STI's, breast, family planning

how to prevent reproductive tract infections

* Education & counseling 
* Identification of those infected, asymptomatic or  with symptoms 
* Effective diagnosis & Tx
* Evaluation, Tx and education for those at risk
* Vaccination for those at risk to prevent STIs
* If diagnosed with one STI → greater risk for multiple (especially HIV)
* Tx of partners to be expedited

normal findings on vaginal assessment

* **Leukorrhea – clear to cloudy**
* **Non Irritating, inoffensive**
* **Acidic –pH 3.8-4.5**
* **Contains lactobacilli & epithelial cells**

abnormal findings on vaginal assessment

* **Heavy discharge**
* **Offensive discharge** 
* **Change in color** 
* **Itching** 
* **Vaginal infections** 
* **bacterial infections**

Causative organism for bacterial vaginosis

Gardnerella vaginalis (bacterial) & mycoplasma hominis

Predisposing factors for bacterial vaginosis

Frequent sexual intercourse without condom use (sperm and seminal fluid have pH greater than 7)

trauma from douching

having a new sexual partner or multiple partners in the previous 6 months

and an upset in normal vaginal flora

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(More prevalent in sexually active females, but not considered STI because it can occur in virginal women)

Bacterial vaginosis Etiology

related to change in normal vaginal flora → Normal hydrogen peroxide–producing lactobacilli are reduced with an overgrowth of vaginal anaerobes and subsequent rise in vaginal pH.

Bacterial vaginosis Signs/symptoms

excessive amount of thin, watery, white or gray vaginal discharge with a foul odor sometimes described as “fishy.”

Diagnostic test/ findings for bacterial vaginosis

The characteristic “clue cells” are seen on a __wet-mount preparation__

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The addition of a 10% potassium hydroxide (KOH) solution to the vaginal secretions, called the **“whiff” test**, releases a strong, fishy, amine-like odor, due to the release of the biologic amines

Treatment for bacterial vaginosis

Metronidazole (ok to use in pregnancy)

Trichomoniasis causative agent

T. Vaginalis

Trichomoniasis signs/ symptoms

Asymptomatic or mild symptoms including: Discharge that is odorous, yellow-green, and frothy, Vulvar itching, Dysuria and dyspareunia

trichomoniasis predisposing factors

multiple sex partners

Effects from trichomoniasis

Risks for other STI’s

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Pregnancy: Premature rupture BOW, preterm delivery

Screening and diagnosis for trichomoniasis

nucleic acid amplification test (NAAT) or saline wet mount, metronidazole both partners 

management/ treatment for trichomoniasis

Metronidazole-  Partners should avoid intercourse until both are cured

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avoid alcohol for 24 hours after taking metronidazole and 72 hours after taking tinidazole

**Vulvovaginal candidiasis causative agent**

Candida albicans

**Vulvovaginal candidiasis predisposing factors**

**Antibiotic therapy,** DM, pregnancy, tight-fitting clothing, Oral contraceptives, immunosuppressants

what is **Vulvovaginal candidiasis also known as**

a yeast infection

signs and symptoms of **Vulvovaginal candidiasis**

nonmalodorous, thick, white, curdy (cottage cheese–like) vaginal discharge,

severe itching, dysuria (external vs. urethral), and dyspareunia

→ repeated yeast infections can be an early indicator of **diabetes mellitus**

management/ test for **Vulvovaginal candidiasis**

Antifungal oral and/or topical meds,

intravaginal meds

(Monistat or clotrimazole)

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Blood glucose

**Vulvovaginal candidiasis treatment in pregnancy**

treated only with topical azole preparations applied for 7 days; fluconazole is contraindicated 

* Infection at the time of birth may cause thrush (a candidal infection of the mouth) in the newborn.

**Chlamydia causative organism**

Chlamydia trachomatis

**Chlamydia symtoms**

Usually silent, **purulent discharge**, post-coital bleed

**what is a** Severe sequelae can result from untreated chlamydial infection

* **pelvic inflammatory disease (PID), infertility, and ectopic pregnancy.**

**Chlamydia predisposing factors**

Risky behaviors, lower socioeconomic bracket

**Chlamydia effects from infection**

Ectopic pregnancy, infertility, cervicitis, salpingitis, PID, ophthalmia neonatorum

who should be screened for **Chlamydia**

Sexually active women 20-25 age group, pregnant women

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\-→ cervical cultures

How is **Chlamydia treated**

Azithromycin or doxycycline

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retest pregnant women 3-4 wk following tx

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**treat all sex partners**

 what is a newborn of a woman with untreated chlamydia at risk of developing

ophthalmia neonatorum

how is ophthalmia neonatorum treated/ prevented

 erythromycin ophthalmic ointment prophylaxis at birth.

**Gonorrhea causative agent/ transmission**

Neisseria gonorrhoeae gram-negative, 

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transmission – sexual contact any mode

**Gonorrhea symptoms**

Absent or **purulent discharge**

lower abd pain

painful menstruation

**Gonorrhea predisposing factors**

same as CT

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Risky behaviors, lower socioeconomic bracket

**Gonorrhea effects from infection**

Ectopic pregnancy, infertility, cervicitis, salpingitis, PID

**how is Gonorrhea screened/diagnosed**

Endocervical cultures

**Gonorrhea treatment/management**

Ceftriaxone (Rocephin) IM,

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counseling,

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condoms

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contact all partners (exam, c/s, tx)

**Syphilis causative agent**

Treponema pallidum spirochete

**Syphilis primary stage symtoms**

a chance appears at the site where the T. pallidum organism entered the body → Symptoms include slight fever, loss of weight, and malaise. The charance  persists for about 4 weeks and then disappears.

**Syphilis secondary stage symtoms**

1. skin eruptions called condylomata lata (resemble wart-like plaques and are highly infectious- may appear on the vulva) 


1. Other secondary symptoms are acute arthritis, enlargement of the liver and spleen, nontender enlarged lymph nodes, iritis, and a chronic sore throat with hoarseness. 

**Syphilis latent phase symtpms**

no lesions may be followed by a tertiary stage. Approximately 30% of those patients who are not treated may progress to tertiary syphilis (major systems affected here)

**Syphilis transmission**

via subcutaneous tissue thru microscopic abrasions during SI, kissing, biting, oral-genital sex

**Syphilis effects from infection**

Neurosyphilis, congenital syphilis

**Syphilis screening and diagnosis**

Prior STI diagnosis

all pregnant women-→ serology tests – nontreponemal tests such as VDRL or RPR. Treponemal test – (FTA-ABS)

**Syphilis treatment**

Benzathine penicillin G

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education

**Syphilis treatment in non pregnant women who are allergic to penicillin**

doxycycline

what is PID

defined as a clinical syndrome resulting from an ascending infection from the vagina and endocervix to the endometrium and fallopian tubes

symptoms of PID

Pain, fever, vaginal discharge cervical motion tenderness

(can possibly be asymptomatic)

PID predisposing factors

Prior GC or CT infection

PID effects from infection

Ectopic pregnancies, infertility, dyspareunia, tuboovarian abscesses, pelvic adhesions

PID screening and diagnosis

Documentation of prior STI

Perform CBC

PID treatment

Antibiotics, analgesia

what strains of HPV predispose women to reproductive health cancers

16 & 18

clinical presentation of HPV

Soft papillary lesions on external genitalia posterior introitus, buttocks, single or clustered, (cauliflower appearance), painless flesh-colored or dark papules on vaginal or cx

HPV managment

Clean with oatmeal, cotton underwear, limit sex partners,

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prophylactic vaccination – Gardasil, yearly gyn exam/pap smear screening

strains of Genital Herpes Simplex Virus (HSV)

HSV-1 r/t oral blisters

HSV-2 – sexually transmitted

clinical presentations of HSV

Fever, chills, malaise, tender lesions, lymphadenopathy

effects from hsv infection

Miscarriage in 1st trimester of pregnancy, neonatal herpes

hsv screening/diagnosis

Culture of secretions

hsv managment

NS cleansing, analgesic

acyclovir (antiviral)

c/s delivery if active herpes present

viral hepatitis types

A – acquired fecal-oral route

B - transmitted sexually or through blood transfusion

C – as B

clinical presentations of hep. B

n/v, fever, abd pain

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late – jaundice & clay colored stool

risk factors for hep B

Multiple sex partners, IV drug use.

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All pregnant women and healthcare providers

hep B managment

Bedrest, diet, education. Newborns of Hep B+ mothers need Hep B immune globin (HBI)g vaccine

what does HIV lead to

Severe depression of cellular immune system leading to acquired immunodeficiency syndrome (AIDS)

clinical presentations of HIV

No symptoms may be present; seroconversion 6-12 weeks,

Flu-like, ↑esr, ↓wbc, platelets CD4 r/t AIDS, death

effects from HIV

↑ transmission during pregnancy is during perinatal period

risk factors/ screening & diagnosis for HIV

Sexual behaviors, IV drug use, h/o multiple partners.

Western Blot confirmed screening test

management of HIV

Zidovudine orally, in labor & prior to c/s delivery, ART or HAART given IV. Mode of delivery depends on viral load. Post-delivery no breastfeeding, oral zidovudine to newborn

what is **Pediculosis pubis caused by**

Pthirus: a grayish, parasitic “crab” louse that lays eggs that attach to the hair shaft

how is **Pediculosis pubis treated**

For either pregnant or nonpregnant women, it is treated by applying 1% permethrin cream rinse or pyrethrins with piperonyl butoxide

**symptoms of Sarcoptes scabiei**

itching that worsens at night or when the individual is warm. Noticeable erythematous, papular lesions or furrows may be present

how is **Sarcoptes scabiei treated**

* permethrin cream 5% applied to all body areas from the neck down and washed off after 8 to 14 hours or ivermectin 200ug/kg taken orally and repeated in 2 weeks.

difference between a BSA vs BSE

* breast self-awareness (BSA): the need for a woman to be aware of how her breasts normally look and feel
* **BSA** is now being advocated as a good method for detecting breast masses early. 
* Women at high risk for breast cancer are specifically encouraged to be attentive to the importance of early detection through BSA. 

The effectiveness of *BSE* is determined by the woman’s ability to perform the procedure correctly, by her knowledge of her own breast tissue, and by the density of her breast tissue

what is a clinical breast examination (CBE)

* a trained healthcare provider, such as a physician, nurse practitioner, or nurse-midwife, is an essential element of a routine gynecologic examination. 
* every 1 to 3 years for women ages 25 to 39 and annually for women 40 years and older

what is the gold standard for screening and cancer detection

mammography

when is ultrasound used

< 35 yrs of age

when is an MRI used

* clients at high risk of cancer, silicone injects, difficulty finding mass, chest radiation at young age

When is a biopsy performed

*  if mass is suspicious on mammogram

examples of benign breast conditions

* Fibrocystic breast changes
* Fibroadenoma
* Intraductal papillomas
* Nipple discharge
* Inflammatory conditions – duct ectasia
* Infections of the breast

fibrocystic breast disease presentation

* Lumpiness in both breast,+/- tenderness  
* Involves glandular tissue
* Cyclic pain 
* reports pain, tenderness, and swelling that is cyclic, worsening in the late luteal phase of the menstrual cycle (just before menses) and improving about 1 to 2 days into the menstrual cycle

Fibrocystic breast disease diagnosis

 u/s, mammogram, fine needle aspirate (FNS)

Fibrocystic breast disease management

dietary, social behaviors, pain meds

what is the most common benign tumor usually seen in adolescents

Fibroadenoma

description of a fibroadenoma

* Asymptomatic, mobile, well-defined, painless tumor 
* No increase in size in response to menstrual cycle compared to fibrocystic disorders

how is a fibroadenoma diagnosed

*   mammography or u/s. Surgery depends on severity of symptoms or suspicion of lump

description of nipple discharge

Can be normal, r/t endocrine issue or malignancy

what is Galactorrhea

nipple discharge not associated with lactation

how to diagnose the inflammatory lesion associated with nipple discharge

analysis of breast discharge, mammogram, prolactin & thyroid levels

what is **Intraductal papilloma**

A benign condition, develops in terminal nipple ducts, unilateral

what age category does intraductal papillomas usually occur in

occurs 20-50 age group

description of intraductal papillomas

*  non-palpable mass r/t size
* serous, serosanguinous or bloody nipple discharge

how to diagnose intraductal papillomas

* triple test (CBE + imaging + biopsy)

treatment for intraductal papillomas

 CBE x 6 months, excision of papilloma

what is **Mammary duct ectasia**

inflammation of ducts behind nipples occurring during perimenopausal period; acquired condition

how does **Mammary duct ectasia present**

nipple discharge, pain, inflammation

pathophysiology behind **Mammary duct ectasia**

*  ducts filled with epithelial secretions with skin bacteria leading to mastitis -→ Signs of infection, inverted nipple, greenish discharge

treatment for **Mammary duct ectasia**

conservative (pain management) – pain meds, ABX, comfort measures

description of cellulitis

* Occurs with or without abscess
* u/s to assess amt of fluid
* I&D if needed and ABX

predisposing factors for malignant breast disease

* Age
* Gender
* History of breast cancer
* Inherited gene – BRCA1 or BRCA2
* Family history 
* Postmenopausal use of hormones
* Sedentary lifestyle

diagnosis of malignant breast disease

* Lump is **painless**
* Usually in upper outer quadrant (%)
* Changes to skin and nipple – redness, dimpling, swelling (advanced & aggressive form of cancer)
* Clinical exam of lymph nodes – provides useful data on staging

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