Uterine Disorders Flashcards
Important information to know about vaginal discharge:
- Onset/Duration
- Character
- Association w/ cycle
- Prior similar symptoms /Tx
- Vaginal hygienic practices
- Current Rx: Antibiotics, hormones
- Trial of tx before seeking care?
Physiologic discharge:
Not all cervical/vaginal discharge is abnormal
Cyclic discharge:
Midcycle/Peri-ovulatory: E dominant
Post-ovulatory: P dominant
Mid-cycle E dominant discharge:
clear, stretchy mucus (dominant follicle produces E)
May present as vaginal d/c or just be present on speculum exam
Post-ovulatpry P dominant discharge:
white, pasty or floccular discharge (CL produces P)
Again, may present as d/c or incidental finding
Spinnbarkheit=
stringiness of cervical mucus. Many women can detect this change in cervical mucus midcycle around the time of ovulation. It has been used as a “natural contraception” method–+/- effective, high failure rate
Obtaining a detailed sexual hx about discharge:
LMP
Sexually active currently? Recently? Ever?
Contraception: compliance, use of condoms
Type of exposure: oral, vaginal, anal
Partner history: gender, #
Known exposure to STD? Suspicion of exposure?
ROS:
-Vulvovaginal pruritis, burning
-Dyspareunia
-If malodorous, worse after sex? After menses?*
-Dysuria, frequency, urgency
-Fever, chills
-Pelvic/abdominal/flank pain
cervical/Vaginal discharge Ddx:
Infectious discharge: Bacterial Vaginosis (BV) Trichomonas vaginalis (Trich) Neisseria gonorrhoeae (GC) Chlamydia trachomatis (Chl) Vulvovaginal Candidiasis (VVC) Herpes Simplex Virus 1 or 2 (HSV 1 or 2)
External vaginal lesions:
HSV may present with vesicles externally and internally
Syphilis may have painless chancre
condyloma…more in separate lecture
STD testing:
: Nucleic Acid Amplification Test (NAAT)
what should you always encourage?
- HIV testing
- Pregnancy testing
bimanual pelvic exam:
Cervical motion tenderness “chandelier sign”
Uterine or adnexal tenderness or mass:
- Endometritis
- PID
- TOA (tuba-ovarian abscess)
Bacterial vaginosis (BV):
a polymicrobial syndrome resulting from replacement of normal flora (lactobacillus) with anaerobic bacteria
**Remember, this is an –osis not –itis!!
BV symptoms:
Asymptomatic
Watery, white/gray discharge
No pruritis or urinary symptoms, no pain
Foul “fishy” odor, especially after menses or sex
Most common cause of vaginal d/c in childbearing age women (40-50%) ?
BV
BV exam signs:
Thin, gray-white discharge present at introitus & coating vaginal walls*
pH 4.5 or > * ; normal pH 3.8-4.2
Positive “whiff” (amine)test with application of alkali (10%KOH) to wet mount*
Presence of Clue cells on saline wet mount*
Usually no mucosal irritation/inflammation**
BV tx:
Goal is to decrease anaerobic bacteria in vagina and allow patient to regenerate her own lactobacilli = restore vaginal homeostasis (normal flora) Metronidazole (Flagyl) 500 mg. po BID x 7 days* Metrogel (0.75% Metronidazole Gel) intravaginally once daily for 5 days* Cleocin Vaginal (Clindamycin 2% Cream) intravaginally at HS for 7 days**
Clindamycin 300 mg. po BID x 7 days*
Clindesse (2% ER Clindamycin Cream) once intravaginally*
Tinidazole 1 G. po x 5 days or 2 G po x 2 days***
Trichomonas Vaginalis (Trich)
Infection with the protozoan
T. vaginalis
Trich symptoms:
Asymptomatic Copious yellow/gray/green discharge, may be frothy Possibly mixed with blood Malodorous Often have vulvar pruritis and dysuria
even though no “itis” in name, this is an inflammatory process with inflam sx!
HIV transmission enhanced by this
need testing for other STDs
Trich exam signs:
May have vulvar/vaginal erythema &
inflammation
Strawberry cervix
pH 4.5 or >
Wet prep saline with numerous WBCs &
motile TrichomonadsTrich Tx:
Metronidazole 2 Gm. x 1 dose* Tinidazole 2 Gm. X 1 dose** Alternative regimens/Treatment failures:** MTN 500 mg. BID x 7 days MTN or TND 2 Gm. Daily x 5 days
repeat testing with NAAT 2 wk - 3 mo
2nd most commonly reported communicable disease in U.S.
Women age 20-24, age 15-19; Men age 20-24
African American >12: 1 Caucasian
GC
the most commonly reported bacterial infection in the U.S.
Women age 15-24; Men age 20-24
African American 6:1 Caucasian
Chl
Difference in men and women sx of GC/Chl?
Women often asx but can have… mucopurulent cervicitis and cervical friability (easy bleeds when touched) or edema
Men:2-5 day incubation period
Purulent penile discharge and dysuria
Treatment: usually early due to sx; frequently after transmitted to partner
Long term GC/Chl sequelae in females:
PID Infertility Ectopic pregnancy Chronic pelvic pain Facilitation of transmission of HIV Neonatal infection (ophth, pneumonia with Chl)
GC/Chl diagnosis:
Nucleic acid amplification test (NAAT)
Wet prep w/ WBC’s
Clinical suspicion/risk factors/known exposure
Routine annual screening of ALL sexually active females <25y/o for GC and Chlamydia
Routine screening of all pregnant women in 1st trimester
Screening of sexually active women >25 with risk factors
GC/Chl high risk:
Sexually active women <25 years old Pregnancy Inconsistent condom use Hx of multiple partners/partner with multiple partners/new partner Presence of current STI (Trich, HSV) or sexually associated disease (BV) Partner with culture-proven STI Hx of repeated episodes STI Sex work or drug use
Gc tx:
Much more complex due to resistant strains of N. gonorrheoae
GC, uncomplicated infection: single agent not recommended!!!
Ceftriaxone 250 mg. IM single dose
PLUS
Azithromycin 1 G. po single dose*
Doxycycline 100 mg. BID x 7 days alternative 2nd agent**
Chl Tx:
Azithromycin 1 Gm. po single dose (observed therapy in office)
Doxycycline 100 mg. po BID x 7 days
Doxycycline 200 mg. daily x 7 days*
Appropriate to treat presumptively for both GC & Chl if hx of exposure to unknown STD by partner**
EPT—expedited partner therapy appropriate
Test for other STIs including HIV
Measures to limit GC/Chl:
Education—abstain until completed course of treatment of pt/partner
Aggressive partner evaluation and treatment (EPT)
Retesting–Aggressive detection—at 3 months or whenever next seek care**
Use of condoms or spermicides with nonoxynol 9 (???)
Vulvovaginal Candidiasis (VVC)
Description: usually a sporadic, uncomplicated fungal overgrowth caused by Candida Albicans
Complicated VVC is a chronic or recurrent infections, may be caused by other Candida species (C. glabrata) and/or may be associated with underlying disease (uncontrolled DM or HIV)
Other risk factors: recent use
of antibiotics which may alter
normal bacterial flora
of vagina
VVC symptoms:
Vulvovaginal pruritis
Vulvovaginal burning
Thick white odorless “cottage cheese” discharge
VVC diagnosis:
Diagnosis:
Commonly self-diagnosed and treated, often incorrectly
Usually presents with failed treatment or recurrent sx
On exam, variable degrees of vulvovaginal erythema and edema
Thick adherent white odorless discharge
pH normal
Yeast on wet prep (spores and/or hyphae)
Culture*
*Culture not necessary if clinical picture and wet prep confirms
Culture useful if neg wet prep or if recurrent CVV after treatment, to differentiate between species of Candida
VVC Tx:
Multitudes of OTC antifungal products effective:
Vulvar/intravaginal creams and/or external cream/intravaginal suppository for 1-14 days*
80% cure rate
Rx:
Oral Fluconazole 150 mg. x 1 dose**
Terconazole/Butoconazole/Nystatin Cream or Suppos. x 3-7 days
Symptomatic relief
Combined topical steroid and antifungal for vulvar inflammation
Sitz bath with bicarbonate of soda
Avoid contact with other contact irritants
Resistant disease*
Recurrent disease*
HSV 1 or 2:
Description: viral infection acquired by skin-to-skin contact or mucous membrane contact during periods of active shedding
Genital HSV previously mostly HSV 2 related
Genital HSV 1 shift related to increase in oral-genital contact
Primary infection becomes latent in dorsal root ganglia and can reactivate, causing recurrent infection
Neonatal herpes with serious consequences
HSV symptoms:
Wide spectrum from asymptomatic to painful genital ulceration to rare systemic complications
Primary infection typically with more symptoms*
Cervical involvement can be isolated & present with profuse vaginal discharge
HSV signs:
Vulvovaginal and cervical vesicular lesions/discharge
Culture—type specific for 1 vs. 2
DNA polymerase chain reaction**
