Common Gynecologic Disorders Flashcards
Diseases of the Vulva (Vulvitis)
Vulvitis Imflammation of the vulva -STIs -Other infectious organisms. -Noninfectious conditions
Diseases of the Vulva (Contact Dermatitis)
Caused by local irritants → i.e., detergents, bleach, tight & nonabsorbent underwear, aerosol sprays, bath oils, bubble baths, toilet paper dye, perfumed soaps & powders, vulvar deodorants.
Presents with pruritis & rash – can be vesicular.
Best treatment → eliminate source of irritation.
Hydrocortisone ointments(0.1-0.25%) → topical relief.
Advise wearing cotton underwear washed in mild detergent without bleaching.
Diseases of the Vulva (Intertrigo & Seborrheic Dermatitis)
“dandruff’ of the vulva.
Extreme form → thickening & cracking of the intralabial skin folds.
Commonly seen in diabetic women.
Treatment:
Dusting with cornstarch to absorb moisture.
Low strength hydrocortisone cream for pruritis.
Diseases of the Vulva (Folliculitis)
Staph invasion of sebaceous ducts & hair follicles.
Furuncle → infection spreads & causes localized cellulitis. “boils”
Carbuncle → several follicles in close proximity infected.
Sx include pain, tenderness, & lymphadenitis.
Spontaneous healing usually occurs.
Diseases of the Vulva (Vulvodynia)
Vulvar discomfort, most often described as burning pain, occurring in the absence of relevant visible findings or a specific, identifiable, neurologic disorder.” ISSVD
Pt presents with c/o ‘sensitivity of the vulva to touch’& usually no other physical findings.
Diseases of the Vulva (Vulvodynia & proposed causes)
embryologic abnormalities increased urinary oxalates genetic or immune factors hormonal factors Inflammation Infection neuropathic changes.
Most likely no single cause.
Diseases of the Vulva (Vulvodynia Treatments)
Vulvar care measures: Advise gentle care. Cotton underwear during day, none at night. Avoid irritants. Lubrication during intercourse. Cool gel packs.
Diseases of the Vulva (Vulvodynia Treatments) Topical therapies
Use ointments.
Topical creams – more preservatives & stabilizers → often produce burning on application.
Lidocaine ointment 5% - apply prn for sx relief & 30 minutes before sexual activity.
Vaseline → provides relief for some.
Estrogen has been used with variable results.
Diseases of the Vulva (Vulvodynia Treatments) Topical therapies - Long term therapy
Long-term use of overnight topical lidocaine may minimize pain & allow for healing.
Copious amount of lidocaine ointment to affected area at bedtime & a cotton ball coated with ointment place on the vestibule to assure overnight contact with area.
After 7 weeks, significant decrease in dysparunia.
Disease of the Vulva
Vulvodynia other Treatments)
Oral medications – used for pain control.
Tricyclic antidepressants.
Anticonvulsants.
Biofeedback & physical therapy
Abnormally high muscle tone, or spasm, poor contraction & relaxation cycles, & instability within muscular structure of pelvic floor can be identified & relieved with specific exercises.
Majority of women had some improvement with sx with PT.
Diseases of the Vulva (Vulvodynia- injections & surgery)
Intralesional injections
Trigger point steroid & anesthetic injections have been successful for some patients with localized vulvodynia.
Surgery Treatment of last resort. Local excision of small painful areas. Total vestibulectomy. Perineoplasty.
Diseases of the Vulva
Neonneoplastic White Lesions of the Vulva
White lesions → refer for diagnosis by colposcopy and/or biopsy to rule out cellular atypica.
Diseases of the Vulva- Hyperkeratosis
Increased deposit of keratin often occurring with inflammation or irritation.
Deposition of keratin occurs as protective response to original irritative lesion.
Appears as a white or greyish-white area.
Tx with local corticosteroid therapy.
Diseases of the Vulva Lichen sclerosus
Patchy white change in the labia.
Most common in midlife.
Asymptomatic in early stage.
In postmenopausal woman → may cause severe pruritus & may lead to malignancy.
Diseases of the Vulva Bartholin’s gland cyst
Bartholin’s glands are duplicate structures located on either side of the vaginal orifice & slightly posterior to it.
Cysts usually found in menstruating women.
Cysts may be asymptomatic & present only as a mass → tx unnecessary.
Recurrent cysts may be tx with marsupialization.
Diseases of the Vulvus- Bartholin’s gland abscess
Pt may present with localized pain & systemic manifestations including fever, chills, malaise.
Usual causes → Neisseria gonorrhea, E. coli, Proteus mirabilis, mixed bacterial flora.
If no systemic sx, can try conservative tx.
Warm vaginal baths and soaks.
If no relief or with systemic sx → antibiotic therapy and/or incision & drainage.
Diseases of the Vulva- Vulvar Intraepithelial Neoplasia (VIN)
Noninvasive potential precursor of squamous cell carcinoma of vulva
Disease of the Vulva- VIN
Graded according to degree of histologic changes:
VIN 1: low-grade or mild dysplasia.
VIN 2: intermediate-grade or moderate dysplasia.
VIN 3: high-grade or severe dysplasia – including carcinoma in situ.
Disease of the Vulva 2 major types of VIN
Classic or bowenoid (undifferentiated) disease.
Associated with HPV virus - #16 most common
Occurs at any age; 30-40’s most common
Simplex (differentiated) disease.
Postmenopausal women.
Not associated with HPV.
Stronger association with invasive squamous cell carcinoma.
Disease of the Vulva- VIN signs & symptoms
VIN – varied signs & symptoms
No single, specific clinical feature describes VIN lesions.
Color – white, gray-white, hyperpigmented, reddish.
Appearance – slightly elevated, roughened, crusted, ill-defined lesion.
Diseases of the Vulva- VIN Symptoms
May be asymptomatic:
Lesions may be noted by HCP during routine exam.
Symptomatic women:
Pruritis – most common sx.
Other sx include – vulvar pain & swelling, soreness, warts, discoloration, vaginal discharge & vaginal bleeding.
Disease of the Vulva- DX of VIN
Diagnosis of VIN
Suspicious lesions:
Punch biopsy.
Colposcopy.
Diseases of the Vulva - Treatment of VIN
Treatment of VIN Aldara cream – effective in tx of some VIN. Usual tx: Surgical excision of lesion. Loop electroexcision. Laser ablation. Definitive tx: Partial or total vulvectomy.
Diseases of the Vulva- NP Role in VIN Management
Thorough history & meticulous examination of genitalia.
Refer to MD for diagnosis & treatment.
Patient education:
Teach women to do vulvar self-examination.
Advise to contact HCP with
Any vulvar changes – discolorations, ulcerations or growths.
Sx – itching, burning, bleeding, discomfort
Diseases of the Vulva- Invasive Cancer of the Vulva
2009 projected cancer statistics: 3,580 new cases. 900 deaths. Rarely occurs before age 40. Associated diseases – diabetes, hypertension, CVD, obesity, STDs.
Diseases of the Vulva- Invasive Cancer of the Vulva
Most commonly found in labia majora & may involve clitoris & bartholin’s gland.
Sx:
May be asymptomatic.
Mass or growth may be present.
Pruritis, bleeding, or pain.
Dx made by biopsy.
Tx surgical – extent of surgery depends on the disease stage.
Diseases of the Cervix - Cogenital Abnormalities of the Cervix
Embryonic development → lack of fusion or incomplete fusion of the mullerian ducts or incomplete or absent development of one duct.
Cervix may be septate, double or incomplete (hemicervix)
Septate cervix → may be confined to cervix, more often continuous with a uterine or vaginal septum.
Double cervix may also exist with a longtitudinal vaginal septum.
Diseases of the Cervix - Structural abnormalities seen after in utero DES exposure:
Cockscomb → raised ridge usually on anterior cervix.
Collar → flat rim involving part to all of circumference of cervix.
Hypoplastic cervix → diameter > 1.5 cm.
Diseases of the Cervix - Benign Disorders of Cervix- Cysts
Nabothian cyst
Obstructed endocervical cell that becomes distended with mucus.
Slightly raised blue or yellow nodules on surface of cervix.
1-3mm diameter.
Not clinically significant, needs no treatment.
Diseases of the Cervix- Polyps
Most common tumors of cervix.
Most often found in women in menstruating years.
Soft, red lesions, usually pedunculated.
Often protrude from os.
Vary from several mm to 2cm diameter.
Usually asymptomatic → may cause bleeding especially postcoital.
Dx made by inspection.
Refer for removal, polyp should be sent for biospy to r/o rare cases of malignancy.
Disease of the Cervix - Cervicitis
Inflammation of cervix.
Causes: infection, injury, irritation.
1st sx → usually a vaginal discharge that becomes more pronounced immediately after menses.
Other sx → pain, bleeding, dysuria, may be asymptomatic.
Cervix may be edematous & erythematous; friable, reddened areas around os.
Diagnosis:
Std screening, wet mount, colposcopy for suspicious lesions, biopsy as indicated.
Diseases of the Cervix- Cervicitis Treatment
Treat identified organisms appropriately.
Nonspecific bacterial infections:
Sulfa vaginal cream.
Acid douches or jellies to readjust acid/alkaline balance.
Topical estrogens for postmenopausal women.
Chronic cervicitis
May do procedure to destroy abnormal cells on surface of cervix:
Cautery.
Cryosurgery.
Laser treatment.
Diseases of the Cervix- Cervical Cancer statistics
Worldwide Statistics:
2nd most common cancer in women.
Approximately 500,000 cases of cervical cancer are diagnosed each year.
About 80% of cervical cancer cases occur in developing countries.
Leading cause of cancer-related death in women in undeveloped countries → lack of screening.
Diseases of the Cervix- Cervical Cancer - U.S. stats
Estimated new cases 2009 – 11,270
Estimated deaths 2009 – 4,070
14th most common cancer in women.
Incidence and mortality rates dramatically in the US Pap screening.
Diseases of the Cervix - Human Papillomavirus (HPV)
Recognized as the main cause of cervical cancer.
Nearly 100% of women with cervical cancer have evidence of cervical infection with HPV.
Estimated that 75% of sexually active men and women have been exposed to HPV at some point in their lives.
Malignant cervical lesions most frequently associated with HPV 16 & 18.
Diseases of the Cervix - HPV Signs & Symptoms
Early cervical cancer often asymptomatic.
In women who receive regular screening first sign of disease is usually an abnormal pap test result.
Symptoms usually do not appear until abnormal cervical cells become cancerous and invade nearby tissue.
Most common symptom is abnormal vaginal bleeding
Diseases of the Cervix - HPV Prevention
Regular pap screening
No effective antiviral drugs have been developed to slow the progression of HPV.
Detection of advanced premalignant lesions by pap testing, followed by effective treatment, prevents invasive cancer.
Diseases of the Cervix- HPV Vaccines
Gardasil® (quadrivalant HPV vaccine - HPV4)
HPV types 6, 11, 16, 18.
Indicated for girls & young women 9 to 26 years of age.
May be given to boys & men - 9-26 years of age to prevent genital warts
Cervarix® (bivalent HPV vaccine – HPV2)
HPV types 16 & 18
Indicated for girls & young women – 9-26 years of age.
Diseases of the Cervix- Cervical Cancer Prognosis
Stage I Cancer is confined to the cervix. 5 year survival rate – 80-90%. Stage II Cancer extends beyond the cervix. 5 year survival rate – 50-60%. Stage III Cancer extends to the pelvic wall. 5 year survival rate – 25-35%. Stage IV Cancer extends beyond the pelvic area. 5 year survival rate – 0-15%.
Diseases of the Cervix- Cervical Cancer Treatment preinvasive
Treatment
Cervical cancer treatments are dependent on the location & staging of the cancer.
Preinvasive stage – treatment may include: Conization Laser surgery LEEP Cryosurgery
Diseases of the Cervix- Cervical Cancer Treatment Invasive
Invasive stage – treatment may include:
Hysterectomy
Simple hysterectomy – removal of the cancer, the cervix, and the uterus.
Radical hysterectomy – removal of the cervix, uterus, part of the vagina, & lymph nodes in the area.
Radiation
Chemotherapy
Diseases of the Cervix- Cervical Cancer Treatment -Radical trachelectomy
Radical trachelectomy
Can be done with early-stage cervical cancer
Women may be able to preserve their fertility.
Involves removal of cervix & lower part of uterus. Lymph nodes in the pelvis are also removed to determine whether cancer has spread.
Enough of the uterus is left in place so that the woman may be able to carry a child.
Diseases of the Uterus
Cogential Abnormalities
Septate Uterus
Complete /Incomplete – limited to fundus
Uterus grossly normal on pelvic exam.
Woman usually presents with c/o 2 or more second trimester losses not explainable by other causes.
Treated only when a term pregnancy cannot be achieved.
Surgical correction.
Diseases of the Uterus - Bicornate Uterus
Result from incomplete or absent fusion of mullerian ducts.
2 separate uterine cavities.
Bimanual exam – uterus may be palpated as large & heart-shaped.
Associated with prematurity, abnormal fetal presentation, & late second trimester SAB
Diseases of the Uterus- Myomas (leiomyomata)
Most common tumors of the female pelvis.
Called ‘fibroids’ → but arise from muscle cells.
Almost always benign.
Etiology unknown – estrogen, growth hormone, human placental lactogen → may cause tumor growth.
Arise from proliferation of smooth muscle cells.
All begin in the same part of the uterus → the central area of the myometrium.
Myomas identified by name according to location at time of diagnosis.
