vulvovaginal disorders and menstrual disorders Flashcards
What are they?
What are they?
Ofer to a wide spectrum of health conditions that impact the vulva (outer part of female genitals) and vagina
Why are they of concern?
Why are they of concern?
generally perceived as minor health problems BUT certain infections such as bacterial vaginosis and trichomoniasis have been linked to significant health problems such as…
pelvic inflammatory disease
UTI’s
tubal infertility
increased susceptibility to HIV transmission
Vaginal pH testing
use
limitations
Vaginal pH testing
used to distinguish between other infectious etiologies
- can indicate a VVC infection
a. pH> 4.5 indicates BV or Trich=refferall - 85% of pts obtain same pH as providers office
- may reduce inappropriate use
- limitations
a. do not use within 72 hours of using a vaginal prep
b. do not use within 48 hours after intercourse/douching
c. cannot use until 5 days after menses
Disorder: Vulvovaginal Candidiasis (VVC) “Yeast Infection”
Cause:
Increased risks:
Presentation:
Clinical and diagnostic findings:
Non pharmacologic Treatment:
diet:
Pharmacologic Treatment
Partner Treatment?:
b.
MOA:
AE:
pearls:
Disorder: Vulvovaginal Candidiasis (VVC) “Yeast Infection”
Cause: 80-92% of vaginal year infections are caused by C. albicans
common: 20-25% of vaginitis infections
Increased risks:
- medications: ABX, immunosuppressants estrogen containing contraceptives, estrogen replacement therapy, synthetic steroids, SGLT2 inhibitors
- pregnancy
- onset of sexual activity
- diabetes
- high intake of refined sugar products
- vaginal sponge
- oral sex
Presentation:
Clinical and diagnostic findings:
1.white curd like discharge, no odor
2.complaints of itching, burning, pain, swelling, fissures, external dysuria, redness, excoriations (scratches)
Microscopy:
cx of candidiasis such as C. albicans, C. tropical, C. Galbrata, or Saccharomyces app.
pH: normal
Non pharmacologic Treatment:
diet:
1. decreased consumption of sucrose and refined carbohydrates
2.D/C of appropriate medications that may increase risk
3. probiotics (oral or vaginal) are not recommended
Pharmacologic Treatment Partner Treatment?: NO OTC products a. Topical Imidazoles (available OTC and RX) 1. Miconazole (Monistat) 2.Clotrimazole (Gyne-Lotrimin/ Mycelex 3. Tioconazole (vagistat)
RX products
a. topical imidazoles
1. Butoconazole (Gynazole)
2. Terconazole (Terazole)
b. Oral products
fluconazole (diflucan)
NEW: Ibrexfungerp
MOA: antifungal effect by altering the membrane permeability of the fungi
AE: (minor) burning, itching, irritation (may be increased with 1 day treatment
Counseling: how to apply, what to avoid, common AE, symptom improvement, symptom resolution
pearls: all equally effective, patient preference. improvements in 2-3 days. resolved by day 7 regardless of method.
anti fungal treatments end in -CONAZOLE
Disorder: Bacterial Vaginosis (BV)
Cause:
Increased risks:
Presentation:
Microscopy:
Nonpharm treatment
Pharmacologic Treatment
Partner Treatment?:
MOA: –
AE: –
Counseling: –
pearls: –
Disorder: Bacterial Vaginosis (BV)
Cause: mot common: 33% of vaginal infections; overgrowth of bacteria in vagina
Increased risks:
- cigarette smoking
- mutiple partners
- new partners
- douching
- African american race
- use of IUD
- reception of oral sex
Presentation: Clinical and diagnostic findings: 1.thin off-white or discolored, foamy discharge with a fishy odor 2. vaginal discomfort 3. dysuria 4. itching
Microscopy: clue cells (cells covered in bacteria)
pH: >4.5
Non pharmacologic Treatment:
- oral/vaginal L. acidophilus or yogurt
- if symptoms return try an alternative regimen then was originally selected
Pharmacologic Treatment
Partner Treatment?: NO
OTC products: NONE
RX products
1. metronidazole 500 mg PO BID for 7 days
2.metronidazole 0.75% gel 5g intravaginally for 5 days
3.clindamycin 2% crea intravaginally at bedtime for 5 days
4. alternative regimens
a. secnidazole 2g PO x1 dose
b. tinidazole 2g PO daily for 2 days
c.tinidazole 1g PO daily for 5 days
d. clindamycin 300 mg BID for 7 days
e. clindamycin ovules 100 mg intravaginally QHS
MOA: –
AE: –
Counseling: –
pearls: –
Disorder: Trichomoniasis
Cause:
Increased risks:
Presentation:
Clinical and diagnostic findings:
Microscopy:
pH:
Non pharmacologic Treatment: –
Pharmacologic Treatment
Partner Treatment?:
MOA: –
AE: –
Counseling: –
pearls:
Disorder: Trichomoniasis
Cause: 15-20% of vaginal infections; caused by trichomonad vaginalis
Increased risks:
- multiple sex partners
- non barrier contraceptions
- presence of other STI’s
Presentation:
Clinical and diagnostic findings:
1. strawberry spots: ulceration on vagina/ cervix
2.copious yellow green, malodorous discharge
3. vulvar irritation, may be asymptomatic
Microscopy:
- trichomonas vaginalis a flagellum (protozoan)
- WBC in vaginal culture
pH: elevated (5-7.5)
Non pharmacologic Treatment: –
Pharmacologic Treatment Partner Treatment?: YES! TREAT PARTNER OTC products: NONE RX products type: a. symptomatic and asymptomatic: 1.Metronidazole 2g PO as single dose 2. Tinidazole 2g PO as a single dose
b. persistent, recurrent infections
1. Metronidazole 500 mg PO BID for 7 days
2. Tinidazole 2g PO as a single Dose
c.Pregnancy: metronidazole 2g PO as a single dose
MOA: –
AE: –
Counseling: –
pearls:
1. if symptoms return, try an alternative regimen then was originally selected
2. preferably chose single dose regimens
3. avoid intercourse until both partners have completed treatment
Disorder: Atrophic Vaginitis
Cause:
Increased risks:
Presentation:
Clinical and diagnostic findings:
Microscopy:–
pH: –
Non pharmacologic Treatment:
Pharmacologic Treatment
Partner Treatment?:
OTC products:
for mild cases
MOA: –
AE: –
Counseling: –
pearls: –
Disorder: Atrophic Vaginitis
Cause: inflammation of vagina related to atrophy of the vaginal mucosa secondary to decreased estrogen levels
Increased risks:
- post menopausal
- post partum
- currently breast feeding
- anti-estrogenic medications (clomiphene, medroxyprogesterone, tamoxifen, raloxifene, danazol, leuprolide, nafarelin
Presentation:
Clinical and diagnostic findings:
1. decrease in vaginal lubricatoin
2. vaginal irritation, dryness, itching, leukorrhea, and dyspareunia (painful intercourse)
3. thin watery, sometimes bloody, or yellow malodorous discharge
a. if bleeding present, patient needs to be evaluated to rule out endometrial cancer
Microscopy:–
pH: –
Non pharmacologic Treatment:
1. avoid irritants and allergens such as powders, perfumes, spermicides and panty liners
Pharmacologic Treatment Partner Treatment?: NO OTC products: for mild cases 1. water soluble products for vaginal lubrication for daily use or prior to intercourse
RX products
for moderate-severe cases
1.hormone therapy (topical estrogen products)
MOA: –
AE: –
Counseling: –
pearls: –
Disorder:Amenhorrea
What is it:
Causes:
Signs and Symptoms:
Clinical Presentation:
Laboratory Tests:
Pathophysiology:
Treatment:
address underlying cause
Disorder:Amenhorrea
What is it: No menstrual bleeding in a 90 day period
Causes:
- unrcognized pregnancy is the most common cause.
- anorexia
- hyperprolactinemia
- pcos
- others
Signs and Symptoms:
1. Primary: absence of menses by age 15 in the presence of normal sexual development
2.Secondary: absence of menses for 3 cycles for 6 months in a previous menstruating woman
may present with also infertility, vaginal dryness or decreased libido
weightloss or weight gain
present of acne, hirsutism, hair loss (androgen excess)
Clinical Presentation:
pts usually concerned about cessation of menses and implications of infertility, generally not in acute distress
Laboratory Tests:
if pregnancy suspected: pregnancy test
if hypothyroidism suspected. TSH
if hyperprolactinemia suspected: prolactin
if PCOS suspected: consider total testosterone, 17-hydroxyprogesterone, fasting glucose, fasting lipid panel
if premature ovarian failure suspected: consider FSH and LH
Pathophysiology: depends on the cause
Treatment:
address underlying cause
1.anorexia/ excessive exercise
a. increase weight gain, decrease level of exercise, consider psychotherapy
b. if effective, continue. if not, consider estrogen therapy (CHC, conjugate equine estrogen, or ethinyl estradiol patch)
2.hyperprolactinemia: dopamine agonist
- annovulation secondary to pcos
a. is pregnancy an immediate goal?
yes: weight loss and letrozole (oral ovulation stimulating agent)
no: weightloss, use of CHC containing a progesterone with reduced or antiandrogenic effects - other/ unknown
a. progestin to induce withdrawal bleeding followed b y estrogen/progestin therapy
Disorder: Menorrhagia/ Heavy menstrual bleeding (HMB)
What is it:
Causes: –
Signs and Symptoms:
Clinical Presentation:
Laboratory Tests:
Pathophysiology:
Treatment:
Disorder: Menorrhagia/ Heavy menstrual bleeding (HMB)
What is it: menstrual loss greater than 80mL per cycle or menstrual bleeding lasting greater than 7 days per cycle
Causes: –
Signs and Symptoms:
1. patients may complain of heavy/ prolonged menstrual flow
2. may have signs of fatigue, lightheadedness, pallor in severe blood loss
+/- symptoms of dysmenorrhea
Clinical Presentation:
pts may or may not in acute distress
Laboratory Tests:
1. CBC, ferritin (to check for anemia)
Pathophysiology: depends on the cause, alterations in endometrium may lead to uterine contractility changes.
impaired platelet function
Treatment:
- NSAIDS: may decrease blood loss by 20-50% in 75% of women
- oral contraceptive, oral CHC, or POP
- LNG IUD: reduced menstrual flow up to 90%
contraception desired? no: 1.use NSAIDS 2.if ineffective, try tranexamic acid 3.if ineffective, consider CHC such ad LNG IUD or conservative endometrial ablation surgery
yes:
1. CHC or LNG IUD
2. if ineffective: insider other CHC or progestin only options
3. if still ineffective, endometrial ablation surgery
Disorder: anovulatory bleeding/ abnormal uterine bleeding with ovulatory dysfunction
What is it:
Causes: –
Signs and Symptoms:
Clinical Presentation:
Laboratory Tests:
Pathophysiology:
Treatment:
Disorder: Anovulatory bleeding/ abnormal uterine bleeding with ovulatory dysfunction
What is it: irregular bleeding
Causes: –
Signs and Symptoms:
1. irregular, heavy, or prolonged vaginal bleeding (ranging from spotting to heavy flow)
2. perimenopausal symptoms (hot flashes, night sweats, vaginal dryness)
acne, hirsutism, obesity
Clinical Presentation:
pts may or may not in acute distress
Laboratory Tests:
- if PCOS suspected, consider total testosterone, 17-hydroxyprogesterone,faasting glucose, fasting lipid panel
- if perimenopause suspected: FSH
- if hypothyroidism is suspected: check TSH
Pathophysiology: due to ovulatory dysfunction, corpus luteum is not formed, ovary does not secrete progesterone(so the endometrium grows due to estrogen but does not differentiate as this is usually due to progesterone).
a. w/o progesterone, no endometrial differenatiation
b. unopposed estrogen: unopposed endometrial proliferation (vascular and fragile
!. causes non cyclic bleeding.
II. may become hyper plastic and lead t a precancerous state
Treatment:
- NSAIDS: may decrease blood loss by 20-50% in 75% of women
- CHC’s (any form)
a. estrogens: promote endometrial growth and stabilization, prevent anovulatory bleeding thorughsuppresion of ovarian hormones - Medroxyprogesterone acetate (oral or injectable)
a. suppress pituitary gonads (FSH and LH leading to reductions in e and p inhibiting endometrial growth, cyclic use prevents anovulatory bleeding - estrogen modulators: clomiphene or letrozone
a. if goal is to induce ovulation - LNG IUD: reduced menstrual flow up to 90%
Disorder: dysmenorrhea
What is it:
Causes: –
Signs and Symptoms:
Clinical Presentation:
Laboratory Tests:
Pathophysiology:
Treatment:
Disorder: dysmenorrhea
What is it: crampy pelvic pain occurring with or just prior to menses
Causes: –
Signs and Symptoms:
- primary: complaints with normal pelvic anatomy
- secondary: complaints w. abnormal pelvic anatomy, such as PID, endometriosis, cysts, tumors, fibroids,cervical stenosis, IBD, congenial abnormalities, presence of an iud.
Clinical Presentation:
pts may or may not in acute distress depending on level of pain experienced.
Laboratory Tests:
1.pelvic exam to screen for STI
Pathophysiology:
release of arachidonic acid into the menstrual fluid-> increases prostate glands and leukotrienes in the uterus->uterine contractions, stimulating pain fibers, reducing uterine blood flow and causing uterine hypoxia
Treatment:
- non pharmacologic: rest, heat, wearing loose clothing, exercise, rubbing/massaging where it hurts, smoking cessation and avoidance
- NSAIDS
- CHCs: inhibit proliferation of endometrial tissue, reducing endometrial derived prostaglandins
- Progestin (DEpo MPA or LNG IUD): prevent organization of endometrial tissues, reducing prostaglandins
Disorder: Premenstrual syndrome (PMS) and premenstrual dysphoric disorder
What is it:–
Causes: –
Signs and Symptoms:
mood symptoms:
physical symptoms:
Clinical Presentation:
Laboratory Tests: –
Pathophysiology:
Treatment:
1. non pharmacologic:
- Pharmacologic:
Disorder: Premenstrual syndrome (PMS) and premenstrual dysphoric disorder
What is it:–
Causes: –
Signs and Symptoms:
PMS: constellation of symptoms including mild mood disturbances, and physical symptoms prior to menses (during the luteal phase and remit during menses)
PMDD: complex psychiatric disorder with multiple biological, psychological and sociostructural determinants (severePMS) EXPERIENCED BY 3% OF WOMEN.
mood symptoms: fatigue, irritability, labile mood, depression, oversensitivity, social withdrawal, crying spells, forgetfulness, difficulty concetrating
physical symptoms: abdominal pain, breast tenderness, acne, appetite changes and food cravings, swelling of the extremities, headache, GI upset.
PMS: need at 1 moos and 1 physical symptom
PMDD: atleast 5 o the following symptoms
a. one mustt be markedly depressed mood, anxiety, irritability, or affective lability
b.symptoms: significantly interfere with life
c. not the results of another psychiatric disorders
Clinical Presentation:
pts may or may not in acute distress
Laboratory Tests: –
Pathophysiology:
cyclic changes in e and p ;eves trigger symptoms and may lead to neurotransmitter changes
P is a smooth muscle relaxant, this may result in constipation and bloating
Treatment:
1. non pharmacologic: diet, exercise, cognitive behavioral techniques
1. Pharmacologic:
a. PMS: saids, diuretics
b. PMDD:
I. SSRI’s: sertraline, paroxetine (teratogenic), fluoxetine, citalopram, escitalopram. luteal phase or continuous use
II. SNRI’s: venlafaxine
III.CHCs: provide continuous level hormone preventing fluctuations that give rise to alterations in neurotransmitters.
a. CHC with limited hormone-free pills (extended cycle)
b.drospirenone containing agents (diuretic activity)
severe cases: gnrh therapy to medically ablate hormone synthesis with add back therapy
