Gyn 2 Pt 2

Question 1

What is vaginitis and what are the most common causes?

Answer 1

Infectious or non-infectious inflammation of the vaginal mucosa and sometimes the vulva
Many causes: most are infectious or due to normal flora imbalances

Question 2

Predisposing factors to vaginal bacterial pathogens

Answer 2

• Use of antibiotics (→ ↓ lactobacilli)
• Alkaline vaginal pH due to menstrual blood, semen, or ↓ in lactobacilli
• Poor hygiene
• Frequent douching
• Pregnancy
• DM
• HIV

Question 3

Most common sx complaints for vaginitis

Answer 3

abnormal vaginal discharge (m/c), irritation, pruritis, erythema

Question 4

Compare normal vs abnormal discharge

Answer 4

abnormal when: odor is offensive, pruritis or irritation, burning, pain, blood in discharge, amount of discharge is distressing to the woman

Normal discharge: Milky white/mucoid, odorless, non-irritating

Question 5

Etiology for vaginitis differs depending on what demographic factor?

Answer 5

Patient Age!

Question 6

Causes of Vaginitis in Kiddos

Answer 6

infxn usu involves GI tract flora –> common contributing factors are: poor perineal hygiene, not wiping hands after BM, fingering the area in response to pruritis

Others:

• Chemicals in bubble baths/soaps can cause inflammation
• Foreign bodies
• S/t specific pathogens: strep, staph, candida, occ’l. pinworms and E.Coli

Question 7

Causes of Vaginitis in Reproductive Age Women:

Answer 7

Usu infectious. M/C types: trichomonas vaginitis (STI), Bacterial Vaginosis (BV), Candida

Other contributing factors:

• things that ↑ pH such as: menstrual blood, semen, tight non-porous underclothing, poor hygiene, frequent douching and diaphragm/spermicide use
• Foreign bodies (forgotten tampons)
• Inflammatory vaginitis (non-infectious) is UNcommon in this age group

Question 8

Causes of Vaginitis in Menopausal Women

Answer 8

Usu atrophic or inflammatory vaginitis, mb overlapping BV or candida
• Decrease in estrogen causes vaginal thinning, ↓ lactobacillus, ↑ vaginal pH increasing vulnerability to infection and inflammation
• Poor hygiene (patients who are incontinent or bed-ridden)

Question 9

Additional things that could cause vaginitis at any age:

Answer 9

• Fistulas between the intestine and genital tract
• Pelvic radiation or tumors
• CHEMICALS: Hygiene sprays, perfumes, laundry soaps, bleaches, menstrual pads, fabric softeners, fabric dyes, synthetic fibers, bathwater additives, toilet tissue, spermicides, vaginal lubricants/creams, latex condoms, vaginal contraceptive rings or diaphragms

Question 10

Pertinent Hx for Vaginitis

Answer 10

• Qual/quant. of discharge and relation to menstrual cycle
• Pruritus, burning, or pain
• Duration and intensity
• changes in urination
• Self-treatment/chemicals incl: douching, vaginal creams, lubricants, BC use (OC’s, condoms, vaginal ring, etc)
• OB/gyn history, menstrual history
• Pregnancies
• Sexual habits/practices and orientation
• Personal hygiene: including changes in laundry products, sprays or perfumes
• Does male sexual partner have urethral discharge, pruritis, penile lesions or post-coital irritation? Female partner as well – ask about sexual practices
• Recurrent symptoms
• Treatments tried and response to treatment

PMHx

• Recurrent antibiotic use, hypothyroid, DM, HIV, other immunosuppressive d/os (risk factors for candida)
• Crohn’s dz, GU/GI cancer, pelvic/rectal surgery, lacerations during delivery (fistulas)
• Unprotected intercourse or multiple sexual partners (STIs)

ROS: Fever, chills, abdominal or suprapubic pain, polyuria, polydipsia

Question 11

PE for Vaginitis

Answer 11

EXTERNAL/SPECULUM: Lymph Nodes; Examine external genitalia, vaginal mucosa, glands, urethra and cervix for erythema, edema, excoriation & lesions, amount of d/c, color & odor; Assess vaginal pH
BIMANUAL: assess for CMT, adnexal or uterine tenderness

Question 12

Labs for Vaginitis

Answer 12

• Wet prep, culture and vaginal pH

- Consider DNA culture for BV, Candida, Trichomonas in chronic conditions

Question 13

RED FLAGS for Vaginitis

Answer 13

• Trichomonal vaginitis in children (sexual abuse)

- Fecal discharge (suggesting a fistula, even if not seen)

Question 14

DDX for Vaginitis

Answer 14

DDX:

• Infection: BV, Candida, Trichomonas, Cytolytic, Beta-hemolytic strep
• Atrophic vaginitis (loss of lubrication)
• UTI
• Allergy and irritation
• Malignancy higher in the tract
• Psychological factors: abuse, rape, loss of libido, trauma
• Derm dzs – lichen sclerosus, lichen simplex chronicus
• Systemic diseases
• Paget’s disease (looks like Candida)

Question 15

Etiology and risk factors of Bacterial vaginosis (BV)

Answer 15

Most common infectious vaginitis
- DT Unbalanced ecology! ↓ lactobacillus leads to ↑ anaerobic bacteria

Risk Factors: IUD’s, Low vitamin D, Poor nutritional status, Douching, No condom use, Anal sex before vaginal intercourse/sex/penetration, Partner change: increased #, uncircumsized, new male, Sex with uncircumcised male partners, Spermicides, Smoking, Non-white ethnicity

Question 16

What conditions does BV increase the risk of?

Answer 16

Main highlights: PID, HPV, Pre-term labor & pre-term birth
Others: Post-abortion and post-partum endometritis, Post-hysterectomy vaginal cuff infections, Chorioamnionitis, Pre-mature rupture of membranes (PROM)

Question 17

BV Sxs

Answer 17

Mild and often ASx!

• Vaginal D/C usu malodorous (fishy odor), gray, thin and profuse; usu stronger after menses and intercourse (pH more alkaline)
• Common: Pruritus and irritation
• UNcommon: Erythema and edema

Question 18

Dx of BV

DDX?

Answer 18

AMSEL's CRITERIA (3-4 req'd):
o	gray discharge
o	vaginal pH >4.5
o	fishy odor
o	clue cells present on wet prep (KOH test) – pleomorphic rods

Also: usually < 50 WBC’s (if higher likely concomitant infection-trich., GC, CT-need additional testing)

DDX: Trichomonas vaginitis

Question 19

Etiology and Risk Factors of Candida

Answer 19

most FUNGAL vaginitis is caused by Candida species, usu albicans
Risk Factors:
- use of antibiotics or corticosteroids
- pregnancy
- constrictive undergarments
- immunocompromised
- use of IUD
- OC’s or vaginal ring
- Diabetes, HIV

Question 20

S/SX of Candida

Answer 20

• Thick white cottage cheese D/C that adheres to vaginal wall
• Vaginal or vulvar pruritus, burning or irritation
• Erythema, edema and excoriation are common, s/t fissures at introitus
• Dyspareunia is common
• Sx. Increase the week BEFORE menses

Question 21

Dx of Candida

Answer 21

Wet prep: budding yeast, pseudohyphae and sometimes mycelia (If no buds or pseudohyphae are visualized, mb Glabrata strain of Candida)

• *Only 30% of the time are yeast seen on wet-prep
• pH will be normal (<50

Question 22

DDX for Candida

Answer 22

• contact irritant or allergic vulvitis
• chemical irritation
• vulvodynia
• Paget’s disease
• Cytolytic vaginosis

Question 23

Definition and Risk Factors of Atrophic/Inflammatory Vaginitis

Answer 23

Definition: vaginal inflammation with the absence of usu causes of infectious vaginitis
Risk Factors
- E loss d/t menopause, POF/POI
- Genital atrophy predisposes to inflammatory vaginitis and increases risk of recurrence
- Possible autoimmune

Question 24

Sxs of Atrophic/Inflammatory Vaginitis

Answer 24

• DC: Clear or purulent
• Dyspareunia, dysuria, vaginal irritation
• Vaginal pruritus, erythema, burning, pain or minor bleeding
• Thin and dry vaginal mucosa

Question 25

Dx of Atrophic/Inflammatory Vaginitis | DDX?

Answer 25

Dx: - pH >6 - Wet prep: Inc WBC’s, dec lactobacillus, parabasal cells - Mb inc. cocci (streptococci overgrowth) DDX: erosive lichen planus

Question 26

Definition/Etiology of Trichomonas

Answer 26

- caused by trichomod protozoa | - a STI

Question 27

Signs/Sxs of Trichomonas:

Answer 27

- D/C: copious yellow/green frothy - soreness of vulva and perineum - dyspareunia, dysuria - mb edema of the labia - punctate red (strawberry) spots vaginal walls and surface of the cervix - mb urethritis or cystitis

Question 28

Dx of Trichomonas

Answer 28

- pH > 5.5 - Wet Prep: Elevated WBC’s, flagellated trichomod - Can be dx. Incidentally on PAP smear

Question 29

Etioliogy of Cytolytic Vaginosis | S/Sxs

Answer 29

``` Overgrowth of lactobacillus strain Sxs/Signs - Burning, pruritus - rawness - vulvovaginitis - dyspareunia - erythematous & excoriated tissue ```

Question 30

Dx of Cytolitic Vaginosis

Answer 30

- pH: normal or ≤ 3.5 | - wet prep: small amount WBC’s, increased rods, false/atypical clue cells

Question 31

Definition and Etiology of Pelvic Inflammatory Disease (PID)

Answer 31

PID is an infection of the upper female genital tract-the cervix, uterus, fallopian tubes, and ovaries Etiology - SPREAD: microorgs ascend from the vagina/cervix into endometrium, fallopian tubes commonly; If severe, into the ovaries and then peritoneum - A polymicroorganism etiology: Neisseria Gonorrhea (GC), Chlamydia trachomatis (CT), and STIs are common causes - Other causes: anaerobic and aerobic bacteria, including pathogens that cause bacterial vaginosis - In women 35 y/o usu caused by an overgrowth of anaerobic/aerobic bacteria in vagina that ascend

Question 32

Risk Factors of PID

Answer 32

- Hx of STI’s or PID - IUD in women >35 - Young, Single, Drinker with no kids (Nulliparous), but has lots of sex - Low socioeconomic status - Non-white ethnicity Adolescents: Occurs when they have older sex partners, hx. of child protective services involvement and hx of attempted suicide

Question 33

SSxs of PID

Answer 33

Sxs can be asx --> mild --> severe - Lower abdominal pain: radiation to the back/sacrum - Fever - Cervical discharge - Abnormal uterine bleeding - Onset is particularly common during or after menses - Dysuria - N/V * PID dt GC is usu more acute with more severe sxs than when dt CT Acute salpingitis: Lower abdominal pain (s/t upper abd) present BL (mb unilateral); early: signs mb mild or absent; Later – CMT, guarding and rebound tenderness

Question 34

PE of PID

Answer 34

VITALS: Fever of 101ᴼ F or greater, Increased pulse rate EXTERNAL: Inguinal lymphadenopathy with tenderness, Guarding and rebound tenderness SPECULUM: Cervix red, erythematous and easily friable, Yellow green mucopurulent discharge from os BIMANUAL: Uterine, adenexal, and/or CMT, enlarged skene’s glands enlarged, tender (with GC or CT)

Question 35

Dx/Labs for PID:

Answer 35

High index of suspicion on PE (all types of tenderness) Wet prep: > 10 WBC’s/hpf CBC: elevated WBC count ESR increased >15 mm/hr * If all of the above are negative it probably excludes endometritis/PID TVUS: If the pt cannot be assessed d/t pain Pregnancy test: to R/O ectopic pregnancy PCR, culture or DNA probe for GC and Chlamydia, or Aptima test on urine

Question 36

Complications for PID:

Answer 36

``` Fitz-Hugh-Curtis syndrome Tubo-ovarian abscesses --> rupture --> severe sx. & possible septic shock; likely if treatment is late or incomplete Pain, fever and peritoneal signs Hydrosalpinx Peritonitis (surgical emergency) Adhesions & tubal scarring Infertility Adnexal torsion Tubal scarring and adhesions → Chronic pelvic pain, menstrual irregularities, infertility, and increased risk of ectopic pregnancy ```

Question 37

Treatment for PID

Answer 37

Any women with risk of PID and either CMT, uterine or adnexal pain MUST be treated with 2 or 3 antibiotics (SAVE THE TUBES!!!) 36 hours of onset of initial sxs increases the likelihood of infertility If patients do not respond to antibiotics within 42-72 hours, TVUS is done ASAP & if dx is still uncertain laparoscopy should be done.

Question 38

DDX for PID

Answer 38

``` Endometriosis Appendicitis Ectopic pregnancy Bowel disorders Septic abortion UTI Complicated ovarian cyst ```

Question 39

Etiology and Sxs of Gonorrhea

Answer 39

Dt Neisseria gonorrhea (Gram neg intracellular diplococcus) infecting the vagina, urethra, rectum & pharynx. Both male and female carriers. 7-10 day incubation period. * Reportable disease S/SX: Sxs 7-21 days after exposure Green/yellow mucopurulent cervical discharge (acutely) Mb urinary sxs Bartholin and Skene’s glands may also be infected Reddened cervix, local glands inflamed Pelvic pain and fever

Question 40

Labs for Gonorrhea | Most serious complication?

Answer 40

``` ↑ pH ↑ WBC’s (> 100/hpf) on wet prep ↑ ESR and WBC DX: Culture or gene probe MUST be done to confirm Aptima (urine) liquid pap ``` *Most serious complication is PID in women

Question 41

Etiology and Sxs of Chlamydia

Answer 41

Infection of urethra and cervix with Chlamydia trachomatis *Reportable disease ``` S/Sxs: most women asx (up to 70%) NO external DC in most cases May mimic GC infection, outcome may be the same as GC Urethritis symptoms ```

Question 42

Labs for Chlamydia | Sequelae?

Answer 42

↑ pH Wet prep: ↑ WBC’s > 100/hpf Fluorescent Ab test should be performed Gene probe, Aptima (urine), liquid pap can test for CT with GC Sequelae: bartholinitis, bartholin gland cysts, damage to fallopian tubes, PID

Question 43

Etiology and Sxs of Cervicitis:

Answer 43

Inflammation of the cervix; endocervical junction especially vulnerable to infxn - Causes: STDs (m/c), then Staph, strep and E coli * may be a major problem during L&D S/Sxs: red congested friable cervix, mb ulceration, pus

Question 44

What is ENDOMETRIOSIS? | What surfaces is it most commonly found on?

Answer 44

Noncancerous d/o: implants similar to endometrial tissue are found outside the uterine cavity. Most commonly found on peritoneal & serosal surfaces: broad ligaments, posterior cul-de-sac, uterosacral ligaments, and ovaries. Less commonly found on surfaces of small & lg intestines, ureters, bladder, vagina, cx, surgical scars, pleura, & pericardium.

Question 45

Pathogenesis of Endometriosis

Answer 45

Bleeding from implants initiates inflammation → fibrin deposition → adhesion formation → scarring which distorts peritoneal surfaces of organs and pelvic anatomy

Question 46

What are some of the hypotheses of etiology for Endometriosis?

Answer 46

``` Retrograde flow of menses (recently disproven) Coelomic metaplasia Embryonic rests theory Estrogen dominance Defective formation & metabolism of estrogen Environmental Exposure PCB’s from meat, fish, eggs and milk Candida overgrowth in GI tract - exacerbating factor Genetics Lymphatic/vascular problems Immune system Menstruation Preconditioning Hypothesis Metaplasia ```

Question 47

Factors that lower risk

Answer 47

o Exercise – esp if begun before 15 yo, > 7h/wk or both o Cigarette Smoking → ↑ SHBG o Pregnancy – multiple o Low dose OC (continuous or cyclic)

Question 48

Sxs & Signs OF ENDOMETRIOSIS | W

Answer 48

Extent of endometrial implants/endometriosis DOES NOT reflect SX presentation *PAIN & INFERTILITY (M/C sxs) Pelvic pain – dysmenorrhea, deep dyspareunia Pelvic mass – endometriomas Dyschezia – esp during menses Dysuria, suprapubic pain Infertility: About 25-50% of infertile women

Question 49

PE Endometriosis

Answer 49

EXTERNAL: vulvar lesions (rarely) SPECULUM EXAM: mb vaginal lesions in post fornix or cx BIMANUAL EXAM: mb normal, or mb retroverted or fixed uterus, enlarged, tender ovaries, fixed ovarian masses, induration in the cul-de-sac, nodularity of uterosacral ligaments RECTOVAG: thickened septum, re-check cul-de-sac & ligaments.

Question 50

Dx of Endometriosis

Answer 50

Dx only by Bx during laparoscopy or laparotomy TVUS, CT, MRI, IV urography, barium enema – can s/t identify extent of dz process & monitor progress – but not specific or adequate for dx. Serum Ca 125 (>35 units/mL) & antiendometrial Ab – may help monitor dz, but still investigational

Question 51

Treatment/management of Endometriosis

Answer 51

ND Tx: Symptomatic treatment for pain (ex. Mirena), more definitive treatment is based on pts age, sxs, desire to preserve fertility & extent of d/o Allopathic options are: Rx to suppress ovarian fxn & implants, surgical resection, & surgery + Rx