Women's Health Exam #3 Flashcards
1
Q
3 things we need for intact menses
A
Intact HPO axis
Endometrial response to stimulation
Way for blood to exit
2
Q
Primary amenorrhea
A
Have never had a period
Often due to a genetic abnormality
3
Q
Secondary amenorrhea
A
Misses 3 cycles or 6 consecutive months
MCC is pregnancy
4
Q
2nd MCC od secondary amenorrhea
A
PCOS
5
Q
Sheehan’s syndrome
A
Blood loss during birth leads to pituitary necrosis
6
Q
Mullerian dysgenesis
A
No internal female sex hormones except for ovaries
7
Q
Asherman’s syndrome
A
Uterine fibroids cause unable evacuation of blood
8
Q
Anatomical blockages causing amenorrhea - 2
A
Transverse septum
Imperforate hymen
9
Q
Dx for asherman’s syndrome
A
Hyerosalpingogram
10
Q
Progesterone challenge test
A
Give progesterin - if they bleed afterwards they are anovulatory
11
Q
Estrogen and Progesterone challenge test
A
No bleed afterwards means blockage
Bleading afterwards = hypogonadism
12
Q
Secondary dysmenorrhea
A
Casued by something demonstrable
13
Q
Membranous dysmenorrhea
A
Due to passage of a cast of the uterus through the cervix
14
Q
Primary dysmenorrhea
A
No known cause - MC type of dysmenorrhea
15
Q
First line tx for dysmenorrhea
A
NSAID - 400-800 with no more than 1200mg per day
May take prophylactically
Acetaminophen less effective
Continuous heat helps - need a break
16
Q
Erythema ab igne
A
Rash associated with chronic heat pad use
17
Q
2nd line tx for dysmenorrhea
A
Hormonal contraceptives
Lyletta, Morena - Progesterone IUD
18
Q
Percent of women with PMS or PMDD
A
75%
Highest in 20s to 30s
19
Q
Tx for mild to moderate PMS/PMDD
A
Dietary changes - caffeine, alcohol, sodium
Exercise - aerobic
Chasteberry, Calcium carbonate - OTC
NSAID for pain
Spironolactone for bloating
Bromocryptine for breast pain
20
Q
Tx for severe PMS/PMDD
A
SSRI - 1st line with 50% helped, can be used periodically
2nd line - Hormonal therapy
May consider alprazolam
GnRH agonist - put pt in menopause
21
Q
Transvaginal US taking
A
Need an empty bladder - see pelvic organs
22
Q
Transabdominal US taking
A
Full bladder, less visualization of pelvic organs
23
Q
Sonohysterography
A
Saline injected into intrauterine cavity - increased sensitivity
24
Q
Gold standard for uterine pathology evaluation
A
Hysteroscopy - camera in the uterus
25
Tx for Dysfunctional Uterine Bleeding
r/o pregnancy or cancer - oral contraceptives, observation if asymptomatic and no cancer
Levonorgestrel IUD, D&C for short term ablation
26
Postmenopausal DUB
MCC - exogenous hormones
Always investigate
May actually be bleeding from vagina
27
Workup to r/o tumors of reproductive tract in DUB
Endometrial sampling
28
Endometrial ablation
Need to take birth control, not want to be fertile
Reduces flow in 70-80%
29
Pretreatment for endometrial ablation
Abx NOT needed
GnRH agonist or D&C to thin out endometrium
30
CI to endometrial ablation
Pregnancy, Desire to have children, Endometrial hyperplasia, Postmenopause, IUD in place
31
Vaporization endometrial ablation
Nd-Yag laser
Early method
Scar endometrium
32
Roller ball
Similar to vaporization
Old method
33
Endometrial resection
Old method - caused a lot of perforation
34
Hysteroscopic thermal endometrial ablation
2nd generation
Heated saline put in uterus
Good for anatomic abnormalities
Higher burn risk
35
Radiofrequency thermal ablation endometrial ablation
2nd gen
No D&C or progesterin needed
Uses a heasted mesh
36
Thermal + RF Endometrial ablation
Brand - Minerva
Silicone contours to shape of cavity
Balloon filled with RF heated Argon gas
Endometrial prep not needed
Higher success rates
2nd gen
37
Water vapor termal endmetrial ablation
Seal with baloons and fill with water
2nd gen
Safer
38
Cryoablation endometrial ablation
Less pain but less effective
2nd gen
39
Theraml balloon endometrial ablation
Use balloon to conform to contours of uterus
No longer done in US - too much burning
40
Sites of endometriosis
Other sites in the abdomen
Or distant site outside of the abdomen - can be anywhere
41
Risk factors for endometriosis
Fam hx
Early menarchy
Nulliparity
LOng flow
Heavy periods
Shorter cycles
IE. anything that increases menstrual bleeding
42
Presentation of endometriosis
Dysmenorrhea
Pelvic pain
Dyspareunia
Infertility
May worsen with period
Severity does not corespond to amount of ectopic tissue
43
PE for endometriosis
Tender nodules in posterior vaginal fornyx
Pain with uterine motion
Tender adnexal masses may be felt
May have no findings
44
Dx for endometriosis
Imaging is usually not helpful
Laparoscopy to diagnose definitively
45
Lesions of endometriosis
Powder burns
Chocolate cysts
Red/Purple raspberry spots
46
Tx for mild/moderate endometriosis
NSAID
Progesterone contraceptives
47
Tx for moderate to severe endometriosis
Hormonal - GnRH agonists or antagonists - ie. danazole, letrozole
Gabapentin
TCAs
Surgery
48
Reason to use surgery for endometriosis
Do it when they are wanting to have children b/c they can come back
49
Danazol
Testosterone derivative that acts like progestin
Inhibits gonadotropic release
SE - Oily skin, acne, deep voice
50
Anastrozole/Letrozole
Aromatase inhibitors
Can be used as an adjuvant to Danazol
51
GnRH agonists
Leuprolide, Goserelin, Nafarelin
For endometriosis
Use for max 6 months
Menopause like symptoms
52
GnRH antagonists
Elagolix (Orlissa)
Most studied
Max 6 months at high or 24 months at low dose
Menopause like symptoms
53
Pelvic inflammatory disease presentation
Lower abdominal pain - insidious or acute usually for 2 ish weeks
Oral temp > 101F
Bilateral lower quadrant tenderness
Skene or Bartholin glands around introitus
54
Fitz-Hugh-Curtis syndrome
Liver inflammation with PID
55
Classic sign of pelvic inflammatory disease
Cervical motion tenderness (chandelier sign
56
Dx for PID
Pregnancy test to r/o
WBCs in vaginal fluid
ESR/CRP may be elevated
57
Imaging for PID
May see thickening, tubo-ovarian complex, may be normal
58
Tx for pelvic inflammatory disease
Outpatient abx if they are not too sick and compliant, IV for inpatient
3 Drugs at same time:
Rocephin shot
Doxy
Metronidazole
14 day course overall
59
Presentation of tubo-ovarian abcess
Tenderness and guarding
Mass in abdomen
Multi-loculated lesion on US
60
Tx for unruptured tubo-ovarian abcess
Same abx as PID (Metro, Doxy, Rocephin) but for 4-6 weeks
61
Tx for ruptured tubo-ovarian abcess
Life threatening emergency
TAH (total abdominal Hysterectomy) and BSO (bilateral salpingo-oophorectomy) with aggressive fluid resuscitation
62
Cystocele
Prolapse of the bladder d/t anterior vaginal wall weakness. Visualized through the vagina and better seen when bearing down
63
Rectocele
Rectal prolapse d/t posterior vaginal weakness
Seen in bearing down
64
Uterine prolapse
Uterus slides down towards the introitus
65
Pelvic organ prolapse stages 0-4
Halfway system
0 - Normal
1 - Halfway to hymen
2 - To hymen
3 - Halfway past hymen
4 - Maximal descent
66
Presentation of pelvic organ prolapse
Feeling of heaviness in vagina, urinary symptoms with cystocele
Talk about putting fingers in vagina to brace it when urinating/defecating
67
Dx for pelvic organ prolapse
Pelvic exam with bearing down
Imaging only if worried about secondary problem
68
Tx for pelvic organ prolapse
Pessary - reexamine in 1-2 weeks for first one, then every 2-3 months after that
Kegal exercises
69
Surgical tx for POP
May use mesh or other surgery - mesh can cause irritation
70
Adenomyosis
Endometrial tissue implants in the myometrium
Focal or diffuse
71
Risk factors for adenomyosis
Parity and age
72
Presentation of adenomyosis
More areas of invasion = more s/s
Menorrhagia, dysmenorrhea
Global uterine ENLARGEMENT with uterine softening
73
Imaging for adenomyosis
TVUS
Focal thickening of myometrium on US
Heterogenous texture on US
74
Tx for adenomyosis
NSAIDs for pain
Combo oral contraceptives
Endometrial ablation/resection may help somewhat
75
Definitive tx for adenomyosis
Hysterectomy
Symptoms also get better after menopause - ride out
76
Leiomyoma
Benign neoplasm of the female genital tract - uterine fibroids
77
Submucous leiomyoma
Directly beneath endometrial lining - on the inside!!
78
Subserous leiomyoma
Directly beneath serosal lining - on the outside!!
79
Intramural leiomyoma
Completely within the myometrium
80
Presentation of leiomyomas
Most are asymptomatic
MC symptoms are - Abnormal bleeding, pelvic pressure/pain
May torse - causing pain
May compress nearby organs
81
PE for leiomyomas
Enlarged uterus with irregular contour
82
Dx for leiomyomas
Iron deficiency on labs
US can detect
MRI for more detail
Hysterography/Scopy can also help
83
Tx for asymptomatic leiomyomas
Can monitor with a yearly US - not a big threat to health
84
Tx for sympomatic leiomyomas
NSAIDs or hormonal therapy depending on sx
Regress spontaneously during menopause - menopausal hormone therapy may bring it back
85
Surgical tx for leiomyomas
Total hysterectomy
Myomectomy - just remove fibroid
Embolization - Clot it up - good results
86
Peak onset for endometrial cancer
70s - many cases can occur younger
Obestity increases risk
87
Precursor to endometrial cancer
Endometrial hyperplasia
Excess estrogen!!
88
MCC of endogenous over production of estrogen
Obesity - From the fat!
89
Other risk factors for endometrial cancer
PCOS
Exogenous unapposed estrogen therapy (w/o progestin and no hysterectomy)
More peiords (ie. early menarche, less pregnancies)
90
Risk reduction for endometrial cancer
Progestin or combination contraceptives
91
MC symptoms of endometrial hyperplasia
Abnormal uterine bleeding
Simple or complex atypia (complex more likely to become cancer but progesterone cures both)
92
Tx for endometrial cancer WITHOUT atypia
Progesterone
93
Endometrial hyperplasia with atypia
More concerning that simple/complex
Progesterone will not cure
94
Type I endometrial cancer
Not as aggressive
YOunger patients
Better prognosis
95
Type II endometrial cancer
Less common
Poorer prognosis
Independant of estrogen
96
Classic endometrial cancer patient
Obese
Nulliparous
Infertile
HTN
DM
White
97
MC type of endometrial cancer
Adenocarcinoma
98
Presentation of endometrial cancer
Abnormal bleeding in 80% of patients - postmenopausal bleeding may be an indicator
Vaginal discharge
Cervical os stenosis
99
PE for endometrial cancer
May feel inguinal lymph nodes
Normal in early stages
100
Imaging for endometrial cancer
US with endometrial thickness over 4 mm is high suspicion for cancer
DDx - Biopsy
101
Other tests that may pick up endometrial cancer
D&C - even better than biopsy
Sometimes picked up on pap smear
102
Tx for endometrial cancer
Surgery is mainstay - total hysterectomy with BSO - curative in low risk
103
Adjuvant pharm for endometrial cancer
Radiation, Progesterone, Chemo - Doxyrubicin and Cisplatin
104
Tx for excess bleeding in endometrial cancer
NO IV estrogen like we would with other bleeding
Tamponade and Packing
105
Functional ovarian cysts
Due to cyclic ovarian changes - do not always cause symptoms
Can rupture causing peritonitis
Impinge organs
106
Dx for ovarian cyst
Pelvic US is MC way to dx
107
Follicular cyst
MC type of ovarian cyst
Follicle doesn't rupture appropriately
Usually asymptomatic
May cause irregular menstual bleeding
108
Management of follicular cyst
Usually resolve in 2 months
OCP can keep cysts from forming
May aspirate or surgically remove - usually not necessary
109
Corpus luteum cyst
Corpus luteum did not regress
Progesterone abnormalities may lead to late period
Torsion, pain, can look like ectopic pregnancy
110
Tx for corpus luteum cyst
Manage symptomatically
OCP questionable
Surgery if problematic
Ring of fire on US
111
Theca Lutein cyst
Caused by elevated hCG
Often bilateral and multiple
Resolve once hCG goes down
May aspirate in pregnancy
112
Endometriomas
Implant of endometrial tissue on the ovary
Endometriosis symptoms - chocolate cysts
113
Dermoid cyst
Filled with improper tissue - fat, teeth, etc.
Not cancer
May rupture
114
Cystadenomas
Cysts that get massive - pain and discomfort
Pop, drain, remove
115
PCOS
Stein Leventhal syndrome
Enlarged ovaries with multiple cysts
Anovulaotry, amennorheic
Obese, overweight patients
116
Diagnosis of PCOS
Pt. with variable periods, obesity, hirsutism, oligomenorrhea
Polycystic ovaries on US - Oyster ovaries
117
Presentation of PCOS
Menstural abnormalities, early pregnancy loss, Pelvic pain/pressure, T2DM
Young endometrial cancer dx
Acanthosis nigricans
118
Hormones in PCOS
Mild elevation of androgens
Lower sex hormone binding globulin
Increased LH:FSH ratio
119
US of PCOS
Ovary with many cysts in it - look like dark pockets
120
Tx for PCOS - conservative
Observe symptoms - should be having at least 8 periods a year
Lifestyle changes -loose weight, well balanced diet
121
PCOS moderate therapy
Pregnancy test
COC - if not trying to conceive or ring patch if eligible, helps with hyperandrogenism
Progesterone alone - second line
122
PCOS insulin sensitization
Metformin is MC drug - safe in pregnancy
May also use GLP-1 agonist
123
Tx for PCOS hirsutism
Takes 6-12 months to work
COC or GnRH agonist
Laser removal, etc.
Spironolactone - androgen antagonist
5 alpha reductase inhibitors - finasterid/dutasteride
124
Vaniqua
Expensive hair removal medicine
125
Novel PCOS therapies
Myo-inositol
NK34 antagonist
126
PCOS tx for patients who want to get pregnant
Weight loss and lifestyle
Letrozole on days 3-7 of period
Not safe once pregnant
(Clomid used to be first line - SERM - blocks estrogen in hypothalamus)
127
MOA of letrozoleand 4 SEs
Inhibits aromatoase
SE - hot flashes, dizziness, fatigue, pain
128
Clomid for PCOS
causes ovarian enlargement, hot flashes, bloating
Not great
129
FLuid retention of PCOS tx
Can be extreme - present with hypovolemia and swelling
MC with Clomid, FSH
LC with Letrozole
130
Surgery for PCOS
Ovarian drilling - laparoscopic laser biopsies jump start the ovaries
131
Ovarian torsion
Emergent condition like testicular torsion
Often due to enlarged ovaries
May occur in early pregnancy
132
Presentation of ovarian torsion
Sudden onset severe, one sided unilateral abd pain
Painful adnexal mass
May radiate to thigh, flank, or groin
Women may be used to abdominal pain!!
133
Dx for ovarian torsion
Sonography - dx of choice
Bull's eye, whirlpool, snailshell pattern
Doppler flow disruption
Do pregnancy test
Transvaginal US may be better
134
Tx for ovarian torsion
Laparoscopic detorion ( can do laparotomy)
Remove cyst causing problem
Remove if 12+ hours - obvious necrosis
135
MC source of ovarian cancer
Epithelial ovarian cells
136
Ovarian cancer
CA-125 marker - from serous cystadenomas
Typical in menopausal patients
137
Other types of ovarian cancer
Germ cell tumor - younger patients
Sex cord stromal tumors
138
Risk factors for ovarian cancer
Anything that increases cell turnover
Talcum powder
139
Presentation of ovarian cancer
Vague early symptoms
Early satiety
Fatigue, back pain
Late - abdominal pain, ascites, solid irregular adnexal mass
140
Sister Mary Joseph nodule
Belly button nodule due to ovarian cancer
141
CA-125 marker for ovarian cancer
Elevated in 50% of ovarian cancer
Associated with many other things - fibroids, endometriosis
More specific for postmenopausal women
142
Dx for ovarian cancer
Various markers
Pelvic US w/ solids, separation, ascites
CT/MRI for more exact
Bx for definitive
143
Tx for ovarian cancer
Remove omentum, ovaries, uterus
Watch CA-125 to see if cancer resolved
144
Tx for germ cell ovarian cancer
Often try to save the uterus - not as aggressive
145
MC GYN malignancy
Uterine cancer
Ovarian - 2nd
146
Sexual response stages - 4
Desire
Arousal
Orgasm
Resolution
147
Hormones that increase libido
Estrogen
Testosterone - uspraphysiologic
Dopamine
Norepinephrine
Oxytocin
Melanocortins
148
Hormones that inhibit libido
Serotonin - at high levels
Prolactin
Opioids
Endocannabinoids
149
Average female puberty onset
8-13 years old
150
MC sexual dysfunction in women
Low sexual desire - 39% of disorders
151
Female arousal/interest disorder
Low desire or abnormal arousal - must occur 75%+ of the time, lasts for 6+ months
Causes distress
152
6 criteria for female interest arousal disorder
Must report 3:
Absent interest in sex
Reduced fantisizing
Reduced initiation
Reduced interest/arousal to stimuli
Reduced excitment/pleasure
Reduced sensation
153
Genitopelvic pain/Penetration disorder
Pain majority of time with sex
TIghtening of muscles
Avoid vaginal sex
Common hx of trauma or abuse
154
Female orgasmic disorder
Don't feel like they finish the way they want to
May be due to neuropathy, partner issues, etc.
155
Medications related to sexual disorders
SSRI!
TCA
Benzos
Lithium
Anticholinergic
HTN meds - BB
SERM/Aromatise inhibitors
156
Estrogen for sexual disorders
Increases libido, vaginal lubrication, blood flow to genitalia
CI - Blood clots, endometrial cancer
Recommended if more than just libido
157
Androgens for sexual disorders
Generally not recommended - may be used in menopause
Cause hirsutism, acne, liver disease
Last line
158
Dosing testosterone for women
Much lower dose than used for men
159
Serotonin/Dopamine for sexual disorders
Flibanserin - post menopause serotonin agonist/modulator helps with SE of SSRI
CI with alcohol, hypotension
160
Bupropion for sexual dysfunction
Helps with norepi and dopamine
Helps with arousal response, etc.
CI in seizures, anorexia, MAOI use
161
PDE-5 inhibitors in womens sexual dysfunction
Slidenafil
Most helpful with physiologic problems - ie. vascular, neuro
CI with nitrates
162
Bremelanotide
Agonist of melanocortin receptors for sexual dysfunction
New drug -PRN injection stop if no benefit in 6 weeks
CI in liver disease, pregnancy
163
Other tx for female orgasmic disorder
Sexual devices
Directed masturbation - usually best for partner not to participate at first
No scientific evidence for genital cosmetic precedures
164
Tx for sexual pain disorders
Lubricants and estrogen for vaginal atrophy
PT for pelvic floor if estrogen fails
165
Tx for vaginismus
PT, Counseling, Gabapentin/Botox
166
Tx for vulvodynia
Lidocaine, TCA, Remove irritants, PT
167
MC symptom of cevicitis
Discharge -many are asymptomatic
168
Cervicitis v. Vaginitis
Discharge see from cervcle os in cervicitis
169
Strawberry cervix
Indicates trichomoniasis
170
Presentation of chronic cervicitis
Often asymptomatic
Discharge - less than acute
Vaginal bleeding
Cervical tenderness
Proximal vagina may look okay
Urethritis, pelvic pain
171
Microscopic analysis for cervisitis
Gram stain, Wet mounts - clue cells
KOH prep
PCR
172
Pap smear/ Colposcopy for cervicitis
Double hairpin capillaries for trichomonas
Excess leukocytes
Cell enlargement - HPV
Multinucleated cells with ground glass cytoplasm - HSV
173
Biopsy where cell properties have changed
Indicative of a virus!!
174
Cervicitis prevention and screening
Barrier contraception
Routine screening in 19-25
Remove cervix with hysterectomy
175
Incompetent cervix
Cervix shortens before 28 weeks gestation
Painless
176
Risk factors for cervicle insufficiency
Cervical conization or Hx of previous episode
177
Presentation of cervical insufficiency
2+ cm dilation with minimal contractions
2nd trimester
178
Screening for cervical insufficiency
US at 14-16 weeks
Look for funneling and shortening abnormalities
No way to predict
179
4 cervical insufficiency abnormalities
TYVU - Trust Your Vaginal Ultrosound
Shape of cervix -increasing risk and progression from T to U
180
Tx for cervcal insufficiency
Circlage
181
3 things to look for before circlage -Contraindications
Make sure fetus is still viable 1st
Rupture of membranes
Look for infection - treat first
182
Pharm tx for cervical insufficiancy
Adjunct to circlage - progesterone
183
Nabothian cysts
Blocked glands on the cervix
Smooth rounded, whitish area that does not hurt
Benign!!
184
CIN I-III
I - 1/3
II - 2/3
III - In theory entire cervix
185
When do we NOT treat CIN I and II
Pregnant women - wait for delivery
Adolescents - observe at first
186
Main risk factor for cervicle dysplasia
HPV!!!
187
Pap smear screening
Start at 21 3 years
Every 3 years or PAP+HPV every 5 years 30-65
188
Pap screening after 65
Stop screening if:
No hx of mod-severe dysplasia/cancer
3 negative Pap or 2 neg PAP+HPV
189
ASC-US cells on pap smear
Undetermined significance
190
ASC-H cells on pap smear
Cannot exclude a high grade lesion
191
LGSIL/LSIL on pap smear
Corresponds to CIN I
192
HGSIL or HSIL on pap smear
Corresponds to CIN II or III
193
Atypical glandular cells
Rare - cells from endocervix - MAY indicate cancer, may not
194
Management for ASC-US
2 pap smears over 6 months - send for colposcopy if abnormal
Might try vaginal estrogen
195
Management for anything that is NOT ASC-US
Send for colposcopy
196
Colposcopy
Low power magnification of cervix - uses camera
Add acetic acid to light up abnormal areas
Bx abnormal areas
197
Indications for colposcopy - 5
Abnormal pap smear
Clinically abnormal cervix
Unexplained bleeding
Vulvar/Vaginal neoplasia
Hx of in utero DES exposure
198
Tx for CIN II-III after biopsy
Surgery with evaluation afterwards
199
Management of cervical dysplasia - cryotherapy
Probe to blanch tissue in cervical os - 7mm margin
Makes it hard to visualize for later colposcopy
200
Carbon dioxide laser for cervical dysplasia
More often in operating room
Very precise
More depth of excision
Can biopsy
201
Loop electrosurgical excision procedure
LEEP - Small wire loop to remove with electrical generator
Can biopsy
Best procedure
For cervical dysplasia
202
Cold knife
Cervical displasia
For large areas
No risk to being able to biopsy
203
Prognosis for cervical dysplasia
80-90% success rates for any method
204
Risk factors for cervical dysplasia recurrence -4
Large lesions
Gland involvement
Positive margins
Positive endocervical curretage
205
MC type of cervical cancer
Squamous cell carcinoma
206
Presentation of cervical cancer
MC symptom = Abnormal vaginal bleeding
Bloody leukorrhea, spotting, postcoital
207
Late signs of cervical cancer
Fistula to recum or bladder leading to incompetence
Radiating pain
Weight loss, fever
208
Signs of cervicle cancer
Cervix appears abnormal
Ulceration
209
Endophytic cervix
Barrell shape, enlarged - cancer
210
Exophytic cervix
Friable, bleeding, cauliflower lesions
211
Dx for cervical cancer
Cancer may be present despite negative cytology - if the cervix look suspicious, still suspect
212
Tx for cercal cancer
Radical hysterectomy with lymphadenectomy
Chemo is mostly palliative
213
Normal vaginal flora
Aerobes, anaerobes, yeast
Lactobacilli that make it acidic
214
Normal vaginal pH before and after menopause
Before - 4-4.5
After - 6.5-7
215
Things that can alter vaginal flora
Low estrogen - decrease
Menses - Increase
Abx
Pregnnacy, Hysterectomy
Foreign substances
DM/Poor diet - worse
216
Candidal vulvovaginitis presentation
Often in DM
Pruritis
THick white cottage cheese discharge
Minimal odor
217
Dx for vulvovaginal candidiasis
Normal pH
Branching filaments and psudohyphae on wet prep/KOH
218
Pharm tx for vulvovaginal candidiasis
Azole - 1st line ie. fluconazole
May extend therapy for recurrent cases
219
Alternative vulvovaginal candidiasis tx
Boric acid
Gentian violet
220
Vaginal antifungal administration
Administer at night
221
MOA of azoles
Inhibit enzyme for cell membrane synthesis
222
MOA of nystatin
Increase permeability of cell walls
223
Ibrexafungerp MOA
Inhibits glucan synthesis - cell wall production
DO NOT TAKE with an azole
224
MOA of boric acid
Interferes with metabolism
CI in pregnancy
225
Gentian Violet MOA
May inhibit protein synthesis
Not many drug interactions
226
Presentation of bacterial vaginosis
Milky, homogenous, malodorous discharge
No inflammation
Malodorous esp. after intercourse - fishy
227
Dx of bacterial vaginosis
Vaginal pH 5.5-7
Clue cells - covered in bacteria
Fishy odor on KOH prep - wiff test
228
Tx for Bacterial vaginosis
Metronidazole or Clinda
Can also use an expensive -azole
229
MOA of metronidazole
Bind to and deactivate enzymes
Dizziness, HA, Fatigue
Disulfiram reaction
230
Clindamycin MOA
Binds to ribosomes
C diff - and not with imodium
231
Vaginal douche
Washing out of vagina - only for bacterial vaginosis - NOT for regular cleaning
232
Presentation of trichomonal vaginitis
Frothy, copious green, foul smelling vaginal discharge
Strawberry cervix
233
Dx for trichamoniasis
pH 5-5.5
Motile wet prep - look at right away before they die
Culture = Best test
234
Tx for trichomonal vaginitis
Metronidazole or other ~idizole's
Cross reactivity to alcohol
Liver disease
235
Presentation of gonorrhea
80-85% asymptomatic
Copious mucopurulent discharge
236
Dx for gonorrhea
Nucleic acid probe
Or culture of discharge
237
Tx for gonorrhea
One shot IM rocephin
Treat partners
238
CHlamydia presentation
Cervicitis, dysuria, bleeding
May progress to PID or lymphogranuloma venereum
CERVIX MAY LOOK NORMAL
239
Dx for chlamydia
Culture
Immunoassay
Pap smear
240
Tx for chlamydia
Doxycycline
ALT: Zmax
241
Noninfectious vaginitis
Irritants, Allergens (latex), Atrophic, Excess sexual behavior
242
Presentation of noninfectious vaginitis
Itching with no bacteria detectable - get a good hx
243
Tx for noninfectious vaginitis
Lubricants
SERM
Sitz bath
Steroid if very painful/inflamed
244
Alternitive tx for vaginitis
White vinegar - better option
Herbals
Iodine
Tea tree oil
May kill of good bacteria!
245
Presentation of genital herpes
Vescicles that become painful erosions or ulcers
My have a buringing prodrome with inguinal lymphadenopathy
246
Dx for genital herpes
Most often clinical
Tzank smear
247
Initial tx for herpes outbreak
7-10 days valacyclovir, Famcyclovir, Acyclovir
1-5 days for recurrent
Same drugs for prophylaxis
248
Condyloma acuminatum MC strains
MC HPV 6-11
249
Presentation of condyloma
Culiflower growths - can be anywhere
May also be flat with rough surface
250
Before tx analysis for condyloma
PAP smear and biopsy
251
Tx for condyloma
Cryotherapy
Podofilox, Imiquimod, Interferon
252
Molluscum contagiousum cause
Pox virus
253
Presentation of molluscum contagiosum
Up to 1cm sized umbilicated papules
Inclusion bodies in cell cytoplasm
254
Tx for molluscum contagiosum
Dessication, Freezing, Imiquimod
May observe - can cause scarring when removed
255
Presentation of syphillis - 3 stages
1 - Painless sore
2 - Palm and sole rash
3 - Involves heart, brain, etc.
256
Tx for Syphillis
PCN 1st line
ALT: Doxy
257
Bartholin gland disease
Glands near vaginal orifices get infected or plugged
Red flag post menopause
258
Presentation of bartholin gland disease
Tenderness - have to duck waddle
Fluctuant tender mass
Systemic signs of infection
259
Tx for bartholin gland disease
Draining won't help
Catheter inflation
Marsupialization - create a pouch
Check for cancer post menopause
260
Abx for Bartholin gland disease
Usually not needed - may still use for prophylaxis
261
Lichen sclerosis
MC non-neoplastic epithelial vulvar disorder
Usually women over 60
262
Presentation of lichen sclerosis
Pruritis is MC sx
May see pain, white lesions, dyspareunia
263
Progression of lichen sclerosis
Erythema w/ no response to yeast tx
White plaques develop
Scratching worsens and inflammation does
264
Chronic presentation of lichen sclerosis
Ciggarette paper
Phimosis of clitoral hood
Labial fusion
General loss of structure
265
Complication of lichen sclerosis
SCC - send for biopsy
266
Tx for lichen sclerosis
Potent steroid - Clobetasol with a taper BID to QD eventually PRN for life
267
Adjuncts for lichen sclerosis
Antihistamine, Tacrolimus, Methotrexate
268
Lichen Simplex Chronicus
Due to a specific trigger or chrinic irritation
No loss of structure like in Lichen Sclerosis
Lots of itching
269
Dx of LSC
Biopsy of lesion
270
Tx for LSC
Hygeine and Sitz bath
Medium potency steroid - fluocinolone, triamcinolone)
271
Lichen planus
Flat white plaques on vagina
Papules on skin
Send to GYN for biopsy
Steroids
272
Dark non cancer vulvar lesions
Melanosis lentigo, etc.
273
Vulvar varicosities
Common in pregnancy, concerning in elderly or non-pregnant
Sclerosing agent to tx
274
Preinvasive vulvar disease
Strong association with HPV
White hyperkeratotic papules with pruritis
Dx through biopsy
275
Tx for preinvasive vulvar disease
More aggressive for higher grade
Excision, ablations, laser
276
Paget's disease - vulvar
Itching, soreness
Red velvet cake presentation with white plaques
Can cause structural breakdown
277
Tx for paget's disease
WIDE local excision - need to recheck
Stop as soon as possible
Very poor prognosis if mets to lymph nodes
278
Vulvectomy
Partial or radical
Removes area of skin +/- lymph nodes
Not great - last resort for cancer
279
Vulvar cancer
90% SCC
Older patients with chronic inflammation or HPV
280
Presentation of vulvar cancer
Itching or macerous skin lesion
May just be a "weird spot" w/ no sx
281
Tx for vulvar cancer
Remove tumor - excise
Rad vulvectomy - may radiate to reduce
Pelvic exenteration if widespread
282
Pelvic exenteration
Removal of everything in the pelvis - diversion of GI and GU tracts
283
Vaginal Intraepithelial Neoplasia
Vagina rather than vulva
Colposcopy andbx to dx
Condylomatous lesions or flat and granular
284
Tx for Preinvasive vaginal disease
Resection, 5FU not as effective
Difficult to get everything out
285
True vaginal cancer
Not spread from the cervix
HPV, Smoking are RF
286
Vaginal SCC
Exophytic or ulcerative lesions in the upper 1/3 of vagina
287
Vaginal adenocarcinomas
MC vaginal primary tumor in young patient
288
Vaginal sarcoma
Highly aggressive with grape like masses
Older pts -upper vaginal wall
289
Vaginal melanoma
Usually towards the distal vagina
290
Tx for vaginal cancer
Exenteration, Radiation
Poor prognosis
