MDT's Part 2 Flashcards
What is Premenstrual Syndrome (PMS)?
Recurrent variable cluster of troublesome physical and emotional symptoms that develop during the 5 days before the onset on menses and subsides within 4 days after menstruation occurs
What is Premenstrual dysphoric disorder (PMDD)?
When emotional or mood symptoms predominate along with physical symptoms and there is clear functional impairment with work or personal relationships
- May be thought of as complicated PMS
What are some general considerations of PMDD?
- Intermittently effects about 40% of premenopausal woman
- Primarily age 25-40
- About 5-8% of symptoms are severe
What are signs and symptoms of PMDD?
- Bloating/sense of increased weight
- Ankle swelling
- Skin disorders
- Irritability/aggressiveness
- Depression/lethargy
- Libido change
- Food cravings
Work up for PMS/PMDD?
- Provide emotional/physical support
- Careful eval of Pt
- Advise Pt to maintain daily diary of all Sx’s for 2-3 months
- If Sx’s occur throughout month, Pt may have mental health problem or depression
Treatment for mild to moderate PMS/PMDD?
- Aerobic exercise
- Reduction of caffeine, salt, and alcohol
- Increase dietary calcium
- Vitamin D or magnesium
- Increase carbohydrate
- Alternative therapy (acupuncture or herbal treatments)
Medication for PMS/PMDD?
- Combined oral contraceptives (Depro-provera or Nexplanon)
- SSRI’s (either daily or on Sx’s days)
What is Vaginitis?
Inflammation and infection of the vagina resulting from:
- Pathogens
- Allergic reactions to contraceptives
- Vaginal atrophy
- Friction during sex
What Hx should be included for vaginitis?
- Onset of LMP
- Recent sexual activity and use of any latex products
- Use of contraceptives, douches, or tampons
- Recent changes in medication or use of antibiotics
What are some S/Sx’s of vaginitis?
- Vaginal irritation or pruritus
- Pain
- Unusual or malodorous discharge
- Bimanual exam may show:
- Pelvic inflammation
- Cervical motion tenderness
- Adnexal tenderness
What are some differential diagnosis of vaginitis?
- Vulvovaginal Candidiasis (Yeast infection)
- Trichomonas Vaginalis Vaginitis
- Bacterial Vaginosis
What are some predisposing factors for vulvovaginal candidiasis?
- Pregnancy
- Diabetes
- Use of broad spectrum antibiotics or corticosteroids
- Heat, moisture, and occlusive clothing
Signs and symptoms of vulvovaginal candidiasis?
- Pruritus
- Vulvovaginal erythema
- White curd-like discharge that is NOT malodorous
What is Trichomonas Vaginalis Vaginitis?
- Sexually transmitted protozoal flagellate
- Women: infects vagina, Skene ducts, and lower urinary tract
- Men: infects lower GU tract
What are some S/Sx’s of Trichomonas Vaginalis Vaginitis?
- Pruritus
- Malodorous frothy, yellow-green discharge
- Diffuse vaginal erythema
- Strawberry cervix (red macular lesions) in severe cases
What is bacterial vaginosis?
Polymicrobial disease that is NOT sexually transmitted
- Chronic in nature
- Overgrowth of gardnerella and other anaerobes
- Increased malodorous discharge without obvious vulvitis or vaginitis
What are some other types of vaginitis?
- Chlamydia
- Gonorrhea
- Contact dermatitis
- Chemical irritation
Labs for vaginitis?
- No labs operationally
- KOH
- Wet prep
- NAAT urine testing
- Vaginal pH
Treatment of vulvovaginal candidiasis?
Fluconazole
Treatment of Trichomonas Vaginalis Vaginitis?
- Treat both partners
- Metronidazole
Treatment of bacterial vaginosis?
- Metronidazole
- Clindamycin vaginal cream
- Metronidazole gel
Treatment of chlamydia?
Doxy 100 mg 7 days BID
Treatment of gonorrhea?
Ceftriaxone (Rocephin) 500 mg IM
Pt education for vaginitis?
- Avoid nonabsorbent undergarments
- Avoid douching
- Delay sex until Tx complete and Sx’s resolve
What is Bartholin’s gland abscess?
Trauma or infection of the Bartholin duct causing gland obstruction leading to pain, swelling and abscess formation
- Reinfection causes recurrent tenderness further enlargement of duct
With respect to Bartholin’s gland abscess, what happens to develop a chronic Bartholin’s gland?
Persisting of stenosis of duct outlet with distension
- Often benign and aseptic
What are S/Sx’s of Bartholin’s gland abscess?
- Periodic painful swelling on either side of introitus
- Dyspareunia (Pain with sex)
- Fluctuant swelling 1-4 cm
- Tenderness is evidence of active infection
Treatment of Bartholin’s gland abscess?
- Manual aspiration or I&D
- Antibiotics unnecessary unless signs of cellulitis
- If suspect G/C, treat for both
- Frequent warm soaks
- Marsupialization by OB/GYN if recurrence
- Women >40, biopsy or removal recommended
Follow up for Bartholin’s gland abscess?
Refer to OB/GYN for frequent reoccurrences
What may infection with HPV lead to?
Cellular abnormalities in the cervix
The tissue of the cervix can undergo cellular changes during puberty due to what?
Hormonal influences and changes in vaginal pH
Are there varying degrees of dysplasia?
Yes, aka neoplasia
What is cervical dysplasia also called?
Cervical Intraepithelial Neoplasia (CIN), a grading system applies
Are there any specific signs/symptoms of cervical dysplasia?
No, often asymptomatic
How is a presumptive diagnosis of cervical dysplasia made?
- PAP Smear
- Biopsy/possible therapy by OB/GYN of visible, abnormal cervical lesions
When should cervical cancer screening begin in immunocompetent woman?
Age 21 regardless of age of onset of sexual intercourse
When does USPSTF recommend screening?
- Screening for cervical cancer age 21-65 and cytology (PAP Smear) every three years
OR - Screening in combination with cytology and HPV testing ever 5 yrs in 30-65 assuming negative HPV risk factors
When does the USPSTF NOT recommend screening for cervical cancer with HPV testing alone or in combination with cytology?
- In woman younger than 30
- In woman older than 65
What are risk factors that require more frequent screening with Cervical Intraepithelial Neoplasia?
- HIV infection
- Immunosuppression
- Exposure to diethylstilbesterol (DES) in utero
- Previous Tx for CIN 2, CIN 3, or cervical cancer
What are the two different ways diagnostic findings can be described for PAP Smear?
- Atypical squamous cells of unknown significance (ASC-US)
- Squamous intraepithelial lesions (SIL)
- Can be low grade or high grade
What are the methods of diagnosing cervical dysplasia?
- PAP Smear
- Colposcopy
- Biopsy
When is follow up for woman with ASC-US and a negative HPV screening?
1 year for repeat PAP and HPV co-testing
What are some prevention methods for cervical dysplasia?
- Vaccination
- Regular Cytologic screening
- Limit number of sexual partners
- Use a condom
- Smoking cessation and avoid second hand smoke
Treatment for CIN?
- Performed by OB/GYN
- Biopsy should precede treatment
- Cryosurgery
- CO2 Laser
- LEEP
- Conization of Cervix (reserved for severe cases)
Follow up for CIN?
- All Pt’s with abnormal Pap, refer to physician sup or OB/GYN
- close f/u after colposcopy and biopsy due to possibility of recurrence within 2 yrs
What are some general considerations of Leiomyoma of the uterus?
- Most common benign neoplasm of female genital tract
- May cause miscarriage and pregnancy complications
What is Leiomyoma of the uterus?
Discrete, round, firm, often multiple uterine tumor composed of smooth muscle and connective tissue
What are signs/symptoms of Leiomyoma of the uterus?
- Frequently asymptomatic
- Pelvic pressure
- Abnormal uterine bleeding
- Pain
What are labs for Leiomyoma of the uterus?
- CBC
- Iron deficiency anemia
Imaging for Leiomyoma of the uterus?
- Transvaginal US
- MRI with contrast
Emergent treatment of Leiomyoma of the uterus?
Surgery may be required for acute torsion of a pedunculated myoma
- Treat anemia prior to surgery
- LNG IUD can help decrease bleeding associated with fibrosis
What is the specific treatment for Leiomyoma of the uterus?
- Asymptomatic managed expectantly
- NSAIDS decrease menstrual blood loss
- Hormonal therapies
- Surgical therapy definitive treatment
Follow up for Leiomyoma of the uterus?
- Refer to gynecologist
- MEDEVAC for suspected torsion of fibroid and hemorrhage
What are some general considerations for carcinoma of the endometrium?
- AUB present in 90%
- Pap smear frequently negative
- Pain usually late Sx
What is the second most common cancer of the female reproductive tract?
Adenocarcinoma of the endometrium
What are some risk factors of carcinoma of the endometrium?
- Obesity
- Nulliparity (unopposed estrogen)
- Diabetes
- Polycystic ovaries with prolonged anovulation
- Unopposed estrogen therapy
- Extended use of tamoxifen for Tx of breast cancer
- FamHx of colorectal cancer
Signs and symptoms for carcinoma of the endometrium?
- AUB present in 90%
- Pain generally occurs late in disease with metastases or infection
Imaging for carcinoma of endometrium?
- Vaginal US
- Hysteroscopy
Treatment of carcinoma of endometrium?
- Surgery
- Post-operative radiation
- Chemotherapy
Surgical options for carcinoma of endometrium?
- Total hysterectomy
- Bilat salpingo-oophorectomy
- Peritoneal washing for cytology
- Lymph node sampling
Prognosis for carcinoma of endometrium?
- Overall 5 year survival: 80-85%
- Less than 66% invasion: 98%
- > 66% invasion: 78%
What is endometriosis?
Ectopic growth of endometrium outside the uterus, particularly in parts of pelvis and ovaries
What are signs and symptoms of endometriosis?
- Dysmenorrhea
- Chronic pelvic pain
- Dyspareunia
- AUB
- Infertility
- May be asymptomatic
What may the physical exam show for endometriosis?
- Tender nodules in cul-de-sac or rectovaginal septum
- Cervical motion tenderness
- Adnexal mass or tenderness
Definitive diagnosis for endometriosis?
Laparoscopy
Treatment for endometriosis?
- NSAIDS
- Hormonal therapy
- Inhibit ovulation for 4-9 months
Surgical options for endometriosis?
- Laparoscopic ablation of endometrial implants
- Hysterectomy
Who to refer for endometriosis?
OB/GYN
