Test 2 Flashcards
Is it mandatory to have a chaperone in the exam?
Yes
Primary purpose of pap smear. Treatment, screening or diagnostic?
- screening used to identify abnormal/atypical cervical cells
- can identify some infections of cervix and vagina, more definitive tests are needed for diagnosis
Pap screening recommendations
- Less than 21 years-do not screen
- 21-29 years-Pap every 3 years
- 30-65 years-Pap every 3 yrs alone, HPV test every 5 yrs alone, or HPV and Pap co-test every 5 yrs
- Older than 65-do not screen if not at high risk for cervical cancer
Preferred maneuver order for pelvic exam
- inspection of external genitalia
- speculum exam
- bimanual exam
- rectovaginal exam
Describe normal vaginal discharge
white or clear; thin or mucoid
Normal physical exam for nulliparous female.
- cervical os small and round and in center of cervix
- ovary can be felt in thin, relaxed pt; may be difficult in some pts
- Ovary size-1.5cm x2.5cm x4cm and weighs 3-6 gm; in ovarian fossa
- Uterus size and length-6-8 cm; weight 60 gms; larger in parous women
What is the Q-tip check test is and what is it used for? What actions if positive?
- urethral hypermobility
- positive test is rotation of q-tip greater than 30 degrees
- management based on cause, severity, and pt expectations
- avoid caffeine, smoking, alcohol
- timed voiding, limit fluid intake, bladder diary/training
- weight loss, pelvic floor muscle exercises, kegel exercises
- incontinence pessary, pharmacotherapy
What are expected findings of vaginal pH exam less than 4.5?
- Less than 4.5 vulvovaginal candidiasis (typically)
- Pt c/o vaginal itching, burning, and/or discharge; may be asymptomatic
- vulvar pruritus, swelling, excoriation, redness
- S/S: thick or thin, white curd-like (resembling cottage cheese), adherent odorless discharge
- 3.5-4.5 also associated with normal flora
- Discharge-white or clear; thin or mucoid
- No odor or associated s/s
What is a clue cell?
- squamous epithelial cells in vagina covered in bacteria
- change to fuzzy look when coated w/ bacteria
- key indicator of BV
Diagnosis criteria for bacterial vaginosis
Must have 3 of the 4 to have official diagnosis (Ansel diagnostic criteria
- thin white or gray discharge that coats the vaginal walls
- fishy odor of the vaginal discharge
- Vaginal pH greater than 4.5; (normal vaginal pH range is 4-4.5)
- Clue cells on microscopic examination (50% of slide) via wet prep
How is yeast vaginitis diagnosed?
- vaginal pH less than 4.5 vulvovaginal candidiasis (typically); yeast culture
- Pt c/o vaginal and vulvar itching, burning, irritation, redness, swelling; may be asymptomatic
- S/S: thick or thin, white curd-like (resembling cottage cheese), adherent odorless discharge
Common causes of non-GYN pelvic pain
- Acute: appendicitis, UTI, gastroenteritis, kidney stones, diverticulitis, trauma
- Chronic: chronic appendicitis, urinary tract disease, IBS, interstitial cystitis, ulcerative colitis, diverticulosis, neuromuscular disorders
Differential diagnosis for pelvic pain
Gyn: ectopic pregnancy, uterine fibroids, ovarian cyst, PID, endometriosis (EUROPE)
GI: appendicitis, bowel obstruction, constipation, IBS
Urinary: cystitis, pyelonephritis, UTI
What is not an appropriate differential?
Stages of female puberty
- Thelarche: 8-11 yrs; onset of breast development in around 9 yrs, complete development in 2-4 yrs
- Pubarche: 12 yrs; onset of pubic hair growth
- Menarche: first occurence of menstrual bleeding, avg 12.5 yrs, about 2.5 yrs following breast development
Precocious puberty
Females: breast development or onset of menstruation before 8 yrs (breast, pubic hair, or menstruation)
Males: testicles and penis growth, pubic/facial hair and deeper voice before age 9
Important questions when counseling teens/adolescents
“Late periods”-When was LMP start date?, Pattern of menses? Sexually active? Abnormal menstrual patterns?
“Dizziness”-History of fainting spells? History of anemia? Dehydration? Heat exposure?
“Nausea/vomiting”-Food poisoning? Exposure to infection/illness? History of GI issues? Stress/anxiety? Medication/allergies? motion sickness/dehydration? possible pregnancy?
Most likely cause of pelvic pain in adolescent
gynecological
Define amenorrhea
- Amenorrhea is the absence of menstruation during reproductive years, it is a symptom not a diagnosis
- Primary amenorrhea- no menstruation by 16 years regardless of secondary sex characteristics.
- Secondary amenorrhea- absence of menses for 3 months-6 months (ACOG) in a previously menstruating woman
Most probable causes of primary and secondary amenorrhea
Primary: chromosomal or genetic abnormalities (about 50% of cases) i.e. Turner’s, hormonal issues
Secondary: pregnancy most common, birth control, eating disorder, stress, extreme wt gain/loss, thyroid dysfunction
Which amenorrhea is most common?
secondary
Primary amenorrhea is less than 0.1%
What is atrophic vaginitis? Who is affected?
- condition that occurs when body produces less estrogen, causing inflammation and thinning of vaginal walls
- occurs in women experiencing peri/postmenopausal women, lactation, chemotherapy, diabetes
Atrophic vaginitis differentiation
Pt c/o:
* vaginal dryness-scant vaginal secretions,
* burning, irritation, itching, discharge-atrophic epithelium pale, smooth shiny with patch erythema,yellow/light brown discharge
* odor
* dysuria, urinary frequency, nocturia, frequent UTIs
* petichiae may be seen on cervix
* elevated vaginal pH (typically greater than 4.5-5.0) and WBCs
* cervical os may be stenoic-unable to insert cytobrush or broom to obtain sample
Describe microscopic findings of atrophic vaginitis
Histologic findings
* decreased superficial squamous cells and lactobacilli
* increased parabasal cells and WBCs
- Wet smears: small, round parabasal cells with denser nuclei
Vaginismus
- involuntary spasms of vaginal muscles
- penetration painful or impossible
- pt w/ heightened fear of pain and emotional distress due to vaginal penetration (tampons, intercourse, gyn exam)
Management of dyspareunia (painful sex)
- Vaginal infections: antibiotic or antifungal meds
- Dermatologic: topical corticosteroids
- Peri/Postmenopausal: vaginal estrogen preparations, nonhormonal medications
- Vulvodynia: cotton underwear, avoid irritants, avoid self-treatment
- Pelvic floor PT, cognitive behavioral therapy
Is female sexual dysfunction: normal?
- common; 41% of women experience
What is the origin of female sexual dysfunction?
Medical
* heart disease, neuro, Gyn
Psych
* depression, anxiety
* relationship issues, social stress
* sexual abuse
Meds
* antiepileptics
* heart/blood pressure
* opioids, psych
* NSAIDs
* chemotherapy
* birth control
Hormonal
* menopause, pregnancy, endocrine
Can female sexual dysfunction be managed or should it be referred?
- Management: encourage communication w/ partner, lifestyle habits, refer for counseling, vaginal lubricants/stimulation devices, estrogen therapy, androgen therapy (testosterone), Addyi (antidepressant, can help w/ low desire), Vyleesi (injection)
- When interpersonal and sociological factors such as relationship conflict, sexual abuse, strict religious upbringing, and stress involved-collaborate with mental health/sex therapist
Hypoactive sexual desire disorder
- most common FSD; more common in men than women
- low libido or lack of sexual desire that causes personal distress
Female sexual arousal disorder
inability to develop or maintain adequate genital response (vulvovaginal lubrication, engorement/sensitivity of genitalia) for a minimum of 6 months
Female orgasmic disorder
- recurrent, distressing compromise of orgasm pleasure, intensity, frequency and/or timing (PIFT)
- minimum of 6 months
Primary orgasmic dysfunction
female who has never had an orgasm
*subcategory of female orgasmic disorder
What is the normal presentation of trichomonas and how is it diagnosed?
- yellow to green, purulent, may be bloody
- “musty” odor
- vulvovaginal itching, irritation, burning
- dysuria, cloudy urine
- dyspareunia, postcoital bleeding
- “strawberry spots” or tiny petechiae on cervix or vaginal walls; may bleed on contact
- elevated pH-greater than 5.0
- Wet mount: one-celled flagellate trichomonads, increased WBCs, strong amine odor
What medication is used to treat trichomonas?
- Metronidazole 2g orally in single dose
What is the presumptive treatment for gonorrhea and chlamydia for non-pregnant patients?
-
Gonorrhea: Ceftriaxone 500 mg IM in single dose
If cephalosporin allergy: gentamicin 240 mg IM
single dose PLUS azithromycin 2gm orally
single dose -
Chlamydia: Doxycycline 100 mg orally twice daily for 7 days
Alternative: Alternative: Azithromycin 1 g oral
single dose OR Levofloxacin 500 mg orally
once daily for 7 days
What are the primary and alternative treatments for chlamydia?
- Doxycycline 100mg orally 2 times/day for 7 days
Alternative regimens: azithromycin 1 g orally in a single dose
OR Levofloxacin 500mg orally once daily for 7 days - If PREGNANT: Azithromycin 1g orally in a single dose
Alternative regimen: amoxicillin 500mg orally 3 times day for 7 days
What are the new CDC recommendations for gonorrhea and chlamydia treatment for pregnant patients?
- Gonorrhea-Ceftriaxone 500 mg single IM dose, if allergic referral to infectious disease
- Chlamydia-Azithromycin 1gm single oral dose
Alternative: Amoxicillin 500 mg orally 3X daily for 7 days
What education should be given to a patient with chlamydia?
- sexual partners in the past 60 days should be referred for testing and possible treatment
- Women should be advised to abstain from sex until their sexual partners are treated
- wait 7 days after single dose treatment or until completion of a 7-day regimen before resuming sexual activity
What is the treatment for condyloma?
Pt-applied: Ointment, cream, gel
Provider-applied: Cryotherapy, surgical removal, TCA
What education would you provide to a patient with newly diagnosed Herpes?
- No sex during outbreaks or if you feel the prodrome; keep affected area clean/dry
- Use condoms, limit sexual partners
- Avoid creams, lotions, or powders on lesions unless instructed
- If urination is painful, pour water over the genital area while urinating
- Notify provider if pregnant
How does herpes present?
- pts can be asymptomatic
- painful, itchy, ulcerated or crusted blisters around genitals, rectum, or mouth (outbreak)
- blisters break and leave painful sores-up to 1 wk or more to heal
- flu-like symptoms (fever, body aches, or swollen glands) during first outbreak
- repeated outbreaks are shorter and less severe and can recur in same location
- lifelong infection; # of outbreaks decrease over time
Discuss recurrent HSV infections. What happens with and w/o treatment?
- antivirals can treat and reduce symptoms, recurrences, and transmission
- after use, antivirals do not cure or impact frequency or severity of recurrences
Differential diagnosis of Syphilis chancres
Herpes simplex, herpes zoster, chancroid, genital warts, HIV, scabies, varicella and drug eruptions or reactions
What is secondary syphilils and how to differentiate?
- generalized maculopapular rash, nonpruritic, copper colored, palms of hands/soles of feet
- erythematous or scaly, mucus patches; painless white, mucus membrane lesions
- generalized lymphadenopathy; flu-like syndrome, fever, headache, sore throat, malaise; patchy alopecia
Primary: chancre w/ min pain or painless, min exudate, regional lymphadopathy
Tertiary: locally destructive granulomatous tumors involving various organs or systems, CV and neuro involvement
Latent: asymptomatic
What is the best test for diagnosing syphilis? What can yield false positives?
presumptive diagnosis of syphilis requires two laboratory serologic tests: a nontreponemal test (screening) and a treponemal (confirmation) test
Nontreponemal-VDRL and RPR-faster
Treponemal-TPHA and FTA-Abs
False positive nontreponemal d/t pregnancy-common, IV drug use, HIV, lupus, increased age, RA, vaccinations
What is the CDC recommended syphilis treatment for pregnant women?
- Penicillin G 2.4 million units IM single dose; second dose can be administered 1 week after initial dose
- if allergic to PCN, desensitive and treat
- based on stage of infection
- additional therapy recommended to treat congenital syphilis
What education should be given to patients with syphilis?
- adherence to monthly serologic testing to assess treatment; condoms until treatment successful
- avoid sexual contact until chancre healed
- notify at-risk partners: Primary-3 months plus the duration of symptoms; Secondary-6 months plus duration of symptoms; Latent-1 year plus the duration of symptoms
At what stage can neurosyphilis occur?
at any stage of syphilis infection
Which serologic titers should prompt concern about syphilis treatment failure or reinfection?
- Fourfold rise or failure of a fourfold decrease of titer within 6-12 months suggests reinfection or treatment failure
- Nontreponemal antibody titers usually decrease at least fourfold during the 12 months after syphilis treatment
How to determine GTPAL
Gravida: # of times a woman has been pregnant regardless of outcome and including current pregnancy
Term: # of deliveries after 37 wks
Preterm: # of pregnancies between 20-36 6/7 wks regardless of outcome
Abortions: # of fetal losses before 20 wks (spontenous miscarriages and elective terminations)
Living Children: # of children born and are alive
Nullipara
a woman who has not carried a pregnancy to 20 weeks
Parity (para)-# of pregnancies completed or at 20 weeks or greater
Primigravida
completed one pregnancy at 20 weeks or greater
Primi=first; Gravida=pregnancy
Multipara
completed two or more pregnancies at 20 weeks or greater
Multi=many
Who and what testing is recommended for women without risk factors for osteoporosis?
- All women 65 and older
- bone mineral density (BMD) via DEXA (DXA) scan
What age is recommended for osteoporosis screening in women?
65
Most common occurring cancer in females (U.S.)
Breast
Leading cause of cancer mortality in females (U.S.)
Lung cancer
What cancer screenings are routinely recommended in 50-year-old women? (which is not recommended?)
- Breast cancer screening-yearly mammograms
- Colorectal cancer screening every 10 years
- Cervical cancer screening-HPV and Pap co-test every 5 yrs, Pap alone every 3 yrs, or HPV alone every 5 yrs
- Risk assessment for BRCA testing
