Uterine Disorders Flashcards
(90 cards)
1
Q
Important information to know about vaginal discharge:
A
- Onset/Duration
- Character
- Association w/ cycle
- Prior similar symptoms /Tx
- Vaginal hygienic practices
- Current Rx: Antibiotics, hormones
- Trial of tx before seeking care?
2
Q
Physiologic discharge:
A
Not all cervical/vaginal discharge is abnormal
Cyclic discharge:
Midcycle/Peri-ovulatory: E dominant
Post-ovulatory: P dominant
3
Q
Mid-cycle E dominant discharge:
A
clear, stretchy mucus (dominant follicle produces E)
May present as vaginal d/c or just be present on speculum exam
4
Q
Post-ovulatpry P dominant discharge:
A
white, pasty or floccular discharge (CL produces P)
Again, may present as d/c or incidental finding
5
Q
Spinnbarkheit=
A
stringiness of cervical mucus. Many women can detect this change in cervical mucus midcycle around the time of ovulation. It has been used as a “natural contraception” method–+/- effective, high failure rate
6
Q
Obtaining a detailed sexual hx about discharge:
A
LMP
Sexually active currently? Recently? Ever?
Contraception: compliance, use of condoms
Type of exposure: oral, vaginal, anal
Partner history: gender, #
Known exposure to STD? Suspicion of exposure?
ROS:
-Vulvovaginal pruritis, burning
-Dyspareunia
-If malodorous, worse after sex? After menses?*
-Dysuria, frequency, urgency
-Fever, chills
-Pelvic/abdominal/flank pain
7
Q
cervical/Vaginal discharge Ddx:
A
Infectious discharge: Bacterial Vaginosis (BV) Trichomonas vaginalis (Trich) Neisseria gonorrhoeae (GC) Chlamydia trachomatis (Chl) Vulvovaginal Candidiasis (VVC) Herpes Simplex Virus 1 or 2 (HSV 1 or 2)
8
Q
External vaginal lesions:
A
HSV may present with vesicles externally and internally
Syphilis may have painless chancre
condyloma…more in separate lecture
9
Q
STD testing:
A
: Nucleic Acid Amplification Test (NAAT)
10
Q
what should you always encourage?
A
- HIV testing
- Pregnancy testing
11
Q
bimanual pelvic exam:
A
Cervical motion tenderness “chandelier sign”
Uterine or adnexal tenderness or mass:
- Endometritis
- PID
- TOA (tuba-ovarian abscess)
12
Q
Bacterial vaginosis (BV):
A
a polymicrobial syndrome resulting from replacement of normal flora (lactobacillus) with anaerobic bacteria
**Remember, this is an –osis not –itis!!
13
Q
BV symptoms:
A
Asymptomatic
Watery, white/gray discharge
No pruritis or urinary symptoms, no pain
Foul “fishy” odor, especially after menses or sex
14
Q
Most common cause of vaginal d/c in childbearing age women (40-50%) ?
A
BV
15
Q
BV exam signs:
A
Thin, gray-white discharge present at introitus & coating vaginal walls*
pH 4.5 or > * ; normal pH 3.8-4.2
Positive “whiff” (amine)test with application of alkali (10%KOH) to wet mount*
Presence of Clue cells on saline wet mount*
Usually no mucosal irritation/inflammation**
16
Q
BV tx:
A
Goal is to decrease anaerobic bacteria in vagina and allow patient to regenerate her own lactobacilli = restore vaginal homeostasis (normal flora) Metronidazole (Flagyl) 500 mg. po BID x 7 days* Metrogel (0.75% Metronidazole Gel) intravaginally once daily for 5 days* Cleocin Vaginal (Clindamycin 2% Cream) intravaginally at HS for 7 days**
Clindamycin 300 mg. po BID x 7 days*
Clindesse (2% ER Clindamycin Cream) once intravaginally*
Tinidazole 1 G. po x 5 days or 2 G po x 2 days***
17
Q
Trichomonas Vaginalis (Trich)
A
Infection with the protozoan
T. vaginalis
18
Q
Trich symptoms:
A
Asymptomatic Copious yellow/gray/green discharge, may be frothy Possibly mixed with blood Malodorous Often have vulvar pruritis and dysuria
even though no “itis” in name, this is an inflammatory process with inflam sx!
HIV transmission enhanced by this
need testing for other STDs
19
Q
Trich exam signs:
A
May have vulvar/vaginal erythema &
inflammation
Strawberry cervix
pH 4.5 or >
Wet prep saline with numerous WBCs &
motile Trichomonads
20
Q
Trich Tx:
A
Metronidazole 2 Gm. x 1 dose* Tinidazole 2 Gm. X 1 dose** Alternative regimens/Treatment failures:** MTN 500 mg. BID x 7 days MTN or TND 2 Gm. Daily x 5 days
repeat testing with NAAT 2 wk - 3 mo
21
Q
2nd most commonly reported communicable disease in U.S.
Women age 20-24, age 15-19; Men age 20-24
African American >12: 1 Caucasian
A
GC
22
Q
the most commonly reported bacterial infection in the U.S.
Women age 15-24; Men age 20-24
African American 6:1 Caucasian
A
Chl
23
Q
Difference in men and women sx of GC/Chl?
A
Women often asx but can have… mucopurulent cervicitis and cervical friability (easy bleeds when touched) or edema
Men:2-5 day incubation period
Purulent penile discharge and dysuria
Treatment: usually early due to sx; frequently after transmitted to partner
24
Q
Long term GC/Chl sequelae in females:
A
PID Infertility Ectopic pregnancy Chronic pelvic pain Facilitation of transmission of HIV Neonatal infection (ophth, pneumonia with Chl)
25
GC/Chl diagnosis:
Nucleic acid amplification test (NAAT)
Wet prep w/ WBC’s
Clinical suspicion/risk factors/known exposure
Routine annual screening of ALL sexually active females <25y/o for GC and Chlamydia
Routine screening of all pregnant women in 1st trimester
Screening of sexually active women >25 with risk factors
26
GC/Chl high risk:
```
Sexually active women <25 years old
Pregnancy
Inconsistent condom use
Hx of multiple partners/partner with multiple partners/new partner
Presence of current STI (Trich, HSV) or sexually associated disease (BV)
Partner with culture-proven STI
Hx of repeated episodes STI
Sex work or drug use
```
27
Gc tx:
Much more complex due to resistant strains of N. gonorrheoae
GC, uncomplicated infection: ***single agent not recommended!!!***
Ceftriaxone 250 mg. IM single dose
PLUS
Azithromycin 1 G. po single dose*
Doxycycline 100 mg. BID x 7 days alternative 2nd agent**
28
Chl Tx:
Azithromycin 1 Gm. po single dose (observed therapy in office)
Doxycycline 100 mg. po BID x 7 days
Doxycycline 200 mg. daily x 7 days*
Appropriate to treat presumptively for both GC & Chl if hx of exposure to unknown STD by partner**
EPT—expedited partner therapy appropriate
Test for other STIs including HIV
29
Measures to limit GC/Chl:
Education—abstain until completed course of treatment of pt/partner
Aggressive partner evaluation and treatment (EPT)
Retesting--Aggressive detection—at 3 months or whenever next seek care****
Use of condoms or spermicides with nonoxynol 9 (???)
30
Vulvovaginal Candidiasis (VVC)
Description: usually a sporadic, uncomplicated fungal overgrowth caused by Candida Albicans
Complicated VVC is a chronic or recurrent infections, may be caused by other Candida species (C. glabrata) and/or may be associated with underlying disease (uncontrolled DM or HIV)
Other risk factors: recent use
of antibiotics which may alter
normal bacterial flora
of vagina
31
VVC symptoms:
Vulvovaginal pruritis
Vulvovaginal burning
Thick white odorless “cottage cheese” discharge
32
VVC diagnosis:
Diagnosis:
Commonly self-diagnosed and treated, often incorrectly
Usually presents with failed treatment or recurrent sx
On exam, variable degrees of vulvovaginal erythema and edema
Thick adherent white odorless discharge
pH normal
Yeast on wet prep (spores and/or hyphae)
Culture*
*Culture not necessary if clinical picture and wet prep confirms
Culture useful if neg wet prep or if recurrent CVV after treatment, to differentiate between species of Candida
33
VVC Tx:
Multitudes of OTC antifungal products effective:
Vulvar/intravaginal creams and/or external cream/intravaginal suppository for 1-14 days*
80% cure rate
Rx:
Oral Fluconazole 150 mg. x 1 dose**
Terconazole/Butoconazole/Nystatin Cream or Suppos. x 3-7 days
Symptomatic relief
Combined topical steroid and antifungal for vulvar inflammation
Sitz bath with bicarbonate of soda
Avoid contact with other contact irritants
Resistant disease***
Recurrent disease***
34
HSV 1 or 2:
Description: viral infection acquired by skin-to-skin contact or mucous membrane contact during periods of active shedding
Genital HSV previously mostly HSV 2 related
Genital HSV 1 shift related to increase in oral-genital contact
Primary infection becomes latent in dorsal root ganglia and can reactivate, causing recurrent infection
Neonatal herpes with serious consequences
35
HSV symptoms:
Wide spectrum from asymptomatic to painful genital ulceration to rare systemic complications
Primary infection typically with more symptoms*
Cervical involvement can be isolated & present with profuse vaginal discharge
36
HSV signs:
Vulvovaginal and cervical vesicular lesions/discharge
Culture—type specific for 1 vs. 2
DNA polymerase chain reaction**
37
Management of HSV:
Symptomatic
Topical acyclovir is not effective
Oral acyclovir/famciclovir/valacyclovir
Topical comfort: anesthetic—2% lidocaine gel, warm saline baths, urinate in tub, avoid contact irritants
Prevention of recurrences* with associated viral shedding
Abstinence with prodrome or lesions if asymptomatic
Episodic treatment of recurrent infection—EARLY!!
Daily suppressive treatment with recurrent infection**
Assess patient and partner for coexistence of other STDs (HIV, Syphilis) and counsel about reducing transmission***
38
Foreign body in vag:
Malodorous, possibly bloody discharge
Post-menses—suspect tampon
Removal is treatment—hidden glove technique
39
Genitourinary Syndrome of Menopause (GSM)
```
Description: Decreased E stimulation of vulva, vagina and lower urinary tract resulting in thinning and dryness
Associated :
Vulvar thinning and atrophy
Loss of elasticity of CT
resulting in shortening
and narrowing of vagina
Atrophic changes in
urinary tract
```
40
GSM symptoms:
Vary in Severity
Vaginal: dryness, pruritis, burning, discharge, spotting, dyspareunia, thin gray or yellow discharge
Urinary: urgency, frequency, dysuria, recurrent UTI, incontinence
41
GSM sign on exam:
Vulvar atrophy—thin, pale mucosa, possible urethral caruncle
Vaginal atrophy—use small speculum! Pale, thin, dry mucosa with loss of rugations, discharge. May be erythematous with petechiae, erosions, contact bleeding
Pelvic organ prolapse
Microscopy—pH elevated, increase in WBCs, loss of superficial epithelial cells
42
GSM tx:
Topical/Local E comes in many forms: vaginal creams, tablets, rings
Relatively recent options:
Ospemifene—SERM that acts as an E agonist in the vagina that appears to have no E effect in breast or endometrium (FDA approved 2013)
effective in treating dyspareunia and vaginal dryness in women with GSM
no studies comparing with E therapy
side effects: hot flashes
still studying: risk of thrombotic adverse events, endometrial & breast effects, safety in women with hx of breast cancer
potential additional benefit: reduction in bone turnover
Laser—fractional CO2 laser energy to vaginal wall tissue intended to improve vaginal epithelium morphology and thereby improving sx of GSM
- -scant data
- -not FDA approved
- -more study needed
43
GSM non-estrogen tx:
EVOO
44
What has caused Atrophic vulvovaginitis to be a problem?
viagra
45
Cervical polyps:
```
Most common benign neoplasia
Originate in ectocervix or endocervix
Symptoms: None or abnormal bleeding, post-coital bleeding, vaginal discharge
DDx:
Endometrial polyp
Prolapsed myoma
Malignancy
Tx:
Avulse with polyp forceps, cautery prn
Pathology!
```
46
Nabothian Cyst:
Mucinous retention or epithelial inclusion cysts on ectocervix
Dx:
Can be large, multiple
Symptoms:
Usually none, possibly vaginal fullness if large
Tx:
None Cautery (scarring)
47
Bartholin gland cyst/ abscess location
4 and 8 o'clock
48
Bartholin Gland Cyst
Blocked Bartholin Duct with accumulation of mucus
49
Bartholin Gland Abscess
- Obstructed duct becomes infected
| - Higher risk in women at risk for STIs
50
Bartholin Gland Cyst
| Presentation:
asymptomatic, coincidental finding on exam, larger cysts may cause discomfort
51
Bartholin Gland Abscess
| Presentation:
acute pain, unable to walk, sit or have intercourse
Fever
Prior history of bartholin cyst or abscess
Unilateral, warm, tender, soft or fluctulent mass in lower medial labia majora, can extend into upper labia
Can be surrounded by erythema and edema
Purulent spontaneous drainage possible
52
Cyst Management:
No intervention if asx
>40 y/o—I & D with bx to exclude malignancy
If symptomatic, manage same as abscess
53
Abscess Management:
Spontaneous drainage—analgesics, sitz baths
I & D with placement of Word Catheter*
Culture/NAAT of purulent discharge (STI, MRSA)
I & D with marsupialization if recurrent**
Definitive treatment—gland excision***
Antibiotics—only for recurrent abscess, MRSA or STI positive, high risk of sepsis
54
Congenital uterine anomalies
Mullerian fusion defects
55
Acquired uterine anomalies
Asherman’s syndrome
56
Benign uterine disorders
```
Endometritis
Endometrial polyp
Endometriosis**
Adenomyosis
Leiomyoma uteri
Endometrial hyperplasia without atypia
```
57
Malignant/pre-malignant uterine disorders
Endometrial hyperplasia with atypia
Endometrial carcinoma**
Uterine Sarcoma **
58
Disorders of Mullerian fusion
```
Uterine septum most
common disorder seen
with pregnancy loss
Resection may result in
higher delivery rates
```
Bicornuate or Unicornuate
more frequently associated
with mid-trimester loss
or preterm birth
59
Disorders of Mullerian fusion
Uterine septum
Resection may result in
higher delivery rates
```
Bicornuate or Unicornuate
more frequently
associated
with mid-trimester loss
or preterm birth
```
60
Most common disorder seen with pregnancy loss?
uterine septum
61
Vaginal septum-
results from incomplete canalization of mullein tubercle
Prepubescent—asx unless development of mucocolpos or mucometrium
Usually diagnosed at puberty with bulging hymen/hematocolpos /hematometra—may have pelvic mass/primary amenorrhea
62
Hysterosalpingogram
HSG = hystero (uterus) salpingo (tubes) gram (study)
useful to dx many uterine/tubal disorders
used a lot in infertility work ups
63
Asherman’s Syndrome:
```
intrauterine synechiae (adhesions) usually occurring after recurrent curettage
interfere with normal placental development in pgy and can be associated with pgy loss,
adhesions can be hysteroscopically resected
```
64
Recurrent curettage
most commonly from repeated miscarriages or Elective pgy terminations
65
Benign endometritis:
Inflammation of the endometrial lining of the uterus. Occurs in obstetrical population* and non-pregnant population
66
Benign endometritis pathophys:
Ascending infection from the lower genital tract. Polymicrobial from normal vaginal flora or associated cervicitis with GC/Chl
67
Endometritis risk factors:
: Invasive gyne procedures**, IUD, high risk sexual behavior/STD exposure, douching
68
in non-pregnant population __________ is most commonly associated with PID.
endometritis
69
Endometrial polyp:
```
overgrowth of endometrial cells attached to the inner wall of the uterus that extends into the uterine cavity
Typically benign (occasionally atypical or malignant)
```
Size range: few mm. to several cm. Attached by stalk, may prolapse through cervix
DDx: cervical/endocervical polyp
70
who does endometrial polyp normally occur in?
peri & post-menopausal women, occasionally younger
71
symptoms of endometrial polyps?
```
Asymptomatic
Irregular/intermenstrual
bleeding or menorrhagia
Post-coital bleeding
Post-menopausal bleeding
```
72
diagnosing endometrial polyps:
Sonohysterogram (SHGM)
73
endometrial polyp tx:
Hysteroscopic resection
74
Ddx of enlarged uterus:
```
Pregnancy
Uterine adenomyosis
Leiomyoma uteri
Hematometra (cervical stenosis/vaginal septum)
Malignancy*
Uterine sarcoma
Uterine carcinosarcoma
Endometrial carcinoma
Metastatic disease (other reproductive tract primary)
```
75
Benign
| Adenomyosis
The presence of ectopic endometrial glands and stroma in the myometrium
Incidence: Parous women, usually presents between 35-50 y/o
76
Adenomyosis symptoms:
Often asymptomatic, discovered incidentally
Secondary dysmenorrhea, abdominal pressure & bloating
Menorrhagia
Chronic pelvic pain, dysparenuia
77
Signs of adenomyosis:
Diffusely enlarged, globular, tender uterus
78
Adenomyosis diagnosis:
High index of suspicion based on clinical history and exam findings
Characteristic findings on ultrasound (SHGM) & MRI (may not be necessary)
79
Adenomyosis management:
```
Rule out coexistent uterine
pathology: fibroids, endometriosis,
endometrial hyperplasia or polyps
Medical: NSAID, Hormonal,
Await menopause
Surgical: Hysterectomy
UAE, ablation, resection, electro-
coagulation
```
80
Leiomyoma Uteri
Description: Benign tumors of smooth muscle origin (arise in myometrium)
Most common solid pelvic tumor in women
Most frequent indication for benign hysterectomy
Incidence
20-50% of women in U.S., higher in African American women (possibly as high as 70-80% by age 50)
Increases with increasing age—peak in 40’s with sharp decrease post-menopausally*
Genetic component—especially in AA population
81
Leiomyoma Uteri: Fibroids
```
Multiple sizes &
possible locations
Pedunculated can
be confused with
adnexal mass
Intracavitary can
mimic endometrial
polyp, may prolapse
through cervix
Very large uterus
can compress ureters
and affect renal fcn &
ureteral patency
```
82
Leiomyoma Uteri symptoms:
```
Asymptomatic (majority)
Bleeding abnormalities
Abdominopelvic pressure/bloating
Urinary pressure/frequency
Constipation
Reproductive complications
```
Pelvic pain—less common symptom
83
Leiomyoma Uteri eval:
Abdominal examination may reveal uterus above pubic symphysis (pregnancy sizing, >12 weeks)
Pelvic examination revealing an enlarged, firm and multinodular mass
Transvaginal ultrasound (TUS) can confirm and better delineate mass & confirm no adnexal mass, SHGM for submucosal/intracavitary identification
Occasionally MRI and/or renal evaluation
84
Leiomyomata Uteri management:
Asymptomatic
Most fibroids do not require treatment!
Education of patient
Short-interval surveillance after initial dx to confirm stability of findings*
Symptomatic
Abnormal bleeding not responsive to medical management
Pain or pressure symptoms that interfere with QOL
Urinary tract symptoms (urgency, frequency, obstruction/hydronephrosis)
Infertility or recurrent pregnancy loss
Size???*
85
A 49 y/o female patient presents for routine gyne exam. She reports that for the last 6 months her menses have been getting longer and heavier. She also says she has been experiencing urinary frequency and constipation. Her abdominal exam is unremarkable. On pelvic exam, you feel a slightly enlarged irregular uterus and a left adnexal mass that moves with the uterine fundus. No other clinical findings. What is the most likely diagnosis?
Leiomyoma uteri (fibroids)
86
Endometrial hyperplasia:
overgrowth of proliferative endometrium resulting from protracted E stimulation in the absence of P “unopposed E”
-typically peri/postmenopausal
87
endometrial hyperplasia risk factors:
```
Obesity*
Nulliparity
Early menarche/late menopause onset
Anovulation (PCOS)
Postmenopausal E therapy without Progestin
Diabetes, hypertension, hypothyroidism**
Breast cancer/Tamoxifen use***
Caucasian
Family history of ovarian, colon or uterine cancer****
Smoking
```
88
endometrial hyperplasia diagnosis:
Pap smear may show glandular cells, may be atypical*
Office endometrial biopsy**
TUS/SHGM—endometrial thickness >5 mm in post-menopausal pt, may show polypoid mass or fluid in cavity***
Hysterocopy with dilation and curettage (outpatient)
89
endometrial hyperplasia w/o atypia management:
-cyclical progestin therapy
90
endometrial hyperplasia w/ atypia:
Hysteroscopy/D & C to rule out/in coexisting adenocarcinoma
