Vaginal disorders

Question 1

What causes vulvovaginal candidiasis

Answer 1

Candida Albicans (or other candida organisms) 
VERY common (75% of women will have 1 in a lifetime)

Question 2

How does vulvovaginal candidiasis present

Answer 2

vulvar pruritis 
external dysuria
burning
dyspareunia 
swelling 
redness
excoriation 
thick, curd like discharge

Question 3

RF for vulvovaginal candidiasis are

Answer 3

taking Abx

immunocompromised

Question 4

normal vaginal pH is

Answer 4

<4.5

Question 5

How do you diagnose vulvovaginal candidiasis

Answer 5

clinically! presentation
But you can test to confirm-
Wet prep (budding yeast and hyphae)
candida culture

Question 6

How do you treat vulvovaginal candidiasis

Answer 6

Uncomplicated: 1-3 days topical azole (clotrimazole)
Complicated: 7-14 days topical azole; or oral Fluconazole if albicans
Pregnant: topical azole x 7 days, or single dose Fluconazole (low dose)

Question 7

What is a “complicated” yeast infection

Answer 7

4+ in one year
non-albicans
pt has uncontrolled DM
immunocompromised

Question 8

Can men get candidiasis?

Answer 8

They can develop balanitis (skin covering glans) in which case they need Tx

Question 9

If a patient has difficult to treat or recurrent yeast infections, eval for

Answer 9

HIV or DM

Question 10

What causes bacterial vaginosis

Answer 10

disruption of healthy vaginal microflora (lactobacillus) causing overgrowth of other bacteria
MCC” polymicrobial (garnerella vaginalis and mobiluncus anaerobes)

Question 11

How does BV present

Answer 11

vaginal irritation

thin white/grey discharge w/ strong fishy odor (amine)- worse after intercourse

Question 12

RF for BV are

Answer 12

new/multiple sex partners (rarely affects women never sexually active)
douching

Question 13

What is Amsel’s criteria for Dx BV

Answer 13

Need 3 of the 4 
1. thin white homogenous discharge coating vaginal walls
2. clue cells on microscopy 
3. vaginal fluid pH >4.5
fishy odor when adding KOH (whiff test)

Question 14

What is the best lab test to assess BV

Answer 14

Gram stain! will see anaerobes and lack of lactobacilli

gold standard, but rarely used

Question 15

What are clue cells

Answer 15

vag epithelial cells studded with adherent coccobacilli indicating BV

Question 16

How do you treat BV

Answer 16

Treat if symptomatic! but NOT partners 
Metronidazole (flagyl) PO x 7 days 
Metronidazole gel transvaginal x 5 days 
Clindamycin oral,transvaginal 
Pregnant: oral meds ONLY

Question 17

What should you avoid when taking metronidazole

Answer 17

alcohol!

Question 18

Complications of BV include

Answer 18

increased risk of HIV, herpes, gonorrhea, chlamydia
associated with PID
Commonly persists and recurs

Question 19

Good patient education for someone with BV is

Answer 19

it is highly recurrent! it is not them or their hygiene 
Don't use scented products 
wear loose clothing 
no panty liners 
come back ASAP at Sx onset

Question 20

What is atrophic vaginitis

Answer 20

epithelial lining of vulva, vagina, and bladder becomes dry and connective tissue less elastic 2/2 loss of estrogen

Question 21

Symptoms of atrophic vaginitis include

Answer 21

dyspareunia
post-coital bleeding 
leukorrhea 
burning, raw, dry sensation (feels like yeast infection) 
urinary Sx

Question 22

On PE of atrophic vaginitis what will you see

Answer 22

vagina loses rugae 
pale-red coloring 
petechiae 
purulent vag discharge, fissures, or erosions 
pH >5

Question 23

How do you treat atrophic vaginitis

Answer 23

Replens (vaginal moisturizer) if CI to estrogen
Vaginal estrogen: premarin, estrace 1gm 2x week// Vagifem 10mcg 2x week// Estring q90 days
Vaginal prasterone (DHEA)
Ospemifene 60mg daily (SERM)

Question 24

What is a potential ADE of Ospemifene

Answer 24

thrombotic events - it is an estrogen agonist

Question 25

What is vaginal intraepithelial neoplasia (VaIN)

Answer 25

complication of HPV, associated with CIN | occurs around 35-55 y/o

Question 26

RF for VIN are

Answer 26

smoking multiple sex partners early onset sexual activity Hx of CIN III (but some womwn w/ primary vaginal cancer have no Hx of CIN III or cervical cancer)

Question 27

What is the pathogenesis of VIN

Answer 27

HPV exposure- great deal of time to develop VIN Frequency is lower than CIN (vaginal epithelium is differnt than cervical) VIN does not progress to cancer like CIN

Question 28

Most VIN lesions are located

Answer 28

upper 1/3 of vgina

Question 29

What are the VIN classifications

Answer 29

VIN1: benign viral proliferation VIN2: intermediate risk VIN3: true precursor to vaginal cancer

Question 30

How can you test for VIN

Answer 30

``` Pap smear (cytology) colonoscopy ```

Question 31

How do you manage VIN

Answer 31

VIN1: obs in young women- cytology/HPV/colonoscopy q6 months VIN2-3: Surgery or topical chemotherapy

Question 32

What is a vaginectomy

Answer 32

Removal of upper 1/3 of vagina 2/2 VIN2-3 | 90% success rate

Question 33

What is laser vaporization

Answer 33

Destroy dysplastic cells in VIN2-3 | 63-90% success rate

Question 34

What is topical chemotherapy for VIN2-3

Answer 34

insert 2g PV x 5-7 nights, and zinc oxide to introitus and vulva in AM- causes sloughing of vaginal epithelium 50-85% success

Question 35

What are ADE of topical chemo for VIN2-3

Answer 35

dyspareunia vaginal burning, ulceration, irritation No FDA approved for VIN2-3

Question 36

When should you consider chemo topical to Tx VIN2-3

Answer 36

if no other Tx is optional- this hurts!

Question 37

What is the MCC of invasive vaginal cancer

Answer 37

mets from endometrium, ovary, or cervix | -but FIGO says it can only be called vaginal cancer if the primary growth is there

Question 38

What is the MC vaginal cancer

Answer 38

Squamous cell | <20% are Dx under 50

Question 39

How does vaginal cancer present

Answer 39

``` ASx Leukorrhea Vaginal odor post-coital bleeding abnormal pap (white changes, punctation, or mosaic on colposcopy) ```

Question 40

How do you treat vaginal cancer

Answer 40

Nothing standard 2/2 extremely rare occurrence Vaginectomy + radiation 5 year survival 61%