Women's health exam 2

started at vaginitis

vulvovaginitis

a spectrum of condition that cause vaginal or vulvar itching burning, irritation, and abnorm discharge

commonly caused by bacterial vaginosis, candida, and trichomoniasis

from the alteration of the normal flora

not currently consider a STI

risk factors: sex, other ST, douching, and smoking

presentation of bacterial vaginosis

presentation: mild vaginal irritation, thin white or yellow discharge

amine like fishy order = + whiff test

dx and tx of bacterial vaginosis

dx: gold standard is gram stain, more often done via KOH/wet prep

Amsel criteria: (needs 3 of the 4)

1. abnormal high pH over 4.5

2. abnormal think, grey white discharge

3. + whiff test

4. presence of clue cells greater than 20% epithelial cells

tx= metronidazole, clindamycin, metronidazole gel

complications of bacterial vaginosis

increase risk of PROM, and preterm delivery

associated with PID and post op infection

increase risk of inquiring an STI

tx of partners does not always prevent recurrence

candidiasis presentation

often time the tissue is red and there is a orderless cotton cheese discharge

itching is the big sx but can also have burning, dysuria, dyspareunia

candidiasis dx and tx

NAAT

budding yeast, pseudohyphea under microscopy

pH 4-4.5

tx with one dose of fluconazole or topical imidazole’s (miconazole, clotrimazole) for seven days

if it severe three doses fluconazole three days apart

if reccurrent candidiasis

think autoimmune,DM get A1C

trichomonas vulvovaginitis

from the unicellular flagellate protozoan trichomonas vaginalis

can infect the urogenital tract in both men and women

most common nonviral STI in the world

presents with frothy, thin, green-yellow, can have vulvar pruritic burning can have vaginal or cervical erythema with small petechiae with strawberry spots

dx and tx of trichomal vulvovaginitis

pH less than 4.5

microscopy showing motile organism with flagella in saline or + NAAT

women diagnosed should be screened for other STI

tx: diagnoise both partners at the same time (sx or not) females get metronidazole 7 days and men get metronidazole one dose + no sex until both partners get treated and no longer have sx.

repeat testing 3wks to 3 months after treatment

atrophic vaginitis

atrophy of the vagina epithelium due to a decrease in estrogen

pH is less than 4.7

sx: decrease discharge, dryness, itch/burn, urinary urgency and increase frequency, incontinence

dx: clinical

tx: hyaluronic acid as vaginal moisturizer and lubricants like astroglide

subsequent tx can be low dose estrogen but CI in endometrial cancer

chlamydia

the most frequent reported STI in US

can be asymptomatic - annual screening for any women less than 24

mucopurulent discharge - green or yellow and can also have cervical friability causing vaginal bleeding

extragenital sx: reactive arthritis (cant see, pee, climb a tree) proctitis, conjunctivitis

sx: NAAT

can also have annually and orally

chlamydia tx

doxy if pregno azithromycin

repeat testing in 3 months unless they are pregno or concern for adherence than retest 4 wks

chlamydia complications

PID

ectopic pregnancy

salpingitis

transmission to fetus

conjunctivitis

Gonorrhea

mucopurulent discharge - that is green/yellow can also have vaginal bleeding due to cervical friability

can also have inflammation of Bartholin gland, rectal proctitis and pharyngitis

NAAT testing

tx: ceftriaxone single dose and repeat testing 3 months or TOC is sx persist, if there is an oropharyngeal infx

no sex until tx is complete and partners are treated

complication of gonorrhea

conjunctivitis, salpingitis (Inflammation of the fallopian tubes), PID, and infertility. Preterm delivery, PROM, spontaneous abortion

soutine screening sexually active acitive women

PID

upper genital tract infection (endometrium, tubes, ovaries, and pelvic peritoneum

presentation: lower abdominal pain, abnormal uterine bleeding, abnormal vaginal, fever many be subtle with postcoital bleeding and urinary frequency.

dx: cervical motion, uterine or adnexal tenderness

is patient presents with RUQ

could be possible perihepatitis (fitz-hugh-curtis syndrome)

w/u pelvic inflammatory dx

pregnancy test

microscopy of vaginal discharge (wet prep)

NAAT for gonohrea, chlamydia, syphilis, and mycoplasma genitalium

CBC, CRP, ESR

pelvic ultrasound

when to admit for PID

Suspected pelvic abscess

  The patient is pregnant

  The patient cannot follow or tolerate an outpatient regimen

  The patient has not responded clinically to outpatient therapy within 72hrs

  The patient has severe illness, nausea and vomiting, or high fever

  Another surgical emergency, such as appendicitis, cannot be ruled out

tx for PID

IM ceftriaxone plus PO doxy plus PO metronidazole

close follow up within 42-72 hours needed

if prego 2 gen cephalosporin and azithro

make sure they have had testing for gonorrhea, syphilis, and HIV

complication of PID

infertility and ectopic pregnancy

Fitz hugh-curtis syndrome (involving inflammation of the liver capsule and surrounding peritoneum)

tubo-ovarian abcess

chronic pelvic pain, repeated infections, dyspareunia (recurrent pain with sex)

genital herpes

HSV -2 remains dormant in dorsal root ganglia

can still be spread during asymptomatic shedding

triggers for recurrence: stress, sun exposure, trauma, fever, viral infection, immunosuppression

lesions are tender, small grouped vesicles on an erythematous base and transition to ulcers

there will be pain and flu like sx with initial infection

genital herpes testing and tx

PCR testing

can do serological testing how has had neg HSV or PCR but hx of lesions

tx: valacyclovir ideally within 72 hrs of lesion appearance

suppressive th can decrease frequency only for severe or reduce risk to partner

Complications of herpes

aseptic meningitis, urinary retention, sacral radiculitis

when pt is pregno start suppressive therapy at 36 weeks if they have an active lesion or prodrome at tome of delivery they must have c section to prevent transmission

HPV

virus that only affects humans high risk 16 and 18

clinical presentation: condyloma acuminata- anogenital warts they are soft

there can also be cervical dysplasia/ cancer almost asymptomatic and not visible on speculum exam

dx: cytology on pap smear or clinical

tx: chemical tx like imiquimod, fluorouracil, cyro (preferred in pregnancy)

know NSAID

wet pt

pharm

HPV complications

progression to cancer

HPV vaccine important starting at age 11

syphilis

organism: treponema

• primary: painless chancre at site of inoculation and reginal lymphadenopathy (avg 21 days after exposure)

• secondary: 4-10 wks with constitutional sx sore throat, fever, weight loss, HA, rash, and more

• early latent: within one year but no sx***

• late tertiary syphilis (tertiary) 1-30 yrs and cause gummatous and aortitis, CNS affects

• late latent sypohilis: no sx but present over one year**

syphilis dx

presumptive dx can be made with non-treponemal testing

VDRL and RPR test

start with RPR test and if positive then do the treponemal test for confirmation

tx of syphilis

for primary, secondary, and early latent: penicillin G Benzathine once

if tertiary or late latent do once weekly for three weeks

common reaction to tx= jarisch-herzheimer rxn that is fever, HA, and myalgias, diaphoresis, rigors within 24 hours

in responded to tx the titer should fourfold decline if not there is tx failure repeat RPR 6, 12months and again at 25 for late syphilis

syphilis screening

all pregno patients between 28-32 weeks

any symptomatic pt

asymptomatic pt if high risk:

•Sexual partner with syphilis

•MSM

•HIV+

•On PrEP

•High risk sexual activity

•Hx of incarceration or commercial sex work

•Age 15-44 living in county with syphilis rate > 4.6/100,000 females

what is a medication that can prevent syphilis

doxy-PEP

doxy one times dose within 72 hrs of sexual intercourse

Lymphogranuloma venereum

genital ulcer disease caused by chlamydia trachomatis (different strain than chlamydia so two different things)

painless small genital ulcer/papules and lymphadenopathy 206 weeks later

dx: clinical plus c. trachomatis NAAT

tx: doxy unless pregno than azithro

repeat testing in 3 months plus partners should be tx

complications of Lymphogranuloma venereum

anal fistulas and strictures

what diseases are reportable

•Gonorrhea

•Chlamydia

•Syphilis

•HIV

•Chancroid

•LGV Lymphogranuloma venereum

chancriod

bacteria that causes genital ulcer and is more common in developing countries

causes by Haemophilus ducreyi often coinfection with HSV or T. pallidum

painful genital ulcer plus or minus inguinal lymphadenopathy

dx: clinical most places can not test for H. ducreyi but can make a probable dx from having all of the following:

• painful genital ulcer (one or many)

• no evidence of syphilis

• typical presentation

• beg HSV-1 OR HSV-2 NAAT or culture

tx and complications of chancroid

tx single dose of azithromycin may have to drain nodes and tx partners if contact within 10 days of sx and no sex until ucler is dried and resolved

complications: easier to get or transmit HIV

Bartholin gland cyst and abscess

4 and 8 in the vulvar vestibule can be painful and can lead to secondary infection where there is an abcess formation

present as a soft non tender mass when it is a cyst

severe pain, dyspareunia, soft tender, warm, fluctuant, edema, and erythema when it has developed to an abscess

dx: clinical and if purulent drain and culture

tx of Bartholin gland and cyst

•Small cyst <3cm: sitz bath, warm compress

•Small abscess <3cm: I&D + sitz bath, warm compresses

•Large mass ≥ 3cm: I&D + placement of word catheter

•Role of antibiotics: NOT routinely recommended unless recurrent or large mass with risk factors (immunocompromised, DM, etc.)

•Biopsy recommended when:

•Solid component, fixed to surrounding tissue, persists despite tx, or if the pt is post-menopausal (increased malignancy risk!)

You are so

smart

review risk at beginning of power point

21-29 year old screening HPV

cytology alone

30-65 HPV

if low to normal risk do HPV every five years -recommended

or cytology every 3 years

can do a home collected method

over 65 years HPV screening

can stop if last three consecutive negative cytology in the past ten years

or two negative combined test in the last ten year

or if hysterectomy non related to malignancy( if it was you still get cells from that general area)

High risk patient for decrease clearance rates of HPV

HIV

immunosuppressant drugs

…

if they are high risk you can look up specific guidelines for their condition

screening for high risk patient

primary HPV testing is not approved for those who are immunocompromised

visual inspect of the anus, vaginia, and volva annually

must do cytology every year for three years before moving to every three year

co testing every three years

never stop screening, continue longer than 65

disparities in cervical cancer

black women are 60% more likely to die of cervical cancer

1 and 10 women have never had a Pap test or OBYGN

31,31,58 HPV

cause 30% of cervical cancer

who gets three doses of Gardasil 9 vaccine

older than 15 or immunosuppressed

colposcopy

to view to cervix, vagina, vulva, anus stains cells

used for gross lesions, producers, post tx surveillance

complications: bleeding, infection - do not due with anticoag or when there is an active infection

CI for colposcopy

…

what is used to treat abnormal cervical cells

cone biopsy, cold knife conization or LEEP or laser vaporiztion/ conization or cryo or D&C

remove part of the cervix with abnormal cells

done under anesthetia

cone biopsy, cold knife conization complications

bleeding

uterine perforation

infection

cervical insufficiency

cervical stenosis

what is the MC follow up to abnormal PAP result

colposcopy

LEEP

also used for warts. polyps

excisional procedure with a heated wired done in office

same complications as knife

CI: pregnancy, unless stronge suspicion of invasive cancer

laser vaporization/conization

…

cryo

use NO to freeze and destroy abnormal cells

in office

used in CIN and genital warts

comp: spotting, dizzy, infection, and post op cramping

CI: preg

Dilator and curettage D&C

anesthesia

cervical dilator

unable to tolerate biopsy, post menopausal bleed in, to exclude endometrial carcinoma, can be used to manage abnormal uterine bleeding, abortions, removal of molar pregnancy

Dilator and curettage D&C comps and CI

what is cervical intraepithelial neoplasia

prescurion lesion of the uterine cervix that may progress to cervical cancer

CIN refers to squamous abnormalities in the ectocervix

where do 90% of neoplasia arise from (what area)

squamocolumnar junction SCJ which is part of the transformation zone

risk factors for CIN

immunosuppressant chronic renal failure Hodgkin lymphoma

cig smoking multiple partners

chlamydia and oral contraceptives

CIN 1

low grade lesion

mildly atypical cellular changes in the lower third epithelium

HPV cytopathic effect often present

CIN 2

high grade lesion

mod atypical cellular changes confined to the basal two thirds of the epithelium with preservation of epithelial maturation considerable varability in this category

CIN 3

high grade lesion

atypical cellular changes encompassing greater than two thirds of the epithelial thickness and includes full thickness lesions

what system is used to classify cytology results

Bethesda

what is the lowest grade of cell abnormalities in bethesda scale

ASC-US

atypical cells of undetermined significance most common

ASC-H

atypical squamous cells, cannot exclude high grade squamous intraepithelial lesions

LSIL

low grade squamous intraepithelial lesions

HSIL

high grade squamous intraepithelial lesions

what is the highest grade you can get in PAP interpretation

squamous cell carcinoma

what are the endo cervix abnormalities

atypical glandular cells

endocervical adenocarcinoma in situ - glandular precursor lesion

adenocarcinoma

get the mobile app for when to the

the management for abnormal PAP is dependent on

patient risk of developing CIN 3+, adenocarcinoma in situ, and invasive cancer

there fives year risk will be calculated and based on % risk has different management options

•A patient's risk of developing CIN 3+ is determined by their current HPV and cytology results as well as past screening and clinical history, if known

means that the: •The same current screening results may lead to a different management recommendation for one patient versus another patient, depending on past testing results.

what does an unsatisfactory lab results mean

the lab can not provide conclusive result and requires repeat screening or colposcopy

if patient is under 25 years of age

very high rates of spontaneous HPV so it takes more to get colposcopy

acute cervicitis

can be infection and non ( non from trauma, condom, tampon, diaphragm, foreign object)

infectious with strawberry spots thick trichomanias

on PE mucopurulent discharge, friability, edema, and cervical motion tenderness and PID

Nabothian cyst

could be post trauma or birth is when columnar epithelial becomes covered with squamous cells and secrete mucoid material

On PE: translucent or opaque yellow cyst

tx: is symptomatic use ablation to tx or if dx is unclear excise to r/o cervical neoplasia

what confirms the presence and shows severity of CIN

colposcopy

CIN management for pt under 25

CIN 1 with preceding lesions (ASC-US, LSIL, ASC-H, HSIL):  Observation >Treatment, f/u depends on preceding cytology

CIN 2:  Observation preferred, treatment is acceptable

  - 60% of lesions will regress by 24mths

  - generally recommend f/u with cytology and colposcopy at 6 and 12 months

CIN 3:  Treatment (CIN 3 is a direct precursor to cervical cancer)

DO CIN results affect when HPV vaccine should be offered

NO all pt who are candidates for vaccinations regardless of CIN hx the vaccine will not be therapeutic on preexisting HPV or CIN but associated with lower rates of recurrence

CIN management when 25 and older

New-onset CIN 1 and preceding ASCUS, LSIL, or ASC-H: Observation > treatment

  - 90% will regress to negative or remain CIN1, generally recommend f/u HPV testing 12mths

Persistent CIN 1  (≥2yrs): observation preferred, treatment acceptable

CIN 1 and preceding HSIL, or CIN2: Treatment or observation acceptable, For most patients, sources recommend treatment.

  *pts who desire future childbearing & w/ concerns for adverse obstetric outcomes, observation reasonable

CIN 3 – Treatment

tx for acute cervicitis

cover STI empirically

•Chlamydia – Doxycycline PO 100 mg BID x 7 days (tx sex partners!)

•Gonorrhea – Ceftriaxone 500 mg-1g (weight based) IM x 1 (treat sex partners!)

•M.genitalium – Doxycycline 100 mg PO BID x 7 days followed by Moxifloxacin 400 mg PO QD x 7 days

•Trichomoniasis – Metronidazole 500mg PO BID x 7 days (treat sex partners!)

•HSV – antiviral (Acyclovir, Famicyclovir, Valacyclovir) for 7-10 days

•BV- Metronidazole 500mg BID x 7dys or Metronidazole 0.75% gel daily x 5 days

cervical polyps

findings on cervix: single or multiple tear shaped or lobular pedunculated structures arising from the endocervical canal. Red, purple, or flesh colored that looks succulent and glistening.

tx: polypectomy is symptomatic (bleeding, discharge) larger than 3 cm, atypical , post menopausal with risk factors for endometrial cancer so like obesity, DM, tamoxifen use, fam hx. If removed always send to pathology for histology study

cervical stenosis

from , infx, menopause, cervical cancer, radiation trauma or prior surgery

pr: can obstruct mensural flow or sperm entering uterus

dx: inability to pass small cervical dilator through cervical os

tx: increase dilator weekly for 2-3 months can use ripening agents such as misoprostol (prostaglandins)

what organ disease is a risk factor for CIN

renal disease Uremia (the buildup of toxins in the blood) and nutritional deficits in CRF impair T-cell function and natural killer cell activity. This directly prevents the immune system from mounting an effective attack against HPV-infected cervical cells

What is the most common and most useful technique employed for evaluation of obstetric and gyneo condition

pelvic and transvaginal ultrasound

what are the harmful effects of transvaginal ultrasound

nor harmful effects when used appropriately

what is a endometrial biopsy

a catheter is inserted into the uterus through the vagina to remove cells from the uterine lining for examination

when to do an endometrial biopsy

AUB, abnormal pap, atypical glandular cells, adenocarcinoma in situ, endometrial hyperplasia, screening high risk pt, endometritis

CI for endometrial biopsy

pregnancy and acute infection/bleeding diathesis (high risk of bleeding)

what is the anesthesia for endometrial biopsy and when would you use a endometrial brush

NSAID 30-60 minutes prior can do a paracervical block or intrauterine instillation

and you use a brush in post menopausal pt can be used in combination with low pressure suction device

side effects of endometrial biopsy

cramping, vasovagal, reaction, uterine perforation

what are common indications of hysterectomy

leiomyomas, adenomyosis, AUB, endo, uterine prolaspse, maligancy

partial v complete hysterectomy

partial leaves the cervix and complete is cervix removed

what is the pre-op for hysterectomy

antibiotic prophylaxis and thromboprophylaxis (postoperative pelvic infections and deep vein blood clots they will have the injury, hypercoagulability (from surgery) and statis of the triad)

different approaches to the hysterectomy

-vaginal: preferred as it is shorter, faster recovery and low cost,\. C: hemorrhage, UTI, reoperation'

- laparoscopic: same day discharge of no complications but common comp is conversion to laparotomy, hemorrhage, urinary tract injury, vaginal cuff, and bowel injury

-open goes in supraumbilical complications are hem, urinary tract damage, bowel injury 2-4 hospital day stay

laparoscopy v. laparotomy

laparoscopy: min invasive using small incision and laparoscope to visualize abdominal organs and perform surgery

• less post op pain, shorter or tome and perform a more extensive procedure

Laparotomy: larger incision to directly access abdomen and perform more extensive procedure

hysterospalpingography

outpatient fluoroscopy eval uterine cavity and fallopian tube patency, common with infertility evaluation, suspected congenital anomalies, preprocedural planning. CI are pregno, active undiagnosed bleeding, acute pelvic infection, hx of mod-severe rxn to iodinated contrast. SE mild cramps, leaking of contrast, mild bleeding