Lecture 9 - Women's Health Flashcards
Vaginitis
General term for disorders of the vagina caused by infection, inflammation or changes in the normal flora
2 classes:
Not sexually transmitted
Sexually transmitted
What is the most common cause of bacterial vaginosis?
Gardnerella vaginalis
Bacterial vaginosis
Polymicrobial:
Gardnerella vaginalis (MC), mycoplasma hominis
NOT an STD
Sxs: gray/white malodorous discharge
Dx: clue cells on wet mount, “whiff test” fishy odor after adding KOH, pH>4.5 (more basic than normal)
Tx:
Metronidazole 500mg PO BID for 7 days
Candida Vaginitis
Most common cause of vaginitis
NOT STD
Risk factors:
Abx use, pregnancy, oral contraception, steroid use, DM, tight cloths
Signs/Sxs: pruritic, sticky “cottage cheese” discharge
Dx: budding yeast and pseudo-hyphae on wet mount, pH<4.5
Tx: nonpregnant fluconazole 150mg PO once or azole vaginal creams, pregnant vaginal Azole creams (miconazole, fluconazole)
Atrophic vaginitis
Decreased vaginal lubrications and thickness of tissue caused by decreased estrogen after menopause
Treat with estrogen cream topically
Trichomonas vaginitis
STD
S/s: profuse, pruritic, white/yellow/green, frothy, malodorous discharge, strawberry cervix (hemorrhagic foci)
Dx: wet mount motile tichomonads (flagella)
Tx: metronidazole 2g PO x1
NO ETOH for 24hours
Treat partners
What is the most common STD?
Chlamydia
Strawberry cervix
Seen with trichomonas vaginitis
Chlamydia
MC STD
Can be asymptomatic
Major cause of infertility
S/s: mucopurulent or yellow discharge, dysuria, cervical erythema
Dx: DNA probes or ELISA from endocervical sample or urine
Tx: azithromycin 1g PO x 1 (or doxy 100mg PO BID x 7days)
Reiter Syndrome
Urethritis
Conjunctivitis
Rash
Arthritis
(Commonly seen after infections, chlamydia being the most common infection)
Gonorrhea
Men are symptomatic in 80-90% of cases (dysuria and discharge)
Women are asymptomatic 30-40%
Can infect pharynx, conjunctiva, and rectum
Can be disseminated GC
S/s: purulent cervical discharge, dysuria, abnormal vaginal spotting
Dx: culture or DNA probe on endocervical sample or urine
Tx: Ceftriazone 250mg IM x 1 + (treatment for chlamydia 1g azithromycin)
PID
Acute infection of the upper genital tract structures including the uterus, oviducts, and ovaries
(Including endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis)
Pathogens: STIs: chlaymdia, gonorrhea (About 1/3 of cases) Non STIs: anaerobic bacteria (Of women who received a dx of acute PID, <50% test positive for either G/C)
What are the risk factors for PID?
Unprotected intercourse with several partners
Age 15-25yo
Hx of previous PID
What are the sxs of PID?
Asymptomatic
Mild:
Dyspareunia
Abnormal vaginal bleeding, especially post-coital, vaginal discharge
Moderate to severe:
Sepsis, LLQ/RLQ/suprepubic pain, peritonitis
PID should be suspected for any young, sexually active female, who has pelvic discomfort
How is PID dx?
CMT (hallmark)
Uterine tenderness
Adnexal tenderness
If a women is experiencing lower abdominal or pelvic pain and one or more of the above sxs, treat empirically for PID
Starting treatment is unlikely to complicate other common causes of lower abdominal pain
Infertility is a major sequela of missed PID dx/tx
One or more of the following additional criteria can be used to enhance specificity of min clinical to support dx of PID:
- oral temp >101.1 (>38.3)
- abnormal cervical mucopurulent discharge or cervical friability
- abundant WBC on saline microscopy of vaginal fluid
- elevated SED rate
- elevated CRP
- lab cx N. Gonorrhoae or C. Trachomatis
What is the treatment for PID?
Outpt:
Ceftriaxone 250mg IM x1
Doxycycline 100mg PO BID for 14 days
PLEASE consider adding metronidazole 500mg PO BID for 14 days
Inpt:
Doxycycline 100mg IV BID + cefoxitin 2g IV QID or cefotetan 2g IV BID
Clindamycin 900mg IV TID and gentamicin 5mg/kg IV QD
When should you consider admission for PID?
Suspected TOA or pelvic abscess
Pregnant
Vomiting, high fever, failure of outpt therapy
Poor compliance or follow up concern
What do you tell pts being treated with PID in their discharge paperwork?
Women should abstain from intercourse until therapy is completed, sxs resolved, and partners have been treated
- treat all partners within 60 days
- if the last parter >60days, treat the last partner
Should demonstrate clinical improvement in 3 days after administration of treatment
-hospitalization, evaluate microbial agent, and consider further testing
Retest after 3 months if GC/C positive
-if not possible, retest within 12 months
Consider HIV and syphilis testing
21yo F, present with frothy, maloderous, gray green vaginal discharge x 3 days. Denies abdominal pain, N/V. Vitals: T 98.7, HR 65, BP 100/64, exam shows frothy, yellow discharge. Wet mouth sows flagellated organisms. What is the description of the cervix in this condition?
Strawberry
Indication for hospitalization for a women with PID include:
Nulliparous women
Tubo-ovarian abcess
Poor compliance
Failure of outpt regimen
Genital Herpes
HSV1/HSV2
S/s: painful, grouped vesicules, ulcerated lesions on vagina, pre labial and labial
Primary HSV illness:
- virus remains in spinal root ganglia
- last 9-10 days
Dx: PE or ELISA
Tx: acyclovir 400mg PO TID
Famciclovir 250mg PO TID
Valcyclovir Ig PO BID
X 7-10 days
Treponema pallidum
Syphilis
Syphilis
Spirochete treponema pallidum
HIV coinfection
S/S:
primary: painless ulcer (10-90 days post exposure)
Secondary:
Nonspecific systemic sxs (often missed)
Rash - dull, red, papular rash on palms/soles (also trunk, flexor surfaces)
Tertiary:
Neurogenic and cardiac manifestations, gummas
Dx: dark field microscopy for treponemes, serology testing (RPR, VRDL), treponemal antibody testing (FTA-ABS)
Tx:
Primary and secondary:
PCN or doxy (if PCN allergy)
Tertiary:
PCN IM weekly for 3 weeks
Neurosyphilis:
PCN IV 10-14 days
Chancroid
Gram negative bacilluis: Haemophilus ducreyi
HIV/Syphilis coinfection
S/s: PAINFUL papule 4-10 days after exposure
Dx: gram stain - “school of fish pattern”
Tx: azithromcyin 1g PO or ceftriaxone 250mg IM single dose
