Week 5 Sexuality Flashcards
Which of the following is considered a significant barrier to health care for LGBTQ patients?
Clinician knowledge Significant barriers to health care for LGBTQ patients include financial barriers, lack of insurance, historical trauma, lack of clinician knowledge, and restrictive healthcare systems, infrastructure, and policies (Schuiling & Likis).
What should the NP take into consideration regarding health risks for LGBTQ patients when compared to non-LGBTQ patients?
Dosage amounts of estrogen in hormone therapy and oral contraceptives vary between the two. The amount and type of estrogen available in hormone therapy and oral contraceptives are not the same. Substance abuse is higher in the LGBTQ population. Further studies are needed to understand the rates of PCOS in transgender men. Puberty significantly alters the hormone options for transgender children (Schuiling & Likis; Module 5.6).
What HPV types cause most genital pre-cancers and cancers?
16 & 18
At what age does ACIP recommend routine HPV vaccination for adolescents?
Age 11 or 12: two doses scheduled (at 0 and 6–12 months; two doses at least 6 months apart)
What HPV types cause most genital warts?
HPV 6 and 11 (low-risk, non-oncogenic) cause 90% of genital warts
How are genital warts diagnosed?
Visual inspection usually sufficient to diagnose
What are some risk factors associated with acquiring HPV and cervical cancer? #6
- Sexual activity at early age,
- Multiple sexual partners,
- High-risk sexual practices,
- Smoking,
- Lower socioeconomic status,
- Weakened immune system
What options are recommended to screen women age 30 and older for cervical cancer?
Cytology (Pap) alone every three years, Cytology (Pap) and HPV test (co-testing) every five years
At what ages should cervical cancer screening begin and end?
Routine screening should begin at age 21 and continue through age 65 years to prevent invasive cervical cancer.
How often should women ages 21–29 be screened for cervical cancer?
Cytology (Pap) alone every three years recommended for routine screening (HPV testing should not be used to screen as a co-test and used only as a reflex test if cytology (Pap) is ASC-US)
High risk types of HPV
16 and 18
What are the low risk strands of HPV
6 and 11
associated with genital warts
What type of cancer does HPV 16 cause
squamous cell cervical cancer
what type of cancer does HPV 18 cause?
Adenocarcinoma
“Glandular cells”
What makes individuals higher risk for HPV infection?
- Immunosuppression (HIV)
- high parity =3+
- smoking
- long term use OCP (normal risk after off 10 years)
- nutrition (low vit c and folate)
- sex at early age (immature cells)
- multiple partners
Diethylstilbestrol (DES)
risk factor for non HPV cervical cancer
daughters of women who took DES are 40x more likely to develop clear cell adenocarcinoma of cervix and vagina
What is clear cell adenocarcinoma of cervix?
rare neoplasm of all cervical adenocarcinomas
Does IUD increase risk of cervical cancer?
No, reduced risk
“may mobilize immune system with chronic low grade inflammation”
What is the biggest risk factor for cervial cancer?
persistent HPV infection
leads to cervical dysplasia/precancer
especially over 10 years
When will most people clear HPV
after 1 to 2 years
not lifelong
What does the squamous epithelium cover?
vagina and outside of cervix
what does the columnar epithelium cover?
brighter red in color
covers inner cervix and endometrial canal
____ females and during ______ more columnar epithelium is exposed on surface of cervix and sometimes calls ________ or eversion
YOUNGER females and during PREGNANCY more columnar epithelium is exposed on the surface of the cervix and sometimes called CERVICAL ECTOPY or eversion
with advancing age the _____ cells are replaced by _______: this is called ________
with advancing age the Columnar Epithelium cells are replaced by Squamous Cells: this is called Metaplasia and the SCJ migrates up towards the cervical OS and into cervical canal
What is the Transformation Zone?
Area of actively maturing epithelium
Where metaplasia occurs
Most common place on the cervix for abnormal cells to develop
When to start cervical screening
ACOG =
USPSTF =
ACS =
ACOG = 21
USPSTF = 21
ACS = 25
What are general cervical screening recommendations and type of screening
<21 years
21 - 29 years
30+ years
<21 years = No screening
21 - 29 = Cervical Cytology Q 3 years
30+ years =
- Cervical cytology Q 3 years OR
- Co-Testing: Cervical cytology and high=risk HPV Q 5 years OR
- HPV alone testing Q 5 years
Cervical cancer screening recommendations for someone over 65 years
not recommended
3 consecutive negative pap tests in a row
OR
2 negative HPV co test results in a row in past 10 years with most recent in past 5 years
Cervical cancer screening recommendations for total hysterectomy
No pap needed unless…
history of cervical cancer in last 20 years = screen for 20 years after surgery
what is a reflex HPV
HPV test added on after pap test is abnormal
Used to triage abnormal pap tests such as ASCUS results
What is a co-test?
HPV test ordered along with pap test (cytology)
Ages >30 years
HPV test performed regardless if pap test is normal or absnormal
What is primary HPV testing
HPV test alone with NO PAP
True or False
- HPV testing should be done as part of routine STI screening
- People who receive the HPV vaccine do not need pap tests anymore
- The time lapse between HPV infection and cervical cancer is about 2 years
- False
- False; doesn’t cover all strands
- False; 10 years when it causes cervical cancer cell changes
Yes or No?
- 31 y/o had a negative pap 2 years ago. Should she have a pap today?
- 21 y/o with an abnormal pap wants to get HPV vaccine, is it safe to get the vaccine with this abnormal pap test?
- 60 y/o with a negative pap and neg HPV test 3 years ago. Does she need a pap today?
- No; Q 3 years
- Yes;
- No; Q5 years
yes or no?
- 66 y/o who has a history of negative pap tests and has been up to date on her routine cervical cancer screenings. She asks you if she can stop having pap tests now?
- 38 y/o with Total hysterectomy for benign reasons and no PMH of abnormal pap tests. Does she still need pap testing?
- Yes; she can stop
- No; no history of cancer and no cervix
What are the 3 main categories for reporting cervical cytology
- Negative for intraepithelial lesion or malignancy
- Other: See interpretation result (EX endometrial cells in a women >45 years)
- Epithelial cell abnormality: see Interpretation result (specify squamous or glandular)
Epithelial Cell abnormalities: Squamous Cell types abnormalities #4
- Atypical squamous cells: mildly abnormal, unable to determine precancer or cancer ORDER HPV REFLEX
- Low-grade squamous intraepithelial lesion (LSIL): 1/3 way through cervix
- High-grade squamous intraepithelial lesion (HSIL): severe dysplasia; 2/3 thickness
- Squamous cell carcinoma: malignant cells penetrate basement membrane
Cervical cytology: Glandular Cell abnormalities
ENDOcervix: found higher up in cervix
atypical glandular cells have increased association with high grade disease
True or False
- Atypical glandular cells are more concerning than atypical squamous cells on pap?
- Atypical Squamous cells on pap in 26 y/o patient: can ordering an HPV reflex test aid in triaging results?
- Negative pap (cytology) with positive HPV co test for HPV 16 in a 35 y/o means the patient should be referred to GYN for colposcopy and biopsy
- 21 y/o with LSIL on 1st pap test should be referred to GYN for colposcopy
- True; glandular are higher more dangerous
- Yes; order HPV reflex
- Yes; REFER
- No; repeat in year
true or false: you need to perform other STI screening when genital warts are present
true
Molluscum contagiosum
Cause
Transferred by….
POX virus
skin to skin contact
Condyloma lata
Cause
what does it look like?
Secondary syphilis
Flatter & wider than HPV warts
How long does it take for warts to respond to treatment?
What do you do if they do not?
most respond in 3 months
if not, consider another option or surgery
MAKE SURE TO ALWAYS SCREEN FOR HIV & SYPHILIS
What ages are gardasil 9 approved for?
Ages 27 to 45
Can be given as early as 9
What is the HPV vaccine schedule for <14 years old
2 doses given at least 6 months apart
What is the HPV vaccine schedule for >15 years
3 doses given over 6 months
0, 1-2, & 6 months
PrEP takes ____ days to build protective levels of PrEP in anal and rectal tissues and _____ days to achieve protective levels in vagina and blood
PrEP takes 7 days days to build protective levels of PrEP in anal and rectal tissues and 20 days days to achieve protective levels in vagina and blood
What are the PrEP medications?
Truvada/Atripla - approved for vaginal sex
Descovy
What are the recommendations for PrEP? #6
- Documented negative HIV test result before prescribing & Q 3 months
- No s/s of acute HIV infection
- STI screening Q 3 to 6 months
- GFR Q 6 months
- Pregnancy screening & intent Q 3 months
- Hep B vaccination/status…Chronic infection = test Q 6 to 12 months (might cause reactivation of Hep B)
*people with acute HIV infection at risk of developing resistance if started on PrEP*
When can you take PEP?
How is it taken?
up to 72 hours after post HIV exposure
Take 3 ART for 28 days to prevent HIV infection
What are the breast cancer screening recommendations for trans women?
- Mammogram Q2 years if 50 & on estrogen for 10 years
What labs do you want to monitor if someone is on testosterone therapy?
- Lipids: increases triglycerides
- CBC: watch polycythemia
- CMP
- Total Testosterone: goal 400 to 1000
What labs do you want to monitor for someone on estrogen therapy?
- Total testosterone: 40-80
- Prolactin: look for prolactin tumors
- CBC: lower H&H
- CMP: monitor K with diuretc meds
What age do you start Transgender children medications
How long until fertility returns for these children?
Tanner stage 2 or 3 for 3 years with GnRH analogues
*concern about bone growth*
*Reversible
Fertility return ranges from 3 to 6 months; some may experience permanent loss
Your patient’s pap results revealed atypical glandular cells. What is your next step of action? Why?
Means there are atypical cells higher up in ervix
could be sign of adenocarcinoma
REFER for colposcopy
if someone is 25 y/o has low grade pap test what do you do?
refer to colposcopy
When would you stop HPV screening?
- Stop screening at 65 years if
- 3 consecutive negative pap tests or
- 2 negative HPV tests
- No history of CIN 2 or higher cervical dysplasia within last 20 years
What is first line cervical dysplasia treatment?
LEEP/LOOP
Electrical surgical excision
If a woman has a normal pap test with high risk HPV cotest…what do you do?
Repeat pap in one year
Genotype to see if she has 16 or 18
Transmale time frames
0 to 3 months
3 to 6 months
6 months to 5 years
- 0-3 months
- Libido changes (can cause worsening dysphoria because can’t masturbate/sex with correct genitals)
- Increased appetite
- Increased body hair***
- 3-6 months
- Genital changes***
- cessation menses
- Increase muscle mass/strength (quickly in shoulders, neck & trapezius)
- Voice changes (full pitch change at 2 years)
- 6 months – 5 years
- Development terminal facial hair*** (depends on genetics
- Hair loss based on genetics*** (usually at 5 year mark)
- body fat redistribution into abdomen
What is a matoidplasty
Phalloplasty
-
Metoidioplasty:
- create small phallus (only 6 surgeons in world) oral, buccal mucosa used to increase girth; reroute urethra….
- testicular implants
- Orgasm preserved
-
Phalloplasty
- Creates realistic phallus using forearm and lower leg skin
- Sensation but not erectile function
What labs do you monitor on Transmale
- Monitor
- CBC: polcythemia risk
- CMP: elevated cholesterol and triglycerides
- Total Testosterone: 300-1200
- Monitor prolactin, CBC (polycythemia risk); lipids (higher risk for hypercholesterolemia); higher sex drive, body changes
What are the changes for transfem
0 to 3
4 to 10
10 months to 4 years
- 0-3 months
- lower libido
- Softening skin
- Breast budding **permanent
- Emotional changes
- 4-10 months
- genitalia changes; genitalia atrophy
- Facial hair will be softer but will not stop growing
- softening hair
- decreased muscle mass
- Cessation of spermatogenesisi **permanent
- 10mo -4years
- Breast maturation
- Body fat redistribution
What is the MOA for Imiquimod?
active immune enhancer;
stimulates production of interferon and other cytokines
Podofilox
MOA
Contra indication
MOA: antimiotic that causes wart necrosis
Contraindication: Pregnancy,
**total area needs to be <10cm or toxic
What are provider administered therapies?
Trichloroacetic acid or biochloroacetic acid
cryotherapy
surgical removal
Trichloroacetic acid or bichloroacetic acid
MOA
Side Effect
Response time
MOA: destroys warts by chemical coagulation of protiens
*white frost on tissue*
Side Effect
- pigmentation
- moderate pain
Response time: 3 months
Gardasil 9
ages recommended
contraindication
Age 9 to 26 years
Contraindication : yeast allergy
Bivalent HPV
What does it protect against
who is it for?
contraindication
HPV 16 and 18 only
9 to 25 years….FEMALES ONLY
Contraindication: latex allergy
