Week 3 pt 2 highlights: 4/16 lecture

Question 1

The rhythm method:
1) ____% effective with perfect use
2) ____% effective with average use
3) Should you follow in lactational amenorrhea? How long is this?

Answer 1

1) 91%
2) 76%
3) Yes; (~3mos (+/- a few mos) if exclusive breastfeeding)

Question 2

What is the most common form of sterilization in women?

Answer 2

Tubal ligation (BTL)

Question 3

What method of sterilization for women can cause decreased ovarian cancer risk?

Answer 3

Salpingectomy (removal of tubes)

Question 4

1) Define vasectomy
2) Is it safer than female procedures? Is it reversible?
3) Is it immediate?

Answer 4

1) Excision and ligation, electrocautery-occlusion of the vas deferens
2) Safer, less-invasive, more effective than procedures done in women
More easily reversed compared to women, however, reversal is still uncertain for outcome
3) Not immediate sterilization

Question 5

When counseling patients about sterilization:
1) 3% - 25% of women _________their decision to undergo permanent sterilization
2) True or false: Reversals are not guaranteed for either gender

Answer 5

1) regret
2) True

Question 6

Candidiasis:
1) What are the main Sx?
2) Besides clinical Dx, how can it be diagnosed?
3) What is the etiology?
4) What is typically the first round of Tx?

Answer 6

1) White, thick dc, “cottage cheese” + vulvar pruritis
2) KOH wet prep: Hyphae/budding yeast
3) Candida albicans
4) Diflucan (fluconazole) 150mg po x 1 (safe in preg)

Question 7

Atrophic Vaginitis/Atrophy:
1) What is a main Sx?
2) Main etiology?
3) When does it usually occur?

Answer 7

1) Dryness
2) Lack of estrogen (hypoestrogenic)
3) Postmenopausal

Question 8

What atrophic vaginitis med has a black box warning for endometrial cancer or DVT?

(important to know)

Answer 8

Osphena PO
(bc of the estrogen in it)

Question 9

Loss of labia minora/majora is a Sx of what?

Answer 9

Vaginal atrophy

Question 10

Allergic Vaginitis:
1) Sx?
2) Tx?

Answer 10

1) Erythema, pruritis, irritation
2) topical steroid, oral steroid/antihistamine

Question 11

True or false: Anyone can develop an allergy to anything (& sometimes at any point in time)

Answer 11

True

Question 12

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

Answer 12

1) Persistent itching/scratching of vulvar area
-“an itch that rashes”
-Leads to leathery, thickened appearance
2) Antipruritic meds
-Topical steroids
-Vulvar bx (biopsy

Question 13

What is also known as “an itch that rashes”?

Answer 13

Lichen Simplex Chronicus

Question 14

Lichen Sclerosis:
1) Main Sx?
2) Who is it common in?
3) Tx?

Answer 14

1) Tissue paper skin
2) Postmenopausal
3) Topical steroid

Question 15

Lichen Sclerosis causes an increased risk of what?

Answer 15

Increased risk for SCC (squamous cell carcinoma) of vulva

Question 16

Lichen Planus:
1) What are the main Sx?
2) Tx?

Answer 16

1) Vulvar-vaginal-gingival syndrome
Purplish Planar Polygonal Pruritic Papules and Plaques
2) Topical steroid
*chronic condition with no cure

Question 17

1) Treatment for all the Lichens is what?
2) What may you need to perform multiple times?

Answer 17

1) Potent (Category 1) Topical Steroids: Clobetasol 0.05%
2) Multiple biopsies to rule-out SCC

Question 18

Bacterial Vaginosis (BV):
1) Sx?
2) Is it an STD?
3) Dx?

Answer 18

1) Discharge white or gray, thin, fishy/musty odor
2) Not an STD
3) Amsel Criteria (3 of 4

Question 19

What is the common vaginal infection in women of childbearing age?

Answer 19

Bacterial Vaginosis (BV)

Question 20

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

Answer 20

1) Gardnerella bacteria
2) Metronidazole (Flagyl) + Topical Clindamycin

Question 21

Bartholin’s Gland cyst:
1) Who is it most common in?
2) Most common Tx for first time occurrence?
3) What if it occurs >2x?

Answer 21

1) 20-30yo
2) I&D + Word catheter
3) Marsupialization

Question 22

Vulvar Cancer:
1) What are some main Sx?
2) What is the most common Sx?
3) Nearly ____% of women with vulvar cancer have no symptoms.

Answer 22

1) Ulcerative lesion, thickening, or lump
2) Itching (most common complaint)
3) 20%

Question 23

Vulvar Cancer:
1) What area does it most often affect?
2) What is the origin of most vulvar cancers?
3) How common is it? What is it assoc. with?

Answer 23

1) Labia
2) Squamous origin (SCC)
3) Relatively rare
-Has been increasing along with increased HPV

Question 24

Vulvar Cancer:
1) When does it usually occur?
2) What are 3 risk factors?

Answer 24

1) After menopause (70-80yo most common)
2) Previous HPV infection, smoking, + vulvar intraepithelial neoplasia (VIN; rarely metastasizes)

Question 25

Vulvar CA: Describe the steps of Dx

Answer 25

1) Pelvic exam 2) Excision and biopsy: punch biopsy 3) Colposcopy

Question 26

Vulvar CA: 1) What is the cure rate? 2) Is incidence increasing or decreasing?

Answer 26

1) 80% 2) Increasing incidence (possibly due to increasing STD/HPV rate)

Question 27

Vulvar CA: If irritated, pigmented vulvar lesions, must perform _________________ for definitive treatment

Answer 27

excisional biopsy

Question 28

List the types of vulvar CA. Which often presents as a pigmented lesion?

Answer 28

1) Squamous carcinoma (90%) 2) Vulvar melanoma (6%; often pigmented) 3) Sarcomas 4) Adenocarcinoma 5) Carcinoma of the Bartholin Gland

Question 29

Carcinoma of the Bartholin Gland is uncommon, but every new solid Bartholin mass in a women >_________ should be excised

Answer 29

>40yo

Question 30

High-grade squamous intraepithelial lesion of the vulva (HSIL): 1) What is it? 2) What is a common social Hx finding? 3) What is the main complaint? 4) What should you use before selective biopsy? 5) What is the goal of Tx?

Answer 30

1) High-grade, HPV-related lesions 2) Smoking 3) Vulvar pruritis 4) Colposcope 5) Quickly and completely remove all involved areas of skin via wide local excision or laser ablation

Question 31

Give an example of a HSIL

Answer 31

Paget disease

Question 32

Paget disease (an HSIL): 1) What is the gross appearance? 2) What CA may it be assoc with? 3) ______-______%have other associated but noncontiguous cancers such as of the colon or breast 91

Answer 32

1) Fiery, red background mottled with whitish hyperkeratotic areas 2) Adenocarcinoma 3) 20-30%

Question 33

Low-grade squamous intraepithelial lesion of the vulva (LSIL): 1) What are 3 etiologies? 2) What does it occur most often in? 3) Dx? 4) Tx?

Answer 33

1) Non-neoplastic, reactive atypia OR due to HPV infection 2) Condylomata acuminata (genital warts) 3) Biopsy 4) Same as condyloma

Question 34

List the stages of vulvar CA

Answer 34

1) Stage 0 2) Stage 1: 1a + 1b 3) Stage 2 4) Stage 3: 3a, 3b, 3c 5) Stage 4: 4a, 4b

Question 35

Vulvar Cancer: 1) Treatment? 2) What abt for melanoma specifically? 3) 5-year survival rate for all vulvar carcinomas is what?

Answer 35

1) Surgery or Radiation +/- chemotherapy 2) Early local excision 3) ~70%

Question 36

Vaginal Cancer: 1) Rare but usually secondary to what? 2) What is the main type? 3) Tx?

Answer 36

1) Cervical or vulvar cancers 2) Squamous cell carcinoma 3) Surgery, radiation, and neoadjuvant chemotherapy options

Question 37

Vaginal Intraepithelial Neoplasia (VAIN): What are the 3 steps? Which is concerning?

Answer 37

1) VAIN 1 2) VAIN 2 3) VAIN 3: concerning for progression to invasive vaginal carcinoma

Question 38

Vaginal Intraepithelial Neoplasia (VAIN): How do you definitively Dx?

Answer 38

colposcopy with directed biopsy

Question 39

What is a key word to assoc. with trichomoniasis?

Answer 39

Frothy

Question 40

Trichomoniasis: 1) Etiology? 2) Main symptoms? 3) Dx methods? Which is the main one? 4) Main Tx?

Answer 40

1) Parasite 2) Frothy, yellow-green vaginal discharge. -fishy; Strawberry cervix; many asx 3) **NAAT**; flagellated protozoans; culture 4) Metronidazole

Question 41

Hep B & Pregnancy: 1) When do you screen for? Is testing routine? 2) __________ transmission of hepatitis is related to the presence of maternal hepatitis B e antigen (HBeAg)

Answer 41

1) First prenatal visit; Hepatitis B surface antigen (HBsAg). 2) Vertical.

Question 42

Hep B & Pregnancy: 1) What if a pt is neg w risk factors for Hep B? 2) What if a pt is positive?

Answer 42

1) Should be offered vaccine in pregnancy 2) Infant should receive vaccine and HBIg within 12hrs of birth

Question 43

Hepatitis B and C: 1) Sx? 2) Etiology? 3) Main Tx? 4) Main points of prevention?

Answer 43

1) Fatigue, jaundice, elevated LFTs, N/V, abdominal pain 2) Blood-borne/sexual contact 3) Antivirals 4) Vaccine for hep B; No preventative measures known to reduce risk of mother-to- child transmission of HCV

Question 44

1) Is there a way to prevent HBV in newborns? 2) How many doses and when? 3) Is breastfeeding contraindicated in women who are chronic carriers?

Answer 44

1) Vaccine available to prevent HBV 2) 3 doses: first within 24hrs of birth (then +1mo, +6mo) 3) No, as long as their infants have received both the vaccination and HBIg within 12 hours of delivery.

Question 45

Pubic Lice: Pediculosis Pubis: What is the Tx?

Answer 45

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 46

HPV: 1) Strains _______ and ________ cause 70% of cervical cancer cases 2) Strains ______ and _____ cause 90% of genital warts (condyloma acuminata) cases 3) Occurs in ______% sexually active women by 50yo

Answer 46

1) 16 and 18 2) 6 and 11 3) 80%

Question 47

HPV: Condyloma Acuminata: 1) Main Sx? 2) Etiology? 3) Prevention?

Answer 47

1) Flesh- colored growths 2) HPV (strains 6 and 11 primarily) 3) HPV Vaccine (Gardisil):

Question 48

HSV: Herpes Simplex Virus 1) Main ymptoms? 2) How is clinical Dx confirmed? 3) Etiology?

Answer 48

1) Vesicular rash, blisters with clear fluid, and ulcerated sores around genitals/anus (tender) 2) Viral culture and PCR or Tzanck smear 3) HSV-1 or HSV-2 viruses (majority HSV-2) *no cure

Question 49

(HSV) Herpes Simplex Virus: Tx of first clinical episode?

Answer 49

1) Acyclovir 400mg po 5x/day (or 800mg TID) x 7-10d 2) Valacyclovir 100mg po BID x 7-10 days *dosing changes for recurrences* 3) C-section recommended if HSV lesions on cervix, vagina, or on vulva

Question 50

Three primary methods of contracting HIV are what?

Answer 50

1) Intimate sexual contact 2) Use of contaminated needles or blood products 3) Perinatal transmission from the mother to child

Question 51

List 3 ways to reduce HIV transmission

Answer 51

1) Routine screening: first trimester of pregnancy 2) Aggressive therapy at time of delivery (also meds safe to take in pregnancy) 3) Latex condom use/safe sex practices

Question 52

In ___________ HIV patients, the time between infection with HIV and the development of AIDS ranges from a few months to as long as 17 years (median: _____ years)

Answer 52

untreated; 10

Question 53

What is a main characteristic of AIDS?

Answer 53

Opportunistic infections

Question 54

Gonorrhea: 1) Etiology? 2) Main Sx? 3) Tx?

Answer 54

1) Neisseria gonorrhoeae  2) Most asymptomatic 3) Ceftriaxone 500mg IM x 1 (* treat for Chlamydia also*) -Must treat asap in pregnant woman

Question 55

Gonorrhea: 1) What may you see on PE? 2) What is a main part of Dx?

Answer 55

1) Cervical motion tenderness /Chandelier sign 2) NAAT (PCR)

Question 56

Complications of Gonorrhea: 1) High risk for _____. 2) GC is responsible for 75% of young sexually active adult cases of what? How do you Tx this?

Answer 56

1) PID 2) Septic arthritis - 2 weeks of IV antibiotics (IV ceftriaxone), washout

Question 57

Fitz-Hugh-Curtis Syndrome (perihepatitis) can occur due to which STI?

Answer 57

Gonorrhea

Question 58

Most frequently reported bacterial STI in the US is what?

Answer 58

Chlamydia

Question 59

Chlamydia: 1) Etiology? 2) PE finding? 3) Main way to Dx?

Answer 59

1) Chlamydia trachomatis 2) Cervical motion tenderness (chandelier sign) 3) NAAT vagina (preferred method)

Question 60

Chlamydia: 1) Main Tx? 2) What abt in infants?

Answer 60

1) Doxycycline 100 mg po bid x 7d (*if pregnant, Azithromycin 1g PO x 1) AND treat for gonorrhea 2) Antibiotic ointment to protect eyes from G/C (and E-coli)

Question 61

Chlamydia complications: 1) Complications in neonates? 2) Other complications?

Answer 61

1) Neonatal conjunctivitis and pneumonia 2) PID; Reiter's syndrome; cervicitis, endometritis, urethritis, epididymitis

Question 62

Reiter Syndrome is a complication of what?

Answer 62

Chlamydia

Question 63

Chlamydia Complications: **Reiter Syndrome:** 1) What is the triad? 2) When does it generally occur? 3) What do pts present with?

Answer 63

1) Urethritis, conjunctivitis and arthritis (can't see, can't pee, can't climb a tree) 2) 2-6 wks after a GI or GU infection 3) Malaise, fatigue, and fever, low back pain & heel pain

Question 64

Syphilis: 1) Etiology? 2) How is it diagnosed? What confirms the Dx? 3) What should you do for suspected neurosyphilis (tertiary)? 4) Tx?

Answer 64

1) Spirochete Treponema pallidum 2) **RPR/VDRL**, confirmed with treponemal tests 3) LP 4) Benzathine PCN G 2.4M units IM x 1 (if neurosyphilis: high dose for 14d) *Reportable disease

Question 65

List the stages of syphilis and give the main points of each

Answer 65

1) Primary infection: painless chancre. 2) Secondary infection: rash incl. palms and soles of feet. (Latent Stage: no s/sx; + serologic testing) 3) Tertiary infection: damage to CNS

Question 66

List 4 important points regarding pts who should be hospitalized for PID

Answer 66

1) Pregnant 2) Does not respond clinically to oral antimicrobial therapy 3) Unable to follow or tolerate an outpatient oral regimen 4) Tubo-ovarian abscess

Question 67

What is the most common gynecologic reason for ER visits in the U.S.?

Answer 67

Acute Salpingitis & PID

Question 68

1) The most common serious infection of women aged 16-25 years is what? 2) What are the 2 most common cause of that cause?

Answer 68

1) Acute Salpingitis & PID 2) Chlamydia, Gonorrhea

Question 69

Most cases of acute salpingitis occur in 2 stages; list them

Answer 69

1) Acquisition of a vaginal or cervical infection 2) Ascent of the infection to the upper genital tract

Question 70

What is salpingitis?

Answer 70

PID in the fallopian (uterine) tubes

Question 71

PID: 1) Many women with PID have __________ or ___________ symptoms. 2) Dx (diagnosis) of PID is usually _________. 3) Delay in diagnosis may lead to what?

Answer 71

1) subtle or mild 2) clinical 3) Infertility and increased risk of ectopic pregnancy

Question 72

Women diagnosed with PID should also undergo testing for what 3 things?

Answer 72

Chlamydial, HIV, and gonorrheal infections

Question 73

__________ treatment of PID should be initiated in sexually active young women with: a) pelvic or lower abdominal pain b) if no cause for the illness other than PID can be identified c) and if >1 of the following minimum criteria are present on pelvic examination: 1. CMT 2. uterine tenderness 3. adnexal tenderness

Answer 73

Empiric

Question 74

____% of patients have long term consequences of PID

Answer 74

25%

Question 75

True or false: N. gonorrhea or C. trachomatis are a criteria for PID Dx

Answer 75

True

Question 76

CDC Tx Recommendations PID include what 3 meds (simultaneously)?

Answer 76

1) Ceftriaxone 2) Doxycycline 3) Metronidazole