Womens Health: Intro- Vagina and Vulva Flashcards
What are the three layers of the vagina?
Adventicia, Muscularis, mucosa
What are Rugae?
Raised ridges of mucosal layers
What are Rugae composed of?
Epithelial and mucosal layers
What is the function of rugae during sexual intercourse?
Stimulates the penis
What are the different secretions from the vagina?
oMucous from the cervix oMoisture from the endometrial fluids oExudate from bartholin glands oSkene glands oVaginal transudate oSquamous cells shed from the vagina
What is the MOA of mucosal layers release of glycogen?
It undergoes anaerobic bacterial metabolism of the glycogen and Acidifies the vagina, this process is hostile to sperm and protects against infections.
What is the hymen?
The hymen is a piece of tissue that lines the vaginal opening. It has an opening that can be of any size – it can be thin or thick.
Is the hymen vascular?
it is vascular
Is the hymen durable?
It has a variable durability
What is the vaginal fornix?
Recess around the cervix - are the deepest portions of the vagina, extending into the recesses created by the vaginal portion of cervix.
vulva
vulva
What is the vulva?
The external female genitals are collectively referred to as The Vulva.
What type of epithelium is the vulva made up of?
Stratified squamous epithelium
What types of glands can be seen in the vuvla?
Sebaceous glands and apocrine glands
Can you find hair follicles on the vuvla?
Yes there are associated hair follicles.
What is the vagina?
The vagina extends from the vaginal opening to the cervix, the opening to the uterus.
What type of epithelium makes up the vagina?
It is non keratinzed squamous cells
Can you find hair follicles in the vagina?
No
Are there glands in the vagina?
No there are no sebaceous or apocrine glands
What are a Bartholin’s glands
At either side of the vaginal opening are the Bartholin’s glands, which produce small amounts of lubricating fluid, apparently to keep the inner labia moist during periods of sexual excitement.
What are Skene’s glands?
located on the anterior wall of the vagina, around the lower end of the urethra. They drain into the urethra and near the urethral opening and may be near or a part of the G-Spot. These glands are surrounded with tissue (which includes the part of the clitoris) that reaches up inside the vagina and swells with blood during sexual arousal.
Anomalies of the Hymen
Anomalies of the Hymen
What is a Imperforated Hymen?
hymen that is completely closed so that menstrual blood cannot flow out
What is a Microperforate Hymen
A microperforate hymen is when this thin membrane almost completely covers the opening to the vagina, with only a very small hole in the middle, making it difficult for menstrual blood to flow out.
What is a Septate Hymen
a hymen in which there are two openings separated by a narrow band of tissue.
What is hematocolpos?
When the vagina fills with menstral blood
When does a hematocolpos commonly occur?
With combination of menstartion and an Imperforated hymen
Transverse vaginal
Transverse vaginal
What is a transverse vaginal septum?
A faulty fusion or canalization of the ureogenital sinus and Muellerian ducts – A transverse vaginal septum is a horizontal “wall” of tissue that has formed during embryologic development and essentially creates a blockage of the vagina. It can occur at many different levels of the vagina.
When is a complete transverse vaginal septum usually diagnosed
Diagnosis is often delayed until after menarche
How are rare complete transverse vaginal septa diagnosed?
When the menstrual blood is trapped behind an obstructing membrane, the signs and symptoms are similar to an imperforated hymen
When are incomplete transverse vaginal septa usually diagnosed?
The first symptoms of an incomplete transverse vaginal septa usually appear with intercourse.
What is the treatment for transverse vaginal septa?
Corrective surgery.
Longitudinal Vaginal Septum (“Double-barreled vagina”)
Longitudinal Vaginal Septum (“Double-barreled vagina”)
What is a Longitudinal Vagnial Septum?
The distal end of mulerian ducts fail to fuse properly leaving the uterus separate or bicornuate with 1 or 2 cervices.
What is the treatment of Longitudinal Vaginal Septum?
oAsymptomatic- no treatment
oDyspareunia- surgical division of the septum
What is Dyspareunia?
Painful sexual intercourse
Vaginal Agenesis
Vaginal Agenesis
What is vaginal Agenesis?
Congenital absence of vaginal accompanied by variable other genital abnormalities
When a women has vaginal Agenesis what is their keryotype?
Typical normal female keryotype
What will Vaginal Agenesis present with?
Primary amenorrhea or cyclin pain – if there is a functioning uterus
What is the treatment of Vaginal Agenesis?
oMultidisciplinary approach.
oTreatment is deferred until patients contemplating sexual activity
oRepetitive coitus can create a functional vagina
Partial Vaginal Agenesis
Partial Vaginal Agenesis
What is partial Vaginal Agenesis?
When the urogential sinus ( inferior part) fails to contribute to the lower portion of the vagina
What is the lower part of the vagina made up of?
Fibrous tissue
What is the presentation of a partial Vaginal Agenesis?
Similar to an imperforate hymen
Labia Minora Abnormalities
Labia Minora Abnormalities
What are some possible labia minora abnormalities?
Can have labia fusion of hypertrophy in an otherwise normal female, the hypertrophy can be unilateral or bilateral and may occasionally require surgical correction
Abnormalities of labia Majora
Abnormalities of labia Majora
What are some Abnormalities of labia Majora?
Hyperplastic or hypertrophic
Abnormal fusion of the labia Majora is usually associated with what?
Ambiguous genitalia pseudohermaphroditism
Clitoral Abnormalities
Clitoral Abnormalities
What are some Clitoral Abnormalities? Are they common?
No the are rare, agenesis and bifid clitoris, extreamly rare is a double clitoris
Hypertrophy of the clitoris is associated with what?
A number of intersex disorders
Cloacal Dysgenesis
Cloacal Dysgenesis
What are some Cloacal dysgenesis?
Rectocloacal fistula with persistant cloaca is common outlet for the utinary, geneital and intestinal tracts – all go out the same hole
What is a rectovaginal fistua?
Where the vestibule can appear normal but the anus is found in the perineum. A rectovaginal fistula is an abnormal connection between the lower portion of your large intestine — your rectum — and your vagina. Contents of your bowel can leak through the fistula, meaning you might pass gas or stool through your vagina
Benign Disorders of the vulva and Vagina
Benign Disorders of the vulva and Vagina
What is Vaginitis?
Inflammation of the vagina
What is vulvovaginitis?
Inflammation of the vulva and vagina
What is Vaginosis?
Refers specifically to the bacterial overgrowth of normal flora in the vagina
Vulvodynia
Vulvodynia
What is Vulvodynia?
Vulvar pain in the absence of relevant visible physical findings
What are the different types of Vulvodynia?
Generalized and Localized, provoked, unprovoked and mixed
Localized provoked vulvodynia
Localized provoked vulvodynia
What is localized provoked vulvodynia?
Introital pain on vestiular or vaginal entry, dypareunia (pain with sex), vestibular tenderness in the absence of erythemia
Who is localized provoked vulvodynia most commonly seen in?
Younger women (20-30 y/o)
What is the difference between primary and secondary localized provoked vulvodynia?
Primary: pain since the first attempt at physical intercourse
Secondary: Pain after an initial period of pain free intercourse
What is the difference between pure and complicated localized provoked vulvodynia?
Pure: without concomitant vulvovaginitis
Complicated: with recurrent vulvovaginitis
What is part of the DDx for localized provoked vulvodynia?
Vaginismus and Vulcovaginitis
What is vaginismus?
Involuntary contraction of the muscles around introits ( vaginal canal)
What is the treatment of localized provoked vulvodynia?
first 3 mo
next 3 mo
if not improved
The first 3 mo:
•Pelvic floor rehab and biofeedback, maintain vuvlar hygiene (cotton undies), topical 5% lidocaine 1QD, soothing oils, Estrogenic cream, low oxalate diet, supplemental Ca to decrease urinary oxalate crystals.
Next 3 mo if no improved
Oral treatment with TCA or Gabapentin
If not improved:
Surgical therapy or pain clinic
Generalized Unprovoked Vulcodynia:
Generalized Unprovoked Vulcodynia:
what is the common cause of Generalized Unprovoked Vulcodynia?
Unkown etiology, but is commonly seen in older women 60 with HTN
What is Generalized Unprovoked Vulcodynia?
Pain and burning constant sometimes with periods of reliefs and flares
How do you dx Generalized Unprovoked Vulcodynia?
It is a diagnosis of exclusion, must r/o all other possible causes
How do you treat Generalized Unprovoked Vulcodynia?
first 3 mo
next 3 mo
if not relieved:
First 3 mo
TCA- oral Amitriptyline-(BEERS list) initial relief after a few weeks!
Topical amitriptyline with 2% baclofen in water washable base- no s/e
Eliminate irritants
If not relief after 3 mo: Anticonvulsants (Gabapentin)
If not relief: Pain clinic
Bartholin Gland Cysts
Bartholin Gland Cysts
What is a Bartholin Gland Cysts?
Obstruction of the main duct of the Bartholin Gland, retentsion of secretions and cystic dilation
What is the cause of Bartholin Gland Cysts?
Trauma, infection, idiopathic
What is the presentation of Bartholin Gland Cysts?
Vulvodynia, Dyspaarunia, edema, difficulty walking with adducted thighs, fluctuant tender mass
What labs are done for Bartholin Gland Cysts?
Murcopurulent secretions can be cultured.
What is the primary treatment for Bartholin Gland Cysts?
Drainage of infected cyst or abscess by marsupilization or insertion of a word catheter
Can you use abx for the treatment of Bartholin Gland Cysts?
Generally not needed unless surrounding celluitlis
Chemical Vagnitis
Chemical Vagnitis
What is Chemical Vagnitis caused by?
Topical irritants, Allergens, Possibly excessive sexual activity
What is the presentation of Chemical Vagnitis?
Pruitis, buring, irritation, vaginal discharge
What is the treatment of Chemical Vagnitis?
Removal of the offending agent, short course of corticosteroids, sitz baths, topical vegetable oils
Vulvar Lichen Sclerosis
Vulvar Lichen Sclerosis
What is Vulvar Lichen Sclerosis known as?
The most common non- neoplastic epithelial vulvar condition
What is Vulvar Lichen Sclerosis?
Lchen sclerosus (LS) refers to a benign, chronic, progressive dermatologic condition characterized by marked inflammation, epithelial thinning, and distinctive dermal changes accompanied by symptoms of pruritus and pain
thought to be an over activation of the T cells, Autoimmune type disease
Who is most common to have Vulvar Lichen Sclerosis?
Women over 60 y/o
What is the presentation of Vulvar Lichen Sclerosis?
Intense pruitus, Dyspareunia, introtial stenosis, fissures, or posterior deflection of fused labial tissue at the time of intromission (when it goes in)
What does the vulva skin look like in Vulvar Lichen Sclerosis?
Thin, wrinkled, white areas of lichenification and hyperkeratosis (Cigarette paper apperance)
Overall thinning of the epidermis and thickening of the corneum
What may the labia majora look like in Vulvar Lichen Sclerosis?
There may be fusion of the anterior part of the labia majora
What is the effect of excoriation of Vulvar Lichen Sclerosis?
Erosions, fissures, sub epithelial hemorrhages and ulcerations
If there is involvement of the perianal region what will it look like?
In the form of an 8 around the vulva and the anus
What are the complications of Vulvar Lichen Sclerosis?
Associated with a higher risk for SCC
High rate of SSC- need to Biopsy
What is the prognosis of Vulvar Lichen Sclerosis?
Chronic, usually recurs with cessation of treatment, Clobestasole dipropionate
What is used for treatment of Vulvar Lichen Sclerosis?
clobetasol dispropionate ointment- super potent topical steroid
stop the itch scratch itch cycle
Minimize dermal inflammation
Vulvar hygiene
Oral antihistamines
What do patients with Vulvar Lichen Sclerosis need to F/U
Q 3 mo to assess, need to biopsy any changes due to high risk of SCC
Vulvar Lichen Simplex Chronicus
Vulvar Lichen Simplex Chronicus
What is Vulvar Lichen simplex Chronicus?
Benign epithelial thickening and hyperkeratosis of the granulosum later resulting from chronic irritation, Epithelial thinking, Vulvar humid environment will lead to maceration
What do you need to biopsy Vulvar Lichen simplex Chronicus?
Exclude intraepithelial neiplasma nad invasive tumors-
there is no increased predisposition to cancer
What is the histopathology of Vulvar Lichen simplex Chronicus?
Hyperkeratosis and acanthosis
What is the treatment of Vulvar Lichen simplex Chronicus?
Vulvar Hygiene
Oral anti histaminesWhite cotton gloves at night
Topical medium potency BID
How long does it typically take for the vulvar epithelium to heal?
At least 6 weeks
Lichen Planus
Lichen Planus
What is Lichen Planus?
Distinctive inflammatory eruption of the skin and mucos membranes (mouth, vulva, vagina, nails, scalp, nose, ect. )
Does Lichen Planus usually involve the vulva?
No. but if it does it will also be seen in the mouth, be sure to look!
What is the etiology of Lichen Planus?
Disorder of altered cell mediated immunity with exogenoust antigens targeting the epidermin (autoimmune)
Who is Lichen Planus usually seen in?
Women( 40-60)
What is the presentation of Lichen Planus?
Paulosquamous- typically plaques with white lacy patternts on the vulvar trigone and periclitoral area.
May be puritic
How do you treat Lichen Planus?
Typically respond to topical steroids.
Types of Lichen Planus:
Hypertrophic- least common with extensive scarring and destruction may be intensly puritic treatment tends to be resistant
Erosive: Destructive scaring Lichen Planus on the mucose membranes and the vulva with a desqamative vaginitis, variable erosion plus atrophy
Vulvovaginitis
Vulvovaginitis
What are some common risk factors for Vulvovaginitis?
Abnormal anatomy, age, autoimmune disease, BCP, DM, sexual activity
What women must you always consider pregnant?
Any women 8-60 y/o unless tubal ligation, total hysterectomy or menopause
Bacterial Vaginosis (BV)
Bacterial Vaginosis (BV)
What is BV?
An alteration of normal flora, an overgrowth of facultative anaerobes
What is the most common bacteria you will find in BV?
Gardnerella Sp.
What is the presentation of BV?
Homogenous vaginal discharge, an Amine Fishy odor, May have vulvar irritation
What is BV associated with?
Other infections (PID, Post-op infections ect…. )
What is the name of the criteria used to dx BV?
Amsel’s Criteria 3 of the 4 must be positive
What is the Amsels criteria?
o pH> 4.5 (normal is less then 4.5)
o Positive “whiff” test (amine “fishy” smell)
o Malodorous, gray, slightly frothy
o Clue cells
What do Clue cells look like? This may end up on the test like this
Cells with indistinct borders and specks
what is used to treat BV?
Metronidazole (Flagyl) 500mg PO BID x 7 days
What is used for prevention of BV?
Avoid: Douching, use of pany liners, pantyhose, occlusive pantys, undergarments
Use: Regular use of condoms may help [revent BV, exposure to semen may trigger symptoms for some women.
Candidiasis
Candidiasis
What is the Presentation of candidiasis?
Intense Pruritus, burning sensation may follow urination, vulvar erythemia, white curd like vaginal discharge
What is the Etiology of Candidiasis?
Candida sp. Overgrowth (90%)
What is the gold standard for Dx of Candidiasis?
Vaginal culture and saline wet mount
What are some risk factors for developing Candidiasis infection?
Antibiotics, BCP, Steroids, DM, Immunosuppresed, Obese, Pregnancy, Tight Clothes and pantiliners, urinary incontinence, being a women
Is Candidiasis sexually transmitted?
No its not sexually transmitted
What is the treatment of Candidiasis?
OTC Mitconazole (Monistate) or Gentian Violet
Rx: Fluconazole (Diflucan)
Trichomonas Vaginitis
Trichomonas Vaginitis
Trichomonas Vaginitis is know as what?
The most common curable sexually transmitted infection (STI)
What percent of people with Trichomonas Vaginitis develop symptoms?
Only 30%
What is the presentation of Trichomonas Vaginitis ?
Prutitus, Profuse frothy greenish and foul smelling discarge, vaginal Erythema with multipe petechiae (Strawberry spots)
What is the Etiology of Trichomonas Vaginitis ?
Trichomonas Vaginitis which are Flagellated protozoa transmitted sexually – they are motilie organisms that are seen “swimming” in saline under microscope
Where can Trichomonas Vaginitis infect?
The vagina, skene ducts, and urinary tract
What is the treatment of Trichomonas Vaginitis ?
Metronidazole (flagyl) or tinidazole 2 gm once
Flagyl 500 mg BID x 7 days
Normal Discharge:
Normal Discharge:
What is seen midcycle during the estrogen surge?
A clear, mucoid secretion for the cervical os; often perfuse
What is seen during the luteal phase and pregnancy in normal discharge?
Vaginal secretions will be thicker, white and sometime adherent to the vaginal walls
What does estrogen do to the vaginal epithelium?
It thickens the vaginal epithelium by the accumulation of glycogen epithelial cells. Intraepithelial cells metabolizes to lactic acid which will turn the PH to 3.4 to 4.5 which promotes the growth of the normal vagnial flora (Lactobacilli and acidogenic corynebacteria)
What test is used to dx bacterial vaginosis?
Dx: wet mount with clue cells
What test is used to dx candidiasis
Dx via wet prep/KOH cottage cheese look
What test is used to dx Trachomonas Vaginitis?
Dx via wet prep and Trachomonas cells
What test is used to dx normal bacteria?
Dx via wet prep
What is the presentation of a foreign body?
Vaginal bleeding, foul smelling vaginal discharge, less common symptoms: Dysuria, and pelvic pain
Primary Vulvar contact Dermatitis
Primary Vulvar contact Dermatitis
What is Primary Vulvar contact Dermatitis?
Prolonged or repeated exposure to a caustic or physically irritating agent
What are the top three causes of Primary Vulvar Contact dermatitis?
o Over washing
o Use of creams with drying bases
oWetness
Allergic contact dermatitis:
Allergic contact dermatitis:
What is allergic contact dermatitis?
Frank allergic reaction to a low dose substance
What are the three main causes of allergic contact dermatitis?
o Neomycin
o Benzocaine
oPreservative
What is the difference between allergic contact dermatitis and irritant contact dermatitis?
Irritant contact dermatitis is immediate, allergic takes 1-2 days
what is the clinical presentation of vulvar contact dermatitis?
Varying degree of itch, burn and irritation, it can be acute or chonic, may present with acute blistered erosive eruption. Usually subacure or chornic will have excoriations, honey colored crusting, erythemia.
How do you dx vulvar contact dermitis?
Morphology of the rash plus a history of irritants or allergens, biopsys may be needed to sort this out,
How can you dx the allergic etiology:
patch testing by a dermatologist
what are some common vulvar irritants?
Soaps, Medications, sweat, urine, feces, panty liners.
What are some common vulvar allergens?
Vagisil, preservatives, neomycin, condoms, KY jelly, Latex, perfume, nail polish
what is the treatment of Vuvlar Contact dermatitis?
o Stop the irritatnt or allergen exposure
o Topical cortocosteroids
o Non perfumed emollients such as petrolatum or mineral oil
o Night time sedation for sleeping
o Abx may be needed for secondary infections
o If severe- prednosome 1mg.kg decreaseing over 14-21 days
Vaginal and vulvar cancer
Vaginal and vulvar cancer
Preinvasive Disease of the vagina
Preinvasive Disease of the vagina
What is the most asymptomatic Preinvasive Disease of the vagina?
Vagnial Intraepithelial neoplasm- most asymptomatic
Preinvasive Disease of the vagina lesion are often accompanied by what?
Lesions often accompany HPV infections- Vulvar warts
What is commonly the fist signs of a Preinvasive Disease of the vagina?
Abnormal pap spears usually first sign of the disease
How is diagnosis of Preinvasive Disease of the vagina made?
Diagnosis- Coloscopic examination of vagina with directed biopsy- can uses acetic acid whitening of vagina, Lugols iodine will help identify borders of the lesion
Vaginal Cancer
Vaginal Cancer
Vaginal Cancer is AKA as:
Vagnial Intraepitheal Neoplasm (VAIN)
What is the presentation of VAIN?
May present with postcoital spotting or vaginal discharge, mainly it is asymptomatic
VAIN needs to be considered in who?
All women with abnormal PAP
Vulvar cancer:
Vulvar cancer:
What are some risk factors for Vulvar CA?
o HPV (16, 18, 31)
o Genital warts or abnormal PAP
o Chronic Vuvlar irritation- DM, Granulomatous venereal disease, vulvar dystrophy
o Smoking
o Herpes simplex virus type 2
o Immunosupprion
o The vulva is one of the most common sites for extramammary pagets disease
What is the presentation of Vulvar cancer
Pruitis and or irritation, bloody discharge, Vulvar skin hyperplastic and leukolplastic (pale white, pink, red, dark brown)
What/ who is most commonly dx with vulvar CA?
Peak – 60-70 years old the avg age of dx is 65
What is the main etiology of vuvlar CA?
Squamous lesions- 65 % originate in labia majora and minora
What needs to be done for dx of Vulvar CA?
Biopsy
Vulvar Intraepithelial Neoplasm (VIN)
Vulvar Intraepithelial Neoplasm (VIN)
What are the three types of VIN?
VIN I: Mildly abnormal changes in the skin
VIN II: Moderate abnormal changes in the skin
VIN III: Severely abnormal changes in the skin
What is the treatment of Vulvar CA?
Depends on the stage, it could include sxr, pelvic exenteratoin, radiation therapy, Chemo or biologic therapy.
What is the common reoccurrence of vulvar ca?
Appx 80% in the first 2 years
