Vaginal disorders Flashcards
What causes vulvovaginal candidiasis
Candida Albicans (or other candida organisms) VERY common (75% of women will have 1 in a lifetime)
How does vulvovaginal candidiasis present
vulvar pruritis external dysuria burning dyspareunia swelling redness excoriation thick, curd like discharge
RF for vulvovaginal candidiasis are
taking Abx
immunocompromised
normal vaginal pH is
<4.5
How do you diagnose vulvovaginal candidiasis
clinically! presentation
But you can test to confirm-
Wet prep (budding yeast and hyphae)
candida culture
How do you treat vulvovaginal candidiasis
Uncomplicated: 1-3 days topical azole (clotrimazole)
Complicated: 7-14 days topical azole; or oral Fluconazole if albicans
Pregnant: topical azole x 7 days, or single dose Fluconazole (low dose)
What is a “complicated” yeast infection
4+ in one year
non-albicans
pt has uncontrolled DM
immunocompromised
Can men get candidiasis?
They can develop balanitis (skin covering glans) in which case they need Tx
If a patient has difficult to treat or recurrent yeast infections, eval for
HIV or DM
What causes bacterial vaginosis
disruption of healthy vaginal microflora (lactobacillus) causing overgrowth of other bacteria
MCC” polymicrobial (garnerella vaginalis and mobiluncus anaerobes)
How does BV present
vaginal irritation
thin white/grey discharge w/ strong fishy odor (amine)- worse after intercourse
RF for BV are
new/multiple sex partners (rarely affects women never sexually active)
douching
What is Amsel’s criteria for Dx BV
Need 3 of the 4 1. thin white homogenous discharge coating vaginal walls 2. clue cells on microscopy 3. vaginal fluid pH >4.5 fishy odor when adding KOH (whiff test)
What is the best lab test to assess BV
Gram stain! will see anaerobes and lack of lactobacilli
gold standard, but rarely used
What are clue cells
vag epithelial cells studded with adherent coccobacilli indicating BV
How do you treat BV
Treat if symptomatic! but NOT partners Metronidazole (flagyl) PO x 7 days Metronidazole gel transvaginal x 5 days Clindamycin oral,transvaginal Pregnant: oral meds ONLY
What should you avoid when taking metronidazole
alcohol!
Complications of BV include
increased risk of HIV, herpes, gonorrhea, chlamydia
associated with PID
Commonly persists and recurs
Good patient education for someone with BV is
it is highly recurrent! it is not them or their hygiene Don't use scented products wear loose clothing no panty liners come back ASAP at Sx onset
What is atrophic vaginitis
epithelial lining of vulva, vagina, and bladder becomes dry and connective tissue less elastic 2/2 loss of estrogen
Symptoms of atrophic vaginitis include
dyspareunia post-coital bleeding leukorrhea burning, raw, dry sensation (feels like yeast infection) urinary Sx
On PE of atrophic vaginitis what will you see
vagina loses rugae pale-red coloring petechiae purulent vag discharge, fissures, or erosions pH >5
How do you treat atrophic vaginitis
Replens (vaginal moisturizer) if CI to estrogen
Vaginal estrogen: premarin, estrace 1gm 2x week// Vagifem 10mcg 2x week// Estring q90 days
Vaginal prasterone (DHEA)
Ospemifene 60mg daily (SERM)
What is a potential ADE of Ospemifene
thrombotic events - it is an estrogen agonist
What is vaginal intraepithelial neoplasia (VaIN)
complication of HPV, associated with CIN
occurs around 35-55 y/o
RF for VIN are
smoking
multiple sex partners
early onset sexual activity
Hx of CIN III (but some womwn w/ primary vaginal cancer have no Hx of CIN III or cervical cancer)
What is the pathogenesis of VIN
HPV exposure- great deal of time to develop VIN
Frequency is lower than CIN (vaginal epithelium is differnt than cervical)
VIN does not progress to cancer like CIN
Most VIN lesions are located
upper 1/3 of vgina
What are the VIN classifications
VIN1: benign viral proliferation
VIN2: intermediate risk
VIN3: true precursor to vaginal cancer
How can you test for VIN
Pap smear (cytology) colonoscopy
How do you manage VIN
VIN1: obs in young women- cytology/HPV/colonoscopy q6 months
VIN2-3: Surgery or topical chemotherapy
What is a vaginectomy
Removal of upper 1/3 of vagina 2/2 VIN2-3
90% success rate
What is laser vaporization
Destroy dysplastic cells in VIN2-3
63-90% success rate
What is topical chemotherapy for VIN2-3
insert 2g PV x 5-7 nights, and zinc oxide to introitus and vulva in AM-
causes sloughing of vaginal epithelium
50-85% success
What are ADE of topical chemo for VIN2-3
dyspareunia
vaginal burning, ulceration, irritation
No FDA approved for VIN2-3
When should you consider chemo topical to Tx VIN2-3
if no other Tx is optional- this hurts!
What is the MCC of invasive vaginal cancer
mets from endometrium, ovary, or cervix
-but FIGO says it can only be called vaginal cancer if the primary growth is there
What is the MC vaginal cancer
Squamous cell
<20% are Dx under 50
How does vaginal cancer present
ASx Leukorrhea Vaginal odor post-coital bleeding abnormal pap (white changes, punctation, or mosaic on colposcopy)
How do you treat vaginal cancer
Nothing standard 2/2 extremely rare occurrence
Vaginectomy + radiation
5 year survival 61%
