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Womens Health Gynecology Exam 2: Vulva, Vagina, Vulvavaginitis

Terms in this set (42)

lichen sclerosis:
- burning, itching, irritation
- white, thin skin around vulva (tears easily) & may extend to anus causing halo

dx: punch biopsy
tx: high dose topical steroid (clobetasol) - txs symptoms but doesnt resolve

increased risk for squamous cell cancer of vulva
how do you diagnose and treat lichen sclerosis? what does this condition increase your risk of?
lichen simplex chronicus
- itching that leads to a rash (diffuse redness around vulva)

dx: only need punch biopsy if no improvement in 3 months
tx: low potency topical steroid cream (1-2% hydrocortisone cream)
A 22 yo patient presents with vaginal itching and irritation. She states that it started as itchiness, which was relieved by scratching, but overtime this caused a rash to develop and the skin of the vulva became diffusely inflamed/red. What do you suspect? How is this diagnosed and treated?
lichen sclerosis:
- burning, itching, irritation
- white, thin skin around vulva (tears easily) & may extend to anus causing halo

dx: punch biopsy
tx: high dose topical steroid (clobetasol) - txs symptoms but doesnt resolve

-increased risk for squamous cell cancer of vulva
A 24 yo patient comes in complaining of vaginal itching, burning, and irritation. What do you suspect? How is this treated and diagnosed?
lichen simplex chronicus

dx: only need punch biopsy if no improvement in 3 months
tx: low potency topical steroid cream (1-2% hydrocortisone cream)
- curative treatment (if used for lichen planus it is not curative, just treats symptoms)
A 22 yo patient presents with vaginal itching and irritation. She states that it started as itchiness, which was relieved by scratching, but overtime this caused a red rash to develop around the vulva. She states that she recently started a using a new soap in the shower around her private parts. What do you suspect? How is this diagnosed and treated?
lichen planus
- tx: low dose topical steroid (1-2% hydrocortisone cream)
- will not have atypical cells with cytology (normal pap)

*treatment is symptomatic (not curative, chronic skin condition)
A 22 yo patient presents with chronic vulvar burning with profuse amounts of vaginal discharge. She also states that sex is painful. You note desquamative lesions around the vagina that appear diffusely raw/red. What is this? How is it treated?
lichen planus
- causes whole top layer of vulva to peel off (becomes diffusely red)
- vulvar burning, painful sex, profuse vaginal discharge (chronic)

tx: low dose topical steroid (1-2% hydrocortisone cream) - treats symptoms but doesnt cure
A rare, chronic inflammatory skin condition that causes desquamative lesions and sometimes wickham straie of the vagina is called ______. what are the symptoms?
lichen planus - wickham striae (white lacy bands of keratosis around ulcers)
- chronic condition so just treating symptoms

tx: low dose topical steroid (1-2% hydrocortisone cream)
If a patient presents with vaginal burning, large amounts of discharge and painful sex, what do you suspect?
Vestibulitis (localized vulvodynia)
- suspect in new onset insertional dyspareunia
- will have redness/inflammation between 4 and 8 oclock

dx: physical exam (do not use speculum)
- cotton tip application will cause pain

tx: topical steroids (1-2% hydrocortisone) and topical lidocaine jelly
A 22 yo patient presents complaining of pain with sex that has recently developed. How is this treated and diagnosed?
vestibulitis (vulvodynia)
- will have redness/inflammation around 4 and 8 oclock

dx: physical exam (do not use speculum)
- cotton tip application will cause pain

tx: topical steroids (1-2% hydrocortisone) and topical lidocaine jelly

*chronic insertional pain could be this or lichen planus, etc.
If a patient presents with newly onset insertional dyspareunia, what should you suspect?
bartholian gland cyst - no pain or itching

dx: culture
- biopsy if solid (doesnt transilluminate)
- biopsy if fixed to surrounding tissue and immobile
- biopsy if no response to tx
- biopsy if patient is postmenopausal

tx:
1. I&D with word catheter (left in place for 4-6 weeks)
2. marsupialization (new outlet for gland secretions, do iif reoccurence after 2 word catheters are placed)

*if bartholian gland abscess it would be painful and have swelling (cause: ecoli)
If a 22 yo patient presents with this and states that there is no pain, what do you suspect? How is it treated?
bartholian gland cyst - no pain or symptoms with mass
bartholiian gland abscess - painful and swelling mass (ecoli)

dx: culture, biopsy if....
- solid component, doesnt resolve with tx, women is postmenopausal, is fixed to surrounding tissue

tx: I&D with word cathetor placement (left in place 4-6 weeks)
- do marsulialization if reoccurance after 2 word cathetors are placed
What are bartholian gland masses and how do you tell the difference between them? how are they treated?
LSIL:
- very little atypia of cells (not pre-cancerous)
- usually occurs in condyloma acuminate (genital warts)

dx: punch biopsy
tx: same as condyloma
What is low-grade squamous intraepithelial lesion (LSIL) of the vulva? How is this diagnosed?
LSIL usually occurs with condyloma acuminate (genital warts)
If a patient presents with this, what do they have a high chance of getting?
HSIL
- HPV related lesion
-white, red, or brown patches
- true neoplasia with high risk for carcinoma if left untreated

dx: colposcopy (using 3-5% acetic acid solution) if lesions are not visible + biopsy in multiple spots

tx: surgical (wide local excision or laser ablation)
A patient presents with irritation and vaginal itchiness, you note this. What do they have?
HSIL
- HPV related lesion
-white, red, or brown patches
- true neoplasia with high risk for carcinoma if left untreated

dx: colposcopy (using 3-5% acetic acid solution) if lesions are not visible + biopsy in multiple spots

tx: surgical (wide local excision or laser ablation)
A patient presents with irritation and vaginal itchiness, what is this?
HSIL
-white, red, or brown patches
- vaginal irritation and itchiness

dx: colposcopy (using 3-5% acetic acid solution) if lesions are not visible + biopsy in multiple spots

tx: surgical (wide local excision or laser ablation)
these HPV-related lesions are considered true neoplasia, as they are high risk for progressing to severe intraepithelial lesions and eventually cancer if left untreated. How are they diagnosed and treated?
VIN:
- not HPV related
- primarily older women

need excision and biopsy
VIN, differentiated type is _____ HPV related. It is seen primarily in ____ women and it causes genital warts, ulcers, or thickened white plaques.
vulvar cancers:
- squamous cell
- post-menopausal women (70-80)
- CC: itching
- treated with surgery

*smoking and HSIL/LSIL increases risk
Most vulvar cancers are _____ cell type. They often occur in ______ women, and the main complaint patients will have is _____. It is treated with _____
vaginal cancer dx:
1. cytology (pap smear) - if abnormal (positive) do step 2
2. colposcopy with biopsy

*if papsmear is normal you can rule out vaginal cancer
Vaginal neoplasias or cancer are rare and usually secondary to cervical or vulvar cancers. Vaginal cancers usually affect the upper 1/3 of vagina. How are they diagnosed?
BV, Candidasis, Trichomoniasis*

*is an STI
Vulvovaginitis (itching, burning, discharge, discomfort, pain) is most commonly caused by what?
vaginal pH testing (apply to vaginal wall, avoid posterior fornix, do not premoisten)
- specimen is stable at room temp for 2-5 minutes
- most important vaginal discharge test

can also use:
- saline wet mount (candidiasis, trichomoniasis)
- KOH wet mount (candidasis) + amine/whiff test (BV)
- cant use KOH for trichomonas bc they are motile
If a 25 yo patient comes in complaining of abnormal vaginal discharge, what should you do to diagnose a cause?
pre-puberty pH: 6-8 (more alkaline)

puberty/reproductive age: 4-4.5 (more acidic)

at puberty, glycogen levels increase (which increases lactobacilli), glycogen is broken down to lactic acid (lowers pH)
- glycogen and discharge due to ER levels
What is the vaginal pH for pre-puberty, reproductive years, and menopause women? What causes pH to change?
cervical mucus and exfoliated squamous cells from vaginal wall
discharge comes from ____ and ____, as well as endometrial fluid, accessory gland exudates, and vaginal transudate.
environment: growth of gardnerella vaginalis (decrease in lactobacilli)

pH: > 4.5

discharge: fishy odor, gray/white-yellow discharge
- BV should be on ddx if patient has itching and abnormal discharge

diagnosis: Amsel criteria (at least 3 must be present):
- vaginal discharge (thin, white/gray-yellow)
- pH > 4.5
- positive amine/whiff test (fishy odor)
- clue cells
*if no microscope available can use DNA probe assays for BV, candiasis, or trichomonas
Describe the bacterial environment, pH, and discharge of a person with BV. How is BV diagnosed?
-preterm delivery
-herpes, gonorrhea, chlamydia, trichomonas, PID, HIV (+transmitting)
-cervical lesions that are precancerous (HSIL, LSIL, etc)
- endometrial growth of bacteria (endometritis, postpartum fever, etc)

*bold = same for trichomonas
What does BV increase a patients risk for?
BV (pH > 4.5, vaginal discharge, clue cells)

Tx:
- metronidazole (oral or intravaginal) prefer if breastfeeding
- or clindamycin (topical or oral)

*both can cause pseudomembranous colitis
*pregnant patients may avoid metronidazole 1st term due to crossing placenta (no tertogenicity)
*tx is for sx relief and to prevent post-op infx for patients getting hysterectomy or abortion
A 24 yo patient, LMP 2 weeks ago, G1P1, comes to your office complaining of itching and thin-yellowish vaginal discharge. She states that she is currently breastfeeding. A vaginal pH test shows the pH to be 5. A saline wet prep shows clue cells. What does this patient have and how do you treat it?
candidasis (uncomplicated)
- normal pH (4-4.5 at her age)
- cottage cheese discharge and vaginal itching

dx: saline or KOH wet prep (look for blastospores or pseudohyphae)
A 22 yo patient presents with vaginal itching. She states that she also has noticed odorless, thick-white "cottage cheese" discharge. An initial pH test shows her pH to be 3.5. What do you suspect and how would you diagnose this?
increased risk: anything impacting immune system
- obesity, DM, pregnancy, immunosuppression
- oral contraceptives, broad spectrum ATB, steroids

not common before puberty or after menopause (due to lack of ER, pH 6-8)
- not on DDx

candidiasis (candida albicans) does not co-exist with other infections
Who is vulvovaginal candidiasis more likely to occur in? who is it less likely to occur in?
Candidasis (complicated)

tx:
-uncomplicated: oral fluconazole (1 dose) or topical clotrimazole or miconazole

-complicated: oral fluconazole (2-3 doses, 72 hours apart) or if pregnant use topical clotrimazole or miconazole for 7 days.

-recurrent: culture first, then oral fluconazole (3 doses, 72 hours apart), then fluconazole weekly for 6 months
A 44 yo white female patient with DM I presents with thick white vaginal discharge and itching. A pH test shows her pH to be 3.9 and a saline wet prep reveals blastospores. What is this and what is the treatment?
uncomplicated: oral fluconazole (1 dose) or topical clotrimazole or miconazole

complicated: oral fluconazole (2-3 doses, 72 hours apart) or if pregnant use topical clotrimazole or miconazole for 7 days.

recurrent: culture first, then oral fluconazole (3 doses, 72 hours apart), then fluconazole weekly for 6 months

Uncomplicated:
- less than 4 episodes in a year
- mild/moderate symptoms
- likely candida albicans
- healthy, non-pregnant and immunocompetent

Complicated:
- 4+ infections a year (treat for recurrent after culture)
- severe symptoms
- non-c albicans
- pregnant, DM, or immunocompromised
How is candidiasis treated?
trichomonas:
- most are asymptomatic
- frothy, yellow-green discharge with rancid odor
- itching, burning, punctate hemorrhages (strawberry cervix)

pH > 4.5

dx: saline wet prep
What are trichomonas symptoms and how is it diagnosed?
Trichomoniasis dx:
- saline wet prep under microscope (cant use KOH because these are undulating/motile)
- can also culture or rapid antigen & DNA hybridization, or nucleic acid amplification
A 33 yo patient presents with vaginal itching and a foul odor discharge that is yellowish-green. A cervical exam shows punctate hemorrhages. What does this patient have and how do you diagnose it?
metronidazole or tinadazole (single 2g dose)
- patients should have significant other come in for treatment
- no sex until both are treated and asymptomatic
- no alcohol for 24 (metronidazole) or 72 hours (tinadazole)

*if patient is pregnant use metronidazole, can also do 500 mg BID for 5-7 days to help with NV side effects

RISKS:
- PID, infertility, cervical neoplasia, endometritis/cystitis/urethritis, ectopic pregnancy, HIV, PROM, preterm, LBW
*bold = same for BV
A 22 yo asymptomatic patient is diagnosed with trichomonas after a wet saline prep revealed undulating/motile pear-shaped organisms under the microscope. How is this treated? What does this patient have an increased for?
menopausal women who have atrophy, dryness and pain with sex due to low ER (pH 5+)

All menopause patients have this but symptoms are what matters (clinical diagnosis)
tx: MHT therapy - ex. estradiol +/- micronized PR if uterus
What is genitourinary syndrome?
round = blastosphere (candidasis)
- yeast cells (blastospheres must be budding off other cells)

thin lines = lactobacilli (normal)

epithelial cells fade into background
What does this microscopic image show?
pseudohyphae + blastospheres (round) = candidiasis
-pseudohyphae must have yeast cells budding off
- yeast cells (blastospheres must be budding off other cells)

tx:
-uncomplicated: oral fluconazole (1 dose) or topical clotrimazole or miconazole

-complicated: oral fluconazole (2-3 doses, 72 hours apart) or if pregnant use topical clotrimazole or miconazole for 7 days.

-recurrent: culture first, then oral fluconazole (3 doses, 72 hours apart), then fluconazole weekly for 6 months
What does this show?
pseudohyphae = candidiasis
-pseudohyphae must have yeast cells budding off

tx:
-uncomplicated: oral fluconazole (1 dose) or topical clotrimazole or miconazole

-complicated: oral fluconazole (2-3 doses, 72 hours apart) or if pregnant use topical clotrimazole or miconazole for 7 days.

-recurrent: culture first, then oral fluconazole (3 doses, 72 hours apart), then fluconazole weekly for 6 months
What does this show?
clue cells - >20% so diagnosis is BV
- irregular/grainy edges with dots of bacteria

****to see clue cells must do saline wet prep instead of KOH (KOH kills cells)

Tx:
- metronidazole (oral or intravaginal) prefer if breastfeeding
- or clindamycin (topical or oral)
What is this?
black = clue cells - grainy border
green= 3 epithelial cells

since 2/3 cells are clue = 66% = BV (must be 20%+)
What is this?
A - WBC
B - parabasal cell
+ few lactobacilli

= normal in menopausal women (genitourinary syndrome if sx)
What does this show?
parabasal cell (circled) with normal epithelial cells, no WBCs or lactobacilli

= normal in menopausal women (genitourinary syndrome if sx)
What does this show?
Trichomoniasis microscope - would be motile

tx: metronidazole or tinadazole (single 2g dose)
- patients should have significant other come in for treatment
- no sex until both are treated and asymptomatic
- no alcohol for 24 (metronidazole) or 72 hours (tinadazole)

*if patient is pregnant use metronidazole, can also do 500 mg BID for 5-7 days to help with NV side effects
What is this?
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