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Lecture 15: Vulvovaginal Disorders Flashcards

1
Q

The MC type of bacteria in the vagina is

A

Anaerobes

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2
Q

The MC specific bacteria seen in normal vaginal flora is

A

Lactobacillus

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3
Q

T/F: Normal vaginal pH is more acidic than post-menopausal vaginal pH

A

True! Normal is 4-4.5

Postmenopausal is 6.5-7.0

Glycogen in vaginal mucosal secretions is converted to lactic acid

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4
Q

The younger you are, the ?? lactobacillus you have in your vagina

A

More

Less estrogen as u age = less lactobacillus ty viv

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5
Q

What kind of foods are the WORST for altering vaginal flora

A

Sugary foods

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6
Q

The MC organism of candidal vulvovaginitis is…

A

Candida albicans

90% of all cases

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7
Q

The MC systemic disorder that presdisposes you to candidal vulvovaginitis is…

A

DM

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8
Q

Candidal Vulvovaginitis is characterized by these S/S: (4)

A
  • Intense itching
  • Thick, white, cottage cheese discharge
  • Minimal odor
  • Erythema and possible edema

Might also burn after ya pee

Cheesy Candida

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9
Q

If you did a saline prep of suspected candidal vulvovaginitis, you would expect to see (2)

A
  • Branching filaments/budding yeast
  • Pseudohyphae
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10
Q

If you did a KOH prep of suspected candidal vulvovaginitis, you would expect to see (1)

A

Fungal mycelia

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11
Q

The gold standard for diagnosing candidal vulvovaginitis is…

A

Culture

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12
Q

The pharm tx options for simple candidal vulvovaginitis are: (4)

A
  • Topical azole creams for 1-3 days
  • Single dose of fluconazole 150mg PO
  • Boric acid
  • Gentian violet
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13
Q

What makes candidal vulvovaginitis complicated?

A
  • 4+ eps/year
  • Severe symptoms
  • Non-albicans
  • Uncontrolled DM
  • HIV
  • Steroid use
  • Pregnant
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14
Q

What is the management and tx protocol for complicated candidal vulvovaginitis? (3)

A
  • 1-2 weeks of topical azoles or 2 PO doses of fluconazole
  • Culture to confirm
  • Consider Boric acid
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15
Q

The two primary cons of using oral antifungals for tx of candidal vulvovaginitis are

A
  • Rx only
  • Higher risk of systemic SE
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16
Q

The OTC therapy that is absolutely contraindicated in pregnancy for tx of candidal vulvovaginitis is…

A

Boric acid intravaginal

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17
Q

Generally, you want to avoid combining fluconazole/ketoconazole with () drugs and (-toxicity drugs)

A
  • QT-prolongation drugs
  • Hepatotoxic drugs
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18
Q

The MOA for both topical and oral antifungals is primarily

A

Inhibiting the enzyme that synthesizes cell walls.

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19
Q

Why is ibrexafungerp better than azoles for candidal vulvovaginitis?

A

Preventing long-term recurrence

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20
Q

The main use of boric acid intravaginal is that it can treat…

A

Non-candidial vulvovaginitis

Interferes with fungal metabolism

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21
Q

The main/iconic SE of gentian violet is…

A

Discoloration of clothing and skin

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22
Q

For recurrent cases of candidal vulvovaginitis, you can use prophylactic antifungals for up to…

A

6 months

Azoles PO 1x/wk or PV 1-2x/wk

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23
Q

You should recommend a patient wear …. undergarments to prevent candidal vulvovaginitis

A

Absorbent so it stays dry down there

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24
Q

The MC bacteria present in bacterial vaginosis is…

A

Gardnerella vaginalis

A Garden of bacteria

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25
T/F: Bacterial vaginosis is common in both sexually active and non-sexually active patients
False, rare in nonsexual | But it is NOT AN STI
26
Bacterial vaginosis is characterized by (1) discharge, smells (2), and has a lack of (3)
1. **Milky**, homogenous, malodorous vaginal discharge 2. **Fishy** smell 3. **Lack of vaginal mucosal inflammation**
27
Bacterial vaginosis increases the risk of () in pregnant patients
Preterm delivery
28
Buzz Words for Bacterial vaginosis (3)
* **Clue cells on saline prep** * **Fishy odor** via whiff test on KOH prep * **Milky, homogenous** discharge
29
The two preferred medications to treat bacterial vaginosis in pregnant patients are...
* Metronidazole PO/Vaginal * Clindamycin PO/vaginal/vaginal cream | **all for 1 week**, except only 3 days for clinda ovules PV ## Footnote **If pregnant, you want to use the PO version of these!**
30
The 2nd line tx for bacterial vaginosis patients who are NOT pregnant are...
* Tinidazole oral * Secnidazole oral | Both are higher cost, but secnidazole is a single dose
31
The MOA of the nitroimidazole is...
Binding and deactivating enzymes
32
Pt counseling for usage of metronidazole includes... (2)
* Don't drink alcohol 3 days after * Don't use disulfiram +/- 2 weeks
33
Generally, all the pharm tx for the vagina seem to interact with...
Anticoagulants
34
The MOA of clindamycin is...
Binding to ribosomes to block protein synthesis
35
The primary SE of taking oral clindamycin is...
C diff
36
The MC non-viral STD in the US is...
Trichomonal vaginitis
37
Trichomonas is characterized by a (color) & (odor) vaginal discharge and a (appearance) cervix
* Frothy green * Foul-smelling * Strawberry | A Trip to the strawberry farm to see the green ones
38
Saline prep of trichomonas should show...
Actively motile trichomonads
39
The most sensitive and specific method for dxing trichomonas is
Culture
40
First-line tx of trichomonas is
Metronidazole 2g PO x **1 dose** or 500mg BID x **7 days** (less SE) | Can also use the other nitroimidazoles
41
For more resistant trichomonas, the preferred tx is...
Tinidazole 500mg PO TID x 7d | Tough Trichomonas needs Tinidazole
42
T/F: A partner of someone with trichomonas also needs tx
True
43
Generally, the MC S/S of gonorrheal vulvovaginitis is...
Asymptomatic 80%+ | the other 20% get PID
44
Gonorrheal vulvovaginitis is diagnosed with a () and should show ()
Nucleic acid probe/culture showing **G- diplococci** within leukocytes
45
The tx for gonorrheal vulvovaginitis is...
Rocephin + Doxy/azithryomycin (chlamydia) | Also tx partner
46
The preferred tx for chlamydial vulvovaginitis is...
Doxycycline 100mg PO BID x 7 days | Also treat gonorrhea with rocephin
47
Generally, the mainstay of tx for noninfectious vaginitis is...
Identifying and removing the underlying cause
48
Tx of noninfectious vaginitis w/ atrophy includes (4)
* Lubricants * Moisturizers * HRT * Ospemifene (SERM)
49
The characteristic presentation of herpes genitalis is...
Vesicles becoming **painful** erosions/ulcer + erythematous halo | I also think theyre grouped
50
The tx for herpes genitalis is...
**7-10 days** of the antivirals (val, fam, a)
51
Recurrent herpes genitalis is treated with...
**1-5 days** of antivirals | Can take a giant dose or steady doses
52
The two MC types of HPV that result in condyloma acuminatum are...
HPV 6 & 11
53
The S/S of condyloma acuminatum are...
* White exophytic/papillomatous growth * Tend to coalesce * Can also be flat | Can also spread
54
Prior to treating condyloma acuminatum, you should... (2)
* Pap smear * Colposcopy | Might even need a biopsy
55
The tx options done by a provider for condyloma acuminatum include... (5)
* Topical application of bichloroacetic acid, **Trichloroacetic acid, or podophyllin** * Cryotherapy * Electrosurgery * Simple excision * Laser
56
What should you remember to let patients know after tx of condyloma acuminatum?
Recurrence is common
57
The underlying cause of molluscum contagiosum is...
Poxvirus
58
Microscopy of molluscum contagiosum should show...
**Inclusion bodies** (molluscum bodies) in the cytoplasm
59
Tx of molluscum contagiosum includes... (5)
* Desiccation * Freezing * Curettage * Chemical cauterization * Topical imiquimod | May cause scarring, so you can just observe if ya want
60
Primary syphilis is characterized by 2 things:
* **Lone painless** ulcer (CHANCRE) * +/- LAD
61
Secondary syphilis is characterized by 3 things:
* Generalized rash * Malaise * Fever
62
The causative organism for syphilis is
Treponema Pallidum
63
First line tx for syphilis
Penicillin (Benzathine penicillin)
64
Tx for a pregnant woman allergic to penicillin
Desensitize and give penicillin
65
For PCN allergic and non-pregnant women, the TOC for syphilis is
Doxycycline x 2 weeks | increase to 4 weeks if 1+ years of latent, tertiary, or cardio involved
66
Generally, bartholin glands get obstructed because of...
Infection
67
What might suggest a patient has a bartholin gland cyst?
* Pain, tenderness, dyspareunia * **Duck waddling gait** * Fluctuant, tender mass * **No pain/discomfort if solely cystic**
68
The first-line tx of bartholin gland disease is (2)
* Marsupialization * Insertion of Word catheter | Drain and then do above^
69
When is excision indicated in bartholin gland disease?
* Recurrent * Post-menopausal
70
The MC **non-neoplastic epithelial vulvar** disorder is...
Lichen Sclerosus
71
Lichen sclerosus is primarily seen in these populations: (3)
* Vit A deficiency * Women > 60 * Autoimmune dz
72
The MC presenting S/S of Lichen Sclerosus is...
Pruiritis | Can see vulvar pain, dyspareunia, or asymptomatic white lesions
73
Acute Lichen Sclerosus follows a general pattern: (4)
* Plaques develop * You keep itching it * You get telangiectasias and hemorrhages * You get erosions/ulcerations/fissuring
74
Chronic lichen sclerosus describes the skin as...
Cigarette-paper | Thin, wrinkled, and white ## Footnote Chronic Lichen Sclerosus = Cigarette-Like Skin
75
What secondary conditions can occur in chronic lichen sclerosus?
* Phimosis * Introital stenosis * Perianal involvement
76
The main concern with Lichen sclerosus is...
High rate of **SCC development** | Biopsy all new lesions!
77
Besides stopping the itchy cycle, the 3 patient recommendations to help with Lichen Sclerosus are...
* Avoid tight underwear * Daily cleansing with mild soap * Drying skin with hair dryer | Improvement of vulvar hygiene
78
The first-line tx for Lichen Sclerosus is...
Clobetasol propionate 0.05% topical | HIGH potency steroid
79
Surgery is indicated for Lichen Sclerosus in (2)
* **Introital narrowing** due to dyspareunia * Invasive **squamous cell** neoplasia
80
What should you NOT USE in Lichen Sclerosus?
* Topical testosterone cream * Topical progesterone cream * Intralesional alcohol injection * Vulvectomy
81
Chronic lichen sclerosus will recur when...
You stop tx :(
82
What the main differentiating factor between Lichen Simplex chronicus vs Sclerosus?
Simplex has a **simple explanation** | Obvious cause for it i think is what she said
83
Generally, the main cause of Lichen Simplex Chronicus is...
Chronic irritation (pads, infection, cancer)
84
The S/S of Lichen Simplex Chronicus include... (3)
* Lichenified, scaly, localized plaque (itchy!!!) * Red papules that coalesce * Pigmentation
85
The dx of Lichen Simplex Chronicus is via..
Biopsy of lesion | Must rule out CIN or invasive CA
86
Lack of what differentiates Lichen Simplex Chronicus from Sclerosus?
87
The pharmacological tx for Lichen simplex Chronicus includes... (2)
* Oral antihistamines * Topical med-pot CS (Fluocinolone, triamcinolone)
88
For intractable cases of Lichen Simplex Chronicus, the two tx options are:
* Intralesional SQ steroid injections * Oral antidepressants (TCAs like amitriptyline)
89
Lichen Planus, a mucocutaneous dermatosis, is () sharply marginated on skin and () sharply marginated on mucous membranes | Either More or less
* More on skin * Less on mucuous membranes | Rarely on the vulva
90
The initial tx for Lichen Planus on the vagina is
Topical hydrocortisone foam (Colifoam)
91
Secondary tx for Lichen Planus is...
* Higher potency topical steroids * Topical tacrolimus
92
If Lichen planus ends up with introital stenosis or adhesions, we tx with (2)
* Vaginal dilators * Surgical release
93
What are the more common dark vulvar lesions?
* Melanosis/lentigo (looks like melanoma) * Vulvar melanoma (actual cancer but v rare) * Capillary hemangiomas (Childhood = red, senile = dark blue)
94
Varicose veins in the vulva are rare outside of what condition?
Pregnancy | Normal could signify underlying vascular dz or pelvic tumor
95
What is the recommended tx for vulvar varicosities?
Supportive compression undergarments if preggo | Otherwise, rarely need to tx!
96
What is the tx for vulvar varicosities that persist postpartum?
Sclerosing agent
97
A patient with vulvar intraepithelial neoplasia (VIN) most likely has () lower genital tract disease
Multifocal
98
What age range is most likely to have VIN?
Younger women
99
The MC factor seen in VIN is...
HPV | Smoking increases risk of it being high-grade
100
The MC presentation of VIN and MC symptom is...
* MC Presentation: White, hyperkeratotic papules * MC symptom: Pruiritis (60%)
101
The gold standard for Dxing VIN is...
Colposcopy + Biopsy of suspicious lesions
102
The follow-up protocol for VIN is...
* Colposcopy Q3months until disease free for 2 years * Pelvic exam Q6m after those 2 years are good.
103
Extramammary Paget's disease is MC in...
White women 60-70
104
What exactly is Extramammary Paget's disease?
Intraepithelial neoplasia/adenocarcinoma in situ | Almost always confined to the EPITHELIAL layer
105
The two MC symptoms of extramammary Paget's disease + hallmark appearance is... | put on your privacy screen and spit out your food
* Pruiritis * Vulvar soreness * **Red velvet cake**
106
The Dx of extramammary paget's disease is...
Vulvar biopsy
107
The tx for extramammary paget's disease is...
Wide local excision
108
What suggests a good prognosis for extramammary paget's disease?
No lymph node metastases | lymph node metastases = almost always fatal
109
90% of vulvar cancers are (cell type)
SCC | 2nd MC is malignant melanoma
110
Gyn cancers are rare overall, but the MC RFs for them are (2)
* Poor * Elderly
111
The MCC of vulvar cancer in young women is...
HPV
112
The MCC of vulvar cancer in older women is...
Chronic inflammation
113
Generally, vulvar cancer presents with (2)
* Pruiritis * Mass
114
Generally, most SCC vulvar cancers originate from the (anatomical structure)
Labia
115
Between exophytic/endophytic vulvar lesions, which one is more likely to become **large, necrotic, and infected?**
Exophytic lesions | Cauliflower one
116
Overall, the mainstay of tx for vulvar cancer is...
Remove all tumor wherever possible! (**Wide local excision with inguinal lymph node excision)** | If lymph metastases, add radiation
117
When is pelvic exenteration indicated with vulvar cancer?
* Anus * Rectum * Rectovaginal septum * Proximal urethra * Bladder | Any involved
118
Once someone has vulvar cancer treated, how often do they followup?
Q3 months for 2 years, then Q6months | 80% recurrence in first two years
119
Where do vaginal intraepithelial neoplasias (VAIN) tend to appear in the vagina?
Upper 1/3 of vagina | Same RFs as CIN/VIN (HPV, smoking)
120
What kind of appearance description of preinvasive vaginal disease is usually associated with dysplasia?
Condylomatous | Spicules
121
The Dx of Preinvasive vaginal disease/VAIN is via...
Colposcopy + biopsy
122
Tx of VAIN 1 is with...
Nothing, usually regresses
123
Tx of VAIN 2/3 is...
* Surgical excision * CO2 laser * Topical 5-FU
124
How often do you followup post VAIN excision/tx?
Q4-6months | Might need multiple tx
125
85% of all vaginal cancers are (cell type)
SCC
126
What is the MC form of vaginal malignancy?
Extension of cervical cancer
127
Define primary vaginal cancer
Minimal to no cervix involvement
128
The MC primary vaginal cancer in young patients specifically is (cell type)
Adenocarcinomas
129
A highly aggressive, polypoid, edematous, grape-like vaginal cancer is most likely a (cell type) | Prepare yourself
Sarcoma
130
MC symptom of primary vaginal cancer
Postmenopausal or postcoital bleeding
131
Dx of primary vaginal cancer is via...
Colposcopy + biopsy
132
Tx of primary vaginal cancer is via...
* Hysterectomy * Vaginectomy * Lymphadenectomy | If locally invasive, gotta do pelvic exenteration
133
The worst prognosis cell type of primary vaginal cancer is...
Melanoma | Extremely rare tho

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