Week 3 pt 2: 4.16 lecture

Question 1

You must be diligent in all aspects of the rhythm method; list the 4 aspects

Answer 1

1) Menstrual calendar
2) Basal body temperature: AM temp
3) Cervical mucous analysis
4) Avoidance of intercourse during fertile periods

Question 2

Tubal ligation:
1) Can it be reversed?
2) What is the failure rate?
3) What is the recovery?

Answer 2

1) Reversal success depends on type used; Difficulty differs
2) Approx. 1%
3) 2-4 weeks

Question 3

Risks associated with bilateral tubal ligation (BTL) include what?

Answer 3

1) Damage to the bowel, bladder or major blood vessels
2) Reaction to anesthesia
3) Improper wound healing or infection
4) Continued pelvic or abdominal pain/lifting restrictions
5) Failure of the procedure, resulting in a future unwanted pregnancy
6) Increased risk of ectopic pregnancy

Question 4

Vasectomy:
1) What are some rare complications?
2) How often does pregnancy occur?
3) What needs to be confirmed before sterilization is declared? When?

Answer 4

1) Bleeding, hematomas, acute and chronic pain, and local skin infections rare
2) About 1% of cases
3) Azoospermia confirmed by semen analysis (8-16wks post op; 98-99% by 6mos)
-Secondary method of contraception during this period

Question 5

Sterilization counseling:
1) Approximately ___% of men regret their decision to undergo vasectomy
2) ________________ at time of sterilization statistically increases risk of later regret

Answer 5

1) 2%
2) Younger age

Question 6

What are the Txs for candidiasis?

Answer 6

1) Diflucan (fluconazole) 150mg po x 1 (safe in preg)
OR
2) OTC Monistat or generic (Miconazole) x 7days

Question 7

Candidiasis:
1) Sx?
2) How to Dx?
3) Etiology?

Answer 7

1) White, thick dc, “cottage cheese”
-Vulvar pruritis, erythema
2) Clinical dx or culture
-KOH wet prep: Hyphae/budding yeast
3) Candida albicans
-Normal flora altered: abx, sex, DM, etc.

Question 8

Atrophic Vaginitis/Atrophy:
1) Sx?
2) Dx?
3) Etiology?
4) Pt population?

Answer 8

1) Vulvar bleeding, dyspareunia, tears, dryness, urinary urgency/incontinence
2) Clinical
3) Lack of estrogen: menopause or surgical removal of the ovaries or other hypoestrogenic states (postpartum, breastfeeding)
4) Postmenopausal primarily

Question 9

Atrophic Vaginitis/Atrophy: What is the Tx?

Answer 9

1) OTC vaginal moisturizers
2) Estrogen replacement cream (topical)
3) May also receive rx for Osphena po based on sxs (*blackbox warning: endometrial ca, DVT)

Question 10

True or false: you never want to give PO estrogen without progesterone (topical is safer)

Answer 10

True

Question 11

Describe the visible Sx of atrophic vaginitis

Answer 11

1) Thinning pubic hair, narrowing vaginal introitus
2) Petechiae of vaginal tissues
3) Loss of labia minora/majora

Question 12

Allergic vaginitis:
1) Dx?
2) Etiology?

Answer 12

1) Clinical
2) New soap, new bath oil or bubble bath, new laundry detergent or fabric softener, a change in tampon or pad brands, using tampons or pads with deodorant, douching, condoms (LATEX), spermicides, lubricants
[Anyone CAN develop an allergy to anything]

Question 13

List 3 lichens that can occur in the labial area

Answer 13

1) Lichen simplex chronicus
2) Lichen sclerosis
3) Lichen planus

Question 14

Lichen Simplex Chronicus:
1) Sx?
2) Etiology?
3) Tx?

Answer 14

1) Persistent itching/scratching of vulvar area
“an itch that rashes”
Leads to leathery, thickened appearance
2) Many conditions may cause (irritant dermatitis)
3) Antipruritic meds (Benedryl, Atarax)
Topical steroids
Vulvar bx (biopsy) if no improvement in 3mos

Question 15

Lichen Sclerosis:
1) Sx?
2) Etiology?

Answer 15

1) White, shiny plaque on vulva or anus; tissue paper skin, non-elastic
-Itchy patch
-Dyspareunia
-Burning perineal pain
2) Unknown (thyroid d/o?)

Question 16

Lichen Sclerosis:
1) Pt population?
2) Dx?
3) Tx?
4) Incr. risk of what kind of cancer?

Answer 16

1) Postmenopausal (men can get too)
2) Skin punch bx
3) Topical steroid
4) SCC (squamous cell carcinoma) of vulva

Question 17

Lichen planus: What are the Sx?

Answer 17

1) May be vulvar or may involve the mouth as well (vulvar-vaginal-gingival syndrome)
2) Purplish Planar Polygonal Pruritic Papules and Plaques
3) Whitish, lacy bands (Wickham striae) of keratosis
4) Burning pain and dyspareunia
5) Increased vaginal discharge

Question 18

Lichen planus:
1) Etiology?
2) Pt population?
3) Dx?
4) Tx?

Answer 18

1) Inflammatory, autoimmune component
2) 30-60yo
3) Clinical or biopsy
4) Topical steroid *chronic condition with no cure

Question 19

Treatment for all the Lichens is what?

Answer 19

1) Potent (Category 1) Topical Steroids
2) Clobetasol 0.05% bid for a month then daily for 3 months
-Then use once or twice a week prn sx

*May need multiple biopsies to rule-out SCC.

Question 20

Bacterial Vaginosis (BV)
1) Is it an STD?
2) Main Sxs?
3) How to Dx?

Answer 20

1) Not an STD
2) Discharge white or gray, thin, fishy/musty odor
3) Amsel Criteria (3 of 4; abnl gray d/c, pH >4.5, +whiff test, presence of clue cells)
-microscopic exam: clue cells
-wet prep/KOH “whiff test”- fishy odor (+whiff test)

Question 21

Bacterial Vaginosis (BV):
1) Etiology?
2) Tx?

Answer 21

1) Gardnerella bacteria
2) Metronidazole (Flagyl)
-Clindamycin (topical)

Question 22

Bartholin’s Gland cyst:
1) Where are these glands?
2) Sx?
3) Etiology?
4) Pt population?

Answer 22

1) Mucous producing glands sit in the vulva
2) Acute, painful labial swelling
3) Blockage of the Bartholin duct
abscess can turn malignant (>40yo)
4) 20-30yo
If over 40: bx, high malignancy chance

Question 23

Bartholin’s Gland cyst:
1) Tx?
2) Explain the Tx

Answer 23

1) Tx: I&D (if first time) + Word catheter
-The Word catheter is a balloon placed in the Bartholin gland after I&D to allow continued drainage and re-epithelialization of a tract for future drainage.
2) Marsupialization (if >2x) + dissolvable sutures

Question 24

Vulvar Cancer Symptoms:
Describe the location of the potential ulcerative lesion, thickening, or lump

Answer 24

1) Usually on the labia majora (most commonly the posterior 2/3)
2) May be anywhere on the vulva

Question 25

What are some of the main Sx of vulvar CA?

Answer 25

1) Ulcerative lesion, thickening, or lump 2) Local itching (most common complaint), pain, burning, bleeding 3) Pain with urination (dysuria) 4) Pain with intercourse (dyspareunia) 5) Unusual odor

Question 26

Nearly ____% of women with vulvar cancer have no symptoms.

Answer 26

20%

Question 27

Vulvar CA 1) What does it most often affect? 2) Where may it start? 3) What type of CA are most (90%) of vulvar CAs? 4) What are some other possibilities?

Answer 27

1) Labia 2) On the clitoris or in Bartholin glands 3) Of squamous origin (SCC) (90%) 4) Melanoma(2%), sarcoma, adenocarcinoma, and basal cell carcinoma

Question 28

Vulvar CA: 1) When does it usually occur? 2) What are some risk factors?

Answer 28

1) After menopause, typically in women age 50 or older (70-80yo most common) -However, 20% of cases occur in women < 40yo 2) Previous HPV infection, previous cervical or vaginal cancer, lichen sclerosus, syphilis or HIV infection, smoking

Question 29

**Vulvar CA:** Who have a greater risk of developing vulvar cancer that metastasizes?

Answer 29

Women with vulvar intraepithelial neoplasia (VIN) *Although most cases of VIN never lead to cancer.

Question 30

Describe the steps of diagnosing vulvar CA

Answer 30

1) Pelvic exam to look for any skin changes 2) Excision and biopsy of the lesion to make an accurate diagnosis 3) Punch biopsy -If irritated, pigmented vulvar lesions, must perform excisional biopsy for definitive treatment 4) Colposcopy for evaluating known vulvar atypia and intraepithelial neoplasia

Question 31

Vulvar cancer: 1) Describe the presentation of Squamous carcinoma (90%) 2) Describe the presentation of Vulvar melanoma (6%)

Answer 31

1) Usually appear as a growth on the surface of the vagina. -May present as an open sore (ulcer). 2) Often appears as a raised, irritated, pruritic, pigmented lesion -On the labia minora or clitoris

Question 32

Vulvar CA: 1) ______________ often appear as a grape-like mass. 2) Describe adenocarcinomas

Answer 32

1) Sarcomas 2) May lie deeper so that it is not visible and detected only by palpation; usually appear as a growth on the surface of the vagina

Question 33

High-grade squamous intraepithelial lesion of the vulva (HSIL) 1) What is it? What is a common social Hx finding? 2) What do Sx include?

Answer 33

1) High-grade, HPV-related lesions; Smoking 2) Vulvar pruritis, Chronic irritation, Development of raised mass lesions

Question 34

High-grade squamous intraepithelial lesion of the vulva (HSIL): 1) What should be done after using a colposcope? 2) What are the 3 types?

Answer 34

1) Selective biopsies 2) Warty, Basaloid, Mixed

Question 35

Low-grade squamous intraepithelial lesion of the vulva (LSIL): 1) What is it? 2) What does it often occur in? Is it a cancer precursor?

Answer 35

1) Minimal to mild squamous atypia limited to the lower epidermis 2) Occurs most often in condylomata acuminata (genital warts) *Little evidence it is a cancer precursor

Question 36

Low-grade squamous intraepithelial lesion of the vulva (LSIL): 1) What is it? 2) Is it a cancer precursor?

Answer 36

1) Minimal to mild squamous atypia limited to the lower epidermis 2) Little evidence it is a cancer precursor

Question 37

Vulvar Cancer: Treatment 1) When should you do surgery? 2) When may you do radiation +/- chemotherapy? 3) What is the survival rate?

Answer 37

1) Large tumor (>2 cm) or has grown deeply into the underlying skin; the lymph nodes in the groin area may also be removed. -Melanoma- early, wide, local excision for diagnosis and staging 2) To treat advanced tumors or vulvar cancer that comes back. 3) 5-year survival rate for all vulvar carcinomas: ~70% 60-80% for SCC Stages 1-2, 45% stage 3, 15% for stage 4

Question 38

Vaginal CA: 1) Is it common? 2) What are the types?

Answer 38

1) Rare but usually secondary to cervical or vulvar cancers 2) a) Squamous cell carcinoma (80-90%): Primarily in women >55yo b) Adenocarcinoma, vaginal melanoma, sarcoma -Small cell cancer, lymphoma, carcinoid cancers (total 1%)

Question 39

Vaginal CA 1) What are the Tx options? What should you base them on? 2) What is the survival rate?

Answer 39

1) Surgery, radiation, and neoadjuvant chemotherapy options (based on patient’s sexual functioning and anatomic location) 2) 49% overall (42% for SCC)

Question 40

Vaginal Intraepithelial Neoplasia (VAIN): What are the 3 steps? Describe each

Answer 40

1) VAIN 1: Basal epithelial layers; do not require more than monitoring 2) VAIN 2: Up to 2/3 vaginal epithelium 3) VAIN 3: More than 2/3 vaginal epithelium (including CIS) Potential for progression to invasive vaginal carcinoma

Question 41

Trichomoniasis: 1) Etiology? 2) Sx?

Answer 41

1) Parasite (trichomonas vaginalis) 2) Frothy, yellow-green vaginal discharge Malodorous or fishy odor Dyspareunia Dysuria Strawberry cervix Many asx

Question 42

Trichomoniasis: 1) Dx? 2) Tx?

Answer 42

1) Microscope: flagellated protozoans; NAAT; culture 2) Metronidazole 500mg po bid x 7d (Flagyl) *Alcohol contraindicated -Treat sexual partners

Question 43

Hep B & Pregnancy: 1) When is it screened? Describe 2) Is it transmitted to baby?

Answer 43

1) At first prenatal visit -Testing for Hepatitis B surface antigen (HBsAg) during pregnancy is routine -If neg with risk factors for Hep B, should be offered vaccine in pregnancy -If pos, infant should receive vaccine and HBIg within 12hrs of birth 2) Vertical transmission of hepatitis related to the presence of maternal hepatitis B e antigen (HBeAg) -If +pos., 70% to 90% risk of fetus becoming infected (increases if maternal infection increases in 3rd tri)

Question 44

Hepatitis B and C: 1) Sx? 2) Long term consequences? 3) Transmission occurs how?

Answer 44

1) Fatigue, jaundice, elevated LFTs, N/V, abdominal pain 2) Lifelong infection, scarring, cirrhosis, liver cancer, liver failure, and death 3) Blood-borne/sexual con

Question 45

Hepatitis B and C: 1) Tx? 2) Prevention of hep B? 3) Prevention of HCV?

Answer 45

1) Antivirals may help treat chronic disease 2) Vaccine available to prevent HBV -3 doses: first within 24hrs of birth (then +1mo, +6mo) 3) No preventative measures known to reduce risk of mother-to- child transmission

Question 46

Hep B & C 1) What are the long term consequences? 2) Is breastfeeding contraindicated for Hep B & C?

Answer 46

1) Lifelong infection, scarring, cirrhosis, liver cancer, liver failure, and death 2) Breastfeeding is not contraindicated in women who are chronic carriers of HBV if their infants have received both the vaccination and HBIg within 12 hours of delivery. -Also not contraindicated in HCV + unless cracked or bleeding nipples

Question 47

Pubic Lice: Pediculosis Pubis 1) Etiology? 2) Dx? 3) Tx?

Answer 47

1) Louse, Pthirus pubis: lays eggs in pubic hair -Can be acquired during sexual activity or from sheets, towels, or commodes used by infected people 2) Clinical: louse 3) Permethrin 1% OTC topical, rinse off p 10 min *All linens, towels, etc. must be sanitized in hot water and dried in a hot dryer

Question 48

HPV: 1) How many types? 2) How common is it?

Answer 48

1) More than 100 types 2) Occurs in 80% sexually active women by 50yo

Question 49

Condyloma Acuminata are also called what?

Answer 49

Genital warts

Question 50

Condyloma Acuminata (HPV): 1) Sx? 2) Etiology? 3) Dx?

Answer 50

1) Soft, flesh- colored growths 2) HPV (strains 6 and 11 primarily) 3) Clinical or bx

Question 51

Condyloma Acuminata (HPV): 1) Tx? 2) Prevention?

Answer 51

1) Chemical treatments, cautery, immunologic treatments (ie. Imiquimod cream) 2) HPV Vaccine (Gardisil): recommended for males and females 11-26yo x 2 doses

Question 52

HSV: Herpes Simplex Virus 1) Sx? 2) Dx? 3) Is there a cure? What etiology makes up the majority of cases?

Answer 52

1) Flu-like syndrome, vesicular rash, blisters with clear fluid, and ulcerated sores around genitals/anus (tender) 2) Clinical, confirmed by viral culture and PCR or Tzanck smear (giant multinucleated cells) 3) No cure; most HSV-2

Question 53

HIV/ AIDS: 1) Prevalence? 2) What increases risk of acquiring HIV through sexual contact?

Answer 53

1) 1.2mil in the US are HIV+ 2) If also +STI and increased risk of transmitting HIV if HIV+ individual also has an STI

Question 54

1) Describe the progression of HIV in untreated pts 2) List some opportunistic infections

Answer 54

1) The time between infection with HIV and the development of AIDS ranges from a few months to as long as 17 years (median: 10 years) 2) Cryptococcal meningitis, toxoplasmosis, PCP (pneumocystis jirovecii), chronic candida, Kaposi’s sarcoma

Question 55

Gonorrhea: 1) Sx? 2) Do you screen for this? 3) Dx?

Answer 55

1) Sx: most asx; if sxs, dysuria, greenish or yellow d/c from cervix (cervicitis), vaginal d/c, bleeding between periods 2) Screen yearly if sexually active <25 and if high risk >25yo (for chlamydia also) 3) Screening in pregnancy Culture of vagina, penis, rectum or pharynx PCR (NAAT) or urine

Question 56

Describe gonorrhea Tx?

Answer 56

1) Ceftriaxone 500mg IM x 1 (* treat for Chlamydia also*) a) Must treat asap in pregnant woman (can cause blindness, joint infection, sepsis in baby) *Reportable disease

Question 57

Complications of Gonorrhea: 1) Include what? 2) GC is responsible for 75% of young sexually active adult cases of septic arthritis; describe this condition & Tx

Answer 57

1) Sepsis; Fitz-Hugh-Curtis Syndrome (perihepatitis); High risk for PID 2) Fever, joint pain, limited ROM, purulent aspirate CBC, ESR, CRP -ADMIT and consult ortho -Tx: 2 weeks of IV antibiotics (IV ceftriaxone), washout

Question 58

Fitz-Hugh-Curtis Syndrome (perihepatitis): 1) What STI is it assoc with? 2) What is the main Sx? 3) What is the cause?

Answer 58

1) Gonorrhea 2) Severe RUQ pain in addition to PID symptoms 3) "Violin string” adhesions under the liver

Question 59

Chlamydia: 1) Sx? 2) Dx? 3) What can occur in newborns? How do you prevent this? 4) Is it reportable?

Answer 59

1) No sx or very mild sx , dyspareunia, abnl vaginal discharge, mucopurulent d/c from cervix (cervicitis) 2) Urine (high false-negatives) OR culture (PCR/NAAT) from the ectocervix or vagina (preferred method) 3) Ophthalmia neonatorum; Antibiotic ointment to protect eyes from G/C (and E-coli) 4) Yes

Question 60

Chlamydia complications: List & describe these

Answer 60

1) Neonatal conjunctivitis and pneumonia 2) PID (40% if untreated): May include the fallopian tubes (salpingitis) and result in permanent sterility, ectopic pregnancy, and chronic pelvic pain 3) Reiter’s Syndrome (venereal arthritis) 4) Cervicitis, endometritis, urethritis, epididymitis

Question 61

Chlamydia Complications: Reiter Syndrome: 1) What is the triad? 2) How does it present? Explain

Answer 61

1) Triad of nongonococcal urethritis, conjunctivitis and arthritis 2) Present with malaise, fatigue, and fever, low back pain & heel pain -Arthritis typically involves hips, knees, or ankles and tends to by asymmetrical

Question 62

Syphilis: 1) Etiology? 2) How does it develop?

Answer 62

1) Spirochete Treponema pallidum 2) In stages, and symptoms vary with each stage/may be asymptomatic

Question 63

Syphilis: Describe each of the 3 stages

Answer 63

1) Primary infection: small, painless chancre on genitals, rectum, or mouth 2) Secondary infection: maculopapular red/brown rash of trunk including palms/soles of feet; lymphadenopathy, fever, fatigue, h/a (Latent Stage: no s/sx; + serologic testing) 3) Tertiary infection: 1/3 untreated cases; damage to the brain, nerves, eyes, or heart

Question 64

Patients Who Should be Hospitalized for PID include who?

Answer 64

1) Surgical emergencies (e.g., appendicitis) cannot be excluded 2) Patient is pregnant 3) Does not respond clinically to oral antimicrobial therapy 4) Unable to follow or tolerate an outpatient oral regimen 5) Has severe illness or high fever 6) Tubo-ovarian abscess

Question 65

PID may include infection of any or all of which anatomic locations?

Answer 65

1) Endometrium (endometritis) 2) Fallopian (uterine) tubes (salpingitis) 3) Ovaries (oophoritis) 4) Uterine wall (myometritis) 5) Uterine serosa and broad ligaments (parametritis) pelvic peritoneum 6) Tuboovarian abscess (TOA); requires admission

Question 66

PID: 1) Common Sx? 2) How is it diagnosed?

Answer 66

1) Many women with PID have subtle or mild symptoms 2) Usually clinical: CMT, adnexal tenderness, uterine tenderness

Question 67

Empiric treatment of PID should be initiated in sexually active young women with what?

Answer 67

1) Pelvic or lower abdominal pain 2) If no cause for the illness other than PID can be identified 3) and if >1 of the following minimum criteria are present on pelvic examination: 1. CMT 2. uterine tenderness 3. adnexal tenderness

Question 68

List the additional criteria for PID Dx

Answer 68

1) PO temperature >101°F (>38.3°C) 2) abnormal cervical or vaginal mucopurulent discharge 3) presence of abundant numbers of WBC on wet prep 4) elevated erythrocyte sedimentation rate (ESR) 5) elevated C-reactive protein (CRP) 6) + N. gonorrhea or C. trachomatis

Question 69

25% of patients have long term consequences of PID; list them

Answer 69

1) Tubal factor infertility 2) Ectopic pregnancy 3) Chronic pelvic pain 4) Dyspareunia 5) Menstrual disturbances 6) Pelvic adhesions

Question 70

List the CDC Tx recommendations for PID

Answer 70

1) Ceftriaxone 1g IV q 24hrs  plus 2) Doxycycline 100 mg po (or IV- ideally PO) bid x 14d plus 3) Metronidazole 500 mg po (or IV) bid x 14d