Vulvar, Vaginal, & Ovarian Disease Flashcards
dyspareunia =
painful intercourse
Most common cause of dyspareunia in women under 50?
vestibulodynia
Signs of vestibulodynia vs vulvodynia
Both have pain that is burning, stinging, sore in nature that can be generalised around vulva or localized; not typically itchy
vestibulodynia - provoked pain with light touch (e.g. tampon or sex) and asx at other times
vulvodynia - unprovoked, spontaneous pain
Most common cause of dyspareunia in postmenopausal women.
vulvovaginal atrophy (aka atrophic vaginitis)
Causes of inadequate lubrication
Estrogen deficiency in menopause
Decreased arousal
Medications
Appearance/signs of Vulvar Lichen Sclerosus
small white, atrophic patches or plaques; tissue thickens and may fissure
labia and clitoris may disappear d/t scarring
pruritis and pain
Hallmark of Vulvar Lichen Sclerosus
extreme pruritis, vulvar pain and burning
Two peaks of onset of Vulvar Lichen Sclerosus
prepubertal and peri/post-menopausal
Why is taking patient off intravaginal therapy for 2 weeks helpful in dx?
Eliminates adverse reactions to meds from the differential diagnosis
Allows adequate eval of vaginal secretions, cultures will be reliable
How is Vulvar Lichen Sclerosus confirmed?
vulvar biopsy
Vulvar Lichen Sclerosus treatment
Preventative education
Topical corticosteroids (Dermovate)
Clobetasol or halobetasol propionate 0.05% ointment daily at night
F/U within 3 months
If no improvement, refer to GYN
Vulvar Intraepithelial Neoplasia associated with ______ infection.
HPV
Vulvar Intraepithelial Neoplasia signs/sx’s? Similar to what other disease?
ITCHING
vulvar lesion that are raised and/or veracious and white plaques (sometimes red or brown)
presents like vulvar cancer
Vulvar Intraepithelial Neoplasia diagnosis
turn white with vinegar wash
biopsy to r/o cancer
Vulvar Intraepithelial Neoplasia treatment
surgical excision because pre-cancerous
common cause of sudden onset vulvar pruritus
contact dermatitis (soaps, new clothes, spermicides, condoms, etc.)
Treatment of contact dermatitis on vulva
Antihistamines
Topical steroids (only 7-10 days)
Cool compress, baking soda, Aveeno baths
Vulvar Paget’s Disease signs/sx’s
Usually red, velvety areas with white island of tissue
May appear pink
Moist oozing ulceration that bleed easily
50% complain of itching
flesh-colored papule or nodule on vulva that appears fluid filled
sebaceous or inclusion cysts
Bartholin Gland Abscess treatment
drain and insert catheter or marsupialize (incision over center of cyst to dissect from mucosa)
abx if surrounding cellulitis
may excise if reforms
Woman has small smooth flesh-colored bumps with central umbilication on vulva. Likely dx? tx?
molluscum contagiosum
tx: cryosurgery, topical Retin A, topical benzoyl peroxide
Cauliflower-like warty lesions on vulva and perineum.
HPV (condyloma acuminatum)
Patient comes in with groin rash that looks like cystic acne. Likely dx? tx?
Hidradenitis suppurativa
tx: refer to derm, abx, intralesional steroids
What is a urethral caruncle?
benign fleshy outgrowths at urethral meatus, occurring primarily in post-menapausal women
Pathophysiology of atrophic vaginitis
decreased circulating estrogen
signs/sx’s of atrophic vaginitis
Vaginal dryness and dyspareunia
PE: tissues thin, friable, and pale
Treatment of atrophic vaginitis
Vaginal moisturizers (Vagisil, Replens, K-Y SILK-E) and lubricants (KY jelly, Astroglide)
Estrogen preparations
- Topical cream (Premerin, Estrace)
- Vaginal tablet (Vagifem)
- Vaginal ring (Estring)
Characteristics of normal vaginal discharge
White or transparent, thick, odorless
Quantity increases with ovulation, pregnancy, and oral contraceptives
Normal flora of vagina
Lactobacillus
Predisposing factors to getting vaginal yeast infection
Recent antibiotics Diabetes Increased estrogen Pregnancy, oral contraceptives, estrogen therapy Immunocompromised Vaginal or vulvar irritants
Thick cottage cheese vaginal discharge =
Candida vulvovaginitis
How is yeast dx’d in lab?
KOH wet mount shows budding yeast with hyphae
Candida vulvovaginitis treatment
Single dose oral fluconazole 150 mg
Intravaginal antifungal
Longer tx regimens for recurrent disease, diabetes and immunosuppression
Woman comes in for recurrent candidas +4 episodes per year. What should be ruled out?
Diabetes and HIV
- treat these before yeast infection
Normal pH of vagina
4.0 - 4.5
Physiological changes of vagina in bacterial vaginosis
Reduction in vaginal flora
pH rises
overgrowth of vaginal anaerobes
Fishy odor, off-white thin discharge =
bacterial vaginosis
Wet mount of bacterial vaginosis
pH > 4.5
fishy odor with KOH (+ whiff test)
Clue cells = epithelial cells coated with bacteria
Bacterial vaginosis treatment
Topical Metrogel BID X 5 days or Cleocin Gel hs X 7 days OR
Oral Metronidazole 500 BID X 7 Days (avoid alcohol)
What is added to treatment of yeast or bacterial vaginal infections if recurrent (> 3-4 episodes per year)?
Intravaginal Boric Acid 600 mg
copious greenish frothy vaginal discharge =
Trichomonas vaginalis
Treatment for Trichomonas vaginalis
Metronidazole 500 mg x 1 dose
No EtoH for 24 hrs
Typical presentation of vaginal cancer
60 yo woman with post menopausal bleeding
- same as uterine cancer
Most common cause of vaginal cancer
metastatic cancer
What is not found in lower UTI that is found in kidney infection?
Fever
CVA tenderness
UA results of lower UTI
> trace leuks
nitrites
Treatment of uncomplicated UTI
3-day regimen of TMP-SMX or Fluoroquinolone
- Macrobid 100 mg BID x 3-7 days has less chance of yeast infections from abx
What is complicated UTI? Treatment?
- DM, elderly, immunocomp’d, catheter, h/o recurrance
- Proteus, Klebsiella, Pseudomonas, Serratia
Tx: Fluoroquinolone x 7-14 days
DDX of female dysuria
Lower UTI Interstitial cystitis Acute pyelonephritis Chlamydia or GC urethritis Trichomonas, Candidas, or bacterial vaginosis Herpes Simplex
Follicular vs corpus luteum cyst causes
Follicular cyst
- Follicle fails to rupture, no ovulation occurred, or didn’t resolve after ovulation
- Can enlarge with each cycle or be reabsorbed
Corpus luteum cyst
- Occur when corpus luteum doesn’t involute after ovulation but instead continues to enlarge
Define adnexa
Area between the lateral pelvic wall and the uterus
consists of ovaries, fallopian tubes and upper portion of the broad ligament
How to dx ovarian cyst?
U/S will confirm
Treatment of ovarian cysts
Most resolve spontaneously in a couple weeks
May need oral contraceptives or surgery
Most common cause of androgen excess and hirsutism
Polycystic Ovarian Syndrome
Signs of Polycystic Ovarian Syndrome
Effects of androgen excess - hirsutism, acne, male pattern balding
Effects of ovulatory dysfunction - oligomenorrhea or amenorrhea, menstrual irregularities, infertility
Patient with polycystic ovary syndrome likely has what other conditions?
obesity
DM
metabolic syndrome
hyperinsulinemia
Women c/o amenorrhea and excessive hair growth that are at risk for Type II DM.
Polycystic Ovarian Syndrome
PCOS treatment
Hirsutism: oral contraceptives, Spirolactone
Endometrium thinning: oral contraceptives
Infertility: WEIGHT LOSS, Clomid (clomiphene)
Insulin resistance: Metformin
What is an ectopic pregnancy?
blastocyst implants anywhere other than endometrial lining of uterus (98% in tubes)
Risk factors of ectopic pregnancy
previous ectopic current IUD use tubal surgeries history of PID prior infertility
When is transvaginal U/S not useful in eval of pregnant woman?
4-6 weeks after gestation; won’t see anything
Clinical features of ovarian neoplasms
History: pelvic pain, dysmenorrhea, dyspareunia
Eval: enlarged ovary, complex mass on U/S
How is risk for ovarian cancer assessed based on history?
FHX!!! (10%)
Decreased risk with h/o pregnancy, use of OC, breastfeeding, tubal ligation or hysterectomy
Genetic testing for ovarian cancer?
Annual CA-125 screen (poor predictive value, used to assess cancer progression)
BRCA1 and 2 gene mutation
While evaluating a female for suspected ectopic pregnancy, the transvaginal U/S finds echogenic fluid in the Pouch of Douglas. What does this suggest?
Hemoperitoneum following the rupture of an ectopic pregnancy
