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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
(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
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
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
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)
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
-→ cervical cultures
How is Chlamydia treated
Azithromycin or doxycycline
retest pregnant women 3-4 wk following tx
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
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,
counseling,
condoms
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
skin eruptions called condylomata lata (resemble wart-like plaques and are highly infectious- may appear on the vulva)
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
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,
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
late – jaundice & clay colored stool
risk factors for hep B
Multiple sex partners, IV drug use.
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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