Goljan's chapter 22: Female Repro + Breast Disorders Flashcards
1
Q
Description and treatment of Candida albicans
A
- Yeasts and pseudohyphae
- part of normal vaginal flora
- Second most common vaginitis in the US
- Risk factors: diabetes, antibiotics, pregnancy, OCPs
- Pruritic vaginitis with a white discharge and fiery red mucosa
- Treatment: single oral dose of fluconazole or itraconazole
2
Q
Description and treatment of Chlamydia trachomatis
A
- Third most common STD; often coexists with Neisseria gonorrhoeae (45% of cases)
- Incubation period 7–12 days after exposure
Infections in males: NSU (sterile pyuria), epididymitis, proctitis - Infections in females: urethritis (sterile pyuria), cervicitis, PID, perihepatitis (FHC syndrome—scar tissue between peritoneum and surface of liver from pus from PID), proctitis, Bartholin gland abscess
- Infections in newborns: conjunctivitis (ophthalmia neonatorum), pneumonia
- Nucleic acid amplification test has the highest sensitivity and specificity
- Treatment: azithromycin or doxycycline
3
Q
Description and treatment of Gardnerella vaginalis
A
- Gram-negative rod that causes bacterial vaginosis (most common vaginitis)
- Douching alters the microenvironment by decreasing lactobacilli (gram-positive rods that produce lactic acid and the normal vaginal pH of 3.8–4.5); new or multiple sex partners also predisposes to this vaginitis because pH of semen is alkaline (7.2–7.8), which allows the bacteria to proliferate and produce a malodorous vaginal discharge with a vaginal pH >4.5
- Organisms adhere to (they do not invade) squamous cells producing “clue cells”
- Increased incidence of preterm delivery and low-birth-weight newborns
- Treatment: metronidazole; same treatment in pregnancy
4
Q
Description and treatment of Haemophilus ducreyi
A
- STD; gram-negative rod that causes chancroid
- Male dominant disease (10 : 1); high incidence of HIV
- Incubation 4–7 days
- Painful genital and perianal ulcers with suppurative inguinal nodes
- Diagnose with Gram stain (“school of fish” appearance) and culture
- Treatment: ceftriaxone or azithromycin
5
Q
Description and treatment of HSV-2
A
- STD; virus remains latent in the sensory ganglia
- Characterized by recurrent vesicles that ulcerate; locations—penis, vulva, cervix, perianal area
- Tzanck preparation: scrapings removed from the base of an ulcer show multinucleated squamous cells with eosinophilic intranuclear inclusions
- Pregnancy: if the virus is shedding, the baby is delivered by cesarean section
- Treatment: acyclovir (decreases recurrences)
6
Q
Description and treatment of HPV
A
- Second most common overall STD (a few studies still consider it the most common STD)
- types 6 and 11 (90% of cases; low risk types) produce condyloma acuminata (venereal warts); they are fern-like or flat lesions located in the genital area. Approximately 80% of sexually active women will have acquired HPV by age 50 years
- Virus produces koilocytic change in the squamous epithelium, cells have wrinkled pyknotic nuclei surrounded by a clear halo
- Approximately 90% of the warts spontaneously clear within 2 years (most within 8 months); older women more often have persistent disease, because of a decrease in cellular immunity
- HPV vaccine decreases the risk for developing venereal warts
- Treatment: topical podophyllin, sinecatechin (botanical drug) ointment, α-IFN injection, imiquimod cream, laser phototherapy
7
Q
Description and treatment Klebsiella granulomatis
A
- STD; gram-negative coccobacillus that causes granuloma inguinale
- Organism is phagocytized by macrophages (Donovan bodies)
- Creeping, raised sore that heals by scarring; no lymphadenopathy
- Treatment: doxycycline
8
Q
Description and treatment of Neisseria gonorrhoeae
A
- Fourth most common STD; gram-negative diplococcus that infects glandular or transitional epithelium; symptoms appear 2–7 days after sexual exposure
- Infection sites are similar to C. trachomatis
- Complications: ectopic pregnancy, male sterility, disseminated gonococcemia (C6–C9 deficiency is a risk factor), septic arthritis, FHC syndrome, disseminated gonococcemia (septic arthritis [knee], tenosynovitis [hands, feet], pustules [hands, feet], women > men)
- Nucleic acid amplification test has the highest sensitivity and specificity; other tests: urethral swab in symptomatic males with Gram stain; endocervical swab for culture
- Treatment: ceftriaxone
9
Q
Description and treatment of Treponema pallidum
A
- Fifth most common STD; gram-negative spirochete that causes syphilis
- Primary syphilis: solitary painless, indurated chancre; locations—penis, labia, anus, mouth
- Secondary syphilis: maculopapular rash on trunk, palms, soles; generalized lymphadenopathy; condylomata lata, which are flat lesions in the same area as condylomata acuminata; alopecia (hair loss)
- Tertiary syphilis: neurosyphilis, aortitis, gummas
- Nonspecific screening tests: RPR or VDRL; titers decrease after treatment
- Confirmatory treponemal test: FTA-ABS; positive with or without treatment
- Jarisch-Herxheimer reaction: intensification of the rash in secondary syphilis may occur because of proteins released from dead organisms after treatment with penicillin
- Treatment: penicillin
10
Q
Description and treatment of Trichomonas vaginalis
A
- Most current studies consider it to be the most common STD; flagellated protozoan with jerky motility in a wet prep of discharge
- Most women are asymptomatic or have a vaginal discharge; men are asymptomatic carriers who serve as a reservoir for infection in women; increased susceptibility for HIV and increased HIV shedding
- Produces vaginitis, cervicitis, and urethritis, PID, preterm delivery, low-birth-weight babies; strawberry-colored cervix and fiery red vaginal mucosa; greenish, frothy discharge
- Diagnosis: nucleic acid amplification test has the highest sensitivity and specificity; other tests: culture, monoclonal fluorescent antibody staining; oral and rectal tests not recommended
- Treatment: metronidazole (both partners)
11
Q
What organism most commonly causes a Bartholin gland abscess?
A
Neisseria gonorrhoeae
12
Q
What is lichen sclerosis?
A
- Usually occurs in postmenopausal women
- Thinning of the epidermis
- Parchment-like appearance of the skin
- Small risk for developing squamous cell carcinoma (SCC)
13
Q
What is Lichen simplex chronicus?
A
- White plaque-like lesion (leukoplakia)
- Due to squamous cell hyperplasia
- Small risk for developing SCC
14
Q
Papillary hidradenoma
A
- Benign tumor of the apocrine sweat gland
- Painful nodule on the labia majora
15
Q
Vulvar intraepithelial neoplasia (VIN)
A
- Dysplasia ranges from mild to carcinoma in-situ (CIS)
- Strong association with human papillomavirus (HPV) type 16
- Precursor for developing SCC
16
Q
Vulvar squamous cell carcinoma
A
- Most common cancer
- Risk factors: HPV type 16, cigarettes, Immunodeficiency
- Metastasize first to the inguinal nodes
17
Q
Extramammary Paget disease
A
- Red, crusted vulvar lesion
- Intraepithelial adenocarcinoma
- Tumor derives from primitive epithelial progenitor cells
- Malignant Paget cells contain mucin
- Mucin is periodic acid–Schiff (PAS) positive.
- Spreads along the epithelium, rarely invades dermis
18
Q
Vulvar malignant melanoma
A
- Melanoma cells are histologically similar to Paget cells
- Unlike Paget cells, melanoma cells are PAS negative.
19
Q
Rokitansky-Küster-Hauser (RKH) syndrome
A
- A condition where the vagina and uterus are underdeveloped or absent
- Ovaries are usually present and functional.
- Most likely results from a combination of genetic and environmental factors
- Some cases appear to have an autosomal dominant inheritance pattern.
- Anatomic cause of primary amenorrhea
20
Q
Gartner duct cyst
A
- Remnant of the wolffian (mesonephric) duct
- Presents as a cyst on the lateral wall of the vagina
21
Q
Rhabdomyoma
A
- Benign tumor (? hamartoma) of skeletal muscle (vagina)
- Other locations are the tongue and heart (associated with tuberous sclerosis).
22
Q
Embryonal rhabdomyosarcoma
A
- Most common sarcoma in girls
- Malignancy of skeletal muscle (rhabdomyoblasts with striations)
- Occurs in girls
23
Q
Clear cell adenocarcinoma of the vagina
A
- Occurs in women with intrauterine exposure to diethylstilbestrol (DES)
- DES was used to prevent a threatened abortion
- DES inhibits müllerian differentiation.
- Müllerian structures include fallopian tubes, uterus, cervix, upper one third of vagina
- Vaginal adenosis is precursor lesion for clear cell adenocarcinoma. Benign remnants of müllerian glands, roduces red, superficial ulcerations in the upper portion of the vagina
- The risk for developing the cancer is small (1 : 1000).
- Cancer involves the upper vagina.
24
Q
Vaginal squamous cell carcinoma
A
- Primary SCC is associated with HPV type 16.
- Most cancers are an extension of a cervical SCC into the vagina.
- Primary cancers metastasize to the inguinal lymph nodes.
25
Q
Where does exocervix begin
A
Cervical os
26
Q
Epithelium of exocervix
A
squamous epithelium
27
Q
Epithelium of endocervix
A
- glands, normally lined by mucus-secreting columnar cells
- Endocervical epithelium normally migrates down to the exocervix
28
Q
Lactobacilli
A
- gram + rod; produce lactic acid; keeps vaginal pH acidic
29
Q
Transformation zone (TZ)
A
site where squamous dysplasia/SCC develop
30
Q
Acute cervicitis
A
- Acute inflammation is normally present in the TZ.
- Pathologic acute cervicitis; causative agents include: Chlamydia trachomatis, N. gonorrhoeae, Trichomonas vaginalis, Candida, HSV2, HPV
- Symptoms: Vaginal discharge (most common), Pelvic pain, dyspareunia (painful intercourse), Painful on palpation, bleeds easily when obtaining cultures, Cervical os is erythematous and may be covered by an exudate.
- Diagnosis: DNA probe for C. trachomatis and N. gonorrhoeae (>50% of cases of acute cervicitis), Wet mount for T. vaginalis (jerky movements), Pap smear
Treatment: If culture +, treat w/ abx. If -, cryosurgery is an option
31
Q
Chronic cervicitis
A
Occurs when acute cervicitis persists
32
Q
Follicular cervicitis
A
- Caused by C. trachomatis
- Pronounced lymphoid infiltrate with germinal centers
- C. trachomatis infects metaplastic squamous cells.
- Cells contain vacuoles (phagosomes) with inclusions (reticulate bodies).
- Reticulate bodies divide into elementary bodies, which are infective particles.
- Cervicitis is the primary source for C. trachomatis, N. gonorrhoeae conjunctivitis (ophthalmia neonatorum), and pneumonia in newborns
33
Q
Cervical pap smear
A
- Screening test to rule out squamous dysplasia and cancer, evaluate the hormone status of the woman
- Sample sites: Vagina, exocervix, TZ
34
Q
Interpretation of pap smear
A
- Superficial squamous cells = adequate estrogen.
- Intermediate squamous cells = adequate progesterone
- Parabasal cells = lack of estrogen and progesterone
- Normal nonpregnant adult woman: 70% superficial squamous cells, 30% intermediate squamous cells
- Pregnant woman: 100% intermediate squamous cells from progesterone effect
- Elderly woman with lack of estrogen and progesterone: Atrophic smear with parabasal cells and inflammation
- Woman with continuous exposure to estrogen without progesterone: 100% superficial squamous cells (Woman may be taking estrogen without progesterone or she has a tumor secretingestrogen)
35
Q
Cervical (endocervical) polyp
A
- Nonneoplastic polyp that protrudes from the cervical os
- Arises from the endocervix
- Most common in perimenopausal women and multigravida women
- Most common between 30 and 50 years of age
- Not precancerous
- Causes: Inflammation, trauma, pregnancy have been implicated.
- Presents with postcoital bleeding, vaginal discharge
- Treatment is surgical excision.
36
Q
Cervical intraepithelial neoplasia (CIN) epidemiology
A
- Majority of cases are associated with HPV (Types 6 and 11 low risk, 16 and 18 high risk)
- HPV produces koilocytosis in squamous cells (Clear halo containing a wrinkled, pyknotic nucleus)
- Peak incidence is 35 years of age.
- False negative rate for detecting dysplasia on a cervical Pap smear is ~40%.
- Risk factors: Early age of onset of sexual intercourse, Multiple, high-risk partners, High-risk types of HPV in a biopsy, Smoking, oral contraceptive pills (OCPs), immunodeficiency
37
Q
Cervical intraepithelial neoplasia (CIN) classification
A
- CIN I: Mild dysplasia involving the lower one third of the epithelium
- CIN II: Moderate dysplasia involving the lower two thirds of the epithelium
- CIN III: Severe dysplasia to CIS involving the full thickness of the epithelium
38
Q
Cervical intraepithelial neoplasia (CIN) clinical findings, treatment
A
- not usually visible to the naked eye and requires colposcopy
- Occasionally, flat to warty condyloma acuminata are visible.
- Colposcopy findings, after application of acetic acid include: White areas with punctation, mosaic pattern, or abnormal vascularity
- Tx: Electrocoagulation, cryotherapy, laser ablation, local surgery (conization)
39
Q
Cervical cancer
A
Least common gynecologic cancer; cancer with lowest mortality
- Cervical Pap smear most responsible for decreased incidence/ mortality
- abnormal vaginal bleeding MC sign
- spreads down and out
- renal failure common cause of death
40
Q
Sequence to menarche
A
breast budding, growth spurt, pubic hair, axillary hair, menarche
