Lecture 9, part 2 (GYN)- Exam 5 Flashcards
Sorry… a lot
What is all that needs to be done as a routine txt after a sexual assault?
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Fill covered spots
Bacterial vaginosis
* What is it not?
* What is the organism?
- Not an STI but can be transmitted sexually
- Organism: Gardnerella vaginalis
Bacterial vaginosis
* What are the first line treatments? (3)
- Metronidazole 500 mg PO BID x 7 days
- Metronidazole vaginal gel – 1 applicator intravaginally once daily x 5 days
- Clindamycin 2% vaginal cream 5 gm intravaginally at bedtime x 7 days
What is the treatment for BV in preg patients?
Oral metronidazole or oral clindamycin x 7 days
Bacterial vaginosis
* What is the treatment for refractory/recurrent infections? What is recommended?
Boric acid capsules 600 mg intravaginally daily x 21 days after initial antibiotic treatment complete
* Partner condom recommended (acid + penis = pain)
*
BV
* What is the Amstel criteria?
* What abotu sex during treatments?
- Amstel criteria: picture
- 50% increase in cure rate if patients abstain from intercourse or use condoms during treatment
Candida vulvovaginitis
* What is it?
* What are the RFs? (5)
* What is the most prominent sxs?
- Fungal infection usually caused by Candida albicans
- Risk factors – broad-spectrum antibiotics, pregnancy, diabetes, immune compromise, silk underwear or workout clothing
- Pruritis may be severe, and is most prominent symptom
Candida vulvovaginitis
* What is the discharge like?
* odor and ph?
* Dx how?
- Thick, adherent curd like white discharge in vaginal vault
- Not malodorous and pH is normal (<4.5)
- Diagnosed by clinical appearance or KOH prep of slide with microscopy
Candida vulvovaginitis treatments
* What are the topical therapies?
1-to-7-day regimens (OTC or Rx)
Antifungal tablets or creams
* Butoconazole
* Clotrimazole
* Miconazole
* Terconazole
*
Candida vulvovaginitis treatments
* What is the oral therapy? not recommended when?
- Fluconazole 150mg PO x 1 to 3 doses (q 72 hours)
- Not recommended in first trimester
Trichomonas vaginalis
* What is the first line txt?
- Metronidazole 500mg PO BID x 7 days (women) – considered safe in pregnancy
- Metronidazole 2gm PO x 1 dose (men
Trichomonas vaginalis
* What is the alternative txt?
* Treat who?
* What is not effective?
- Tinidazole 2mg PO x 1 dose
- Treat sexual partners
- Metronidazole gel not effective
*
N. Gonorrhaeae
* What is the organism?
* What are the sxs? (3)
* What are the locations? (4)
* What is the treatment?
(*) 1000mg IM x 1 dose if ≥ 150kg or for conjunctivitis
#conconmittant treatment for C. trachomatis recommended
*
+Azithromycin 1gm x 1 dose if pregnant
Syphilis (treponema pallidum)
Syphilis (treponema pallidum)
Syphilis treatment
Syphilis treatment
Syphilis treatment
Syphilis treatment
* pregnancy patients?
Penicillin recommended for all pregnant patients; if allergic desensitize
Pelvic Inflammatory Disease (PID)
* What is it?
* Bacteria?
- Acute (typically ascending) infection of the upper genital tract structures in women, involving any or all of the uterus, oviducts, and ovaries
- Polymicrobial; predominant organisms responsible for initiating the infection are gonorrhea and chlamydia
Pelvic Inflammatory Disease (PID)
* What are the RFs? (3)
- Previous PID infection
- Multiple sex partners
- Not using condoms
Pelvic Inflammatory Disease (PID): Dx
* What is the CDC criteria for empirical treatments?
Cervical motion tenderness (chandelier sign) or uterine or adnexal tenderness in the presence of lower abdominal or pelvic pain
Pelvic Inflammatory Disease (PID): Dx
* Additional criteria to support a clinical diagnosis? (5)
- Temp > 101° F
- Mucopurulent cervical discharge
- Abundant WBCs on microscopy of vaginal secretions
- Elevated ESR
- Elevated CRP
Pelvic Inflammatory Disease (PID): Treatment
* Geared towards what?
* What is usually required? Transition?
Geared towards primary cause (GC/Chlamydia)
Hospitalization is usually required
* Transitioning from parenteral to oral therapy started after 24 hours of sustained clinical improvement
Pelvic Inflammatory Disease (PID)
* What is the sequelae? (3)
- Development of tubo-ovarian abscess (surgical/IR involvement)
- Infertility secondary to scarring of fallopian tubes
- Ectopic pregnancy
Pelvic inflammatory disease
* When should you consider outpatient txt?
- WBC < 11,000/mm3
- Temp < 38° C
- Minimal evidence of peritonitis
- Active bowel sounds
- Tolerating PO
- Reliable
*
What is the outpt txt of PID?
- Ceftriaxone 500mg* IM x 1 plus
- Metronidazole 500mg PO BID x 14d
- Doxycycline 100mg PO BID x 14d
KNOW DOSES
(*)1000mg if >150kg and documented gonococcal infection
Pelvic inflammatory disease
* What is the inpatient treatment?
* May swithc what?
- Ceftriaxone 1gm IV q24h plus
- Doxycycline 100mg IV q12h plus
- Metronidazole 500mg IV q12h
May switch to oral regimen when clinically improving and tolerating PO
Pelvic inflammatory disease
* For inpatient txt, what is the discharge medications?
* Patients should be screened for what?
* Partners?
Discharge medications include:
* Doxycycline 100mg PO BID plus
* Metronidazole 500mg PO q12h x 14 days total
Patients should be screened for other STIs including HIV, syphilis
Partners should be screened and treated
Endometriosis
* What happens?
* MC where?
* Functionally the same as what?
- Endometrial cells migrate and implant outside uterus
- MC ovaries, fallopian tubes, uterine ligaments
- Functionally the same as cells inside of the uterus
Endometriosis
* receptors?
* Go through what?
* Bleeds when?
- Same estrogen receptors
- Go through proliferation, secretion, and menstrual cycle
- Bleed during menses
Endometriosis
* High levels of what?
* Releases what?
* What grows blood vessels?
- High levels of aromatase and produce their own estrogen
- Release proinflammatory factors – inflammation, scarring, adhesions
- Estrogen and proinflammatory factors grow blood vessels
Endometriosis treatments
* What are the goals?
Manage pain (dysmenorrhea)
Limit progression of implants
Address subfertility
* Not treated with drug therapy
Endometriosis treatments
* What is first line agents? Second line? Last line?
First-line:
* NSAIDs
* CHCs
* Progestins
Second-line:
* Gonadotropin releasing hormone analogs
* Danazol
Last line:
* Aromatase inhibitors
Endometriosis: first-line agents
* First line combo and what does it cause?? Alternative?
First-line: NSAIDS plus continuous CHCs
* Induces a pseudopregnancy state
* Reduces the effects of painful lesions
NSAIDS plus progestins for women with estrogen contraindications
Multiple combinations can be attempted in women who do not initially respond
Endometriosis: first-line agents
Endometriosis: first-line agents
Endometriosis: second-line agents
* When should this be tried?
* Induces what?
- Patients not responding to first line therapy should be switched to a GnRH analog with add-back therapy
- Induces a pseudomenopausal state
LY
Endometriosis: second-line agents
LY
Endometriosis: second-line agents
LY
Endometriosis: second-line agents
Gonadotropin analogs
* Hypothalamus stimulates what?What does that cause?
Hypothalamus stimulates the release of GnRH
* GnRH stimulates the ANTERIOR pituitary to release LH and FSH
Gonadotropin analogs
* What does LH and FSH stimulate?
- Ovaries to make estrogen
- Testicles to make testosterone
- Estrogen / testosterone act as a negative feedback on the pituitary and hypothalamus
LONG
Gonadotropin analogs
* What is the MOA of Gonadotropin agonists?
LONG
Gonadotropin analogs
* What is the MOA of Gonadotropin antagonists?
Gonadotropin analogs
* What are the SEs? (9)
- Headaches
- Acne
- Depression
- Low estrogen
- Hot flashes
- Vaginal dryness
- Insomnia
- Increased lipids
- Loss of bone mineral density with prolonged use
LY
Gonadotropin analogs
* What is hte add back therapy?
- Recommended to reduced loss of BMD and provide symptom relief
- Low dose progesterone ± estrogen ± bisphosphonates
Gonadotropin analogs
* What are the contraindications? (3)
- Pregnancy
- Osteoporosis
- Liver disease
Gonadotropin analogs
* What do you monitor? (2)
- Monitor BMD every 1-2 years with prolonged use
- Monitor lipid levels every 6 to 12 months
Endometrosis:
* What is a disadvantage of medical txt?
* What can you do?
Cervicitis
* What are the MC organisms? Often what?
* Women have what?
* When should women be screened?
MC organisms chlamydia and gonorrhea
* Often asymptomatic, symptoms non-specific
Women: increased vaginal discharge, endocervical bleeding
Annual screening recommended for sexually active females < 25 years and older women with high-risk behavior
Cervicitis
* how do you dx it?
* Empiric txt is usually when?
Diagnosis – NAAT
* Men – urine sample
* Women – vaginal secretions / urine sample
Empiric treatment usually initiated prior to test results in patients with high suspicion / poor compliance
*
21-29 -> PAP every 3 years
> 30 -> PAP and HPV every 5 years
U. S. Preventive Services Task Force Recommendation (2018)
* What do you women aged 21-29 get? 30-65?
Women 21-29 years:
* Screening with cervical cytology (pap smear) every 3 years
Women 30-65 years
* Screening with cytology every 3 years + HPV testing every 5 years OR with co-testing (both) every 5 years
U. S. Preventive Services Task Force Recommendation (2018)
* Screening > 65 can stop if what? (3)
* When do you have to continue yearly screenings?
Screening > 65 can stop if:
* 3 consecutive negative cytology results OR
* 2 consecutive negative co-testing results within 10 years OR
* 20 years since treatment or spontaneous regression of precancerous lesions
ANY previous abnormal cytology screening or HIV or DES exposure in utero -> continue yearly screening
American cancer society (2020)
* Women 21-24? 25-65 screening?
American cancer society (2020)
* Women over 65?
* Women status post hysterectomy with cervix present?
Women > 65 years
* Screening discontinuation recommendations similar to USPTF recommendations
Women status post hysterectomy with cervix present – screen per age-appropriate guidelines
Cervical Intraepithelial Neoplasia (CIN)
* What is premalignant cells?
* Where does 90% of CIN occur?
* Dx how?
- Dysplasia of the cervix – premalignant cells
- > 90% of squamous cervical intraepithelial neoplasia (CIN) occurs within the transformation zone
- Diagnosis: Pap smear
*
Cervical Intraepithelial Neoplasia (CIN)
* What is the MCC? What are the high risk ones for cancer?
* MC types for genital warts?
MCC human papillomavirus (HPV) types.
* High risk HPV-cancer related types: 16 and 18 (70%), 31, 33 and 45
* HPV types associated with genital warts: 6 & 11 [(90%) condyloma acuminata]
*
Cervical Dysplasia Summary
* What do you do if pap results show ASCUS or LSIL?
*
Cervical Dysplasia Summary
* Do do you do if HSIL is shown on pap?
Colposcopy and biopsy
*
Cervical Dysplasia Summary
* If colposcopy CIN 1->
* If colposcopy CIN 2 or 3 ->
- If colposcopy CIN 1-> next steps determined by additional risk factors
- If colposcopy CIN 2 or 3 -> loop electrosurgical excision procedure (LEEP)
*
Cervical dysplasia – primary prevention
* What is the vaccine? What does it protect?
* Recommended to who?
Prevention: Gardasil-9 valent vaccine
* Protects against HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58
* Recommended for all teens and young adults up to age 26; conditional recommendations up to age 45
Cervical lesions in females due to HPV have decreased by 40% since introduction of the vaccine
Cervical dysplasia – primary prevention
* What is the dosing timeline for HPV?
