CH5: Gynecologic, Reproductive, and Sexual Disorders Flashcards
What is Premenstrual Syndrome (PMS) & its symptoms
The cyclic occurrence, in the luteal phase, of a group of distressing physical and psychological symptoms that begin about 5-7 days before the menstrual period and resolve within about 4 days after onset of menses. Symptoms disrupt normal activities and interpersonal relationships
Symptoms:
- headache
- breast changes
- fluid retention, swelling, bloating
- nausea, vomiting
- changes in appetite, food cravings
- lethargy, fatigue
- exacerbations of chronic conditions, such as asthma
- irritability, depression, anxiety, anger, crying, violent behavior, confusion
- sleep alterations
- difficulty concentrating
- changes in libido
% of folks who experience PMS
50%+, most folks do not require treatment, severe symptoms occur in 3-10%
PMS symptoms recur cyclically in the ______ phase
luteal
Non-pharm therapy options for the treatment of PMS (including herbal/natural supplements)
- reassurance, avoid known physical and emotional triggers, self-management
- 20-30 minutes of aerobic exercise 4 or more times per week
- CBT, relaxation therapies, mindfulness
- biofeedback, acupuncture, massage, light therapy
- supplements, including: vitamin B6 50-150mg/day; calcium carbonate 1200-1600 mg/day; chaste tree berry extract
What medication may be helpful for the treatment of PMS swelling and bloating
spironolactone during the luteal phase
What medication may be helpful for the treatment of PMS fluid retention, breast pain, lower back pain, abdominal and pelvic pain
NSAIDs before and during menstruation
What medication may be helpful in decreasing all of the physical symptoms of PMS
birth control (combined oral contraceptives, progestin-only contraceptives). May be helpful in reducing physical symptoms by suppressing ovulation and/or reducing menstrual bleeding and pain
Medication options for the management of PMS
- birth control
- spironolactone (bloating)
- NSAIDs (pain, bleeding)
- SSRIs
- danazol (androgen receptor agonist, used to suppress ovulation)
- GnRH agonists (inhibits cyclic gonadotropin release, used to suppress ovulation, limit use to 4-6 months unless in combination with hormonal therapy as causes menopause-like side effects)
What is the definition of premenstrual dysphoric disorder (PMDD)
At least 5 PMS-type symptoms severe enough to disrupt normal functioning markedly in most, if not all, menstrual cycles. Occurs in the luteal phase and results within 1 week after menses. Must include at least ONE of these symptoms, specifically: markedly depressed mood, marked anxiety, marked affective lability, persistent and marked anger
Prevalence of PMDD
3-10% reproductive-age females
Medication options for PMDD
- generally, same as for PMS
FDA-APPROVED:
- combination hormonal contraceptives that contain the progestin drospirenone
- fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) [all SSRIs]
OTHER:
- anxiolytic drugs such as alprazolam (Xanax; benzo) or buspirone (Buspar) have mixed results with risk for dependence - use only for short-term
(3) SSRIs FDA-approved for PMDD
fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft)
Define primary dysmenorrhea (age of onset, etiology, characteristic patterns)
Dysmenorrhea is painful menstruation, commonly a sensation of cramping in the lower abdomen during or just before menses, may radiate to the back and thighs. Pain is described as colicky, crampy, or spasmodic.
Primary dysmenorrhea occurs unassociated with an underlying pelvic pathology. It rarely begins after 20yo. It is associated with ovulatory cycles and is stimulated by prostaglandin release
Typically, the pain begins shortly after the onset of menses and usually lasts no longer than 2 days
What is thought to cause primary dysmenorrhea
prostaglandins
Define secondary dysmenorrhea (characteristic onset, pattern, relieving measures, etc.)
Dysmenorrhea is painful menstruation, commonly a sensation of cramping in the lower abdomen during or just before menses, may radiate to the back and thighs.
Secondary dysmenorrhea may onset many years after menarche, most often in folks >20yo, and is related to an organic disease/pelvic pathology
This pain may begin at any time in the cycle, and folks may notice a change in the duration and amount of their menstrual flow. Pain is unlikely to be relieved by OTC measures and symptoms often persist for longer than those with primary dysmenorrhea (>2 days)
General work-up for diagnosis of secondary dysmenorrhea
- vaginal US and hysterosalpingogram to evaluate pelvic structures
- cultures, smears to evaluate for infections
- laparoscopy to evaluate endometrial cavity
- lower GI evaluation
(3) pharm therapies for primary dysmenorrhea, classes
- NSAIDs/prostaglandin synthetase inhibitors (treatment of choice)
- combined hormonal contraceptives
- progestin-only contraceptives (specifically, the arm implant, LNG-IUD, and DMPA)
Describe the use of NSAIDs/prostaglandin synthetase inhibitors for the treatment of primary dysmenorrhea
First line treatment of choice. Best to start 2 days before expected menses and continue for 48-72 hours.
Specific medications shown to be effective include naproxen sodium, ibuprofen, indomethacin, mefenamic acid
Self-help measures for primary dysmenorrhea (non-pharm)
regular exercise, warm heat, relaxation exercises, stress reduction, massage therapy
Define primary amenorrhea
No menstruation by age 14yo (if no secondary sex characteristics have developed) or by 16yo (regardless of the development of secondary sex characteristics)
Define secondary amenorrhea
Absence of menses in a previously menstruating person - no menses for 3-6 months for those with previously regular cycles, or in 3 cycles for those with irregular cycles
Differential diagnosis for/causes of amenorrhea
- disorder of genital outflow tract (vaginal agenesis, imperforate hymen, cervical stenosis)
- endocrine disorders (hyperthyroid, hypothyroid, hyperprolactinemia, hyperandrogenism, ovarian failure, PCOS)
- congenital or chromosomal abnormality (Turner’s syndrome, androgen resistance syndrome, congenital adrenal hyperplasia)
- anorexia nervosa
- excessive exercise or competitive sports
- obesity
- malnutrition
- medications (hormones, contraception, antipsychotics, cancer treatments)
- chronic illnesses (TB, alcohol abuse, T1DM, adrenal gland disorders)
- Asherman’s syndrome (irradiation or surgery resulting in destruction of the endometrium)
- Sheehan syndrome (postpartum hypopituitarism, may occur after massive blood loss)
- excessive or chronic stress
- pregnancy
- menopause
Diagnostic work-up for amenorrhea, initial (3)
- pregnancy test
- serum prolactin
- serum TSH
21yo G0P0 with amenorrhea x7 months with previously regular cycles. Pregnancy test was negative, serum prolactin and TSH WNL. What is the next step in your work-up?
progesterone challenge test to evaluate the availability of estrogen
How do you conduct progesterone challenge test
medroxyprogesterone acetate (Provera) 10 mg PO QD x 10 days.
Bleeding should occur within 7-14 days, which indicates adequate estrogen production and stimulation, as well as no problem with the outflow tract. If no bleeding occurs in 2 weeks, will need further evaluation with FSH/LH tests.
21yo G0P0 with amenorrhea x7 months with previously regular cycles. Pregnancy test was negative, serum prolactin and TSH WNL. You do a 10-day progesterone challenge test and she does not have a withdrawal bleed within 2 weeks. What is your next step in work-up?
FSH and LH
If FSH/LH low … likely hypothalmic or pituitary cause
If FSH/LH high… likely ovarian failure/menopause
21yo G0P0 with amenorrhea x7 months with previously regular cycles. Pregnancy test was negative, serum prolactin and TSH WNL. You do a 10-day progesterone challenge test and she does not have a withdrawal bleed within 2 weeks. You next order serum FSH and LH, which both return abnormally low. You suspect….
hypothalmic or pituitary cause
21yo G0P0 with amenorrhea x7 months with previously regular cycles. Pregnancy test was negative, serum prolactin and TSH WNL. You do a 10-day progesterone challenge test and she does not have a withdrawal bleed within 2 weeks. You next order serum FSH and LH, which both return abnormally high. You suspect….
premature ovarian failure/menopause
21yo G0P0 with amenorrhea x7 months with previously regular cycles. Pregnancy test was negative, serum prolactin and TSH WNL. You do a 10-day progesterone challenge test and she successfully has a withdrawal bleed after 7 days. You suspect….
anovulation
DDx/etiologies of infrequent menstrual bleeding/oligomenorrhea
- perimenopause
- pregnancy
- HPO axis abnormalities
- endocrine disorders (thyroid, adrenal)
- chronic illnesses
- extreme stress or exercise, particularly those causing weight loss
- drug use
Initial laboratory work-up for infrequent menstrual bleeding/oligomenorrhea
pregnancy test, TSH, prolactin, FSH/LH
For those with infrequent menstrual bleeding (oligomenorrhea), treatment with ______ (2) can prevent complications from unopposed estrogen
- medroxyprogesterone acetate (MPA) x10 days of each month
- or combined hormonal contraceptives
Definition of menorrhagia
combination of heavy menstrual bleeding (>80mL blood loss per month) and prolonged menstrual bleeding (bleeding episodes lasting >8 days)
Gynecologic causes of heavy or prolonged menstrual bleeding (5)
leiomyoma (fibroid), adenomyosis, endometrial or endocervical polyp, endometrial hyperplasia, endometrial or cervical cancer
Common bleeding disorders causes of heavy or prolonged menstrual bleeding (5)
von Willebrand disease, ideopathic thrombocytopenia purpura, aplastic anemia, platelet dysfunction, clotting factor deficiencies
Systemic diseases that can cause heavy or prolonged menstrual bleeding (4)
liver disease, kidney failure, adrenal hyperplasia, thyroid dysfunction
Common medications that can cause heavy or prolonged menstrual bleeding (7)
anticoagulants, anticonvulsants, antipsychotics, digitalis, copper IUD, chronic NSAID or aspirin use, tamoxifen,
PALM-COEIN classifications of structural and non-structural causes of AUB
STRUCTURAL: PALM Polyps Adenomyosis Leiomyoma Malignancy/hyperplasia
NON-STRUCTURAL: COEIN
Coagulopathy
Ovulatory dysfunction (PCOS, thyroid, endocrine)
Endometrial (inflammation, infection, vasoconstriction disorder)
Iatrogenic (medications, devices)
Not yet classified (rare disorders, like arteriovenous malformations)
Initial lab tests for work-up of AUB/Heavy or Prolonged menstrual bleeding
- pregnancy test
- pap test as needed
- STI test as needed
- CBC
- TSH
ADDITIONALLY -
- FSH/LH (to evaluate estrogen stimulation, rarely indicted)
- endometrial evaluation if >40yo (biopsy, TVUS, saline infusion sonohysteroscopy)
- coagulation studies as indicated
Non-hormonal medication options for the management of heavy menstrual bleeding (2)
- NSAIDs
- tranexamic acid
Instructions for use of NSAIDs in the treatment of heavy menstrual bleeding
Start at menses onset and continue for 5 days or until cessation of menstruation. Works by increases the ratio of vasoconstrictive prostaglandins to vasodilating prostaglandins
Instructions for the use of tranexamic acid in the treatment of heavy menstrual bleeding
this is an antifibrinolytic agent that blocks the lysis of fibrin clots. Take up to the first 5 days of menses. Works to decrease blood loss in folks who have increased endometrial plasminogen activity. Side effects include nausea, leg cramps. Contraindicated in folks with h/o or at risk for thrombosis/clots
Hormonal medication options for the management of acute heavy menstrual bleeding (2)
- parenteral estrogen or high-dose oral estrogen gradually tapered, then MPA added last 10 days to initiate a withdrawal bleed (UTD: Premarin 2.5mg BID - 4x daily until bleeding is minimal [no more than 21 days] followed by MPA 10mg x 10 days to have a withdrawal bleed)
- high-dose oral progestin therapy, gradually tapered (UTD: norethindrone 5mg QD-BID or MPA 10mg -20mg QD-BID for 5-10 days)
According to UpToDate:
First-line therapy for hemodynamically stable women is high-dose oral estrogen. We give Premarin 2.5 mg four times per day until the bleeding subsides or is minimal. For women with moderate bleeding, we change the regimen to twice daily. We do not continue this regimen for more than 21 to 25 days. After the estrogen is discontinued, a progestin should be given; we use oral medroxyprogesterone acetate (10 mg/day) for 10 days.
Estrogen therapy alone is more effective than combined estrogen-progestin or progestin-alone therapy
Also okay to use the OCPs they are already taking! High doses of oral contraceptives (OCs) (eg, an OC containing 35 mcg ethinyl estradiol taken two to four times daily) will cause bleeding to subside in most women within 48 hours [2,17]. We use a cascading regimen (ie, five pills on day 1, four pills on day 2, three pills on day 3, two pills on day 4, and one pill on day 5). For women with moderate bleeding, we start with three pills daily. An antiemetic medication should be prescribed (eg, promethazine 12.5 to 25 mg per rectum, as needed).
Treatment with one pill daily of OCs should continue for at least one week after the bleeding subsides and then should be stopped for three to five days to allow for a withdrawal bleed. Standard dose OCs may then be restarted either to prevent recurrent menorrhagia or for contraception.
Hormonal medication options for the management of chronic heavy menstrual bleeding (3)
- LNG-IUD (FDA approved indication)
- combined hormonal contraceptives (cyclic, extended, or continuous regimens)
- DMPA
Surgical options for management of acute/chronic heavy menstrual bleeding (3)
- endometrial ablation
- dilation & curettage (D&C - both diagnostic and therapeutic)
- hysterectomy
General definition of PCOS
a symptom complex associated with menstrual irregularity due to oligo-ovulation or anovulation and clinical or biochemical signs of hyperanrogenism
Does multiple ovarian cysts alone on TVUS indicate PCOS?
No - approximately 25% of normal females will demonstrate ultrasonographic evidence typical of polycystic ovaries
Prevalence of PCOS
6-7% of reproductive-age females
Folks with PCOS are at increased risk for these (3) future conditions
endometrial cancer, diabetes mellitus, heart disease
Common presenting signs/symptoms of PCOS
- irregular menses (amenorrhea or infrequent bleeding) (>90%)
- gradual onset hirsutism in puberty or early 20s (50-70%)
- other signs of androgen excess (acne, deep voice, male pattern baldness - 15 to 25%)
- infertility
- abdominal obesity (50-60%)
- acanthosis nigricans, skin tags in neck area
Virilization signs of PCOS
hirsutism, increased muscle mass, frontal balding, clitoral enlargement, deepening voice, decrease in breast size
Diagnostic work-up for PCOS
- pregnancy test
- serum prolactin
- serum TSH
- biochemical hyperandrogenism (serum total testosterone and SHBG OR bioavailable and free testosterone)
- serum 17-hydroxyprogesterone (17-OHP) (PER ANNIE: THIS IS NORMAL IN PCOS, ELEVATED IN NCCAH. IN BOOK: >800 ng/dL suggests PCOS; elevated but <800 think congenital adrenal hyperplasia)
- endometrial biopsy to r/o hyperplasia
- TVUS to assess ovaries
- glucose, lipids
Rotterdam Criteria for diagnosis of PCOS
at least 2 of the 3 following must be present in an adult female:
- oligo-ovulation or anovulation
- clinical or biochemical hyperandrogenism
- polycystic ovaries
First line treatment for PCOS if pregnancy is desired
letrozole. If ineffective, refer to reproductive endocrinologist
Treatment options for PCOS if patient desires contraception
direct therapy towards preventing endometrial hyperplasia and pregnancy
- low dose combined hormonal contraceptives with low-androgenicity progestins (i.e., drospirenone) will inhibit LH secretion and LH-dependent ovarian androgen production, increase SHBG of free testosterone, regulate menstrual cycles, and protect against endometrial cancer
- progestin-only contraceptives will provide contraception and prevent against endometrial cancer
Management of PCOS if not desiring pregnancy and not desiring contraception (i.e., not at risk for pregnancy)
focus on preventing endometrial hyperplasia
- endometrial biopsies as needed
- MPA for 10 days of month to induce a withdrawal bleed, can be used every month or Q2-3 months
- may consider metformin use as insulin-sensitizing agent
- monitor for development of diabetes, hyperlipidemia, obesity
Treatment option for undesired facial hair in pt with PCOS
eflornithine HCl topical cream
General definition of endometriosis
the presence of endometrial stroma and glands outside of the uterus
Prevalence of endometriosis
general estimate: 7-10% of premenopausal folks
- found in 5-15% of surgeries performed on reproductive age females
- found in up to 30% of infertile females during surgery
Typical patient with endometriosis has these (3) characteristics
- 20-30 years of age
- caucasian
- nulliparous
Most common cause of chronic pelvic pain
endometriosis
Symptoms suggestive of endometriosis
MOST COMMON
- dysmenorrhea
- infertility
- premenstrual spotting
- heavy menstrual bleeding
- pelvic pain
- dyspareunia
LESS OFTEN
- low back pain
- diarrhea
- dysuria
- hematuria
- difficult or painful defecation
- rectal bleeding
- symptoms classically occur before or during menses
Physical findings suggestive of endometriosis
- fixed, retroverted uterus
- bilateral fixed, tender adnexal masses
- nodularity or tenderness of uterosacral ligaments and cul de sac
- tenderness, thickening, or nodularity of the rectal-vaginal septum
- cervical motion tenderness associated with menses
- visible lesions on laparoscopy
Role of diagnostic tests/imaging in diagnosis of endometriosis?
Direct visualization with laparoscopic procedure is the only means of confirmation. Otherwise, US cannot demonstrate a specific pattern but could possibly be used to differentiate solid vs. cystic lesions and help distinguish an endometrioma from other adnexal abnormalities. CT and MRI can provide only presumptive evidence and are not diagnostic. CA125 levels may correlate with degree of disease or response to treatment, however, they are not diagnostic because of low sensitivity and specificity
Goals of treatment of endometriosis (3)
There is no universal/sure cure. The goal is to relieve pain, restore fertility (as desired), and prevent progression
Medical management options for endometriosis
- analgesics (NSAIDs are first line)
- continuous use of combined oral contraceptive pills produces atrophy of the implants and an acyclic hormone environment
- GnRH agonists or danazol may induce regression of endometrial implants (more aggressive, menopausal symptoms likely)
- progestins like IM DMPA or SQ 104 DMPA
- laser surgery or hysterectomy with BSO
Describe adenomyosis, generally
Benign condition where ectopic endometrium is found within the myometrium, or muscle layer. This is sometimes considered a subtype of endometriosis
Prevalence of adenomyosis
estimates vary greatly, ranging from 10-90% of hysterectomies. Diagnosis is most common in parous females between 40-50yo
(2) symptoms of adenomyosis
- increasingly severe dysmenorrhea and heavy bleeding during menses
- infertility
(3) physical findings possible with adenomyosis
- boggy, tender uterus
- diffuse, globular enlargement - may be 8-10 weeks gestation size
- may see evidence of anemia
How do you diagnose adenomyosis
US and/or MRI may rule out other pathologies and an endometrial biopsy is important in cases of AUB, however, can only be definitively diagnosed upon hysterectomy
Management options for adenomyosis
Symptomatic treatment options include NSAIDs for pain, hormone suppression to alleviate symptoms, hysterectomy is curative
What is a pituitary adenoma
Benign tumor of the pituitary. Most common type of pituitary adenoma secretes prolactin (>50%)
Population/incidence of pituitary adenomas
Incidence is unknown. Most pituitary adenomas occur in folks younger than 40yo.
% of females with amenorrhea of unknown origin who will have elevated prolactin levels
33%
% of females with secondary amenorrhea who have a pituitary adenoma
33%
% of females with elevated prolactin levels on labs who will also have galactorrhea
33%
S/s of pituitary ademonas or prolactinomas
- spontaneous discharge from unilateral or bilateral nipples that is clear or milky
- irregular menses or secondary amenorrhea
- visual disturbances and/or headaches (if adenoma)
Physical exam findings for pituitary adenomas or prolactinomas
May be no remarkable findings. Possible to have milky nipple discharge or papilledema on fundoscopic exam
30yo pt presents with new onset milky nipple discharge and visual changes. Her periods have always been irregular. No remarkable findings on physical exam. What diagnostic tests will you include in the work-up of suspected pituitary adenoma and/or prolactinoma?
- pregnancy test
- TSH
- serum prolactin
- microscopy of nipple secretions
- CT or MRI brain to r/o adenoma
How to interpret prolactin lab results in work-up of suspected pituitary adenoma or prolactinoma
prolactin elevated if >20ng/mL, refer to reproductive endocrinologist. If 100-300 ng/mL, this is very suspicious for adenoma.
Management for known prolactinoma in patient with prolactin levels <20 and no amenorrhea
follow with yearly prolactin level monitoring
Management for prolactinoma or pituitary adenoma (lifestyle, medical and surgical)
Lifestyle = decrease breast stimulation
Medication = dopamine agonist BROMOCRIPTINE or CABERGOLINE, because dopamine inhibits prolactin. This provides symptomatic relief, decreases or stops galactorrhea, is the treatment of choice with highest cure rate.
Surgery = for failed medical management only, may consider transphenoid neurosurgery with recurrence rate of 10-70%, requires close follow-up
Radiation = reserved only for recurrences or refractory cases, may take several years before results seen with declining prolactin levels
What is a cervical polyp
Pendunculated growth arising from the mucosal surface of the endocervix
Prevalence of cervical polyps
4% of gyn patients; most common of the benign neoplasms of the cervix. Most commonly seen in peri-menopausal, multigravida folks between ages 30-50 years old
Are cervical polyps cancer?
Considered benign. Malignant changes are rare.
Etiology of cervical polyps
inflammation, trauma, pregnancy, abnormal local response to a hypoestrogenic state
Symptoms of cervical polyp
may be asymptomatic or may have abnormal vaginal bleeding including intermestrual and post-coital
Physical exam findings for a cervical polyp
May be single or multiple painless polypod lesions at the cervix that range in size from a few mm up to 2-3 cm. They are usually reddish-purple to cherry red in color, smooth, soft, and bleeds easily. Pelvic exam will otherwise be normal
Differential diagnosis for a cervical polyp
Cancer, prolapsed myoma (fibroid), retained products of conception
Diagnostic tests for cervical polyp
Send removed polyp for histologic evaluation to rule out cancer. A pap test can rule out premalignant cervical lesions or cancer of the cervix.
Management and anticipatory guidance for cervical polyp
May be removed which is usually curative. Do not remove during pregnancy. Cervical polyps recur frequently
What is a uterine fibroid?
Aka leiomyoma, leiomyomata, myoma
A nodular, discrete tumor varying in size rom microscopic to large, multiple nodular masses which are classified according to location: submucosal, subserosal, intraligamentous, intramural (interstitial), pedunculated. Most common benign pelvic neoplasm
What are the (5) types of uterine fibroid
- submucosal: protrude into the uterine cavity
- subserosal: bulge through the outer uterine wall
- intraligamentous: within the broad ligament
- intramural (interstitial): stays within the uterine wall as it grows, most common form
- pedunculated: on a thin pedicle or stalk attached to the uterus
What is the most common type/location of uterine fibroid
intramural (interstitial) - within the uterine wall
Why/how do uterine fibroids develop
The etiology is largely unknown. They may arise from smooth muscle cells of the myometrium.
Prevalence of uterine fibroids
20% of gyn patients in reproductive years. Although, asymptomatic fibroids may be found in as many as 40-50% of females >40yo. More common in African American than Caucasian females. There is also an increased incidence with family history
Symptoms of uterine fibroids
Usually asymptomatic. If symptoms, most commonly see heavy or prolonged menstrual bleeding, pelvic pain/pressure, dyspareunia. May cause acute pain if pedunculated/twisted/infarcted. May cause bowel and bladder problems if large and pressing on surrounding structures
Uterine fibroids usually cause what type of AUB
heavy, prolonged menstrual bleeding
Possible physical exam findings with uterine fibroids
may not be detectable. Or, may have abdominal enlargement, an enlarged irregularly shaped or displaced uterus, a pedunculated tumor may be seen protruding from the cervix. Tumors are usually painless on palpation. There is a wide variance in size from 3-4mm up to 15lbs
Possible complications of uterine fibroids (4)
spontaneous abortion, premature labor, anemia, infertility
Diagnostic evaluation of uterine fibroids, options
- pap test to exclude cervical cancer (if visible protrusion)
- pregnancy test (if AUB or enlarged uterus)
- CBC (if heavy menstrual bleeding or anemia suspected)
- fecal occult blood test (if colon or rectal symptoms present)
- endometrial biopsy or D&C (for AUB)
- US, sonohystogram, CT, or MRI to confirm the diagnosis
- hysteroscopy if need to visual inside of uterine cavity
Management plan for uterine fibroids, overview
May not require any treatment if asymptomatic. May be useful to have periodic bimanual examination to ensure no growth or abnormal changes. Medical and surgical options may be considered if symptomatic.
Medical: aimed at reducing growth and bleeding
Surgical: removal of whole or part of fibroid and/or uterus
Pharmacologic options for management of uterine fibroids
- progestin agents may decrease fibroid size and bleeding (i.e., MPA)
- combined hormonal contraceptives may help with heavy menstrual bleeding but will not decrease fibroid size
- LNG-IUDs (i.e., Mirena) may help with heavy bleeding and decrease dysmenorrhea but will not decrease fibroid size and may be contraindicated if fibroids distort the uterine cavity d/t risk for expulsion
- GnRH agonists can reduce fibroid size 40-60% however regrowth occurs 50% of the time and these medications cause significant symptoms including menopause. Best fit for short-term use to shrink fibroid size pre-operatively, before attempting pregnancy, or in folks attempting to avoid surgery
- remember to treat underlying anemia as needed
When to consider surgery with uterine fibroid diagnosis
abnormal bleeding, rapid growth, desire for definitive diagnosis of the mass if otherwise uncertain, encroachment on organs, symptoms are not well-managed on pharm therapies
Surgical options for the management of uterine fibroids (3) and their impact on fertility and recurrence rate
- myomectomy: via hysteroscopic resection, this method is fertility-preserving with a 30% recurrence rate
- uterine artery embolization: may not preserve fertility, increases risk of IUGR in future pregnancy, up to 40% recurrence rate
- hysterectomy: no fertility, no recurrence
(2) main types of ovarian cysts
functional (s/t hormonal stimulation), dermoid (benign cystic teratoma - the most common ovarian germ cell tumor)
(2) types of functional ovarian cysts
- follicular: occur in the follicular phase of the menstrual cycle when continued hormonal stimulation prevents fluid resorption
- corpus luteum: occurs in the luteal phase, when the corpus luteum fails to degenerate
What are follicular ovarian cysts and their prevalence, characteristics
A type of functional ovarian cyst occurring in the follicular phase of the menstrual cycle that persist when continued hormonal stimulation prevents fluid resorption. They are rare before menarche and after menopause. They are the most common adnexal mass in the reproductive years, accounting for 20-50% of all ovarian cysts. They usually will resolve within 2-3 menstrual cycles which may be unnoticeable or rupture may cause pain or ovarian torsion
What are corpus luteum cysts and their characteristics
A type of functional ovarian cyst occurring when the corpus luteum fails to degenerate after 14 days. May hemorrhage into the cystic cavity.
What are dermoid cysts and their characteristics
Aka benign cystic teratoma. They are one of the most common neoplasms of the ovary, occur during the reproductive years. Composed of well-differentiated tissue from all three germ layers. Usually measure 5-10cm in diameter and 10-15% are bilateral.
Symptoms of ovarian cysts
Usually asymptomatic. They may cause acute pain if twist or rupture. If large, may cause sensation of pelvic pressure or fullness. Rarely cause AUB.
Diagnostic evaluation of ovarian cysts
- pregnancy test (r/o ectopic if palpable/pain)
- TVUS (evaluates mass for cystic vs. solid, complex vs. simple, bilateral vs. unilateral, r/o ectopic pregnancy)
- CA125 may be considered in post-menopausal females though it is NOT diagnostic
- MRI may be considered if dermoid cyst is suspected
What is the role of CA125 in the setting of an ovarian cyst
It is NOT diagnostic and may be considered in post-menopausal patient with ovarian cyst. It is a tumor-associated antigen most commonly used to monitor the clinical status of pts with ovarian cancers. It is not routinely used for evaluation of adnexal masses in PRE menopausal folks because of its low specificity for ovarian cancer, as several other conditions may cause elevated levels. Its specificity and predictive value are consistently higher in postmenopausal folks
Management options for functional ovarian cysts, PRE MENOPAUSAL
If <10cm in diameter and simple features on US, may repeat examination after next menses and/or serial US q4-12 weeks to monitor for resolution. If persists >12 weeks and/or is >10cm or solid/complex features, refer to physician
Management options for functional ovarian cysts, POST-MENOPAUSAL
if <10cm and simple features on US with no concerning symptoms or risk factors for ovarian cancer, and if CA125 <35 U/mL, can perform serial US q4-12 weeks. If persists >12 weeks or if CA125 >35, concerning symptoms or risk factors, or complex/solid features, refer to physician
Management options for dermoid ovarian cysts
if it does not resolve on its own, recommend laparoscopic removal
Peak ages of incidence for cervical cancer
45-55yo
Primary agent in the development of cervical cancer
human papillomavirus (HPV)
Risk factors for OVARIAN cancer
- tobacco smoking
- HPV (most commonly malignant = 16, 18, 31)
- early coitus (<18yo)
- multiple sex partners
- no barrier methods
- immunosuppression
- long-term oral contraceptive use
- infrequent/no pap tests
Symptoms of cervical cancer
May be asymptomatic. If symptoms, may have postcoital or irregular painless bleeding, odorous bloody or purulent discharge. Late symptoms could include pelvic or epigastric pain, urinary or rectal symptoms.
Physical exam findings of cervical cancer
The cervix may range from normal to having ulcerated, necrotic, or large bulky lesion filling the vagina. The cervix may be firm or rocklike to soft and spongy. There may be bloody, purulent, or odorous vaginal discharge. Anemia may be present if bleeding heavily.
Diagnostic evaluation of cervical cancer
- pap test is the gold standard for screening
- biopsy any gross cervical lesions
- If malignancy is suspected but there is no gross lesion visible, suggest colposcopy with biopsy
- colposcopic evaluation of the vulva and vagina to rule out other lesions
- CT, MRI, cystoscopy, sigmoidoscopy, and barium enema may be used as indicated
Management of cervical cancer for WHNP
anticipatory guidance regarding surgery, radiation, chemotherapy, or combination treatments. Refer to gynecologic oncologist
Most common gynecologic cancer
endometrial cancer – 90-95% of malignancies of the uterine corpus are endometrial cancer
Median age of onset for endometrial cancer
63yo, only 5% of cases occur <40yo
Many of the risk factors for endometrial cancer are directly related to length of time exposed to ___________
estrogen, particularly unopposed estrogen (either endogenous or exogenous)
Risk factors for endometrial cancer
- early menarche or late menopause
- unopposed estrogen therapy
- oligo-ovulation or anovulation
- obesity
- estrogen-secreting tumors (granulosa cell tumor)
- family history of endometrial or CRC cancer
- personal history of CRC cancer, diabetes, or HTN
Protective factors against endometrial cancer (3)
depo provera, OCPs, multiparity
Symptoms of endometrial cancer
painless vaginal bleeding is typically the first symptom. May start with serous (watery) odorous discharge, soon replaced by bloody discharge with intermittent spotting to steady, painless bleeding followed by hemorrhage. Lower abdominal pain present in 10% of cases
Physical exam findings of endometrial cancer
May be none in early stage. May see blood present in the vaginal vault. Advanced disease may present with a pelvic mass or ascites. Uterus may be enlarged and soft. Anemia may be present with heavy blood loss
Diagnostic evaluation of concern for endometrial cancer
- pap test may demonstrate glandular abnormalities
- endometrial aspiration biopsy
- TVUS to measure endometrial stripe with risk for endometrial cancer rare if <5mm
- if work-up is non-conclusive and symptoms persist, fractional D&C is the gold standard for diagnosis
- hysteroscopy may be considered for identifying lesions or polyps not otherwise found on biopsy
Management of endometrial cancer for WHNP
Anticipatory guidance for likely surgical treatment, usually hysterectomy recommended. Surgical staging will determine adjuvant treatment which may include radiation, chemotherapy, progesterone/steroids, or combination. Refer to gynecologic oncologist
Most common type of ovarian cancer
epithelial ovarian carcinoma accounts for 80-85% of cases
Which has the highest mortality rate of all the gynecologic cancers
ovarian cancer
Ovarian cancer rates are the highest between these ages
55-64yo
Lifetime risk of ovarian cancer in the general population
1-2%
Lifetime risk of ovarian cancer with one first-degree relative affected
5%, and increases with the number of first or second-degree relatives
% of ovarian cancers believed to be caused by genetic inheritance (BRCA, Lynch, etc.)
20-25%
BRCA 1 and 2 mutation risks for ovarian cancer
BRCA 1: 39-4% lifetime risk
BRCA 2: 12-20% lifetime risk
Risk factors for ovarian cancer
- family history
- gene mutations (BRCA, Lynch, Peutz-Jeghers)
- h/o breast, colon, or endometrial cancer
- early menarche or late menopause (increased estrogen exposure)
- nulliparity or birth of first child >30yo
- inferility
- endometriosis
- obesity
- postmenopausal HRT
Protective factors from ovarian cancer
oral contraceptives, with protection lasting up to 2 decades after use. breast feeding
Symptoms of ovarian cancer
Often asymptomatic or with symptoms that are mild, vague, or inconsistent. May include abdominal discomfort, pressure sensation to bladder or rectum, pelvic fullness or bloating, vague GI symptoms. Late signs include increasing abdominal girth, abdominal pain, abnormal vaginal bleeding, nausea, anorexia, and dyspepsia
Physical findings of ovarian cancer
Fixed, irregular, non-tender adnexal mass, possibly bilateral. Ascites. Pleural effusion and subclavicular lymphadenopathy are late signs
Diagnostic evaluation for suspected ovarian cancer
- pelvic US with CT or MRI as needed
- CA215 levels at baseline are not diagnostic but helpful for following response to treatment
- definitive diagnosis is made with laparotomy (surgery)
Conditions that can cause elevated CA125
ovarian cancer, endometriosis, fibroids, pelvic inflammatory infection, hepatitis, other malignancies
Management of ovarian cancer for the WHNP
Anticipatory guidance regarding surgery typically total hysterectomy with bilateral salpingoophorectomy and omentectomy which establishes histologic staging and grading of the tumor. Will consider chemotherapy and/or radiation with gyn onc. Consider genetic counseling to determine if family members at increased risk and if pt themselves is at increased risk for breast cancer. Refer to gyn onc and high risk genetics.
What is the most rare gynecologic cancer
vaginal carcinoma - 2% of gyn malignancies
Mean age of diagnosis for vaginal carcinoma
mean = 65yo. Range = 30-90yo
Risk factors for vaginal cancer
persistent HPV with high-risk subtypes, other genital cancers, DES exposure, prior radiation to the area
Pre-cursor to vaginal carcinoma
vaginal intraepithelial neoplasm (VIN)
5 year survival rates for vaginal cancer
Stage 1 = 80%
Stage 4 = 17%
Symptoms of vaginal cancer
vaginal bleeding, odorous or blood tinged discharge, pruritis, palpable or visible mass or lesion, urinary problems if bladder involvement
Physical exam findings concerning for vaginal cancer
early lesions appear raised, granular, may be white. Late lesions are friable, granular, and cauliflower-life, may be palpable, may have superficial or deep ulceration. If the lesion is darkly pigmented, suspect melanoma. The most common site of occurrence is the upper 1/3 of the vagina
Diagnostic eval of suspected vaginal cancer
- pap test to evaluate for cervical cancer
- colposcopy and biopsy of the lesion
- staging will involve cystoscopy, proctosigmoidoscopy, IV urography, chest radiography, barium enema with CT/MRI to evaluate for metastases
Management of vaginal cancer for the WHNP
Anticipatory guidance regarding treatment includes laser therapy for pre-cancerous lesions (VAIN I, II, and III). Local excision may be an option for early lesions (partial vaginectomy). Radiation is otherwise the mainstay of treatment. Refer to gynecologic oncologist
Risk factors for vulvar cancer
High risk HPV infection (30-50% of cases), multiple sexual partners, cigarette smoking, chronic irritation, vulvar dermatoses
Types of vulvar cancers
squamous cell carcinoma, melanoma, adenocarcinoma, basal cell carcinoma, sarcoma
Mean age of diagnosis for vulvar cancer
mean age = 65yo. Range 30-90 yos.
Symptoms of vulvar cancer
May be asymptomatic. If symptoms, may notice lesion on the vulvar, pruritis, pain, burning, bleeding, odorous discharge that may be blood-tinged
Physical exam findings concerning for vulvar cancer
White, red, or irregularly pigmented vulvar lesions that is ulcerated, flat, or wart-like, may be single or multiple. Hyperkeratotic patches (leukoplakia). Excoriation or erythema. Most common sites of involvement are the labia majora and minora. May also see bartholin gland enlargement or inguinal lymphadenopathy
Diagnostic evaluation of suspected vulvar cancer
- Pap test, colposcopy can help rule out other sites of disease
- Biopsy and wide excision make the definitive diagnosis
- CT or MRI to rule out metastasis
Management of vulvar cancer for the WHNP
Anticipatory guidance regarding treatment which may include local excision, simple or radical vulvectomy, or topical treatments with immunologic agents or chemotherapy. Recurrence is common. Refer to gynecologic oncologist.
What is choriocarcinoma?
a malignant form of gestational trophoblastic disease or may be primary in the ovary. Gestational trophoblastic disease follows any gestational event (i.e., intrauterine or ectopic pregnancy, abortion, hydatiform mole), whereas nongestational choriocarcinoma is a mixed germ cell tumor of the ovary that may occur in childhood or early adolescence…. would be unusual in 20s or 30s. These cancers are disseminated by the blood to the lungs, vagina, brain, liver, kidneys, and GI tract. However, it is one of the few metastatic cancers that can be curable
Symptoms of choriocarcinoma
Symptoms often masquerade as other diseases as a result of metastases to other organs. Strongly suspect if follows a pregnancy event. May have irregular vaginal bleeding (anywhere from intermittent to hemorrhage, or may occur postpartum with uterine subinvolution), or may see amenorrhea (r/t gonadotropic secretion). Lung metastasis may present as hemoptysis, cough, dyspnea. CNS metastasis may present as headache, dizziness, fainting. GI metastasis may present as rectal bleeding or tarry stools, abdominal pain. GU metastasis may present as hematuria.
Physical findings of choriocarcinoma
May have abdominal mass/ascites, blood in vaginal vault, enlarged soft uterus. May see abnormalities of multiple organs if metastatic, including possible vulvar or vaginal metastatic lesion
Diagnostic evaluation of suspected choriocarcinoma
- quantitative beta HCG. Will see abnormal beta HCG regression titers following a molar pregnancy.
- CT scan of abdomen, pelvis, head. Chest radiograph
- lumbar puncture may be necessary for diagnosis
Management of choriocarcinoma for WHNP
Anticipatory guidance that treatment typically consists of surgery and/or chemotherapy. Non-metastatic disease carries a good prognosis and metastatic disease carries a good to poor prognosis. Refer to gynecologic oncologist
What is bacterial vaginosis? (overview)
An alteration of the normal flora of the vagina (Lactobacillus species) with dominance of anaerobic bacteria. This is the most common vaginal infection in the US for females ages 15-44yo
What is the pathophysiology for bacterial vaginosis
Lactobacilli are the hydrogen-peroxide producing strains of bacterial flora natural to the vagina during reproductive years. They maintain an acidic environment. A loss in lactobacilli dominance leads to elevated pH (more basic/alkaline) and subsequent overgrowth of other strains of bacteria. Bacterial concentrations are increased 100 to 1000-fold. There is not one specific offending organism, but there are some most common anaerobic strains including Gardnerella.
Is bacterial vaginosis an STI?
The textbook says not an STI, but then later goes on to say it can be transferred between female sex partners.
It is more common in folks with new or multiple partners, and risk is increased with shared sex toys or douching. BV may also increase the risk for acquiring an STI such as HIV or HSV2
What are the most common anaerobic bacteria contributing to BV?
- gardnerella vaginalis*
- mycoplasma hominis
- bacteroides species
- haemophilus
- mobiluncus
- corynebacterium
Symptoms of BV
most often asymptomatic. Otherwise, may experience pruritis (occasionally), a grayish/yellowish/whitish malodorous discharge, a rancid or fishy-odor during menses and after sex
Physical findings suggestive of BV
- adherent, homogenous, whitish-gray vaginal discharge
- vulvar and vaginal mucosa should appear normal although discharge may coat the vaginal walls and vulva
- presence of foul odor
Diagnostic evaluation of suspected BV
- wet mount of vaginal secretions
- pH testing
Amsel Criteria is diagnostic (at least 3 out of 4 criteria is diagnostic)
+ vaginal pH >4.5
+ clue cells on saline wet mount >20% of epithelial cells (epithelial cell borders are obscured as a result of stippling with bacteria)
+ homogenous discharge that is white and coating the vaginal wall
+ positive “whiff test” demonstrating fishy amine odor to vaginal discharge before or after addition of 10% potassium hydroxide (KOH)
What is the name and components of the criteria used for clinical diagnosis of BV
Amsel Criteria
Amsel Criteria is diagnostic (at least 3 out of 4 criteria is diagnostic)
+ vaginal pH >4.5
+ clue cells on saline wet mount >20% of epithelial cells (epithelial cell borders are obscured as a result of stippling with bacteria)
+ homogenous discharge that is white and coating the vaginal wall
+ positive “whiff test” demonstrating fishy amine odor to vaginal discharge before or after addition of 10% potassium hydroxide (KOH)
Positive whiff test is suggestive of BV, but may also occur with…. (3)
blood, semen, trichomonas
BV is not an inflammatory infection, therefore you would not expect to see this on wet mount
an increase in the normal number of WBCs on wet mount
Is it necessary or useful to do a culture to diagnose strain of bacteria causing BV?
No, cultures for anaerobes are unnecessary at initial evaluation
Management of BV including patient counseling on meds, side effects, and lifestyle
Treatment is recommended for all pts with symptoms.
ORAL: metronidazole (Flagyl) 500mg PO BID x 7 days
TOPICAL: metronidazole gel (Metrogel) 0.75%, use one full applicator (5g) intravaginally at bedtime x5 days; OR clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime x7 days
For metronidazole use, counsel pt to avoid alcohol until 24 hours after completion of therapy. Side effects may include metallic taste, nausea, headache, dry mouth, dark-colored urine. Clindamycin cream is oil-based and thus may weaken latex condoms or diaphragms if these are being used for contraception.
Lifestyle - avoid douching as may increase risk for recurrence.
Oral first line treatment for BV
metronidazole (Flagyl) 500mg PO BID x7 days
Topical first line treatments for BV (2)
- metronidazole gel (Metrogel) 0.75%, use one full applicator (5g) intravaginally at bedtime x5 days
- clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime x7 days
Alternative regimen options for the treatment of BV (not first line)
- tinidazole 2g PO QD x2 days
- tinidazole 1g PO QD x5 days
- clindamycin 300mg PO BID x7 days
- clindamycin ovules 100mg intravaginally QHS x3 days
Do you need partner treatment for BV?
If female partner is symptomatic, yes. If male partner, no as will not change course of condition or prevent its recurrence
What is trichomoniasis?
A vaginal infection caused by trichomonas, an anaerobic flagellated protozoan parasite
What change to vaginal pH would you expect with BV
increased pH >4.5
What change to vaginal pH would you expect with trichomoniasis
increased pH 5.6-7.5
Risk factors for trichomoniasis
- multiple sex partners
- presence of another STI
- lack of condom use
- sex work
- injectable drug use…………..?
Risk of trichomonas in pregnancy
premature rupture of membranes, preterm labor
Risk of BV in pregnancy
intra-amniotic infection, postpartum infection, endometritis
Symptoms of trichomoniasis
Most males and females are asymptomatic. If symptoms, may describe copious, malodorous, yellow-green discharge with vulvar irritation, pruritis, occasionally dysuria/urgency/frequency. May have intermenstrual bleeding. Symptoms often occur after menses
Physical findings suggestive of trichomoniasis
- erythema, edema, excoriation of the vulva
- red speckles “strawberry spots” on the vagina and cervix (punctate lesions)
- homogenous watery yellow-green or grayish frothy discharge
- vaginal pH >5.0
- friable cervix
Strawberry cervix, think….
trichomoniasis
Diagnostic evaluation of trichomoniasis
- saline wet mount is 60-70% sensitive, demonstrates motile trichomonads and an increased number of WBCs
- rapid tests on vaginal secretions (10-45 min for results) have great >82% sensitivity and >97% specificity
- culture is the only definitive test
- urine microscopy may reveal live trichomonads too
- if detected on pap test, 40% positive predictive value
Treatment/management of trichonomoniasis
- metronidazole (Flagyl) 2g PO 1x
alternatively, tinidazole 2g PO 1x OR metronidazole (Flagyl) 500mg PO BID x7 days
Counsel to avoid alcohol until 24 hours after finish course of metronidazole. All sex partners should be treated. Offer repeat testing in 3 months for detection of reinfection. If treatment failure, use metronidazole or tinidazole 2g PO QD x7 days. Screen for other STIs as indicated.
Oral first line treatment for trich
metronidazole (Flagyl) 2g PO 1x
Can you use metronidazole to treat trich in pregnancy or lactation?
Yes, metronidazole crosses the placenta but there has been no teratogenicity or mutagenic effects found in infants. Similarly, metronidazole is secreted in breastmilk but there is no evidence of adverse effects in infants exposed to metronidazole in breastmilk. Some clinicians will defer breastfeeding for 12-24 hours after maternal treatment (2g PO 1x metronidazole).
What is vulvovaginal candidiasis
yeast infection. inflammatory vulvovaginal process caused by a yeast organism (dimorphic fungus), candida, which superficially invades the epithelial cells
How common are yeast infections
Second most common vulvovaginal infection (second to BV). 75% of females will have at least one episode in reproductive years, 45% will have a second episode, and 5% will have recurrent or intractable episodes
What are the most common species responsible for yeast infection/VVC
85-90% is Candida Albicans (C. albicans)
Remaining infections are usually C. galbrata and C. tropicalis, which are more resistant to therapy
Predisposing factors to yeast overgrowth
- pregnancy
- reproductive years
- uncontrolled diabetes
- immunosuppressive disorders
- frequent intercourse
- antibiotic use
- high dose corticosteroids
Symptoms of VVC/yeast infection
- irritation of vulva, pruritis, soreness, external dysuria
- discharge may be thick, curdy, thin/watery, or with yeast odor
- dyspareunia upon penetration
Physical findings suggestive of yeast infection
- erythema of vulva and vagina
- discharge adherent to vaginal wall
- cervix will appear normal on speculum exam
Diagnostic evaluation of yeast infection/VVC
- wet mount of vaginal secretions with 10% KOH will demonstrate mycelia, spores, and pseudohyphae
- vaginal pH is usually normal (<4.5) and amine whiff test negative
- may see increased number of WBCs on wet mount
- fungal culture is the confirmatory diagnosis - most often used in cases of frequent recurrence or intractable episodes to determine which candida is causative
When should you consider a fungal culture when pt presents with yeast infection?
Frequent recurrence (i.e., 4+ symptomatic episodes in 1 year) or intractable episodes, as may be an atypical causative species
Which is more effective for yeast infection treatment - azole antifungals or nystatin?
azole antifungals are more effective than nystatin
First line ORAL therapy for yeast infection/VVC?
fluconazole (Diflucan) 150mg PO x1
Topical OTC therapy options for the treatment of a yeast infection if pt does not prefer the oral therapy
MANY OPTIONS! All must be placed INTO the vagina (not just vulvar application) to achieve effect. Overview: primary options include clotrimazole or miconazole, 1%- 4%, 5g intravaginally x3-7 days
Creams & Ointments -
- clotrimazole 1% cream, 5g intravaginally x7-14 days
- clotrimazole 2% cream, 5g intravaginally x3 days
- miconazole 2% cream, 5g intravaginally x7 days
- miconazole 4% cream, 5g intravaginally x3 days
- tioconazole 6.5% ointment, 5g intravaginally 1x
Suppositories -
- miconazole 200mg vaginal suppository, QD x3 days
- miconazole 1200mg vaginal suppository, 1x
Treatment considerations for recurrent yeast infections/VVC
if 4 or more symptomatic episodes in 1 year with no predisposing factor, culture to identify if non-albicans candida species is present. Consider longer duration of therapy or a maintenance regimen, as well as intravaginal probiotics.
Counseling points regarding yeast infection and sex
- azole creams and suppositories are oil-based so they can weaken latex condoms or diaphragms
- partner treatment is not routinely recommended (unless male partner has balanitis)
- encourage use of cotton underwear
Treatment considerations for severe yeast infection (extensive erythema, edema, or fissure formation)
Usually requires a longer (7-14 day) course of topical azoles, or a repeat dose of fluconazole 72 hours after the initial dose
Treatment considerations for yeast infections in someone with uncontrolled diabetes or on corticosteroid therapy
May need longer (7-14 day) course of topical azoles
Treatment considerations for yeast infections in pregnancy
VVC occurs frequently in pregnancy. DO NOT USE ORAL AGENT. Recommend topical azole therapies applied x7 days.
Risks of chlamydia exposure for neonate (2)
pneumonia, conjunctivits
prevalence of chlamydia
most common STI in the US. The cause of up to 50% of pelvic infections. >4 million annually
If untreated in pregnancy, what is the risk of transmitting chlamydia to the neonate
70%
Sequelae of chlamydia
- cervicitis
- endometritis
- PID
- ectopic pregnancy
- infertility
- acute urethral syndrome (asymptomatic bacteruria)
- postpartum infections
- premature labor
- premature ROM
- perinatal morbidity
Risk actors for chlamydia
- sexually active
- <25 yo
- multiple partners
- no barrier method
Symptoms of chlamydia infection
May be asymptomatic. If symptoms, may experience:
- postcoital bleeding
- intermenstrual bleeding or spotting
- UTI symptoms (dysuria, frequency)
- vaginal discharge
- abdominal pain
Physical Exam findings suggestive of chlamydia
- mucopurulent endocervical discharge
- edematous, tender cervix that bleeds easily (CMT)
- suprapubic pain or tenderness on palpation
Diagnostic evaluation of suspected chlamydia
- NAAT (nucleic acid amplification test) is recommended by the CDC
- culture is also possible, but expensive
Swab should be collected from the vagina (preferred), endocervix, urine (slightly less sensitive), or from any anatomic site of exposure (i.e., rectal, oropharyngeal)
Consider additionally screening for gonorrhea, syphilis, HIV, and wet mount for other vaginal infection
Preferred swab site for chlamydia testing
vaginal
First line treatment of chlamydia
CDC 2015:
- azithromycin 1g PO 1x (preferred)
- alternatively, doxycycline 100mg PO BID x7 days
Alternative treatment options for chlamydia
first line = azithromycin 1g PO 1x or doxycycline 100mg PO BID x7 days
second lines = basically, other options include amoxicillin or erythromycin for 7-14 days
- amoxicillin 500mg PO TID x7 days
- erythromycin base 500mg PO QID x7 days
- erythromycin base 250mg PO QID x14 days
- erythromycin ethylsuccinate 800mg PO QID x7 days
- erythromycin ethylsuccinate 400mg PO QID x14 days
Treatment considerations for chlamydia in pregnancy
azithromycin 1g PO 1x
Doxycycline should not be used in pregnancy because it can cause discoloration of teeth in children. Erythromycin estolate is also contraindicated in pregnancy because of drug-related hepatotoxicity
Patient counseling points regarding partners and sexual activity after chlamydia infection
- All sex partners within past 60 days should be evaluated, tested, and treated
- The most recent sex partner should be evaluated, tested, and treated even if that was >60 days ago
- Expedited Partner Treatment (EPT) laws vary by state
- Avoid intercourse for 7 days after the single-dose azithromycin treatment, or for the full 7 days of the 7-day other regimens
- Recommend return for test of reinfection 3 months after treatment completion
- Test of cure is not routinely recommended; can recommend in cases of suspected nonadherence or persistent symptoms. Should wait at least 3 weeks after treatment before completing (as earlier than 3 weeks may have a false negative)
Does someone treated for chlamydia need to come back in for any follow-up testing?
- Recommend test of REINFECTION in 3 months
- If compliant with therapy and asymptomatic, no test for CURE is necessary. However, if test of cure is requested, should wait 3 weeks before testing (otherwise may get false negative)
HPV genital warts are called…..
condyloma acuminata
Genital warts and cancer?
90% of anogenital warts are caused by HPV strains 6 and 11 which are very low risk for malignancy
Most common strains of HPV to cause genital warts
HPV 6, 11
How is HPV genital warts spread?
Sexually-transmitted through skin-to-skin contract during periods of viral shedding. HPV is highly contagious, as 25-65% of partners will have HPV
Incubation period for HPV genital warts (how long it takes between exposure to notice symptoms)
4-6 weeks
What is the most common viral STI in the US?
HPV genital warts/condyloma acuminata
Immunosuppressive risk factors for HPV genital warts/condyloma acuminata
pregnancy, diabetes, steroid hormones, folate deficiency, immunosuppressive diseases (ESRD)
Symptoms of HPV genital warts/condyloma acuminata
- wart-like lesions of the anogenital region, pedunculated conical or cauliflower appearance that are whitish to pinkish gray, granular, rough texture
- lesions may be singular or multiple, may cluster
- perianal region may bleed easily and be painful, malodorous, and pruritic
Physical exam findings suggestive of genital warts/condyloma acuminata
- wart-like lesions (conical, cauliflower appearance) may be single or multiple anywhere on anogenital region
- may appear granular or cobblestone
- color will vary from pink to gray. If darkly pigmented, have high suspicion for malignancy
Diagnostic evaluation of HPV genital warts/condyloma acuminata
- diagnosis can usually be made clinically, by appearance
- if uncertain, biopsy of lesion. Also consider biopsy if no response to or worsening during treatment, if the patient is immunocompromised, or if the lesions are dark, indurated, bleeding, or ulcerated
- consider swab and serologic testing for other STIs
Anticipatory guidance on what to expect if patient does not want to treat HPV genital wart?
If untreated, it is possible that it may
- resolve on own
- persist, remain unchanged
- increase in size or number
How do you decide between the various treatment options available for HPV genital warts/condyloma acuminata?
No treatment has been proven to be better than another, as such, treatment choice should depend on patient preference, availability, and provider experience
Management of HPV genital warts/condyloma acuminata (overview)
- may leave untreated if pt prefers
- if treatment desired, goal is to eliminate visible disease and improve symptoms
- keep the area clean and dry
- advise condom use
- offer various provider-delivered (cryotherapy, TCA, surgical removal) or patient-applied (imiquimod, podofilox, sinecatechins) treatments
Provider-administered treatment options for HPV genital warts/condyloma acuminata (3)
- cryotherapy using liquid nitrogen; repeat Q1-2 weeks for 6 weeks
- trichloroacetic acid (TCA) or bichloroacetic acid 80-90% solution Q1 week for 6 weeks
If lesions are not resolved at the end of 6 weeks of treatment, may re-evaluate, change treatment plan, or refer to surgery:
- surgical removal with a tangential shave excision, curettage, laser, or electosurgery
How do you use cryotherapy for HPV genital wart treatment
cryotherapy is performed with liquid nitrogen every 1-2 weeks for 6 weeks.
Liquid nitrogen is applied directly to the vulvar or vaginal lesion with a cotton swab or a fine spray. The treatment is applied for 30 to 60 seconds, until an ice ball forms and encompasses the lesion and 1 to 2 mm surrounding area. Repeated weekly application is required until the lesions have resolved. This destroys wart tissue via cell lysis. Although it is an office procedure, cryoablation causes pain during application and variable localized inflammation afterward. Providing local anesthesia for the procedure is especially important when the area undergoing cryotherapy is extensive.
Side effects/adverse reactions include skin irritation, edema, blistering, and ulceration. Posttreatment hypopigmentation is also relatively common.
This is safe in pregnancy.
How do you use trichloroacetic acid (TCA) for HPV genital wart treatment
Use trichloroacetic or bichloroacetic acid 80 - 90% soluation. Apply a small amount to the wart using a cotton swab and allow it to dry. It will turn white. Can apply sodium bicarbonate or talc to neutralize or remove the unreacted acid. Application of an ointment or gel (such as petroleum or lidocaine jelly) to the normal tissue surrounding the wart can help prevent spreading of acid to unaffected areas. Do not apply too much as can cause chemical burns of the vulva. Do not sit, stand, or dress until dried. Reapply weekly for 4-6 weeks. 70% clearance rate.
This is safe in pregnancy.
These are caustic acids that destroy the wart tissue via chemical coagulation of tissue proteins.
Patient-applied therapy options for HPV genital warts/condyloma acuminata
- imiquimod 3.75% or 5% cream 3x weekly for 16 weeks
- podofilox 0.5% gel or solution BID x3 days, withhold x4 days, then repeat weekly PRN up to 4x
- sinecatechins 15% ointment applied TID for up to 16 weeks
Patient instructions for using imiquimoid (Aldara) for HPV genital warts/condyloma acuminata
- imiquimod 3.75% or 5% cream
Apply sparingly to affected area at bedtime, 3x per week. Can use for up to 16 weeks. The area should be washed with mild soap and water in the morning, 6 to 10 hours after application.
Safety during pregnancy is unknown
Patient instructions for using podofilox for HPV genital warts/condyloma acuminata
- podofilox 0.5% gel or solution
Apply sparingly to visible warts BID for 3 consecutive days, then withhold use for 4 consecutive days. Repeat this cycle weekly for up to 4 weeks.
Safety during pregnancy is unknown.
Patient instructions for using sinecatechins for HPV genital warts/condyloma acuminata
- sinecatechins 15% ointment (green tea derivative)
Apply to visible warts TID for up to 16 weeks. Medication should NOT be washed off after use.
Safety during pregnancy is unknown
When to refer for HPV genital warts/condyloma acuminata
- no resolution after 6 weeks of standard therapy
- pt is immunosuppressed
- lesions are darkly pigmented, indurated, ulcerated, or otherwise suspicious - biopsy for HPV type and refer
- cervical condylomas must rule out HSIL before treatment (pap test)
Treatment considerations for HPV genital warts/condyloma acuminata in pregnancy
The patient-applied therapies (imiquimod, podofilox, sinecatechins) should be avoided in pregnancy. May consider wart removal with surgical or ablative provider-administered therapies but complete resolution may not be possible until after pregnancy.
Counsel patients that HPV types 6 and 11 (which cause genital warts) can cause respiratory papillomatosis in infants and children, though risk is low
Chlamydia and gonorrhea are both this type of organism
bacteria
Causative organism of chlamydia
chlamydia trachomatis
Causative organism of gonorrhea
neisseria gonorrhea (gram-negative, intracellular diplococcus requiring a carbon dioxide environment to survive)
Incubation period for gonorrhea
3-5 days
% cases of gonorrhea that are in folks <30yo
80%
Sequelae of gonorrhea
- pelvic inflammatory disease (PID)
- infertility
- ectopic pregnancy
- septic arthritis
- bacteremia
- infections of bartholin or skenes glands
- perihepatitis
- proctitis (rectal inflammation)
- eye infection in neonates (vertical transmission)
- premature ROM
- chorioamnionitis
- premature neonate
Risk factors for gonorrhea
- sexually active <25yo
- multiple partners
- inconsistent condom use
- history of STI
- commercial sex work
- illicit drug uce
Symptoms of gonorrhea
may be asymptomatic. otherwise, may report:
- vaginal discharge
- postcoital bleeding
- dysuria
- vulvar pain (think bartholin or skenes gland infection)
- pelvic pain (think PID)
- proctitis/anal bleeding (think anal infection)
- sore throat (think pharyngeal infection)
- joint pain (think septic arthritis, bacteremia)
Physical findings suggestive of gonorrhea
- mucopurulent endocervical discharge
- inflamed skenes or bartholin glands
- friable cervix
- 20% may have signs of endometritis, salpingitis, or pelvic peritonitis from uterine invasion of infection after menses
- septic arthritis or signs of infection at other sites
Diagnostic evaluation of suspected gonorrhea
- NAAT (recommended by CDC 2015)
- culture on thayer-martin medium (which would also allow for susceptibility testing if treatment failure is suspected)
- concurrent testing for chlamydia, serum syphilis and HIV
First line treatment for gonorrhea (CDC 2015 vs. 2020)
CDC 2015:
- ceftriaxone 250mg IM 1x AND azithromycin 1g PO 1x (co-treatment for chlamydia)
CDC 2020:
- ceftriaxone 500mg IM 1x
- co-treat for chlamydia ONLY if has not been excluded, and do not use azithromycin (growing resistance). Use doxycyline 100mg BID x7 days
Treatment for chlamydia and/or gonorrhea in pregnancy
the single-dose IM injection of ceftriaxone is safe to use in pregnancy for gonorrhea. for chlamydia, doxycycline is contraindicated in pregnancy so must use azithromycin
Does someone treated for gonorrhea need to come back for any routine follow-up?
- test of cure is not recommended
- test for reinfection is recommended 3 months following
Counseling points for patient treated for gonorrhea
- avoid sexual intercourse until all partners are treated and asymptomatic
- all sexual partners within 60 days of onset should be evaluated and treated, or most recent partner even if >60 days
What is herpes simplex virus
A common, incurable, chronic, recurrent viral disease commonly sexually transmitted through skin-to-skin contact
What are the 2 types of HSV
HSV-1 is commonly found in the mouth, accounts for only 15% of genital infections.
HSV-2 causes 85% of genital infections
% of individuals with HSV 2 who are asymptomatic
80-90%
Can you transmit HSV when asymptomatic?
yes! asymptomatic vial shedding accounts for the majority of transmission
% of females exposed to HSV via sexual contact who will acquire it
80-90%
Risk factors for HSV
- h/o STI
- multiple sex partners
- trauma to skin (portal of entry for virus)
- immunosuppressed
Possible sequelae of HSV
- oral or genital lesions
- herpes encephalitis
- herpes meningitis
- diffuse infection in immunocompromised individuals
- perinatal infection
Patient counseling regarding HSV and pregnancy
Most women with infected neonates had no known history of HSV. Infection is transmitted during labor and birth. The risk for transmission to the neonate is highest if pregnant woman gets the primary infection near the time of birth (30-50% risk) vs. if there is a RECURRENT episode near time of birth (<1% risk)
Symptoms of HSV - primary infection
primary infection – 66% will have systemic symptoms including fever, malaise, or headache which begins within 1 week of exposure, peaks on day 4, and subsides over the next week. This will be followed by localized genital pain, with a prodrome of pruritis and erythema 1-2 days before appearance of lesions.
Lesions may then form as small, painful vesicles over the labia, mons pubis, vagina, and peri-anal area (4-10 days). These vesicles then rupture forming shallow, painful, wet ulcerations that last 1-2 weeks which should heal without scarring.
75% will have associated vaginal discharge
90% will have cervical involvement including vesiculation or easy bleeding
Tender inguinal lymphadenopathy may be the last symptom to resolve
Symptoms of HSV - recurrent genital infection
May experience the same symptoms as primary infection but should be more mild and shorter in duration. Usually no constitutional symptoms.
May expect: - prodrome lasts 1-2 days - vesicles 3-5 days - drying out 2-3 days (6-9 days total)
Physical findings indicative of HSV
- small, vesicular genital lesions and ulcerations at varying stages of progression
- exquisite pain at site of lesion
- inguinal lymphadenopathy
Diagnostic evaluation of suspected HSV
- culture collected from the base of the vesicle or ulcer (may have low sensitivity, depending on the stage of the lesion i.e., if closed)
- PCR assay is the most sensitive test (rarely used)
- type-specific serologic tests (blood test) can identify HSV 1 or 2 antibodies with varying degrees of sensitivity and specificity
Sensitivities and specificities for HSV 1 and 2 with type-specific serologic tests (blood tests)
& what is serum testing most useful for?
HSV1:
- blood tests have LOW sensitivity
HSV 2:
- blood tests have HIGH sensitivity (91-100%)
- blood tests have HIGH specificity IF collected 6-12 weeks after initial infection (92-98%)
Serologic is MOST useful for identifying HSV2 antibodies, because up to 97% of US females have antibodies to HSV1
Goal of treatment for HSV1 and 2
there is no definitive cure; virus sticks around forever.
Systemic antiviral drugs can suppress symptoms but they do no eradicate the latent virus or affect risk of recurrence, frequency of recurrence, or severity of symptoms once the drug is stopped.
Suppressive therapy may be used to reduce viral shedding and rate of transmission to sexual partners, as well as to reduce frequency of recurrence
Treatment options for first clinical episode of HSV
valacyclovir (Valtrex) 1g PO BID x7-10 days
- acyclovir 400mg PO TID x7-10 days
- acyclovir 200mg PO 5x daily for 7-10days
- famiciclovir 250mg PO TID for 7-10 days
Treatment options for episodic recurrent HSV infection
initiate treatment during prodrome or within 1 day of lesion onset for most effectiveness
** valacyclovir (Valtrex) 500mg PO BID x3 days **
- valacyclovir (Valtrex) 1g PO QD x5 days
- acyclovir 400mg PO TID x5 days
- acyclovir 800mg PO BID x5 days
- famiciclovir 125mg PO BID x5 days
- famiciclovir 1000mg PO BID x1 day
- famiciclovir 500mg PO 1x, followed by 250mg PO BID for 2 days
Treatment options for suppressive therapy for recurrent HSV
** valacyclovir (Valtrex) 500mg PO QD **
- valacyclovir (Valtrex) 1g PO QD
- acyclovir 400mg PO BID
- famiciclovir 250mg PO BID
Patient counseling on HSV infection and sex partners near pregnancy
Uninfected pregnant person is at most risk of neonatal vertical transmission at birth if acquires near time of birth. If partner has known HSV, use condoms with all sexual contact when asymptomatic. Consider abstaining when partner has prodrome or active genital lesions, as well as near estimated time of birth. Consider treating partner with suppressive therapy to lower risk of transmission
Management of HSV during pregnancy and lactation
- acyclovir can be safely used in all stages of pregnancy and lactation
- valiciclovir and famicyclovir have limited data but are generally considered low risk
- consider using suppressive therapy for pregnant folks with recurrent genital infections starting at 36 weeks gestation
- there is no data to support the use of antiviral suppressive therapy for pregnant folks who have been found to be sero-positive for HSV but have never had a clinical outbreak
- a c-section should be offered if the pregnant person has an active lesion or prodromal symptoms at the time of labor
Non-pharm and OTC measures that may be helpful in management of HSV
- cool topical compresses PRN to reduce swelling and inflammation (i.e., put creams in fridge)
- OTC topical burow’s solution (5% aluminum subacetate)
- topical anesthetics (4% lidocaine cream)
What is molloscum contagiosum, how is it transmitted, and who most commonly has it?
a mildly contagious viral epithelium proliferation of the skin. Caused by virus called molloscum contagiosum, un unassigned pox virus containing double-stranded DNA
Transmitted skin-to-skin, fomite, and auto-inoculation
Most common in children and young adults
Symptoms of molloscum contagiosum
- flesh-colored or white or pink, waxy, smooth, firm, spherical papules
- skin lesions contain umbilicated apex with central plug
- usually <20 lesions
- lesions range in size from pinhead to 2-5mm in diameter
- presents on trunk and lower extremities in children; on lower abdomen, inner thigh, pubic area, and genitalia on adults
- usually asymptomatic or otherwise may have pain, pruritis, and inflammation
Incubation period for molloscum contagiosum
2-7 weeks
Physical exam findings suggestive of molloscum contagiosum
- multiple lesions, usually <20
- lesions are characteristically light-colored with umbilicated center
- lesions are found on face, neck, trunk, lower extremities, abdomen, inner thigh, and/or genital area
Diagnostic evaluation of suspected molloscum contagiosum
- typically a clinical diagnosis, biopsy is not usually indicated but may be considered which would demonstrate cytoplasmic inclusions, molloscum bodies
- consider testing for other STIs in young adults who are sexually active
Treatment/management of molloscum contagiosum
- will usually resolve spontaneously without scarring
- may offer superficial incision to express contents with comedo extractor
- may offer curettage with cautery
- for multiple lesions, cryotherapy may be offered with liquid nitrogen or silver nitrate
- the above treatments may cause scarring
Causative agent of syphilis
treponema pallidum bacteria
Incubation period of syphilis
average 21 days, but may range from 10-90 days
How is syphilis transmitted
the organism enters skin through microscopic breaks in the skin during sexual contact
(4) stages of syphilis, overview
- primary - may be asymptomatic, or painless chancre
- secondary - systemic symptoms, often mucocutaneous lesions
- latent - asymptomatic but may be detected by serum testing
- tertiary - widespread symptoms, nodular lesions, cardiac symptoms, neurosyphilis, serious complications. Not infectious at this point
Describe the primary stage of syphilis
may be asymptomatic
or, may note a painless, ulcerated lesion with raised border and indurated base, rolled edges called a chancre. This may appear anywhere that the point of entry was – genitals, mouth, anus. Will spontaneously disappear on own in 3-6 weeks
May additionally have painless lymphadenopathy
Describe the secondary stage of syphilis
Following resolution of the primary chancre, symptoms become systemic - may begin 4-6 weeks after appearance of the primary lesion, and tends to resolve in 1 week to 2 months. May have a localized or diffuse mucocutaneous rash to palms and soles, may have mucous patches and condylomata lata. May have generalized lymphadenopathy along with flu-like symptoms including low-grade fever, headache, sore throat, malaise, and arthralgias.
- highly contagious
Describe the latent stage of syphilis
Latent stage begins after spontaneous resolution of secondary stage. In this stage, there are no clinical manifestations but infection can be detected by serologic testing.
Early latent = within 1 year
Late latent = after 1 year
May remain latent or may progress to tertiary stage
Describe the tertiary stage of syphilis
- characterized by gummas (nodular lesions) involving the skin, mucous membranes, skeletal system, and viscera
- Cardiac symptoms, aortitis, aneurysm, or aortic regurgitation
- Neurosyphilis may present without symptoms or with nerve dysfunction, acute or chronic meningitis, stroke, tabes dorsalis, meningovascular syphilis, general paralysis, insanity, iritis, chorioretinitis, and leukoplakia
- This stage is not infectious
Physical findings suggestive of syphilis
- chancre on the vulva, vagina, cervix, penis, or at any site of organism entry marks primary stage
- secondary stage may see generalized maculopapular rash, mucocutaneous lesions, and adenopathy
- condyloma lata appear as wart-like lesions on vulva, penis, perianal region, and upper thighs
- gummas are characteristic of tertiary stage - appear as nodules that enlarge, ulcerate,and become necrotic
Serologic testing for syphilis
- nontreponemal tests are often the first step – specifically, the VDRL (venereal disease research laboratory) and/or RPR (rapid plasma reagin)… these are 80-90% accurate in making a diagnosis but are nonspecific
- a positive RPR or VDRL test must be followed by a confirmatory treponemal test… these include FTA-ABS (fluorescent treponemal antibody absorption), or a TP-PA (T. pallidum particle agglutination) which are more specific
- the treponemal tests (FTA-ABS; TP-PA) tend to remain positive for lifetime, regardless of if treated for syphilis
- the non-treponemal tests (VDRL, RPR) titers usually correlate with disease activity, and results should be reported quantitatively
(2) non-treponemal tests for syphilis
VDRL (venereal disease research lab)
RPR (rapid plasma reagin)
(2) treponemal tests for syphilis
FTA-ABS (fluorescent treponemal antibody absorption)
TP-PA (T. pallidum particle agglutination)
Diagnostic evaluation of syphilis, overview
- nontreponemal tests (VDRL, RPR)
- treponemal confirmatory test (FTA-ABS, TP-PA)
- testing for other STIs including HIV
- lumbar puncture makes the diagnosis of neurosyphilis in late latent or tertiary stages
Who NEEDS to be treated for syphilis
- pregnant people
- positive treponemal test
- people previously positive/treated who later have a 4-fold rise in quantitative nontreponemal tests
- people with uncertain diagnosis with syphilis unable to be excluded
- anyone exposed within 90 days preceding the diagnosis of syphilis (any stage) in a sexual partner…. treat this patient presumptively even if sero-negative
- anyone who was exposed more than 90 days preceding the diagnosis of syphilis (any stage) in a sexual partner…. treat presumptively if test results are not immediately available and the opportunity for follow-up is uncertain
22yo F presents with concerns about STIs. She reports she is not currently sexually active, but she just heard from a friend that her ex-boyfriend from 4 months ago was just diagnosed with syphilis. She has no symptoms but wants STI testing today. She has missed multiple appointments in the past including her last 3 annual visits and cites multiple barriers to coming in for follow-up including lack of transportation and cannot tell her parents why she is coming to the office.
Management plan?
- serologic testing for syphilis today
- treat presumptively d/t unsure follow-up! benzathine penicillin G 2.4 million IM single dose
- other STI testing per patient request
Treatment for primary or secondary syphilis (CDC 2015)
- benzathine penicillin G 2.4 million units IM x1 **
- doxycycline 100mg PO BID x 14 days
- tetracycline 500mg PO QID x 14 days
Treatment for latent syphilis (CDC 2015)
early latent
- benzathine penicillin G 50,000 units/kg IM (up to the adult dose maximum of 2.4 million in a single dose)
late latent or unknown duration
- benzathine penicillin G 50,000 units/kg IM (up to the adult dose maximum of 2.4 million in a single dose) given as three doses at 1-week intervals (total 150,000 units/kg across all 3 doses, up to the adult max cumulative of 7.2 million units)
Treatment for tertiary syphilis with normal CSF examination on lumbar puncture (CDC 2015)
benzathine penicillin G 7.2 million units total, administered as three separate doses of 2.4 million units IM each at 1-week intervals
Treatment of syphilis in pregnancy
same penicillin regimen as not pregnancy (benzathine penicillin G)
- pregnant patients who do not have a 4-fold drop in titers after 3-month period need repeat treatment
Evaluation considerations for individuals with HIV diagnosed with syphilis infection
- may have a higher incidence of neuro involvement and higher rate of treatment failure –> close follow-up is important
- serologic test results may be atypical
- when the clinical picture is positive but the serologic test is negative, can use biopsy, dark-field, and direct-flourescent antibody staining to confirm
What follow-up is needed after new diagnosis of syphilis after appropriate treatment?
- perform quantitative non-treponemal serologic tests (VDRL, RPR) at 6, 12, and 24 months
- expect titers to decline at least 4-fold within 12-24 months follow-up
- 4-fold increase in titers at any time indicates inadequate treatment or a new infection (or in pregnancy, a less than 4-fold drop in titers after 3 months needs repeat treatment)
- expect treponemal tests (FTA-ABS, TP-PA) to remain positive for most individuals throughout life, regardless of treatment or disease activity
- report all cases to proper agency for follow-up of sexual contacts
What is chancroid
an acute, contagious, ulcerative bacterial infection caused by haemophilus ducreyi that is sexually transmitted.
haemophilus ducreyi is a short, non-motile gram-negative rod and anaerobe that grows in chains known as a school-of-fish pattern
Occurs only in a few areas of the US in discrete outbreaks - may be associated with drug use, commercial sex, or acquisition outside of US (most commonly seen in tropical and subtropical climates in regions of Africa and the Caribbean)
Symptoms of chancroid
may be asymptomatic. if symptoms,
- papules or painful ulcerations on the labia, anogenital skin, vagina, and or cervix
- may have foul odor
- 30-60% of cases will develop bilateral, tender, suppurant inguinal lymphadenopathy (bubo) after 1 week
- lesions will resolve in 1-2 weeks if treated; 1-3 months if untreated
Diagnostic evaluation of suspected chancroid
- definitive test is culture to identify H. ducreyi, cultere collected from the lesion or bubo. However, may be difficult to isolate on culture and requires a specific medium, sensitivity is <80%
- gram stain may reveal gram-negative rods or chains on microscopy
- clinical signs are characteristic:
+ genital ulcers with typical characteristics
+ regional lymphadenopathy
+ negative HSV test
+ suppurant inguinal adenopathy - test for other STIs including HIV, syphilis as indicated
Physical findings suggestive of chancroid
- deep ulcerations with irregular, scalloped borders
- bilateral tender suppurant inguinal lymphadenopathy
- lesions may be found on the labia, vagina, anogenital skin, or cervix
- may have foul odor
Treatment for chancroid
Treatment is curative, but may leave scarring in severe cases. CDC (2015) recommends the following options:
- azithromycin 1g PO 1x
- ceftriaxone 250mg IM x1
- ciprofloxacin 500mg PO BID x3 days
- erythromycin base 500mg PO BID x7 days
Do you need to return for follow-up after diagnosis and treatment of chancroid?
- yes, re-examine in 3-7 days and re-evaluate plan if ulcerations have not improved
Patient counseling regarding sex partners and diagnosis of chancroid
All sex partners within 10 days before the onset of chancroid symptoms should be evaluated and treated
What is lymphogranuloma venereum (LGV)
An ulcerative, bacterial STI that causes genital ulceration and inguinal lymphadenopathy that is caused by Chlamydia Trachomatis (subtypes L1, L2, and L3).
Very infrequent in the US, endemic in tropical regions, more commonly in males 5:1 ratio males to females
Symptoms of lymphogranuloma venereum (LGV)
may be asymptomatic. if symptoms,
- painless ulcerations that heal within a few days (50%)
- tender lymphadenopathy usually occurs 1-4 after ulcer and may be associated with fever, malaise, headache, and myalgias
- may have painful bowel movements with blood or pus from the rectum
Physical exam findings suggestive of lymphogranuloma venereum (LGV)
- painless genital ulceration at the site of inoculation which disappears in a few days
- tender inguinal and/or femoral lymphadenopathy, most commonly unilateral
- rectal exposure may result in proctocolitis or inflammatory involvement of perirectal or perianal lymphatic tissues, leading to fistulas and strictures
Diagnostic evaluation of suspected lymphogranuloma venereum (LGV)
- aspirate from fluctuant lymph node with culture or NAAT will show chlamydia in 50% of cases
- serologic testing will demonstrate a titer of more than 1:64 in active disease
- CBC demonstrating mild leukocytosis or monocytosis
- elevated ESR
- screen for other STIs including HIV as indicated
Treatment for lymphogranuloma venereum (LGV)
CDC (2015)
- doxycycline 100mg PO BID x21 days
OR… erythromycin base 500mg PO QID x21 days
Antibiotic considerations in pregnancy: doxycycline
should be avoided in the second and third trimesters of pregnancy due to risk of discoloration to fetal teeth and bones
doxycycline is compatible with breastfeeding
Antibiotic considerations in pregnancy: erythromycin
safe in pregnancy and breastfeeding
Does someone need to return for follow-up after diagnosis and treatment of lymphogranuloma venereum (LGV)?
yes, follow clinically until all signs and symptoms have resolved
Patient counseling about sex partners and recent diagnosis of lymphogranuloma venereum (LGV)
all sex partners within the last 60 days before onset of symptoms should be examined and treated with a chlamydia regimen (azithromycin 1g PO 1x or doxycycline 100mg PO BID x7 days)
What is pelvic inflammatory disease (PID)?
A spectrum of inflammatory disorders of the upper female genital tract including any combination of salpingitis, endometritis, tubo-ovarian abscess, and pelvic peritonitis
What are the most common causative organisms of PID
- chlamydia trachomatis
- neisseria gonorrhea
- polymicrobial infection (may include escheria coli, gardnerella vaginalis, haemophilus influenzae, mycoplasma hominis
25% of PID cases result in one or more of these (3) sequelae
infertility, ectopic pregnancy, chronic pelvic pain
Risk factors for PID
- sexually active <20yo
- multiple sex partners
- h/o PID
- chlamydia, gonorrhea, or BV infection
- vaginal douching
Symptoms of PID
may be acute or mild
- abdominal pain
- vaginal discharge
- fever
- dysuria
- dyspareunia
- nausea/vomiting
- vaginal spotting or bleeding (30%)
What are the MINIMUM criterion for empirical treatment of PID in a sexually active patient
complaint of pelvic pain AND the presence of ONE or more of the following three findings on physical exam \+ cervical motion tenderness \+ uterine tenderness \+ adnexal tenderness
Making the diagnosis of PID
Minimum criteria includes PELVIC PAIN and 1 or more of the following
+ CMT
+ uterine tenderness
+ adnexal tenderness
Additional findings that support this diagnosis include
+ fever (>101F or 38.4C)
+ mucopurulent cervical or vaginal discharge
+ abundant WBCs on wet mount microscopy of vaginal secretions
+ elevated ESR and CRP on labs
+ NAAT demonstrating diagnosis of N. gonorrhea or C. trachomatis
Definitive diagnosis includes …
+ endometrial biopsy demonstrating histologic evidence of endometritis,
+ sonography or other radiographic tests revealing a tubo-ovarian abscess,
+ and/or laparoscopic examination demonstrating abnormalities consistent with PID
Presumptive treatment for PID should be initiated in sexually active young females and other folks at high risk for STIs in those who report pelvic pain or lower abdominal pain and no other reason for the illness can be identified AND one of the following criteria (3):
- cervical motion tenderness
- uterine tenderness
- adnexal tenderness
Treatment for PID with tubo-ovarian abscess
hospitalization for at least 24 hours to initiate parenteral antibiotic therapy (will include cefotetan AND doxycycline, cefoxitin AND doxycycline, OR clindamycin AND gentamicin)
Recommended treatment options for PID
- ceftriaxone 250mg IM 1x PLUS doxycycline 100mg PO BID x14 days WITH OR WITHOUT metronidazole 500mg PO BID x14 days
- cefoxitin 2g IM 1x PLUS probenecid 1g PO administered concurrently in a single dose PLUS doxycycline 100mg PO BID x14 days WITH OR WITHOUT metronidazole 500mg PO BID x14 days
(5) criteria for hospitalization in patient with PID
- pregnant
- pelvic abscess is suspected
- surgical emergency could not be ruled out (ectopic pregnancy, appendicitis)
- severe illness including high fever, nausea, vomiting
- failure to improve on initial outpatient therapy
What type of follow-up is needed after diagnosis of PID and initiation of outpatient treatment
follow-up for re-examination within 72 HOURS (3 DAYS)
- if not significantly improved, review diagnosis and treatment - consider hospitalization
- significant improvement would entail: abatement of fever, reduction in direct or rebound abdominal tenderness, reduction in adnexal or uterine or cervical motion tenderness
Patient counseling on sex partners and recent PID diagnosis
All sex partners within the last 60 days before onset of PID symptoms should be evaluated and treated for presumed gonorrhea and chlamydia
Treatment of PID in pregnancy
hospitalization! pregnant folks with PID are at high risk for maternal morbidity and preterm delivery, need hospitalization for parenteral antibiotics
(3) major vulvar dermatoses
lichen sclerosus, lichen planus, lichen simplex chronicus
What are vulvar dermatoses?
Non-neoplastic disorders of the vulvar epithelium that produce a number of visible changes as well as pain or pruritis that may be severe
What is lichen sclerosus, overview
Chronic, progressive inflammatory skin condition that primarily affects the perineal and perianal regions. Most common in postmenopausal women. Multifactorial etiology including genetic, familial disposition, and autoimmune components
What is lichen planus, overview
An inflammatory skin condition manifested in the vulva, vagina, and other mucous membranes of the bone. Typically seen in peri- and post-menopausal women. Will flare and remit spontaneously. Flares last from several weeks to years. Thought to be autoimmune in nature
What is lichen simplex chronicus, overview
Thickening of the skin in response to chronic rubbing or scratching, may be thought of as an atopic reaction. Sometimes is a reaction to chronic inflammation from an underlying skin condition
What autoimmune conditions may be seen with lichen sclerosus and lichen planus (4)
vitiligo, thyroid disorder, alopecia areata, ulcerative colitis
Diagnostic evaluation of suspected lichens (any of the three)
- biopsy confirms diagnosis
- saline and KOH wet mount to rule out vaginitis (BV, trich, yeast)
- STI testing as indicated
Physical findings suggestive of lichen sclerosus
- maculopapular lesions or plaques
- loss of pigmentation
- markedly thin, white epidermis
- symmetry of distribution extends around the anal region (figure eight)
- loss of vulvar architecture with obliteration of the clitoris
- introital stenosis
Physical findings suggestive of lichen planus
- sharply demarcated, shiny, erythematous papules and patches
- gray-white lace strands of hyperkeratosis overlay the patches
- vagina erythema, erosions, and adhesions
- loss of vulvovaginal architecture
- may involve other mucosal surfaces of the body
Symptoms of the lichens
All 3:
- pruritis
- dyspareunia
- dysuria
Planus:
- burning, raw sensation with possible discharge and bleeding
Simplex chronicus:
- chronic itch-scratch cycle
Physical findings suggestive of lichen simplex chronicus
- thickened, leathery plaques on the labia majora
- excoriations and erosions from scratching
- may involve other body areas too such as the nape of neck, forearm, ankle, antecubital and popliteal fossae, scalp
Treatment/management of the lichens (vulvar dermatoses)
- remove all contact irritants
- skin emollients such as vegetable-based oils
- skin protectants such as zinc oxide (calamine lotion) and vitamin A and D ointments
- baking soda soak or burow’s solution (domeboro)
- high potency topical steroids with an ointment base (ointment better for vulva than cream) tapered as symptoms improve and/or may continue on for maintenance
- oral or injected corticosteroids may be needed with lichen planus
- vaginal dilators may be needed to maintain vaginal patency for lichen sclerosus or planus
- referral to dermatologist for severe symptoms, unsure diagnosis, or no improvement with treatment
- yearly vulvar exam with biopsies as indicated for lichen sclerosus which carries increased risk of vulvar cancer
Lichen sclerosus carries an increased risk for….
vulvar cancer (vulvar squamous cell carcinoma) - 4-5%
important to do yearly vulvar exam with biopsies as needed
What is vulvodynia?
A chronic vulvar discomfort, often described as a burning pain, occurring in the absence of relevant physical findings or a specific clinically-identifiable neurologic disorder. May be generalized pain (mons pubis, labia majora, labia minora, perineum) or localized to the vestibule and clitoris (vestibulodynia)
% of folks with vulvodynia
8-16%
Etiology of vulvodynia and associated conditions
not very well understood and thought to be multifactorial
- altered immune inflammatory process
- chronic inflammation
- neurologic dysfunction (heightened sensitivity or nerve fiber proliferation)
- commonly associated with IBS, interstitial cystitis (painful bladder syndrome) and fibromyalgia
Symptoms of vulvodynia
- severe burning, stinging, irritation or raw sensation generalized to the vulva
- burning, stinging, tearing, throbbing, razor-blades or cut-glass sensation to the vestibule
- entry dyspareunia
- dysuria
Physical exam findings with vulvodynia
no visible dermatoses, inflammation, or identifiable cause
Diagnostic evaluation of vulvodynia
- cotton swab test – apply light touch to the inner thighs, labia majora, vestible, clitoris/hood, and perineum with a cotton swab to localize areas of altered sensation
- test for vaginitis or UTI
- colposcopy and/or biopsy may be helpful to rule out a dermatosis
Management options for vulvodynia
limited data exists to support any one therapy. provide anticipatory guidance to expect long-term therapy and may not achieve complete resolution of symptoms
- topical ointments for pain relief such as a lidocaine, capsaicin, gabapentin, nitroglycerine, or amitriptyline with baclofen (muscle relaxer)
- oral neuropathic pain medications, such as amitriptyline, desipramine (TCAs) or gabapentin
- local injections with steroids, interferon, or botox
- physical therapy with a pelvic floor PT specialist
- laser surgery or excision as last resort
- counseling or psychological support for chronic pain
What causes a bartholin’s gland cyst or abscess
ductal obstruction due to infection or just thickened mucus which leads to cyst formation
Symptoms of bartholin’s gland cyst or abscess
- usually nontender
- if tender, think abscess
- may cause discomfort during sexual intercourse or with walking or sitting
Physical exam findings suggestive of a bartholin’s gland cyst or abscess
- medially protruding cystic structure at the inferior aspect of the labia (4 and 8 o’clock positions)
- most are 1-3cm in size
- usually unilateral
- nontender, if tender think abscess
Differential diagnosis for a suspected bartholin’s gland cyst
- epidermal inclusion cyst
- vulvar lipoma
- vulvar hematoma
- cancer of the bartholin’s gland (very rare)
Diagnostic evaluation of a bartholin’s gland cyst or abscess
- usually none are needed, as diagnosis is based off of clinical examination
- culture may be taken of abscess, and if positive is usually polymicrobial
- NAAT for chlamydia or gonorrhea as indicated
- biopsy can be considered of the bartholin’s gland if >40yo rule out carcinoma
Management/treatment of a bartholin’s gland cyst or abscess
Treatment depends on symptoms, size of the cyst, and whether recurrent or infected (abscessed). Options include:
- needle aspiration
- incision and drainage with or without placement of a Word catheter
- Duct marsupialization or gland excision
- broad-spectrum antibiotics tailored to culture results if cellulitis is present
What is a Word catheter used for with bartholin’s gland cysts and how does it work
Word catheter allows for formation of an epithelialized tract and thus continued drainage of the gland, reducing the rate of recurrences
Placement: make a small incision proximal to the hymenal ring. Insert and inflate the catheter. Tuck the end of the catheter into the vagina.
Leave in place for 4-6 weeks until a fistulous tract forms.
Complications may include pain during and after placement, or difficulty maintaining the catheter in place.
What is required for a pap test specimen to be considered adequate vs. inadequate
adequate = presence of endocervical/transformation zone component
inadequate = specimen may be obscured by blood or inflammation, inadequate number of squamous cells, air-dried slide, or not-processed because it was unlabeled
What does NIL and NILM on pap result stand for
negative for intraepithelial lesion
negative for intraepithelial lesion or malignancy
What does ASCUS pap test result stand for and interpretation
atypical squamous cells of undetermined significance
squamous cells on specimen do not appear completely abnormal but they are not able to determine the cause of the abnormal cells
What does ASC-H pap test result stand for and interpretation
Atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion
What does LSIL pap test result stand for and interpretation
Low-grade squamous intraepithelial lesion
this encompasses transient HPV infection, mild dysplasia, and/or cervical intraepithelial neoplasia 1 (CIN 1)
What does HSIL pap test result stand for and interpretation
High-grade squamous intraepithelial lesion
this encompasses persistent HPV infection, moderate dysplasia (CIN 2), and/or severe dysplasia or carcinoma in situ (CIN 3) and will include identification of features consistent with invasion
Pap test returning atypical endocervical or glandular cells, favors…..
neoplastic disease (cancer)
How should you manage a pap test result that was unsatisfactory for evaluation
If HPV is unknown (any age) or HPV is negative (age 30 or older)….. repeat pap test in 2-4 months
If HPV is positive (age 30 or older)… repeat pap test in 2-4 months OR do a colposcopy
How should you manage two consecutive pap test results that were unsatisfactory for evaluation
colposcopy
How should you manage if pap test returns trichomonas vaginalis
These results are highly predictive (though not 100%)… recommend treating
How should you manage if pap test returns candida species
Most of the time this is asymptomatic colonization which would require no treatment
If symptoms, may treat
How should you manage if pap test returns shift in flora suggestive of BV
This is very insensitive and non-specific as an indicator for BV, no not use for diagnosis
How should you manage if pap test returns actinomyces
Evaluate for signs or symptoms of infection if IUD is present and, if symptoms of infection, remove the IUD and treat with antibiotics
Otherwise, no treatment is required and IUD removal is not needed
How should you manage if pap test returns HSV
This has high predictive value. Counsel patient on diagnosis and consider a type-specific serology to confirm prior infection and whether it is HSV1 or 2
How should you manage if pap test returns CMV (cytomegalovirus)
This is not significant in asymptomatic folks who are not immunocompromised or pregnant
How should you manage if pap test returns with reactive changes associated with inflammation
Examine the patient and preform microscopy or other evaluation for vaginitis and STIs as indicated, treat any identifiable cause
How should you manage if pap test returns endometrial cells in a pre-menopausal patient with normal menstrual cycles
Normal, no treatment
How should you manage if pap test returns endometrial cells in a post-menopausal patient
Evaluate with endometrial biopsy
How should you manage if pap test returns endometrial cells in a pre-menopausal patient with abnormal bleeding
Recommend evaluation with endometrial biopsy
How should you manage ASCUS pap in 21-24yo
PREFERRED: repeat pap test again in 1 year
If the repeat test in 1 year is NILM, ASCUS, or LSIL –> repeat again in 1 year. If the repeat test in year 2 is greater than ASCUS, recommend colposcopy. When the test has been negative 2x, resume pap test screening every 3 years.
If repeat test in 1 year was ASC-H, atypical glandular cells, or HSIL –> do a colposcopy
ACCEPTABLE: reflex HPV test.
If HPV negative, repeat pap test in 3 years
If HPV positive, repeat pap test again in 1 year
How should you manage LSIL pap in 21-24yo
Exact same as for ASCUS pap in 21-24yo, except that to do reflex HPV testing is not a recommended/acceptable alternative strategy.
Thus, repeat pap test again in 1 year.
If the repeat test in 1 year is NILM, ASCUS, or LSIL –> repeat again in 1 year. If the repeat test in year 2 is greater than ASCUS, recommend colposcopy. When the test has been negative 2x, resume pap test screening every 3 years.
If repeat test in 1 year was ASC-H, atypical glandular cells, or HSIL –> do a colposcopy
How should you manage ASC-H pap in 21-24yo
colposcopy
How should you manage HSIL pap in 21-24yo
colposcopy
How should you manage ASCUS pap in 25-29yo
PREFERRED: reflex HPV test.
If HPV negative, repeat pap test in 3 years.
If HPV positive, recommend colposcopy
ACCEPTABLE: repeat the pap test in 1 year.
If negative at 1 year fup, repeat pap in 3 years.
If ASCUS or greater at 1 year fup, recommend colposcopy
How should you manage LSIL pap in 25-29yo
colposcopy
How should you manage ASC-H pap in 25-29yo
colposcopy
How should you manage HSIL pap in 25-29yo
immediate excisional treatment or colposcopy
What is the preferred screening regimen for pap tests in folks 21-24yo
pap test cytology only Q3 years
What is the preferred screening regimen for pap tests in folks 25-29yo
pap test cytology only Q3 years
What is the preferred screening regimen for pap tests in folks 30yo and older
co-testing (cytology + HPV) Q5 years
acceptable alternative is pap test cytology alone Q3
How should you manage NILM pap HPV positive in 30+yo
ACCEPTABLE: repeat co-testing in 12 months.
At 1 year fup, if NILM/HPV negative, repeat co-testing in 3 years. If was ASCUS or greater pap and HPV positive, recommend colposcopy
ALSO ACCEPTALBE: complete HPV typing
If HPV 16 or 18 is positive, recommend colposcopy
If HPV 16 and 18 is negative, repeat co-testing again 1 in year.
How should you manage ACUS pap HPV negative in 30+yo
Repeat co-testing in 3 years
How should you manage ASCUS pap HPV positive in 30+yo
colposcopy
How should you manage LSIL pap (HPV not tested) in 30+yo
colposcopy
How should you manage LSIL pap HPV negative in 30+yo
PREFERRED: repeat co-testing in 1 year.
If at 1 year fup pap NILM and HPV negative, repeat co-testing in 3 years. If pap ASCUS or greater or HPV positive, recommend colposcopy
ACCEPTABLE: recommend colposcopy
How should you manage LSIL pap HPV positive in 30+yo
colposcopy
How should you manage ASC-H pap (any HPV) in 30+yo
colposcopy
How should you manage HSIL pap (any HPV) in 30+yo
immediate excisional treatment or colposcopy
What is diethylstilbestrol (DES) and its effect
DES was a synthetic nonsteroidal estrogen approved by the FDA for use to prevent miscarriage and premature labor from 1940 to 1971
It was found to increase the risk for reproductive abnormalities, infertility, and clear cell adenocarcinoma of the cervix and vagina
Patients born between these years should be asked about history of DES exposure
1940-1971
in 2021, that would be folks ages 50 to 81yo
The vagina is originally lined with ______ epithelium, which is eventually replaced by ______ epithelium. If DES exposure occurs in utero, that transformation is not completed and 1/3 of exposed patients will have ________ epithelium in the vagina (adenosis)
This is important, because _____ epithelium of the vagina is especially susceptible to…..
originally lined with columnar epithelium
replaced by squamous epithelium
DES exposure will have columnar epithelium
columnar epithelium of the vagina is especially susceptible to HPV
Structure changes of the cervix and vagina occurred in ____% of patients exposed to DES in utero, including (3)
25%
- vaginal septum
- cervical collar
- uterine constriction band
Risk for clear cell carcinoma of the vagina of patients exposed to DES in utero
1/1000 risk
highest risk for DES-exposed females in their early 20s
Sequelae of DES exposure in utero
HPV and cervical cancer, clear cell carcinoma of vagina, structural changes of cervix and vagina (i.e., vaginal septum, cervical collar), increased incidence of preterm delivery, spontaneous abortion, and ectopic pregnancy
Physical exam findings suggestive of DES exposure in utero
- vaginal adenosis (most common) which refers to glandular epithelium extending from the endocervix into the vagina with a red, granular appearance
- nodularity of the cervix or vagina
- visible cervical abnormalities such as ridges, cockscomb, collar, hood, pseudopolyps, or hypoplasia
- transverse or longitudinal vaginal septum
- uterine abnormalities including T-shaped, bicornate or didelphis uterus, or septate uterus
Diagnostic evaluation of suspected or known DES exposure in utero
- pap test of cervix AND all four walls of the vagina to rule out cancer. This should be done annually
- colposcopy and biopsy of suspicious areas
- hysterosalpingogram or US to evaluate for structural anomalies
- refer to specialist if abnormality suspected or identified
Define chronic pelvic pain
- noncyclic pelvic pain that lasts longer than 6 months
- localized to the pelvic/lower abdominal/lumbrosacral regions
- of sufficient severity to cause functional disability and/or leads the individual to seek medical care
What are some possible gynecologic causes for chronic pelvic pain
- endometriosis
- post-PID chronic pelvic pain
- adhesions
- pelvic congestion syndrome (pelvic varicosity pain syndrome)
- ovarian mass
- uterine fibroids
- adenomyosis
- vulvodynia
- gyn malignancies (particularly late stage)
What are some non-gyn causes for chronic pelvic pain
- interstitial cystitis (painful bladder syndrome)
- myofascial pain syndromes
- IBS
- GI or urologic malignancies
% of folks affected by chronic pelvic pain ages 18-50yo
15-20%
Symptoms of chronic pelvic pain
- paroxysms of sharp, stabbing, sometimes crampy, or dull continuous pain, usually severe
- dysmenorrhea, dyspareunia, dysuria, vulvar or vaginal pain
- pain may or may not be reproducible during abdominal and pelvic examination
- feeling of pelvic pressure or heaviness
Physical exam findings suggestive of chronic pelvic pain
Unless related to an underlying specific gyn, urologic, MSK, neurologic, or GI disorder –> may be completely normal.
Pain mapping may be useful in locating painful areas more specifically
Diagnostic evaluation of chronic pelvic pain
- pelvic US or hysteroscopy
- lab studies are often of little value. may consider:
+ pregnancy test
+ CBC
+ ESR
+ urinalysis
+ vaginal infection tests/STI screening
+ fecal occult blood test
If GI/GU symptoms present, consider barium enema, upper GI series, IV pyelogram
If MSK symptoms present, consider lumbrosacral radiographic images or orthopedic consult
Ultimate diagnosis commonly made by laparoscopy
Supplemental therapies for chronic pelvic pain without identifiable underlying cause (3)
acupuncture, biofeedback, TENS unit (transcutaneous electrical nerve stimulation)
What is a cystocele
herniation of the bladder into the vaginal lumen (anterior vaginal wall bulge)
What is a urethrocele
herniation of the urethra into the vagina
What is a rectocele
Bulging or herniation of the anterior rectal wall into the opening of the vagina (posterior vaginal wall bulge)
What is a enterocele
herniation of a portion of the small intestine into the upper vagina or into the rectovaginal space
What is uterine prolapse
descent of the uterus and cervix into the vagina and towards the introitus
What is the cause of most pelvic relaxation disorders (prolapse)
Weakness in the pelvic support structures, including the pelvic diaphragm, ligaments, and fascia
Commonly related to neuromuscular injury during vaginal childbirth which results in denervation of the muscular floor
Increasing incidence with advancing age
May also be caused by conditions that chronically increase intraabdominal pressure, including obesity, constipation, chronic cough, nerve function alterations from diabetes, pelvic surgery, neurologic disorders, or hypoestrogenism
Symptoms associated with pelvic relaxation disorders (prolapse)
May be asymptomatic and discovered during routine exam. If symptoms, may experience:
- pelvic, vaginal, or low back pain and pressure
- bulging sensation in the vagina, may make walking uncomfortable
- urinary incontinence or incomplete bladder emptying
- fecal incontinence or difficulty evacuating feces
- dyspareunia
- exposed vaginal tissue may become dry and/or ulcerated with purulent discharge
Physical exam findings suggestive of pelvic relaxation disorders (prolapse)
- bulging of the anterior or posterior vaginal walls
- various degrees of descent of the cervix into the vagina indicating uterine prolapse
- valsalva maneuver may be useful in determining full extent of prolapse
- poor muscle strength in the pubococcygeal muscles
- complete prolapse of the uterue (prodentia), ulceration, purulent discharge, or bleeding
Diagnostic evaluation of pelvic relaxation disorders (prolapse)
none - clinical diagnosis
if suspect tumor may require appropriate imaging
Treatment/management options for pelvic relaxation disorders (prolapse)
- pelvic floor muscle strengthening exercises (Kegels)
- pelvic floor PT with specialist which may include biofeedback and other modalities
- local estrogen therapy for postmenopausal folks
- pessary – requires visit for fitting and instructions on care
- surgical repair for severe prolapse
What is toxic shock syndrome (TTS) and its cause
TTS is a rare, potentially fatal, febrile condition affecting multiple systems.
It is associated with toxins produced by certain strains of staphylococcus aureus. Approx. 10% of the population lacks sufficient antitoxin antibodies to S. aureus
Occurs most commonly in caucasian women younger than 30yo using highly absorbent tampons during menstruation. It is rarely caused by other items in the vagina such as a diaphragm, sponge, or cervical cap.
55% of the time caused by non-menstruation associated factors such as puerperal sepsis, post-cesarean endometritis, mastitis, PID, wound infection, or insects
Incidence of TTS in women using tampons
1-2 per 100,000
Symptoms suggestive of TTS
- sudden onset fever of 102F or greater
- diffuse macular sunburn-like rash over the face, trunk, and extremities that desquamates 1-2 weeks after onset
- hyperemia of the conjunctiva, oropharynx, tongue, or vagina
- GI symptoms including n/v, diarrhea, abdominal tenderness, and dysphagia
- GU symptoms including vaginal discharge and adnexal tenderness
- flu-like symptoms including headache, sore throat, myalgia, rigors, photophobia, and arthralgia
- cardiopulmonary symptoms - including signs of pulmonary edema, disseminated intravascular coagulation (DIC), endocarditis, acute respiratory distress syndrome (ARDS), orthostatic hypotension
- organ failure including renal or hepatic failure
- altered sensorium
Diagnostic evaluation of suspected TTS
- cultures to determine the source of infection (i.e., throat, vagina, cervix, blood)
- serologic tests to rule out rocky mountain spotted fever, syphilis, and rubeola
- urinalysis
- evaluation for the presence of multi-organ involvement such as CBC with diff, CMP, clotting profile, ABGs
- diagnostic criteria includes involvement of three or more organ systems
Management/treatment of TTS
refer immediately to the hospital for ICU
Prevention of TTS
- avoid tampons or leave in place no longer than 4 hours
- alternate tampons with pads
- educate about s/s of TTS if using cervical cap, diaphragm, sponge, or tampons
- avoid all of the above if they have a history of TTS
Treatment of choice for HSV genital warts during pregnancy
TCA (or BCA) application are the only treatments known to be safe during pregnancy
DSM5 criteria for disorders of sexual function include these (2) factors
- experiencing the disorder at least 75% of the time for 6 months
- causing significant distress
(3) types of female sexual function disorders
- sexual interest/arousal disorder
- orgasmic disorder
- genito-pelvic pain/penetration disorder
What is sexual interest/arousal disorder
complete lack of or significant reduction in sexual interest or sexual arousal
What is orgasmic disorder
marked delay in, marked infrequency of, or absence of orgasm or reduction in intensity in all or almost all occasions of sexual activity
What is genito-pelvic pain/penetration disorder
persistent or recurrent difficulties in relation to vaginal penetration
What is vaginismus
recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina
(4) types of male sexual function disorders
- hypoactive sexual desire disorder (HSDD)
- delayed ejaculation
- premature ejaculation
- erectile dysfunction
What is delayed ejaculation
unable to ejaculate during sexual activity, specifically after 25-30 minutes of continuous sexual stimulation
What is premature ejaculation
early ejaculation during vaginal intercourse, individual feels unable to control orgasm; climaxes in less than 1 minute after vaginal penetration. no duration has been established for oral or manual stimulation
Prevalence of female sexual function problems, according to the PRESIDE study (2008)
- 43% at least 1 problem with sexual desire, arousal, or orgasm
- 22% reported this caused significant distress
PLISSIT Model for addressing female sexual function disorders
- Permission (validate concerns, express that problems are real and prevalent)
- Limited Information (provide basic education about sexual response cycle, components of desire, identify cause of the problem)
- Specific Suggestion (lubricants, erotica, enhancing clitoral stimulation, positioning for comfort)
- Intensive Therapy (refer to sex therapist for CBT focused on sexual concerns and solutions)
Medication options in the treatment of female sexual function disorders
PRE-MENOPAUSAL
- flibanserin (Addyi; 2015) for interest/arousal disorders in PRE-menopausal females. PO QHS
- bremelanotide (Vyleesi; 2019) - for interest/arousal disorders in PRE-menopausal females. SQ injection 45 min before sexual activity
- sildenafil (Viagra) is not FDA approved for use in females
POST-MENOPAUSAL
- vaginal estrogens for POST-menopausal vaginal atrophy. variety of administration options
- prasterone (Intrarosa; 2016) for dyspareunia. intravaginal insert QHS
MOA of prasterine (Intrarosa)
dehydroepiandrosterone (DHEA, a precursor hormone) preparation that is converted into active androgens and estrogens
Definition of infertility
<35yo - Inability to conceive after 1 year of unprotected vaginal-penile coitus
If >35yo, after 6 months
Or, inability to carry a pregnancy to live birth at any age
% of females in the US who are infertile
6-15%
% of infertility that is female factor, male factor, combined, and unexplained
female factor - 25-50%
male factor - 25-50%
combined - 30%
unexplained - 10-25%
female factors contributing to infertility
- anovulation
- luteal-phase insufficiency
- poor ovarian reserve
- inadequate cervical mucus
- uterine anomalies
- adhesions from surgery or peritonitis
- tubal occlusion
- endometriosis
male factors contributing to infertility
- erectile dysfunction
causes leading to low sperm production….
- low testosterone (hypogonadism)
- varicocele
- toxin exposures (radiation, chemicals, drugs)
- chronic overheating of testicles
- mumps orchitis (testicular inflammation)
other causes….. (s/t obstruction)
- adhesions in the vas deferens (from epididymitis, genital tract surgery)
- hypospadias
- phimosis
- retrograde ejaculation
What is hypospadias
congenital defect in which the urethral meatus is located on the ventral surface of the glans, penile shaft, or perineal area
What is phimosis
tight foreskin that cannot be retracted, may be congenital or the result of recurrent infections of the glans penis and prepuce
History and information-gathering in infertility work-up
- menstrual history
- h/o abnormal pap tests and/or their treatment (i.e., LEEP)
- prior pregnancies
- duration of trying to conceive
- previous fertility treatments and work-ups
- frequency and timing of intercourse
- sexual dysfunction or dyspareunia
- history of STIs or other FU infections
- history of pelvic or abdominal surgeries
- symptoms of or known diagnosis of endocrine disorder
- prior cancer diagnosis and/or chemotherapy/rads
- current medications (rx and OTC)
- substance use (marijuana, alcohol, illicit drugs)
- environmental and occupational exposures
- family history of birth defects or infertility
Diagnostic evaluation in infertility work-up
- pelvic US to describe uterine anomalies, ovarian volume, and ovarian cysts
- hysterosalpingogram to describe tubal patency
- BBT and home predictor kits to detect ovulation
- AMH level (serum) + antral follicle count (US) to describe ovarian reserve
- serum FSH, LH, estradiol (E2), and progesterone
- serum TSH
- STI screening
- semen analysis
Components described in a semen analysis
semen volume, sperm number, sperm concentration, motility, vitality, morphology, and pH
Medical treatment of infertility s/t ovulatory dysfunction
ovulation induction with clomiphene citrate (Clomid; SERM) or letrozole (AI)
Medical treatment of infertility s/t luteal-phase defect
vaginal or IM progesterone
Most basic infertility treatment technology, before ART therapies
intrauterine insemination
What is assisted reproductive technologies (ART)
all the techniques used to achieve pregnancy that involve direct retrieval of the oocytes from the ovary (IVF, GIFT, ZIFT, ICSI)
What is IVF and its success rate
in vitro fertilization - oocytes are extracted from the ovary, fertilized with sperm in the laboratory, and then transferred through the cervix back into the uterus
success rate 15-20%
most common ART procedure
What is GIFT and its success rate
gamete intrafallopian transfer - placement of oocytes and sperm into the fallopian tube
25% success rate
What is ZIFT and its success rate
zygote intrafallopian transfer (ZIFT) - placement of fertilized oocytes into the fallopian tube
18-20% success rate
What is ICSI
intracytoplasmic sperm injection
This ART therapy is used when the male has a low sperm count and is combined with IVF or ZIFT – the oocyte is directly injected with one sperm
What are Mullerian Abnormalities
congenital anomalies involving the uterus, fallopian tubes, and upper vagina resulting from the absence of anti-mullerian hormone (AMH)
As many as 15% of females with recurrent spontaneous abortions and up to 20% of infertile females have this condition
a mullerian abnormality
Types of mullerian abnormalities you may be able to find on physical examination and US
- agenesis of the vagina, uterus, or tubes
- hypoplasia of the vagina, bicornate uterus, or a partial uterine cavity
- atresia with imperforate hymen or cervical atresia (incomplete canalization)
- one-third will also have urinary tract abnormalities including ectopic kidney, renal agenesis, horseshoe-shaped kidney, abnormal collecting ducts
- as the ovaries may be developed, may see expected secondary sex characteristics
diagnostic work-up for mullerian abnormalities
- structural abnormalities may be detected by US, MRI, hysterosalpingogram, or laparoscopy
- chromosomal abnormalities are ruled out with karyotyping (will demonstrate 46XX)
Treatment/management of mullerian abnormalities for the WHNP generalist
referral to reproductive endocrinologist and/or surgeon for consult
What is androgen insensitivity/resistance syndrome
a genetically transmitted androgen receptor deficit. the individual is a genotypic male (46XY) but phenotypic (development) female OR has both male and female secondary sex characteristics.
the individual will have testes that may be partially-descended or intra-abdominal. however, will also have vagina with labia but no uterus or ovaries
What is the etiology of androgen insensitivity syndrome (AIS)
genetic; transmitted by a maternal X-linked recessive gene causing a defect in androgen receptors.
25% risk of having an affected child, 25% risk of having a carrier child
The third most common cause of primary amenorrhea, representing 10% of all cases….
androgen insensitivity syndrome (46XY)
Priority long-term risk of androgen insensitivity syndrome (AIS)
5% risk of malignant transformation of the gonads
Physical exam findings suggestive of androgen insensitivity syndrome (AIS)
- uterus and ovaries are absent
- blind pouch vagina present
- labia may be underdeveloped, absent, or have scant pubic hair
- normal breast development however with small nipples and pale areola
- inguinal hernias (50%) or labial masses due to partially-descended testes which may be intra-abdominal
- scant body hair
- growth and development are normal, however, overall height is usually greater than average female
- may have horseshoe kidneys
Diagnostic work-up of suspected androgen insensivitiy syndrome (AIS)
- karyotyping will reveal 46XY in phenotypically female patient
- testosterone elevated, usually >3ng/mL and LH normal to slightly elevated
Management of androgen insensitivity syndrome (AIS) for WHNP generalist.
Referral to endocrinologist or specialist. Anticipatory guidance - Once full developed is attained (after puberty), gonads should be removed at about age 16-18yo to prevent malignant transformation. Hormone therapy replacement after the gonads are removed to desired sexual/gender identity. Evaluate other family members and provide sensitive, individualized counseling.
What is Turner’s Syndrome
gonadal dysgenesis - 45X
an abnormality in or absence of one of the X chromosomes in a phenotypically female patient
60% have total loss of an X chromosome, 40% are mosaics or have structural abberrations in the X or Y chromosome
Most common chromosomal abnormality found on spontaneously aborted fetuses
Turner’s syndrome - 45X
Prevalence of Turner Syndrome
1 in 2,500-5,000 live-born females
S/s of Turner Syndrome
- short stature
- webbed neck
- shield chest with widely spaced nipples
- increased carrying angle of the elbow
- arched palate
- low neck hairline
- short fourth meta-carpal bones
- disproportionately short legs
- swollen hands and feet
- lack of breast development
- scant pubic hair
- amenorrhea
- lack of sexual development
- may have comorbid autoimmune disorders including hashimoto’s thyroiditis (hypothyroidism with goiter formation), addison’s disease (adrenal insufficiency), alopecia, and vitiligo
- hearing loss
- normal intelligence or may have difficulty with mathematical ability, visual-motor coordination, or spatial-temporal processing
Diagnostic evaluation of suspected Turner’s Syndrome
- genetic karyotyping reveals 45X
- US or MRI
- renal US and cardiology consult
Management of Turner’s Syndrome for the WHNP generalist
referral to endocrinologist and/or multiple specialists as needed to manage multisystem involvement. Anticipatory guidance regarding likely estrogen and progesterone replacement therapies, human growth hormone, and genetic counseling.
What are fibrocystic breast changes
“nondisease” aka physiologic breast changes that include nonproliferative microcysts, macrocysts, and fibrosis as well as proliferative changes such as hyperplasia and adenosis
hyperplasia with atypia is associated with a moderate risk for breast cancer
(4) types of fibrocystic breast changes
- cystic changes
- fibrous changes
- hyperplastic
- adneosis
What are cystic changes of fibrocystic breast changes
refers to dilations of the ducts. May regress with menses, may persist, or may disappear and reappear
What are fibrous changes of fibrocystic breast changes
a mass develops following an inflammatory response to ductal irritation
What are hyperplastic changes of fibrocystic breast changes
a layering of cells, has malignant potential if atypical
What are adenosis changes of fibrocystic breast changes
these are related to changes in the acini in the distal mammary lobules - the ducts become surrounded by a firm, hard, plaquelike material
etiology of fibrocystic breast changes
poorly understood. thought to occur in response to endogenous hormone stimulation, primarily estrogen
Most common benign breast condition in females
fibrocystic breast changes
prevalence of fibrocystic breast changes
detectable on radiograph imaging in 90% of females ages 40 and older
symptoms of fibrocystic breast changes
- breast pain and nodularity which is usually bilateral
- frequently occurs or increases 1-2 weeks before menses
- may have clear or white nipple discharge
physical exam findings suggestive of fibrocystic breast changes
- multiple, usually cystic masses that are well-defined, mobile, and often tender
- absence of overlying breast skin changes
- may have clear or white nipple discharge
- most common sites include the upper outer quadrant and axillary tail
Diagnostic evaluation of fibrocystic breast changes
usually none are needed.
- May order mammography to identify and characterize masses if age 40 or older.
- May use US to determine whether a mass is cystic.
- Fine-needle aspiration (FNA) if there is a dominant mass with cytologic evaluation.
- Biopsy or excision id there is a dominant mass and/or other concerning findings are present (i.e., bloody fluid on aspirate)
Red flags for biopsy with suspected fibrocystic breast change
- blood fluid on aspiration
- failure of a mass to disappear after aspiration
- recurrence of a cyst after two aspirations
- solid mass that is not diagnosed as a fibroma
- bloody nipple discharge
- nipple ulceration
- skin edema or erythema
Treatment/management options of fibrocystic breast changes
treatment is not necessary unless symptomatic/desired by patient. provide reassurance.
- aspiration of palpable cysts may be curative
- supportive bra
- NSAIDs, topical or oral
- reduce irritants (methylxanthines - caffeine, tea, cola, chocolate)
- hormonal contraception may increase or decrease mastalgia
- medications including danazol, tamoxifen, and bromocriptine have all been used to treat severe mastalgia however all have major side effects that limit their utility and mastalgia typically returns once they are discontinued
What is a fibroadenoma
a benign breast mass derived from the fibrous and glandular tissue of the breast
What is the etiology of fibroadenoma
poorly understood. Thought to develop soon after menarche and appears to be hormone-related (as such, may increase in size during pregnancy and regress after menopause)
Most common benign, dominant breast mass in younger females
fibroadenoma
Age group most commonly affected by fibroadenomas
15-25yo
Symptoms of fibroadenoma
- painless, single, round, rubbery mass
- no nipple discharge
- does not change with the menstrual cycle
Physical exam findings suggestive of a fibroadenoma
- firm, well-delineated, free-moveable, smooth, rubbery, round typically 2-4cm marble-sized mass that is non-tender, and usually unilateral
- may grow up to 15cm
- no nipple discharge or skin changes
Diagnostic evaluation of a suspected fibroadenoma
- attempt FNA to determine whether cystic or solid
- excisional biopsy
- US and/or mammography will help distingish singular from multiple nonpalpable masses and US is best choice for younger females
Management of fibroadeoma
If diagnosis is confirmed and the patient is <25yo, reassurance and observation.
May be removed to alleviate patient anxiety or if the diagnosis is uncertan.
Follow-up with an annual breast exam by a clinician with screening mammograms per national guideline schedules
Breast pain is usually associated with…..
fibrocystic breast changes
What is an intraductal papilloma
a benign lesion of the lactiferous ducts from proliferation and overgrowth of the epithelial tissue lining the subareolar collection duct
It is the most common cause of pathologic nipple discharge
Most common cause of non-physiologic nipple discharge
intraductal papilloma
Age group most commonly affected by intraductal papillomas
35-50yo, perimenopausal
Symptoms suggestive of intraductal papilloma
- bloody, serous, or turbid discharge (not milk) which may occur spontaneously
- a mass is not usually palpable
- feeling of fullness or pain beneath the areola is possible
Physical exam findings suggestive of intraductal papilloma
- expression of serosanguinous nipple discharge from a single duct when pressure is applied
- poorly delineated, soft mass may be palpated
- usually singular not multiple
- no associated breast skin changes
Diagnostic evaluation of a suspected intraductal papilloma
- mammography and/or US depending on age
- excisional biopsy of the duct allows for definitive evaluation
- cytology of the expressed fluid (although false-negative rates up to 20% for cancer)
- radiologic ductogram use is controversial due to low sensitivity
Management of intraductal papilloma for the WHNP
referral for surgical excision, which is curative
What is nonpuerperal/periductal mastitis
periareolar inflammation with a mass or abscess in a patient who is not lactating. commonly related to staphylococcous areus
Most common in the reproductive age group
May be associated with breast cysts and cyst rupture
(2) risk factors for nonpuerperal mastitis
nipple piercing, smoking
Symptoms of nonpuerperal mastitis
- reddened, painful nipple or breast
- may or may not have a mass
- may or may not have spontaneous purulent nipple discharge
Physical exam findings suggestive of nonpuerperal mastitis
- subareolar warmth, tenderness, or erythema
- fluctuant or indurated mass
- dimpling or nipple retraction
- purulent nipple discharge
- mammary duct fistula may be present at the areolar margin
Diagnostic evaluation of suspected nonpuerperal mastitis
- breast US to assess for abscess and/or fistula
- biopsy if there is a mass present or if inflammation persists after treatment
Treatment for nonpuerperal mastitis
- oral antibiotic x10 days with an agent that will cover gram-positive organisms (amoxicillin-clavulanate [Augmentin], dicloxacillin, cephalexin)
- if poor response to initial antibiotic, culture for MRSA and if positive, treat with doxycycline or TMP-SMX
- if abscess, aspiration and/or incision and drainage
- remove foreign objects i.e., nipple piercing
- recommend warm packs and NSAIDs for pain relief
- advise smoking cessation
What is mammary duct ectasia
dilation of the mammary ducts with surrounding inflammation and fibrosis. There is a widening of the ducts with thickening of the duct walls - the ducts fill with desquamated ductal epithelium and secretory proteinaceous contents. The skin bacteria collecting in the duct may then cause inflammation and pain.
It is most common in females >50yo and those who smoke.
Symptoms of mammary duct ectasia
- green, brown, or black nipple discharge that is often bilateral and spontaneous
- may have burning, itching, or sensation of pulling in the nipple area
Physical exam findings of mammary duct ectasia
- multicolor, sticky, bilateral, multiductal nipple discharge
- may have a palpable mass behind the nipple
- no overlying breast skin changes
Diagnostic evaluation of suspected mammary duct ectasia
- mammography and/or US
- biopsy if a mass is present
Management of mammary duct ectasia (3)
- antibiotics
- NSAIDs
- smoking cessation
Leading cause of cancer death in women
lung cancer
Second leading cause of cancer death in women
breast cancer
Most common cancer in women (except skin cancer)
breast cancer
75% of patients diagnosed with breast cancer are older than age….
40yo
Cumulative lifetime risk for breast cancer in females
1 in 8 (12%)
Inherited gene mutations are responsible for % of breast cancers
5-10%
Most common gene mutations responsible for breast cancer
BRCA 1 and 2
BRCA 1 or 2 prevalence
1 in 300-500 in the general population
1 in 40 Ashkenazi Jewish ancestry
Lifetime risk of breast cancer in individual with BRCA 1 or BRCA 2 mutation
BRCA 1
- 57% risk on average, up to 85%
BRCA 2
- 47% risk on overage
MALES
- 6% lifetime risk
Who are first degree relatives
parents, siblings, children
Who are second degree relatives
grandparents, grandchildren, aunts, uncles, nephews, nieces
Family history concerning for genetic breast cancer risk
First or Second Degree relatives with:
- known mutation carrier
- breast cancer dx at <50yo
- any male breast cancer
- any ovarian, fallopian tube cancers
- any peritoneal, pancreatic, or metastatic prostate cancer
- multiple primary cancers on the same side of the family
Personal history concerning for genetic breast cancer risk
- personal history of breast cancer dx <50yo
- triple negative breast cancer dx <60yo
- breast cancer at any age if Ashkenazi Jewish
- ovarian or fallopian tube cancer
- pancreatic or primary peritoneal cancer
- multiple primary cancers
Hereditary cancer syndromes associated with breast cancer (3)
- Li-Fraumeni
- Cowden
- Peutz-Jeghers
Risk factors for breast cancer
- increasing age
- family history of breast cancer in one or more first degree relative, especially at early age or in male
- inherited gene mutations
- other hereditary cancer syndromes
- personal history of breast, endometrial, or colon cancer
- biopsy-confirmed atypical hyperplasia
- high-dose radiation to the chest
- high bone density post-menopausal
- menarche before age 12yo
- menopause after age 55yo
- nulliparity
- first pregnancy after 30yo
- hormone therapy and OCPs (conflicting data)
- obesity (postmenopausal)
- heavy alcohol use
- dense breasts
What is breast density
a measure used to describe the proportion of fibroglandular tissue to fatty tissue seen on mammogram
The greater the amount of fibroglandular tissue, the greater the density
Increased breast density is an independent risk factor for…..
breast cancer
Numerous states have passed legislation that requires healthcare clinicians to inform patients with dense breasts that…..
- modest increased risk of breast cancer
- reduced sensitivity of mammography
Most common area for a breast cancer to develop
upper-outer quadrant
Symptoms of breast cancer
- breast mass, commonly in upper-outer quadrant
- spontaneous clear, serous, or bloody nipple discharge
- may have retraction, dimpling, skin edema, erythema, or irritation
Physical exam findings concerning for breast cancer
- mass that is fixed, poorly-defined, irregular, and usually non-tender
- may have nipple discharge or retraction
- may have breast skin changes including dimpling, edema, or color changes
- may have enlarged lymph nodes in the axillary, supraclavicular, or infraclavicular chains
Diagnostic evaluation of suspected breast cancer
- mammogram (detects 30-50% of cancers)
- US (to distinguish solid from cystic mass)
- histology for definitive diagnosis – open excisional biopsy, FNA, or stereotactic core-needly biopsy
- MRI may be useful
- CT of liver, lungs, and bone to r/o metastasis
- estrogen-receptor status is determined by assay
- sentinel node biopsy
- negative mammogram and negative aspiration cytology does not exclude malignancy - make sure you have concordance between all findings/results
