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Repro > week two > Flashcards

week two Flashcards

1
Q

Describe the difference between LSIL and HSIL of the vulva and VIN

A

VIN: vulvar intraepithelial neoplasia

TYPES OF VIN:

LSIL: low grade squamous intraepithelial lesion of the vulva
Aka vulvar LSIL, flat condyloma, HPV effect
associated with HPV 6 and 11

HSIL: high grade squamous intraepithelial lesion of the vulva
VIN usual type, multifactorial
associated with HPV 16, 18, 31

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2
Q

Which type of VIN is not associated with HPV and what is it associated with

A

dVIN (VIN differentiated type): lesions not associated with HPV but with vulvar dermatoses, mainly lichen sclerosus

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3
Q

List common DDX’s for white, red or brown lesions of the vulva.

A

White (hypopigmented): lichen sclerosus, squamous hyperplasia, VIN, vitiligo

Red lesions (erythematous): vestibulodynia, vulvar candidiasis, lichen planus, VIN

Brown lesions (hyperpigmented): VIN, nevi, acanthosis nigricans

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4
Q

What is the most common diagnostic work-up (test) of vulvar lesions?

A

biopsy; punch biopsy most common

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5
Q

Describe the ways HPV affects the vulva (ddx)

A
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6
Q

RF of VIN

A

Impaired immune response
Smoking
Early onset of sexual intercourse
Multiple sexual partners
Unprotected intercourse (mostly vaginal and cervical lesion risk) skin-to-skin contact
Uncircumcised partner(s)
Low socioeconomic status
Diet
HPV infection - about 90% of VIN lesions test pos for HPV
Differentiated VIN associated with lichen sclerosis

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7
Q

Sx of VIN

A

Red, white, or brown lesions; usually flat + often asxs and noted incidentally during pelvic exam
Pruritus and pain or burning
Dysuria if periurethral VIN lesion or if urine comes in contact with a VIN lesion at another site
75% found in non-hair bearing areas, 30-40% multifocal, 15% on both non-hair bearing and hair bearing areas
Persistent abnormal cervical cytology with no abnormality identified on cervical biopsy - given SILs in this region are often multicentric, vulvar SIL can initially present with an abnormal cervical cytology result

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8
Q

Natural oral treatment protocol for VIN

A

Methylated folic acid
Beta-carotene
Green tea extract (GTEx)
Berberine
Coriolus versicolor
Vit E
Vit C

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9
Q

Pt applied tx VIN

A

Podofilox (Condylox)
Compounded cream - thuja EO, lomatium tincture vit A, vit E, green tea
Veregen (sinecatechins) ointment
Imiquimod 5% cream/aldara

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10
Q

dr applied tx VIN

A

Cryotherapy
Trichloroacetic or bichloroacetic acid
Surgical removal

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11
Q

What is the clinical presentation of vulvar cancer?

A

Often with vulvar lesion
Mostly asxs, can be pruritis or bleeding
Lesions unifocal vulvar plaque, ulcer, or mass (fleshy, nodular, warty) on labia majora, labia

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12
Q

What are the signs and symptoms of lichen sclerosus

A

Pruritus (hallmark, often so severe it interferes with sleep)
Vulvar irritation
Burning
Dyspareunia
Testing, bleeding, fragility of vulvar skin
Discomfort due to involvement of perianal skin - pruritus ani, dyschezia and rectal bleeding, dysuria

White, atrophic papules that may coalesce into plaques
Labial agglutination
Pale parchment-like appearance of labia
White plaques
Labial atrophy
Narrowing of introitus
Phimosis or fusion over clitorus may cause diminished sexual sensation or even anorgasmia
May present with white plaques on other body surfaces (thighs, breasts, wrists, shoulders, neck, back, and rarely oral cavity)
Anatomical changes can lead to pain, sexual difficulties, and voiding problems

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13
Q

dx lichen sclerosis

A

BIOPSY - reveals subepithelial fibrosis and four cardinal histological features

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14
Q

what are the four features needed on biopsy for dx of lichen sclerosis

A

Atrophy of epidermis with disappearance of rete pegs
Hypertrophic degeneration of basal cells
Replacement of underlying dermis by dense collagenous fibrous tissue
A monoclonal band-like lymphocytic infiltrate

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15
Q

What is the treatment necessary to decrease progression of disease and how is it prescribed?

A
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16
Q

What naturopathic support can be used for tx of lichen sclerosus?

A

Anti-inflammatory diet
Eliminate gluten
Support TH3 pathway (Probiotics, Fish oil, Vit D)
Healthy hygiene habits

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17
Q

What are some other benign dermatoses?

A
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18
Q

What is necessary to diagnose vulvodynia?

A

Vulvar pain localized to the vulvar vestibule, with or without clitoris, of at least 3 months duration, without clear identifiable cause, pain elicited with pressure point testing, which may have potential associated factors

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19
Q

List the signs and symptoms of vulvodynia

A

Vulvar pain - burning, irritating, sharp, prickly, pruritic with vaginal intercourse, tampon insertion, tight clothing, prolonged sitting, biking, or other spots
Pain can be immediate or delayed and discomfort can persist or resolve on its own
Pain is sufficiently severe to limit sexual function, cause psychological distress, impair relationships, and/or adversely affect routine activities
Often associated with other chronic pain conditions

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20
Q

What test is commonly used during a physical exam of vulvodynia?

A

cotton swab test

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21
Q

As vulvodynia is of multifactorial causes, list 1 or 2 treatments to address each cause.

A

Discontinue scented detergents, soaps, etc
Discontinue OCs
Eliminate tight clothing
Sitz baths
Lubricants without alcohol or warming agents -
Discontinue bikes, horseback riding
Cold sitz baths, ice packs to vulva
Castor oil packs to abdomen and vulva
Low oxalate diet, anti-inflammatory diet
Calcium citrate
Fish oils
Compound cream with vit A/E
Pelvic floor therapy
Superficial perineal massage
Vaginal dilators
Biofeedback
Hypnosis
CBT
Sex therapy, couple therapy
Pharmaceuticals
Topical tx - anesthetics, ELA cream gabapentin, amitriptyline, estrogne, cromolyn, vaginal prasterone, androgens
Oral meds (2nd tier): gabapentin, amitriptyline, cymbalta, lyrica, tricyclic antidepressants
Third tier - intralesional injection of steroids and bupivacaine, botulinum neurotoxin A
Surgery; perineoplasty and vestibuloplasty
Multi level nerve blockade

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22
Q

ASC-US

A

atypical squamous cells of undetermined significance

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23
Q

ASC-H

A

atypical squamous cells cannot r/o high-grade lesion

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24
Q

CIN1

A

LSIL, mild dysplasia (historial)

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25
Q

CIN2

A

HSIL, moderate dysplasia (historical)

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26
Q

CIN3

A

HSIL, severe dysplasia or carcinoma in situ (CIS) (historical)

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27
Q

AGC

A

atypical glandular cells

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28
Q

VaIN vs VIN

A

VAginal va Vulvar intraepithelial neoplasia

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29
Q

What is the cause of virtually all cervical cancer?

A

HPV infxn

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30
Q

what are the two main types of cervical cancer and the main HPV type causing each?

A

SCC (93%) - HPV 16
Adenocarcinoma - HPV 18

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31
Q

How is HPV transmitted and what 2 strains are the most oncogenic or virulent?

A

Genital HPV is transmitted by skin to skin contact via vaginal or anal intercourse most commonly; nonpenetrative genital contact possible but rare
90% cancer cases are HPV 16/18; most virulent

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32
Q

list 4 risk factors that increase the risk of developing cervical cancer

A

smoking
OCPs
uncircumcised males
chlamydia infxn

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33
Q

MOA smoking as a RF for cervical cancer

A

metabolites of nicotine concentrate in cervical tissue, increasing duratino of HPV infxn; lowers immune response

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34
Q

MOA OCPs as a RF for cervical cancer

A

estrogen inhibits oxidative stress induced apoptosis > dec DC ability to present Ag to be kills

dec Th1, inc Th2

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35
Q

MOA chlamydia infxn as a RF for cervical cancer

A

inc expression HPV 16, inc growth factor and receptor expression

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36
Q

Write the key differences between the 2012 and new 2019 guidelines around HPV/cervical cancer testing

A

Change from primary test results-based algorithms to primary “risk-based” guidelines

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37
Q

List the factors that protect against HPV infection or prevention

A

Cervical cancer screening
HPV vaccine
Condoms
Secondary prevention - monitoring

38
Q

List the guidelines for use of HPV testing.

A

Start screening age 21
For women <25; cytology every 3 years
For women >25: cytology every 3 years or HPV testing alone, co testing HPV and cytology every 5 years*, HPV testing alone every 5 years

Stop screening 65-70 that meet criteria; no hx of CIN in last 25 years
Discontinue surveillance with limited life expectancy

39
Q

If HPV testing is used as primary screening what is recommended if the test is negative and what is recommended if the test is positive?

A

Negative: screening is recommended no sooner than 3 years

Positive: reflex cytology regardless of genotyping if reflex testing is not feasible pt should have colposcopy and additional cytology test is recommended

If positive and genotyped to 16/18 go to colposcopy

40
Q

What age is cervical cancer screening to begin; when is it to be discontinues?

A

Begin: 21

Discontinued: at 65-70 yo for women with evidence of adequate negative prior screening (three consecutive negative cytology results or two consecutive negative co-tests within the previous 10 yrs, with the most recent test within the previous 5 yrs)

41
Q

What are the guidelines for patients post hysterectomy for screening or management?

A

If surgery is for benign reasons and no previous diagnosis of CIN 2 within the previous 25 years or have completed the 25 year surveillance period

If surgery is performed for treatment, pt should have 3 consecutive annual HPV-based tests before entering long-term surveillance (3 year HPV testing for 25 years)

42
Q

When are endometrial cells on the pap considered abnormal?

A

Postmenopausal

43
Q

What the sxs of cervical cancer?

A

Postmenopausal bleeding
Metrorrhagia
Postcoital bleeding
Vaginal discharge
Pain

44
Q

When you refer a patient for colposcopy what do you tell her to expect? What do providers do when they perform colposcopy?

A

Visualize the external genitalia, vagina, cervix after application of acetic acid or lugol’s (iodine) to identify lesions/vascular abnormalities

Determine if the colposcopy is satisfactory or adequate: able to visualize the entire SCJ & all of the borders of the lesions

Biopsy the all abnormal lesions on exocervix (2-4 biopsies recommended).

Perform an endocervical curettage. (ECC) unless C/I.

Analyze the histopathology & pap/HPV results in combination with the colposcopy findings to determine the treatment & management plan for the patient.

45
Q

When HSIL is diagnosed, when is immediate tx recommended/preferred and when is observation acceptable and unacceptable?

A
46
Q

What is the suggested guideline for surveillance for HSIL in pats ≥ 25 yo and younger than 25 yo?

A

<25 observation
> 25 colposcopy at 6 and 12 month and diagnostic excisional procedure

47
Q

List excisional treatment options and ablative treatment options for VIN and when it is acceptable to use ablative procedures.

A

Excisional: cold knife, LEEP and laser

Ablation: cryotherapy, laser ablation, and escharotic treatment used with colposcopy is adequate and the lesion covers less than 75% of the surface area of the ectocervix

48
Q

List the obstetrical complications associated with excisional procedures.

A

Cervical stenosis
Premature rupture of membranes
Preterm delivery

49
Q

List the components of escharotic treatment and when it is an option for a patient

A

Bromelain
Calendula officinalis
ZnCl
Vag Pack Suppositories

Indications
Used in cases of CIN 2, 3 with an adequate colposcopy, ECC, in some cases of persistent CIN 1

50
Q

List the common nutrients and botanicals with doses given orally for HPV related disease process.

A

Vitamin E
Folic Acid
Vitamin C
DIM (diindolylmethane)
Green tea extracts (GTE)
Berberine
Coriolus Versicolor

51
Q

Which vaccine is available in the US for HPV and what strains does it cover; what genders and ages is it acceptable to be given.

A

Gardasil 9: 6, 11, 16, 18, 31, 33, 45, 52, and 58

Females: 11-12, catch-up recommended for females aged 13 to 26 years who have not completed the vaccine series

Males: 11-12, catch-up recommended for males aged 13 to 21 and 22 to 26 years old if they are men who have sex with men or immunocompromised

Individuals initiating the vaccine series before 15 years of age – Two doses at 0 and at 6 to 12 months.

Individuals initiating the vaccine series at 15 years of age or older – Three doses of HPV vaccine should be given at 0, 1 to 2 (typically 2), and 6 months.

52
Q

What is the pH of the vagina?

3.5-4.5
3-4
5-6
6-7

A

3.5-4.5

53
Q

What does lactobacillus produce?

Lactic acid
H2O2
H2O
Lactic Acid + H2O2

A

Lactic Acid + H2O2

54
Q

Which of the following does not impact the vaginal ecosystem?

Menstruation
Tampons
Seamen
Water

A

Water

55
Q

What is vaginosis?

Infection of vaginal canal

Inflammation of vaginal canal

Milky white vaginal discharge

Vaginal bleeding

A

Infection of vaginal canal

56
Q

What are hypoestrogenic states?

Postpartum

Lactation

Genitourinary syndrome of menopause

POI

All of the above

A

All of the above

57
Q

What are the effects of low estrogen on the body?

Decreased maturation of vaginal epithelium

Vagina shortens

Loss of rugae

Pale in color

All of the above

A

All of the above

58
Q

Which cells of the vgainal epithelium grow when there is no/low estrogen?

Superficial
Intermediate
Parabasal
Basal

A

Parabasal

59
Q

Which of the following is false in regards to GSM sx

Dyspareunia
Pruritus
Bleeding
Cramping

A

Cramping

60
Q

Which of the following is TRUE in regards to the GSM pelvic exam?

Labia minora enlargement
Urethral meatus decreases in prominence
Tissue fragility
Increase in secretions/lubrication

A
61
Q

Which of the following is TRUE in regards to the GSM pelvic exam?

Labia minora enlargement

Urethral meatus decreases in prominence

Tissue fragility

Increase in secretions/lubrication

A

Tissue fragility

62
Q

How is GSM diagnosed?

Clinically
Diagnosis of exclusion
Imaging
Labs

A

Clinically

63
Q

What is the first line treatment for GSM

Nonhormonal moisturizers and lubricants

Hormonal/estrogen creams

Hyaluronic acid

Oral estrogen

A

Nonhormonal moisturizers and lubricants

64
Q

What are common causes of irritant vaginitis

Latex
Spermicides
Soaps
All of the above

A

All of the above

65
Q

What are the 3 most common vaginitis?

Candida, Chlamydia, Gonorrhea

Candida, trichomoniasis, syphilis

Candida, trichomoniasis, bacterial

Candida, trichomoniasis, chlamydia

A

Candida, trichomoniasis, bacterial

66
Q

What is the discharge associated with Candida vaginitis?

Green
Yellow
White
Gray

A

White

67
Q

What is the pH associated with Candida vaginitis?

4.5
5
7
2

A

2

68
Q

Which infection(s) has a positive whiff test/ KOH test?

Candida
Trichomoniasis
Bacterial
Two of the above

A

Two of above; trich and bacterial

69
Q

What are the findings on a wet mount that suggest candida infection?

Pseudohyphae
Motile trichomonads
Clue cells
Broad waxy casts

A

Pseudohyphae

70
Q

What is the color of the discharge associated with trichomoniasis infection?

Green/yellow
Gray
White
Red

A

Green/yellow

71
Q

What is the pH associated with trichomonas infection?

4.5
5
7
2

A

7

72
Q

What are the findings on a wet mount that suggests trichomonas infection?

Pseudohyphae
Motile trichomonads
Clue cells
Broad waxy casts

A

Motile trichomonads

73
Q

What is the color of the discharge associated with bacterial vaginosis?

White
Green
Yellow
gray/white

A

gray/white

74
Q

What is the consistency of the discharge associated with bacterial vaginosis?

Thick, clumpy,
Frothy, thin
Thin, watery
None of the above

A

Thin, watery

75
Q

What are the signs and symptoms associated with candida?

Vulvar itching
Dyspareunia
Dysuria
All of the above

A

All of the above

76
Q

Which condition is associated with a fishy odor with vaginal discharge?

Bacterial vaginosis
Candida
Trichomonas
Chlamydia

A

BV (Trich can also have fishy odor d/c)

77
Q

How is candida diagnosed?

Normal pH

Spores, hyphae, yeast bids on wet prep

Addition of KOH removes debris that obscures hyphae

All of the above

A

All of the above

78
Q

What are complications associated with bacterial vaginosis?

Preterm birth
PID
Endometritis
All of the above

A

All of the above

79
Q

What are the organisms associated with BV?

Gardnerella
Mycoplasma hominus
Mobiluncus
Ureaplasma urealyticum
All of the above

A

All of the above

80
Q

Which symptoms are not associated with BV?

Pruritus
Fishy odor
Abnormal d/c

A

Pruritus

81
Q

What is not included in the amsel criteria?

Increased homogeneous thin vaginal discharge
pH is greater than 4.5
Positive whiff test
Absence of clue cells

A

Absence of clue cells

82
Q

Which of the following is not a symptom of cytolytic vaginosis?

Pruritus and burning
Dyspareunia and dysuria
Abnormal bleeding
Slight to abundant severe whitish d/c

A

Abnormal bleeding

83
Q

Which of these does not point towards diagnosing cytolytic vaginosis?

Presence of d/c
pH 3.5-4.5
Absence of other causes on wet prep
Low amount of lactobacilli on culture

A

Low amount of lactobacilli on culture

84
Q

What is the discharge of group B streptococcus?

White, yellow, stretchy, copious

Thick, curdly, white discharge

Frothy, green/yellow

Thin, white/gray

A

White, yellow, stretchy, copious

85
Q

What are the results of the wet prep for Group B Strep?

> 50 WBC
Chains of cocci
Hyphae
A and B

A

> 50 WBC
Chains of cocci

86
Q

Desquamative Inflammatory Vaginitis etiology?

Absence of lactobacilli
Overgrowth of lactobacilli

A

Absence of lactobacilli

87
Q

Which of the following is false of the symptoms of Desquamative Inflammatory Vaginitis?

Pain
Copious, yellow, green, or gray
Pruritus
None of the above

A

Pruritus

88
Q

Which of the following wouldn’t you find on PE for DIV?

Vestibule may be thinned, sensitive, erythematous or edematous

Spotty ecchymotic rash

Erosive lesions of cervix

Pale external genitalia

A

Pale external genitalia

89
Q

Which of the following is not a part of the diagnostic criteria for DIV?

At least one of following: vaginal discharge, dyspareunia, pruritus, burning, irritation

Spotted ecchymotic rash, erythema, focal or linear erosion

pH < 4.5

Saline microscopy showering increased numbers of parabasal and inflammatory cells

A

pH < 4.5

90
Q

What is not a way to prevent vaginitis generally?

Whole food diet
Probiotics
Spandex garments
Cotton undergarments

A

Spandex garments

91
Q

Which of the following represents the discharge present in vaginal cancer?

Watery, blood-tinged or malodorous
Copious, yellow, green, or gray
White, yellow, stretchy, copious
Thick, curdly, white discharge

A

Watery, blood-tinged or malodorous

Repro (7 decks)

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