1
Q
Hx needed for vaginal complaint (6)
A
- Personal hygiene – soaps, perfumes, douching
- Sexual activity – use of lubricants, condoms, etc.
- Medications that may alter vaginal pH or flora
a. Oral contraceptive pills, antibiotics - Underlying medical illness – diabetes, HIV
- History of STD
- Use of synthetic undergarments or tight clothing
2
Q
what would you use if suspecting a yeast infection
A
KOH smear
3
Q
non-sexually transmitted diseases
A
Candidiasis (Candida albicans)
Bacterial vaginosis (Gardnerella vaginalis)
Bartholin’s gland cyst/abscess
Mycoplasma hominis and Ureaplasma urealyticum
4
Q
STDs
A
i. Trichomoniasis (Trichomonas vaginalis)
Gonorrhea (Neisseria gonorrhoeae)
Chlamydia (Chlamydia trachomatis)
Herpes simplex virus (HSV)
Syphilis
Human papillomavirus (HPV)
Human immunodeficiency virus (HIV)
5
Q
Presentation of yeast infection
A
- Intense vulvar pruritis
- White “cottage cheese” vaginal discharge
- Vulvar, vaginal erythema
- Burning sensation of the vulva; dysuria
- May be vulvar excoriations
- Extensive erythema and edema may indicate underlying systemic illness
6
Q
Vaginal Discharge dx tests for yeast infection
A
- Thick, white, curdlike, cheesy
- pH ≤ 4.5
- Buds and hyphae on wet mount and KOH prep
- Vaginal secretions may also be cultured for definitive diagnosis
7
Q
manage
A
- Treat all patients with Candida infections
- Control underlying medical illness if present
- Discontinue offending medications
- Avoid douching, nonabsorbent undergarments, tight clothing such as pantyhose
- Not typically sexually transmitted
8
Q
Topical (intravaginal) tx for yeast infect
A
a. OTC or Rx imidazoles
b. 85-95% cure rate
c. Combining with steroids for itching – a good idea?
9
Q
systemic treatment for yeast infection
A
a. Oral fluconazole (Diflucan) 150mg po x 1
b. Oral itraconazole 200mg po bid x 1 day
10
Q
yeast infection tx for pregnant pts
A
a. Avoid imidazoles in the first trimester
b. Nystatin vaginal tabs 100,000 units qhs x 2 weeks
11
Q
MCC of bac vag
A
i. Caused by bacteria Gardnerella vaginalis
ii. Most common cause of symptomatic bacterial infections
12
Q
BV sxs
A
- Malodorous, nonirritating vaginal discharge
- “Fishy” smell more noticeable after sexual intercourse
- May be found incidentally on well woman exam if asymptomatic
- Not considered sexually transmitted infection
a. Women who are not sexually active rarely present with BV - Watery vaginal DC and petechiae on cervix
13
Q
pH of BV
A
vii. pH >4.5
14
Q
what other tests would you want to confirm BV
A
Wet mount shows Clue cells
Numerous stippled or granulated epithelial cells
Adherence of bacteria to cell membrane
15
Q
when would you treat BV
A
only sx or pregnant women
16
Q
non pregnant tx of BV
A
Metronidazole 500mg po bid x 7 days
Metronidazole vag gel: 1 (5g) applicator qhs x 5 d
Clindamycin vaginal ovules 100mg qhs x 3 d
17
Q
pregnant tx of BV
A
Metronidazole 500mg po bid x 7 days
Clindamycin 300mg po bid x 7 days
18
Q
presentation of trichomons
A
- Persistent, copious vaginal discharge, usually without vulvar pruritis
- Worse after menstruation and during pregnancy
- Dysuria may be associated if vulvitis present
- Vaginal erythema with strawberry spots
a. Multiple small petechiae on vaginal epithelium
19
Q
Dx tests for trich
A
- Profuse, greenish, extremely frothy, thin
- May be foul smelling
- pH >5.0
- Wet mount increased PMN leukocytes and motile flagellates (trichomonads)
- Culture and DNA probes for definitive diagnosis
20
Q
Tx for Trich
A
- Treat sexual partners simultaneously and avoid unprotected sex until treatment is finished
- Metronidazole 2g po x 1 or 500mg po bid x 7 days
21
Q
sxs of gonorrhea
A
- Most women (85%) are asymptomatic
- Purulent vaginal discharge, urinary frequency and dysuria, perineal or rectal discomfort
- May cause conjunctivitis, arthritis, pharyngitis
- On PE: erythematous vulva, vagina, cervix, urethra with purulent discharge
22
Q
Tx of gonorrhea
A
- Treat partner concurrently and abstain from sexual contact for 7 days after start of treatment
- Treat presumptively for Chlamydia infection
- Test patient for syphilis; consider HIV testing
- Ceftriaxone 125mg IM x 1 dose or Cefixime 400mg po x 1 dose
a. PLUS Azithromycin 1g po x 1 or Doxycycline 100mg po bid x 7 days for Chlamydia coverage
23
Q
smelly, strawberry cervix, green frothy dischar
A
Trichomoniasis
24
Q
increased discharge, maybe purulent, maybe febrile,
A
foreign body
25
what causes an increase in normal vaginal dc
– increase in vaginal discharge due to estrogen which makes everything plump and juicy
26
mild itching and dyspareunia and a foul odor after intercourse
what labs do you want
```
Urine dipstick (-),
pregnancy test (-),
KOH whiff test (positive if fishy stink -->trichomoniasis, bac vag)
```
if positive wiff send out afirm probe for BV or Trich
27
DDX for pain without itching, dc or dysuria
PID, Bartholin’s cyst/abscess, Herpes
28
vaginal itching x 1 week. Menses irregular, LMP about 8 weeks ago. She notes mild dysuria and vaginal discharg
a. Pregnancy test (+), UA (-)
b. Neg Whiff test
Send Affirm probe for BV, trich, candida
Treat presumptively for Candida
29
possible exposure to STD testing
GC/Chlamydia, HIV, Syphilis, Hepatitis B and C
Vaginal swab for Affirm probe
Urine sample for GC/Chlamydia
30
tx for chlamydia
Doxycycline 100mg PO BID x7 days or Azithromycin 1g PO x1 dose
31
what type of f/u would you do for a pt who tested positive for chlamydia
Repeat GC/Chlamydia DNA on urine in 3 weeks
Abstain or use condoms for at least 1 week
32
tx for primary HSV outbreak
c. Valacyclovir 1g PO BID x10 days for primary HSV infection
33
Patients using HRT who require evaluation
On hormones for 6 months or more and bleeding
Bleeding is irregular, prolonged or heavy
Patients with intact uterus on unopposed estrogen
need endometrial biopsy
34
evaluation of pts on hormones for 6 months or more and bleeding
Yearly endometrial biopsies (preferred)
Transvaginal ultrasound to check endometrial stripe
35
two different stages for treating menopaus
menopause transition (Early)
post menopause (12 months after last mentsraul period)
36
when is HRT not a viable option ?
why?
over the age of 60 or 10 years post menopause
huge risk for cardiovascular or stroke
37
indications for hRT
vasomotor sxs
urogenital atrophy
sx after oophorectomy
AND
prevention of osteoperosis in pts that have failed estrogen tx
38
definite benefits of estrogen (6)
Decreases hot flashes
Improves bone mineral density (BMD)
Decreases fracture risk
Improves sexual function
Improves symptoms of vaginal atrophy
Decreases risk of colon cancer
39
possible benefits
Improves mood, libido
Decreases skin aging
Decreases incontinence
Reduced osteoarthritis
Prevents cataracts
Prevents macular degeneration
Prevents/slows dementia
40
Advantages of using hormones (OCP or IUD):
Prevention of ovarian cancer and endometrial cancer
Reduction of benign breast disease
Decrease dysmenorrhea, menorrhagia and anemia
Improved bone density
Control of erratic vasomotor symptoms
Stabilization of irregular bleeding
41
Reduction of benign breast disease seen with HRT as it relates to fibrocystic and fibroadenomas
30% reduction fibrocystic disease
60% reduction fibroadenomas
42
what type of BC would you want for a pt with hot flashes
OCP
(IUD) is just progesterone good for irregular bleeding
43
when would you switch from oCP to HRT
OCP until age 51 if no contraindications
Can switch without testing
may have some bleeding and some hot flasshes with switch
44
when would you check and FSH in a pt taking OCP to HRT
Check FSH in day 5-7 of pill free week
FSH over 25, probably menopausal
probably just when the pt would want to
45
world health initiative study found that for breast cancer
being overweight caused a greater risk
if on hormones those with breast cancer had more treatable cancer than those that didn't
however if a women does have a estrogen response breast CA they should not be on this
46
if pts have a family hx of breast cancer
want them on hRT for 5 years or less
47
cardiovascular risk form women considering HRT
absolute risk is generally low in newly postmenopausal women, dependent on background rate and risk factors
Must consider other potential risks: DVT, PE, stroke
For many newly menopausal women with moderate to severe symptoms, benefits will outweigh risks
48
biggest risk for CVD with this type of estrogen
oral estrogen
use transdermal
49
Indicated to treat symptomatic patients
Vasomotor, depression/mood lability, genitourinary syndrome, sleep disturbances
Women in their 50’s who are otherwise healthy have very low risks from HRT
Women <60yo or within 10 yrs of menopause and without contraindications or other risk factors are appropriate candidates for HRT
50
How to Prescribe HRT
Use lowest dose possible to achieve symptom relief
Use shortest duration of treatment
Suggest limiting to 5 years
51
suggestion for women taking HRT
transdermal 17-beta estradiol for many women starting MHT
The transdermal route is particularly important in women with hypertriglyceridemia or risk factors for thromboembolism.
52
when should you use topical estrogen?
if atrophy is the only sx
53
what type of progesterone would be used
Recommend micronized progesterone
54
what to say to the pt that is interested in identical hormones
not FDA regulated
| no evidence
55
mammography is indicated for women
age 50-75
every 2 years
family hx of breast cancer probably higher
56
breast ROS (5)
```
Lumps?
Pain or discomfort?
Nipple discharge?
Visible changes?
SBE?
Women: Do it? How often? When
in your cycle?; Men: Do you ever do self exam?
```
57
genita ROS
```
Vaginal discharge?
• Genital pain? Itching? Lesions?
• Dyspareunia?
o Pain during intercourse?
• Post-coital bleeding?
• Sexual satisfaction? Libido? Safe sex practices?
• Last PAP (result, abnormal PAPs)? o **Move to HM: Screening
• Contraception?
o **Move to OB/Gyn Hx
o **Oral Meds move to PMH: Medications
• History of STIs?
o **Move to PMH if yes & Sexual Hx
```
58
GYN ROS
```
_________________________________ 12) GYN – Female (Move to PMH: OB/GYN)
• LMP (last menstrual period date)?
o Flow/timing normal?
o Typical cycle (#days)?
o Changes in cycle: duration,
frequency?
• Abnormal vaginal bleeding?
• Dysmenorrhea (pain with period)? o Pain with period?
• Pre-menstrual symptoms?
• Peri or Post menopausal symptoms?
• Age at menarche (menses onset)?*
• Age menopause?
```
59
OB ROS
– Female (Move to PMH: OB/GYN)
• # of pregnancies (gravida), number of live
births (para), number of spontaneous vs.
therapeutic abortions? (G3,P1,SAB1,TAB1) • Delivery type: Spontaneous vaginal (SVD)
or C-section (reason)
o **Repeat deliveries in PMH: Hospitalizations (NOT in the SOAP)
o **Repeat C-Sections in PMH: Surgeries (NOT in the SOAP)
• Complications during pregnancy or birth? • Contraception method?
o **If pills move to PMH: Meds (& write Drug name, dose, when started). In OB/GYN write: Oral Contraception.
o **Contraception devices go here! • Breastfeeding?
Omit nocturia, incontinence in infants.
Add **enuresis (diurnal or nocturnal) – issues
w/ urination or potty training
o **Move to Sexual Hx
