥65?

Discontinue if no hx CIN ≥2 or ≥3 consecutive cytology results or 2 consecutive co tests in past 10 years, w/ most recent benign in past 5 years

Consider pap if they become sexually active w/ new partner

What is the development of abnormal, precancerous, or cancerous cells of the cervix?

Cervical dysplasia

What is the MCC of cervical dysplasia?

HPV (16, 18, 45)

What zone in cervical dysplasia is highest risk for malignancy?

Transformation zone / squamocolumnar junction

What are the sx of cervical dysplasia?

MC asx, intermenstrual bleeding, post coital spotting/bleeding, dyspareunia

How is cervical dysplasia dx?

Pap smear- Bethesda sx (not diagnostic), indicates follow up

Colposcopy +/- bx (diagnostic)

EMB w/ hysteroscopy if indicated

What term is used to describe Pap test results of the type of cells that covers the cervix (NOT a diagnosis of precancerous or cancer)?

Squamous intraepithelial lesion (SIL)

What is needed to find out if precancerous or cancer is actually present?

Cervical bx

How are pap results reported?

Bethesda sx of grading dysplasia

What bethesda grade?

• atypical squamous cells

• MC

• not always related to HPV

Atypical squamous cells of undetermined significance (ASC-US)

What bethesda grade?

• atypical squamous cells

• can’t exclude high grade intraepithelial lesion

ASC-H

What bethesda grade?

• mildy abnormal

• MC HPV related

• often resolves on its own

Low grade squamous intraepithelial lesions (LSIL)

What bethesda grade?

• Serious cervical cell changes

• more so related to precancerous or cancer

• usually form persistent HPV, often high risk strains (16/18/45)

High grade squamous intraepithelial lesion (HSIL)

What bethesda grade?

• Glandular cells found lining inner cervical canal as well s uterine lining

• often associated with w/ precancerous or cancerous changes

Atypical glandular cells not otherwise specified (AGC-NOS)

What bethesda grade is AIS?

Adenocarcinoma in situ

What bethesda grade is AGC-neoplastic?

Atypical glandular cells suspicious for adenocarcinoma in situ or cancer

What cervical bx grade?

• mild dysplasia → contained in basal 1/3 of epithelium

• usually assoc w/ LSIL

CIN I