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531 > Week 5 Sexual ID, HPV, Pap > Flashcards

Week 5 Sexual ID, HPV, Pap Flashcards

1
Q

transgender

A

mismatch b/t someone identifies their gender and how they appear outside

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2
Q

Gender non conforming

A

behavior/expression of mismatch of gender identity vs assigned sex

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3
Q

sex

A

biological; combination of inherited genetic traits to form specialized cells (XX, YY) chromosomes

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4
Q

gender expression

A

The way person expresses gender identity, via appearance, dress, behavior

changes as someone transitions

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5
Q

sexual orientation

A

Person’s physical/sexual attraction to another person

sexual orientation and gender identity don’t go together

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6
Q

WSW have higher rates of

A
  • breast cancer d/t lack of access to care (offer mammogram if > 40 yrs old)
  • use less barriers = higher STI risk
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7
Q

screenings for transgender men

A
  • same screening guide for cervical cancer, breast cancer
    • except mastectomy or cervix remove = no Pap needed
  • Screening HPV-related cancers
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8
Q

in transgender patients, self swab can be used for

A

those that want more control over their screening process

don’t do speculum exam if it’s just STI screening (urine or self swab ok) for gonorrhea, chlamydia, trichmonas

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9
Q

what is a safe birth control for transgender males?

A

IUDs

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10
Q

is testosterone okay in pregnancy

A

no! teratogen

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11
Q

MSM have higher rates of

A
  • esp African Americans
  • HIV, viral/bacterial STIs (anal sex), rectal mucosa susceptible to STI
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12
Q

what is PrEP?

A

preventative option for women who are HIV negative and use injection drugs, women whose partner have HIV, and those who are at substantial risk for contracting HIV

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13
Q

How should PrEP be taken?

A
  • taken every day
  • oral fixed dose combination of tenofovir disoproxil fumatarate (TDF) 300 mg and emtricitabine (FTC) 200 mg
  • in conjunction with risk reducing service sand behavior changes (safer sex practices)
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14
Q

PreP criteria and screenings

A
  • Negative HIV test result before prescribing PrEP
  • No s/sx of acute HIV infection
  • Normal renal function
  • Hepatitis B Serology
  • every 3 month:
    • HIV test
    • Pregnancy screening and assess pregnancy intent
  • Every 3 to 6 months
    • STD screening
  • Kidney function test every 6 months
  • For PrEP users who have chronic hepatitis B infection, HBV DNA test every 6 to 12 months while prescribed PrEP
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15
Q

what is PEP?

A

post exposure prophylaxis

taking antiretroviral therapy (ART) after HIV exposure; 72 hrs after exposure

3 ART meds for 28 days

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16
Q

when does the USPHS suggest someone can start PrEP?

A

negative HIV antibody test (4th gen test), no s/sx of acute retroviral syndrome in previous 4 weeks

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17
Q

for transgender women: goal of feminizing hormone therapy? what meds are there?

A
  • develop female secondary sex characteristic and suppress male characteristics
  • estradiol - (embolism risk)
  • spironolactone - block testosterone
  • finasteride (5 alpha reductase inhibitors) - blocks testosterone
  • GnRH agonists - shuts down LH and FSH
    • blocks testosterone
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18
Q

what labs do you monitor in transgender women

A
  • Total testosterone
    • < 100
  • Prolactin levels
    • prolactin tumor
  • CBC (anemia)
  • Will have lower H&H and RBC
    • Testosterone makes more RBC so not anemic
    • lab can say abnormal but it’s normal for her
  • CMP
    • monitor elevated K
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19
Q

Informed consent/Risks of meds for transgender women

A
  • Venothrombotic events (VTE)
    • DVT and PE
  • WILL see anemia but it’s actually the range we expect from a woman
  • infertility
    • Reproductive preservation options
  • Mood changes
    • from estrogen
  • prolactinoma
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20
Q

MTF: changes at 0-3 months when starting estrogen/test? which ones permanent?

A
  • Lower libido.
  • softening skin
  • breast budding****
  • emotional changes
    • Does NOT change voice/quality
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21
Q

MTF: change at 4-10 months with estrogen/test therapy?

A
  • Changes to genitalia
    • scrotum less full.
    • Penis smaller
    • less erections
  • softening of hair
    • Facial hair softer but won’t go away
  • Decrease in muscle mass
  • Cessation of spermatogenesis****
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22
Q

MTF: change at 10 months - 4 years with estrogen/test therapy?

A
  • Breast maturation***
  • Body fat redistribution
  • Thickening of hair on head.
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23
Q

MTF surgeries

A
  • Breast augmentation
  • FFS - facial feminization surgery
    • Rhinoplasty
  • Vaginoplasty
    • vagina
  • Orchiectomy
    • Removal of testicles/tissues of scrotum
    • NEED to be on hormones ALL the time ***
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24
Q

FTM lab monitorings

A
  • CBC
    • Testosterone makes more RBC than someone with estrogen
    • polycythemia = abnormal
  • CMP
    • Lipids: (hypercholesterolemia)
  • Total testosterone (N male range: 300-1200)
    • Goal: 400-1000
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25
Q

FTM changes at 0 to 3 months

A
  • Libido goes up
    • adolescents = body dysphoria which is discomfort/dislike of specific parts of body
  • Increase in appetite
    • obesity = educate!
  • **Increase/growth in already present body hair
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26
Q

FTM changes in 3-6 months

A
  • NEW hair growth in new places
  • **Clitorus enlarges
  • Cessation of menses
  • Increase in muscle mass/strength
  • Changes in vocal quality
    • Thicken vocal cords, full pitch not reached til 2 years
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27
Q

FTM changes in 6 months to 5 years

A
  • **Development of terminal facial hair
  • Body fat redistribution
    • goes to hips, thigh, butt
  • **Hair loss
    • Male pattern baldness after 5 years on testosterone
    • See recession of hairline
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28
Q

surgery options for FTM

A
  • Metoidioplasty
    • Enlargen cliterus
  • Phalloplasty
    • Forearm skin 6-9 inch phallus
    • Have sensation but no erectile function
  • Top surgery
    • Subcutaneous mastectomy: MALE CHEST reconstructive surgery
  • Removal of reproductive organs
    • Not necessary unless genital surgery that closes vaginal canal
    • Ovaries, tubes, uterus atrophy so surgery not needed and no risk for malignancy
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29
Q

when do puberty delaying options happen in transgender children?

A

tanner stage 2 ; age 10

100% reversible

low dose hormones to prevent secondary sex characteristics

block puberty and allow to exist as gender they want

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30
Q

things to consider to be trans for children

A
  • Insistence in gender identity
    • Hear from child “no i’m a boy”
  • Persistence/consistency
    • Talking about for a long time
    • Bring it up to parents and everyone on regular basis
  • Informed consent from parent if < 18 yrs old
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31
Q

what meds for transgender children to delay puberty

A
  • GnRH Analogs: Lupron, Syarenl, trelstar
    • Block LH/FSH so no signal to gonads and produce NO hormone secondary sex characteristics
    • Long term: bone growth/ osteoporosis
    • After 3 yrs of delaying puberty, add lose dose hormones in age appropriate doses to desired sex
  • Testosterone dose/delivery
    • Congruent with age and puberty
  • Estrogen dose/delivery
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32
Q

is return to fertility possible after stopping hormone therapy in children?

A
  • Prolonged pubertal suppression using GnRH analogs is usually reversible
  • Return of fertility may be possible after discontinuing hormone therapy for a period of time. If ovaries and testes have not been removed.
  • return in 3-6 months but can be permanent loss of fertility, or require assisted technologies
33
Q

low risk types of HPV are

A
  • 6 & 11
  • doesn’t cause cancer
  • 90% condylomata acuminata
34
Q

high risk types of HPV are

A
  • 16 & 18
  • 70% cervical cancer
  • 16: squamous cell
  • 18: adenocarcinoma/glandular cells
35
Q

risk factors for HPV/cervical cancer? what’s the biggest risk factor?

A
  • Persistent HPV infection biggest risk factor
  • Immunosuppression
  • High parity 3+ kids (immunocompromised state/changing hormones)
  • Smoking
  • Long-term use of oral contraceptives
    • estrogen keeps glandular cells from regressing higher up so it’s exposed
  • Nutritional
    • Low vitamin c or folate
  • Poverty (lack screening)
  • Having sex at an early age
  • Multiple sexual partners
  • Diethylstilbestrol (DES)
    • Daughters of women who took DES are 40 times more likely to develop clear cell adenocarcinoma of cervix and vagina
    • DES taken off the market in 1971
36
Q

what birth control lowers risk of cervical cancer/HPV?

A
  • IUD
    • Progestin and Copper IUDs lower risks of developing cervical cancer
    • IUD induces a chronic low grade inflammation process, mobilizing the immune system to block viral replication.
37
Q

Gardasil vaccination schedule and contraindications

A
  • 2 dose series 6 months apart:
    • 9 yrs old then 10 yrs old
    • OR 11 then 12
    • OR latest 26 yrs old
  • 3 dose if 15 yrs old or immunocompromised:
    • age 15, then 1-2 months, then 6 months after 1st dose
  • main SE: syncope
  • contraindications
    • allergic to HPV components
    • latex allergy for bivalent
    • yeast allergy for quadrivalent
      • pregnant
38
Q

genital wart sx’s

A
  • Single or multiple soft fleshy papillary or flat keratinized growths on genital mucosa
  • Usu asx/painless but can also be painful and pruritic depending on location and size
  • Common on vaginal introitus or shaft of penis
  • 60-90% not visible to eye
39
Q

Genital wart diagnosis

A
  • Visual inspection
  • Classy warty appearance
  • NO biopsy unless atypical, pigmented color or ulcerative, or not responding to treatment
  • NO HPV testing (HPV tests for high risk HPV)
  • STI screening
40
Q

genital warts differentials

A
  • R/o condyloma lata
    • Serology test for syphilis
  • Atypical, pigmented, ulcerative = cancerous lesion = refer for bx
  • Molluscum contagiosum
    • POX virus: domed smooth flesh colored pearly white papules with depressed centers
  • Herpes simplex virus
41
Q

genital warts transmission

A
  • HPV can clear spontaneously but can progress to genital warts or cancer
  • skin to skin thru vaginal, anala, or oral sex
    • Unknown how person remains contagious after warts are treated
  • Difficult to determine how or when person become infected
42
Q

genital warts management & complications

A
  • Goal: remove and resolve sx’s (can go away on own or grow)
  • Can’t eradicate infection
  • Tx only visible warts seen!
  • 2 types:
    • Patient applied
      • Imiquimod 5% (Aldara) or 3.75% (Zyclara) cream
      • Podofilox (Condylox) 0.5% solution or gel
      • Sinecatechins (veregens) 15% ointment
    • Provider administered therapies:
      • Trichloracetic acid (TCA; Tri Chlor) or Bichloroacetic acid (BCA) 80-90%
      • Cryotherapy liquid nitrogen or cryoprobe
      • Surgical removal
  • F/u for regular tx until lesions resolve
    • Most warts respond w/in 3 months of tx
    • Evaluate response; consider alt tx if none
  • Complications of anogenital warts
    • Enlarge and destroy tissue
    • Simulate carcinoma and need bx
    • Pregnant, can enlarge and obstruct birth canal = c section
    • Perinatal transmission low
    • If HIV, fast growing warts and inc HPV cerv dz
43
Q

key points about genital warts

A
  • can’t kill virus; only sx relief
  • Recurr in 1st 3 months
  • Types HPV NOT same as cancer
  • Don’t know when get HPV and can get it months-yrs after infection
  • if 1 sex partners has it, other most likely has it too
  • no sex w new partners til warts gone
    • but can still be transmitted
  • Condom lower chances but not covers all
  • Vaccine protects from other strands
44
Q

cervical cancer prevention

A
  • early detection is key
  • HPV vaccine
  • Pap smear and HPV testing
  • treating pre-cancerous changes early
45
Q

cervical cancer sx’s

A
  • Most asymptomatic until late stages
  • Vaginal discharge
  • Abnormal vaginal bleeding
    • b/t menses
    • Post coital
    • Post menopausal
    • Friable cervix bleeding easily
  • Late sx’s
    • Bladder obstruction
    • Back pain
    • Pelvic pain
    • Leg swelling
46
Q

what risk factor leads to most cervical cancers?

A

persistent HPV infections combined with other cofactors

47
Q

cervical cancer screening USPSTF

A
  • no earlier than 21 to 29
    • cytology/Pap smear every 3 years
    • NO HPV testing unless pap result was abnormal
  • 30-65 yrs old
    • pap smear + HPV co test every 5 years = preferred
    • or HPV only every 5 years (primary HPV testing)
    • or Pap smear only every 3 years
  • 65+ NO Pap test if have negative screenings prior (3 consecutive negative Pap tests in a row or 2 negative HPV co-test in past 5 years)
    • or total hysterectomy
  • if history of cervical cancer, screen for 20 years after surgery
48
Q

don’t have to screen for cervical cancer when

A
  • over 65 years old with
    • hysterectomy including cervix
    • 3 negative Pap tests or 2 neg HPV tests consecutively
  • no hx of CIN 2 or higher
49
Q

Management of sex partners of HPV

A
  • NO testing needed of partners for HPV
  • a positive HPV test does NOT mean cancer
  • HPV does not mean infidelity
50
Q

what is the Bethesda system?

A
  • reports cervical cytology of epithelial cell abnormality
  • Uniform set of terminology and guidance for cervical cancer management
51
Q

Bethesda category: ASC-US

A
  • Atypical squamous cell - undetermined significance
  • Few cells look atypical but no severe dysplasia going on
  • No severe cell change
  • Change not deep
52
Q

Bethesda category: ASC- H

A
  • Atypical squamous cells: cannot exclude High-Grade squamous intraepithelial lesion (HSIL)
  • More concerning change
  • Most cells are atypical but bit more high grade/severe
  • Tx as high grade pap test result
53
Q

Bethesda category: LSIL

A
  • Low-grade Squamous Intraepithelial Neoplasia
    • Lesion involves initial ⅓ of epi layer
    • CIN 1 (mild dysplasia; not that deep)
    • HPV infection
54
Q

Bethesda category: HSIL

A
  • High-grade Squamous Intraepithelial neoplasia
  • Encompasses:
    • HPV persistent infection
    • CIN 2 (moderate dysplasia) lesion
      • ⅓ to less than ⅔ of epithelial layer
    • CIN 3 (severe dysplasia and carcinoma in situ)
      • ⅔ to full thickness
55
Q

Bethesda category: squamous cell carcinoma

A
  • Malignant cells penetrate basement membrane and infiltrate into stromal tissue (supporting tissue)
  • advanced: spread to bladder or via blood/lymph to other sites
56
Q

treatment of histological abnormalities

A
  • first line: LEEP/LOOP for cervical dysplasia
  • cryocautery
  • cold knife cone
  • hysterectomy
57
Q

where is the squamous epithelium located?

A
  • covers ectocervix (visible portion) / vaginal wall
  • pink, stratified, multiple layers
58
Q

where is the glandular cells/columnar epithelium located?

A
  • glandular cells lines the endocervix and endometrial canal
  • glandular cells protrude in early menarche/reproductive years and it goes more inside older/postmenopausal
  • red beefy cells on cervical os
59
Q

when women age, what happens to these cells? what about younger women?

A

aging women: columnar cells replaced by squamous cells called metaplasia and SCJ migrates towards cervical os and into canal

younger females and pregnancy have more columnar cells exposed (everted) making them more vulnerable to HPV infections

60
Q

squamocolumnar junction (SCJ)

A

aka transformation zone

junction where the squamous cells transition to glandular cells

61
Q

metaplasia means? when is it normal?

A
  • change of 1 type of epithelium to another
  • squamous metaplasia is the replacement of glandular cells with more mature squamous cells at the transformation zone
  • most active during adolescence and 1st pregnancy (d/t estrogen)
62
Q

2 types of Pap test

A
  1. conventional cytology - glass slide
  2. liquid based cytology - thin prep or SurePath
63
Q

which Pap test is better?

A

either or not better than the other but majority of labs use liquid based

64
Q

liquid based Pap smear

A
  • rinsing sampling in liquid medium can remove blood, mucus, debris
  • Increase the number of cells sampled
    • when we collect sample off the cervix, we swish it around in the liquid medium to rinse off more of those cells from your sampling devices.
  • Can order HPV co test off this Pap test = less cervical cancer screenings
    • if negative and the HPV test is negative = can go 5 years between pap tests
    • can test for HPV, chlamydia, gonorrhea, trichomoniasis
  • Cons: $$$$
65
Q

where do you collect the Pap smear?

A

transformation zone (SCJ) of cervix where the metaplasia is

location SCJ depends on age and hormones

66
Q

which group have higher rates of cervical cancer due to lack of screening?

A

poor, ethnic minorities (hispanics, blacks, color) and immigrants

67
Q

cervical cancer screenings may be more frequent in who?

A

immunosuppressed (HIV), diethylstilbestrol in utero, previous tx for CIN 2 or 3

68
Q

what is a reflex HPV test?

A

after getting an abnormal Pap test/cytology findings, order an HPV test (25 yrs or older)

69
Q

HPV tests for

A
  • ONLY high risk oncogenic types
  • therefore, only rec this for:
  • cervical cancer screening (NOT general population or warts)
  • conjunction with Pap tests
  • triage of abnormal cervical cytology (reflex test for 25+ yr women)
70
Q

when is NOT a good time to do a Pap test?

A

heavy bleeding

71
Q

when to refer for colposcopy?

A
  • estimated immediate risk of diagnosis of CIN 3 or higher or 4.0% or greater based on prior history and current results.
    • All HSIL pap results regardless of patients age will get colposcopy or immediate treatment (depending on age)
72
Q

when is HPV genotyping recommended

A
  • 30 years and older with negative cytology and a positive high risk HPV test
  • if HPV genotype is positive for strains 16 and 18 = colposcopy
    • if negative = f/u with cytology and/or HPV test in 12 months
73
Q

what are the 4 phases of cycle of abuse?

A
  • tension building phase - verbal putdowns, increased arguing
  • acute battering incident - sexual assault, hitting, kicking, weapons
  • reconciliation phase - abuser repent abuse, apologize
  • calm or loving phase - ‘honeymoon’, apologize, promise won’t happen again
74
Q

USPSTF recommendation for IPV

A

routine screen all women childbearing age for IPV

75
Q

USPSTF and ACOG recommendation for IPV

A

USPSTF: routine screen all women childbearing age for IPV

ACOG: screen 1st prenatal visit, every trimester, post party

76
Q

IPV management

A
  • Assess for immediate safety
  • Provide referrals, IVP hotline information, shelter information
  • Aid in safety planning (pack overnight bag)
  • Encouraged to call police before actual abuse occurs; MOST definitely after abuse occurs
  • Use 24-hour health safety net if no access to a safe place
  • EC in plain envelopes (vs original packaging) if pregnancy risk
  • Document accurately and thoroughly in medical record all findings in physical exam and history in case of any legal proceedings. Document injuries with body diagrams and photo if possible
77
Q

IPV risk factors

A
  • hx depression/low self esteen
  • younger age (college)
  • hx of violence in home
  • pregnancy
  • lower education level
  • no job
  • poverty
  • relationship with dominant or controlling partner
    • living within a community or family with male dominant norms
78
Q

when IPV women present for health care, sx’s can be

A

very general and vague, generalized concerns of unexplained pain or malaise

531 (9 decks)

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