Week 3 pt 2: 4.16 lecture Flashcards
You must be diligent in all aspects of the rhythm method; list the 4 aspects
1) Menstrual calendar
2) Basal body temperature: AM temp
3) Cervical mucous analysis
4) Avoidance of intercourse during fertile periods
Tubal ligation:
1) Can it be reversed?
2) What is the failure rate?
3) What is the recovery?
1) Reversal success depends on type used; Difficulty differs
2) Approx. 1%
3) 2-4 weeks
Risks associated with bilateral tubal ligation (BTL) include what?
1) Damage to the bowel, bladder or major blood vessels
2) Reaction to anesthesia
3) Improper wound healing or infection
4) Continued pelvic or abdominal pain/lifting restrictions
5) Failure of the procedure, resulting in a future unwanted pregnancy
6) Increased risk of ectopic pregnancy
Vasectomy:
1) What are some rare complications?
2) How often does pregnancy occur?
3) What needs to be confirmed before sterilization is declared? When?
1) Bleeding, hematomas, acute and chronic pain, and local skin infections rare
2) About 1% of cases
3) Azoospermia confirmed by semen analysis (8-16wks post op; 98-99% by 6mos)
-Secondary method of contraception during this period
Sterilization counseling:
1) Approximately ___% of men regret their decision to undergo vasectomy
2) ________________ at time of sterilization statistically increases risk of later regret
1) 2%
2) Younger age
What are the Txs for candidiasis?
1) Diflucan (fluconazole) 150mg po x 1 (safe in preg)
OR
2) OTC Monistat or generic (Miconazole) x 7days
Candidiasis:
1) Sx?
2) How to Dx?
3) Etiology?
1) White, thick dc, “cottage cheese”
-Vulvar pruritis, erythema
2) Clinical dx or culture
-KOH wet prep: Hyphae/budding yeast
3) Candida albicans
-Normal flora altered: abx, sex, DM, etc.
Atrophic Vaginitis/Atrophy:
1) Sx?
2) Dx?
3) Etiology?
4) Pt population?
1) Vulvar bleeding, dyspareunia, tears, dryness, urinary urgency/incontinence
2) Clinical
3) Lack of estrogen: menopause or surgical removal of the ovaries or other hypoestrogenic states (postpartum, breastfeeding)
4) Postmenopausal primarily
Atrophic Vaginitis/Atrophy: What is the Tx?
1) OTC vaginal moisturizers
2) Estrogen replacement cream (topical)
3) May also receive rx for Osphena po based on sxs (*blackbox warning: endometrial ca, DVT)
True or false: you never want to give PO estrogen without progesterone (topical is safer)
True
Describe the visible Sx of atrophic vaginitis
1) Thinning pubic hair, narrowing vaginal introitus
2) Petechiae of vaginal tissues
3) Loss of labia minora/majora
Allergic vaginitis:
1) Dx?
2) Etiology?
1) Clinical
2) New soap, new bath oil or bubble bath, new laundry detergent or fabric softener, a change in tampon or pad brands, using tampons or pads with deodorant, douching, condoms (LATEX), spermicides, lubricants
[Anyone CAN develop an allergy to anything]
List 3 lichens that can occur in the labial area
1) Lichen simplex chronicus
2) Lichen sclerosis
3) Lichen planus
Lichen Simplex Chronicus:
1) Sx?
2) Etiology?
3) Tx?
1) Persistent itching/scratching of vulvar area
“an itch that rashes”
Leads to leathery, thickened appearance
2) Many conditions may cause (irritant dermatitis)
3) Antipruritic meds (Benedryl, Atarax)
Topical steroids
Vulvar bx (biopsy) if no improvement in 3mos
Lichen Sclerosis:
1) Sx?
2) Etiology?
1) White, shiny plaque on vulva or anus; tissue paper skin, non-elastic
-Itchy patch
-Dyspareunia
-Burning perineal pain
2) Unknown (thyroid d/o?)
Lichen Sclerosis:
1) Pt population?
2) Dx?
3) Tx?
4) Incr. risk of what kind of cancer?
1) Postmenopausal (men can get too)
2) Skin punch bx
3) Topical steroid
4) SCC (squamous cell carcinoma) of vulva
Lichen planus: What are the Sx?
1) May be vulvar or may involve the mouth as well (vulvar-vaginal-gingival syndrome)
2) Purplish Planar Polygonal Pruritic Papules and Plaques
3) Whitish, lacy bands (Wickham striae) of keratosis
4) Burning pain and dyspareunia
5) Increased vaginal discharge
Lichen planus:
1) Etiology?
2) Pt population?
3) Dx?
4) Tx?
1) Inflammatory, autoimmune component
2) 30-60yo
3) Clinical or biopsy
4) Topical steroid *chronic condition with no cure
Treatment for all the Lichens is what?
1) Potent (Category 1) Topical Steroids
2) Clobetasol 0.05% bid for a month then daily for 3 months
-Then use once or twice a week prn sx
*May need multiple biopsies to rule-out SCC.
Bacterial Vaginosis (BV)
1) Is it an STD?
2) Main Sxs?
3) How to Dx?
1) Not an STD
2) Discharge white or gray, thin, fishy/musty odor
3) Amsel Criteria (3 of 4; abnl gray d/c, pH >4.5, +whiff test, presence of clue cells)
-microscopic exam: clue cells
-wet prep/KOH “whiff test”- fishy odor (+whiff test)
Bacterial Vaginosis (BV):
1) Etiology?
2) Tx?
1) Gardnerella bacteria
2) Metronidazole (Flagyl)
-Clindamycin (topical)
Bartholin’s Gland cyst:
1) Where are these glands?
2) Sx?
3) Etiology?
4) Pt population?
1) Mucous producing glands sit in the vulva
2) Acute, painful labial swelling
3) Blockage of the Bartholin duct
abscess can turn malignant (>40yo)
4) 20-30yo
If over 40: bx, high malignancy chance
Bartholin’s Gland cyst:
1) Tx?
2) Explain the Tx
1) Tx: I&D (if first time) + Word catheter
-The Word catheter is a balloon placed in the Bartholin gland after I&D to allow continued drainage and re-epithelialization of a tract for future drainage.
2) Marsupialization (if >2x) + dissolvable sutures
Vulvar Cancer Symptoms:
Describe the location of the potential ulcerative lesion, thickening, or lump
1) Usually on the labia majora (most commonly the posterior 2/3)
2) May be anywhere on the vulva
What are some of the main Sx of vulvar CA?
1) Ulcerative lesion, thickening, or lump
2) Local itching (most common complaint), pain, burning, bleeding
3) Pain with urination (dysuria)
4) Pain with intercourse (dyspareunia)
5) Unusual odor
Nearly ____% of women with vulvar cancer have no symptoms.
20%
Vulvar CA
1) What does it most often affect?
2) Where may it start?
3) What type of CA are most (90%) of vulvar CAs?
4) What are some other possibilities?
1) Labia
2) On the clitoris or in Bartholin glands
3) Of squamous origin (SCC) (90%)
4) Melanoma(2%), sarcoma, adenocarcinoma, and basal cell carcinoma
Vulvar CA:
1) When does it usually occur?
2) What are some risk factors?
1) After menopause, typically in women age 50 or older (70-80yo most common)
-However, 20% of cases occur in women < 40yo
2) Previous HPV infection, previous cervical or vaginal cancer, lichen sclerosus, syphilis or HIV infection, smoking
Vulvar CA:
Who have a greater risk of developing vulvar cancer that metastasizes?
Women with vulvar intraepithelial neoplasia (VIN)
*Although most cases of VIN never lead to cancer.
Describe the steps of diagnosing vulvar CA
1) Pelvic exam to look for any skin changes
2) Excision and biopsy of the lesion to make an accurate diagnosis
3) Punch biopsy
-If irritated, pigmented vulvar lesions, must perform excisional biopsy for definitive treatment
4) Colposcopy for evaluating known vulvar atypia and intraepithelial neoplasia
Vulvar cancer:
1) Describe the presentation of Squamous carcinoma (90%)
2) Describe the presentation of Vulvar melanoma (6%)
1) Usually appear as a growth on the surface of the vagina.
-May present as an open sore (ulcer).
2) Often appears as a raised, irritated, pruritic, pigmented lesion
-On the labia minora or clitoris
Vulvar CA:
1) ______________ often appear as a grape-like mass.
2) Describe adenocarcinomas
1) Sarcomas
2) May lie deeper so that it is not visible and detected only by palpation; usually appear as a growth on the surface of the vagina
High-grade squamous intraepithelial lesion of the vulva (HSIL)
1) What is it? What is a common social Hx finding?
2) What do Sx include?
1) High-grade, HPV-related lesions; Smoking
2) Vulvar pruritis, Chronic irritation, Development of raised mass lesions
High-grade squamous intraepithelial lesion of the vulva (HSIL):
1) What should be done after using a colposcope?
2) What are the 3 types?
1) Selective biopsies
2) Warty, Basaloid, Mixed
Low-grade squamous intraepithelial lesion of the vulva (LSIL):
1) What is it?
2) What does it often occur in? Is it a cancer precursor?
1) Minimal to mild squamous atypia limited to the lower epidermis
2) Occurs most often in condylomata acuminata (genital warts)
*Little evidence it is a cancer precursor
Low-grade squamous intraepithelial lesion of the vulva (LSIL):
1) What is it?
2) Is it a cancer precursor?
1) Minimal to mild squamous atypia limited to the lower epidermis
2) Little evidence it is a cancer precursor
Vulvar Cancer: Treatment
1) When should you do surgery?
2) When may you do radiation +/- chemotherapy?
3) What is the survival rate?
1) Large tumor (>2 cm) or has grown deeply into the underlying skin; the lymph nodes in the groin area may also be removed.
-Melanoma- early, wide, local excision for diagnosis and staging
2) To treat advanced tumors or vulvar cancer that comes back.
3) 5-year survival rate for all vulvar carcinomas: ~70%
60-80% for SCC Stages 1-2, 45% stage 3, 15% for stage 4
Vaginal CA:
1) Is it common?
2) What are the types?
1) Rare but usually secondary to cervical or vulvar cancers
2) a) Squamous cell carcinoma (80-90%): Primarily in women >55yo
b) Adenocarcinoma, vaginal melanoma, sarcoma
-Small cell cancer, lymphoma, carcinoid cancers (total 1%)
Vaginal CA
1) What are the Tx options? What should you base them on?
2) What is the survival rate?
1) Surgery, radiation, and neoadjuvant chemotherapy options (based on patient’s sexual functioning and anatomic location)
2) 49% overall (42% for SCC)
Vaginal Intraepithelial Neoplasia (VAIN): What are the 3 steps? Describe each
1) VAIN 1: Basal epithelial layers; do not require more than monitoring
2) VAIN 2: Up to 2/3 vaginal epithelium
3) VAIN 3: More than 2/3 vaginal epithelium (including CIS)
Potential for progression to invasive vaginal carcinoma
Trichomoniasis:
1) Etiology?
2) Sx?
1) Parasite (trichomonas vaginalis)
2) Frothy, yellow-green vaginal discharge
Malodorous or fishy odor
Dyspareunia
Dysuria
Strawberry cervix
Many asx
Trichomoniasis:
1) Dx?
2) Tx?
1) Microscope: flagellated protozoans; NAAT; culture
2) Metronidazole 500mg po bid x 7d (Flagyl)
*Alcohol contraindicated
-Treat sexual partners
Hep B & Pregnancy:
1) When is it screened? Describe
2) Is it transmitted to baby?
1) At first prenatal visit
-Testing for Hepatitis B surface antigen (HBsAg) during pregnancy is routine
-If neg with risk factors for Hep B, should be offered vaccine in pregnancy
-If pos, infant should receive vaccine and HBIg within 12hrs of birth
2) Vertical transmission of hepatitis related to the presence of maternal hepatitis B e antigen (HBeAg)
-If +pos., 70% to 90% risk of fetus becoming infected (increases if maternal infection increases in 3rd tri)
Hepatitis B and C:
1) Sx?
2) Long term consequences?
3) Transmission occurs how?
1) Fatigue, jaundice, elevated LFTs, N/V, abdominal pain
2) Lifelong infection, scarring, cirrhosis, liver cancer, liver failure, and death
3) Blood-borne/sexual con
Hepatitis B and C:
1) Tx?
2) Prevention of hep B?
3) Prevention of HCV?
1) Antivirals may help treat chronic disease
2) Vaccine available to prevent HBV
-3 doses: first within 24hrs of birth (then +1mo, +6mo)
3) No preventative measures known to reduce risk of mother-to- child transmission
Hep B & C
1) What are the long term consequences?
2) Is breastfeeding contraindicated for Hep B & C?
1) Lifelong infection, scarring, cirrhosis, liver cancer, liver failure, and death
2) Breastfeeding is not contraindicated in women who are chronic carriers of HBV if their infants have received both the vaccination and HBIg within 12 hours of delivery.
-Also not contraindicated in HCV + unless cracked or bleeding nipples
Pubic Lice: Pediculosis Pubis
1) Etiology?
2) Dx?
3) Tx?
1) Louse, Pthirus pubis: lays eggs in pubic hair
-Can be acquired during sexual activity or from sheets, towels, or commodes used by infected people
2) Clinical: louse
3) Permethrin 1% OTC topical, rinse off p 10 min
*All linens, towels, etc. must be sanitized in hot water and dried in a hot dryer
HPV:
1) How many types?
2) How common is it?
1) More than 100 types
2) Occurs in 80% sexually active women by 50yo
Condyloma Acuminata are also called what?
Genital warts
Condyloma Acuminata (HPV):
1) Sx?
2) Etiology?
3) Dx?
1) Soft, flesh- colored growths
2) HPV (strains 6 and 11 primarily)
3) Clinical or bx
Condyloma Acuminata (HPV):
1) Tx?
2) Prevention?
1) Chemical treatments, cautery, immunologic treatments (ie. Imiquimod cream)
2) HPV Vaccine (Gardisil): recommended for males and females
11-26yo x 2 doses
HSV: Herpes Simplex Virus
1) Sx?
2) Dx?
3) Is there a cure? What etiology makes up the majority of cases?
1) Flu-like syndrome, vesicular rash, blisters with clear fluid, and ulcerated sores around genitals/anus (tender)
2) Clinical, confirmed by viral culture and PCR or Tzanck smear (giant multinucleated cells)
3) No cure; most HSV-2
HIV/ AIDS:
1) Prevalence?
2) What increases risk of acquiring HIV through sexual contact?
1) 1.2mil in the US are HIV+
2) If also +STI and increased risk of transmitting HIV if HIV+ individual also has an STI
1) Describe the progression of HIV in untreated pts
2) List some opportunistic infections
1) The time between infection with HIV and the development of AIDS ranges from a few months to as long as 17 years (median: 10 years)
2) Cryptococcal meningitis, toxoplasmosis, PCP (pneumocystis jirovecii), chronic candida, Kaposi’s sarcoma
Gonorrhea:
1) Sx?
2) Do you screen for this?
3) Dx?
1) Sx: most asx; if sxs, dysuria, greenish or yellow d/c from cervix (cervicitis), vaginal d/c, bleeding between periods
2) Screen yearly if sexually active <25 and if high risk >25yo (for chlamydia also)
3) Screening in pregnancy
Culture of vagina, penis, rectum or pharynx
PCR (NAAT) or urine
Describe gonorrhea Tx?
1) Ceftriaxone 500mg IM x 1 (* treat for Chlamydia also*)
a) Must treat asap in pregnant woman (can cause blindness, joint infection, sepsis in baby)
*Reportable disease
Complications of Gonorrhea:
1) Include what?
2) GC is responsible for 75% of young sexually active adult cases of septic arthritis; describe this condition & Tx
1) Sepsis; Fitz-Hugh-Curtis Syndrome (perihepatitis); High risk for PID
2) Fever, joint pain, limited ROM, purulent aspirate
CBC, ESR, CRP
-ADMIT and consult ortho
-Tx: 2 weeks of IV antibiotics (IV ceftriaxone), washout
Fitz-Hugh-Curtis Syndrome (perihepatitis):
1) What STI is it assoc with?
2) What is the main Sx?
3) What is the cause?
1) Gonorrhea
2) Severe RUQ pain in addition to PID symptoms
3) “Violin string” adhesions under the liver
Chlamydia:
1) Sx?
2) Dx?
3) What can occur in newborns? How do you prevent this?
4) Is it reportable?
1) No sx or very mild sx , dyspareunia, abnl vaginal discharge, mucopurulent d/c from cervix (cervicitis)
2) Urine (high false-negatives) OR culture (PCR/NAAT) from the ectocervix or vagina (preferred method)
3) Ophthalmia neonatorum; Antibiotic ointment to protect eyes from G/C (and E-coli)
4) Yes
Chlamydia complications: List & describe these
1) Neonatal conjunctivitis and pneumonia
2) PID (40% if untreated): May include the fallopian tubes (salpingitis) and result in permanent sterility, ectopic pregnancy, and chronic pelvic pain
3) Reiter’s Syndrome (venereal arthritis)
4) Cervicitis, endometritis, urethritis, epididymitis
Chlamydia Complications: Reiter Syndrome:
1) What is the triad?
2) How does it present? Explain
1) Triad of nongonococcal urethritis, conjunctivitis and arthritis
2) Present with malaise, fatigue, and fever, low back pain & heel pain
-Arthritis typically involves hips, knees, or ankles and tends to by asymmetrical
Syphilis:
1) Etiology?
2) How does it develop?
1) SpirocheteTreponema pallidum
2) In stages, and symptoms vary with each stage/may be asymptomatic
Syphilis: Describe each of the 3 stages
1) Primary infection: small, painless chancre on genitals, rectum, or mouth
2) Secondary infection: maculopapular red/brown rash of trunk including palms/soles of feet; lymphadenopathy, fever, fatigue, h/a
(Latent Stage: no s/sx; + serologic testing)
3) Tertiary infection: 1/3 untreated cases; damage to the brain, nerves, eyes, or heart
Patients Who Should be Hospitalized for PID include who?
1) Surgical emergencies (e.g., appendicitis) cannot be excluded
2) Patient is pregnant
3) Does not respond clinically to oral antimicrobial therapy
4) Unable to follow or tolerate an outpatient oral regimen
5) Has severe illness or high fever
6) Tubo-ovarian abscess
PID may include infection of any or all of which anatomic locations?
1) Endometrium (endometritis)
2) Fallopian (uterine) tubes (salpingitis)
3) Ovaries (oophoritis)
4) Uterine wall (myometritis)
5) Uterine serosa and broad ligaments (parametritis)
pelvic peritoneum
6) Tuboovarian abscess (TOA); requires admission
PID:
1) Common Sx?
2) How is it diagnosed?
1) Many women with PID have subtle or mild symptoms
2) Usually clinical: CMT, adnexal tenderness, uterine tenderness
Empiric treatment of PID should be initiated in sexually active young women with what?
1) Pelvic or lower abdominal pain
2) If no cause for the illness other than PID can be identified
3) and if >1 of the following minimum criteria are present on pelvic examination:
1. CMT
2. uterine tenderness
3. adnexal tenderness
List the additional criteria for PID Dx
1) PO temperature >101°F (>38.3°C)
2) abnormal cervical or vaginal mucopurulent discharge
3) presence of abundant numbers of WBC on wet prep
4) elevated erythrocyte sedimentation rate (ESR)
5) elevated C-reactive protein (CRP)
6) + N. gonorrhea or C. trachomatis
25% of patients have long term consequences of PID; list them
1) Tubal factor infertility
2) Ectopic pregnancy
3) Chronic pelvic pain
4) Dyspareunia
5) Menstrual disturbances
6) Pelvic adhesions
List the CDC Tx recommendations for PID
1) Ceftriaxone 1g IV q 24hrs
plus
2) Doxycycline 100 mg po (or IV- ideally PO) bid x 14d
plus
3) Metronidazole 500 mg po (or IV) bid x 14d
