CMS II: OB/GYN - EXAM #1 (OFFICE PRO/VULVOVAG DZ/GYN CANCER)

pH 4.0 - 4.5 (normal) for premenopausal women
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pH 4.0 - 4.5 (normal) for premenopausal women
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Primary infections in order of prevalence
Bacterial vaginosis ("BV")
Candidiasis ("yeast")
Trichomoniasis ("trich")
Pelvic Inflammatory Disease ("PID")
Other etiologies
Atrophic vaginitis(lack of estrogen)
Contact dermatitis (due to foreign body/substances)
Desquamative inflammatory vaginitis (rare, chronic, yellow/green discharge,possibly related to cervical ectropion)
All vaginitis can increase risk of STI and PID
Vaginitis
Sample lateral vaginal wall
Start with placing sample in normal saline
Visualize under low and high power
Follow with KOH preparation
10% KOH
"Whiff test" - note odor with addition of KOH (smells fishy)
Wet Mount Preparation
M/Cn cause of vaginitis in women of childbearing age

***Not an STI

Etiology: Overgrowth of**Gardnerella vaginalis* & DEC Lactobacillus acidophilus**

S&S:
Homogeneous malodorous vaginal discharge
***Thin, milky, grayish-white
- Often pools at the introitus
- Adheres to vaginal walls ("spilled milk")

***pH is > 4.5, usually 5.0 to 5.5
Test pH with nitrazine (> 4.5)
May be a distinctive odor

***Positive "whiff test" (KOH)
- Amine release - "fishy"
Bacterial Vaginosis (BV)
Diagnosis:
Made by wet mount preparation
*** "Clue" cells - epithelial cells with numerous bacilli clinging to their surface
- Few WBCs are noted

Standard Tx:
Metronidazole 500mg BID x 7 days (or gel)
OR
Clindamycin (oral or gel)

Alternative:
Tinidazole 2 g orally once daily for 2 days
Bacterial Vaginosis (BV)
Second M/C vaginitis (20-30% of vaginitis)
Usually **C. albicans**
- Could be glabrata or tropicalis

S&S:
- 20% of women are asymptomatic
- Flare premenstrually
- Vaginal discharge/pruritus/edema
- Excoriations
- Burning (dysuria)
- Dyspareunia
- Discharge = **"curd-like cottage cheese"**
- pH is normal (pH 4 to 4.5)
- Vaginal mucosa may be tender
- Marked erythema and edema of the vulva and vagina
Candida Vulvovaginitis
Confirmed by finding the organism on wet mount
- **Budding yeast & hyphae**
- Swartz-Lamkins fungal stain - candida stain blue

Risk Factors:
- **DM**
- **Antibiotics**
- INC estrogen levels
- Immunosuppression
- Contraceptive devices

OTC Intravaginal Tx:
- Clotrimazole, Nystatin
- Butoconazole
- Miconazole

Oral Rx Agent:
Fluconazole
Candida Vulvovaginitis
Etiology: Trichomonas Vaginalis: pear shped flagellated protozoa
- STI

Clin Man:
- Vulvar pruritus, erythema, dysuria
- Dyspareunia
- **Vaginal D/C is thin, bubbly, "frothy," Yellow/pale Green/Gray & copious**

***pH is > 5 = elevated!

- **Strawberry Cervix**: Petechiae or strawberry patches on the vaginal mucosa and cervix (10%)
Trichomonas Vaginalis
Diagnosis:
- Wet Mount: mobile protozoa
- WBCs present

Tx:
Metronidazole 2 g orally in a single dose
Tinidazole 2 g orally in a single dose
Metronidazole 500 mg orally twice a day for 7 days

**NO ALCOHOL!

(Sexual partners should be treated and evaluated for other STIs)
Trichomonas Vaginalis
PPP 394
Vaginal Atrophy
Acute salpingitis - peritonitis Bilateral pain Vaginal discharge ***Abdominal, uterine, adnexal, & cervical motion tenderness (CMT) AND one or more of the following: - T > 38 degrees C (100.4 degrees F) - Leukocytosis w/ left shift (>10,000) - Inflammatory mass (PE or U/S) - Gram-negative intracellular diplococci (gonorrhea) - Purulent material (WBC) from peritoneal cavity - N + V, H/A, general malaise/weaknessPelvic Inflammatory Disease (PID)Workup: 1. ***Pregnancy test - r/o ectopic pregnancy 2. Nucleic acid amplification tests for chlamydia and gonococcus Laparoscopy is the MOST ACCURATE test (rarely performed). May be done in uncertain cases, severe Dz, or if no improvement w/Abx.Pelvic Inflammatory Disease (PID)Treatment: OUTPATIENT: - **Ceftriaxone PLUS Doxycycline PLUS Metronidazole** (Antibiotics), IUD removal, analgesics, and bed rest - Levo + Metronidazole for true PCN Allergy INPATIENT: - Bed rest, NPO + NG suction, IVF, IV antibiotics **Cefoxitin + Probenecid PLUS Doxycycline PLUS Metronidazole** - Clinda + Gentamycin if true PCN allergyPelvic Inflammatory Disease (PID)Mimics vulvovaginitis Irritant or allergen exposure Burning, erythema, blisters, scant discharge Can be well demarcated if allergic to feminine hygiene productContact DermatitisTx: Avoidance - Soaps - Sprays - Douches - OTC meds - Spermicides/latex - Cotton underwear instead of synthetics - 1% hydrocortisone topical - short termContact DermatitisDryness, scales and erythema are notable - mimics many forms of vaginitis Key history - chronic condition for months to yearsEczemaBenign, chronic, and progressive Characterized by marked inflammation, epithelial thinning, and distinctive dermal changes Symptoms of pruritus and pain Usually occurs in the anogenital region (85 to 98 % of cases), but can develop on any skin surface Two peaks of onset: prepubertal girls and perimenopausal or postmenopausal women One of the most common conditions treated in vulvar clinicsLichen SclerosusThe major symptoms of vulvar LS are: Vulvar pruritus - hallmark of the disease Often so intense that it interferes with sleep Pruritus ani, painful defecation, anal fissures, and rectal bleeding are common Dyspareunia is often a late symptom Associated with introital stenosis, fissures, or posterior deflection of fused labial tissues at the time of intromission Dysuria and difficulty voiding can occur Lichen sclerosus can be completely asymptomatic, but still lead to whitening, scarring and loss of architectureLichen SclerosusClassic vulvar LS is expressed as white, atrophic papules that may coalesce into plaques Can also be hemorrhagic, purpuric, hyperkeratotic, bullous, eroded, or ulcerated The lesions most frequently affect the labia minora and/or labia majora Whitening may extend over the perineum and around the anus in a keyhole fashion Fissuring is frequently seen perianally, in the intralabial folds, or around the clitoris The introitus may have a yellow, waxy appearance Scratching may result in excoriations and secondary mild lichenificationLichen SclerosusDiagnosis is made by clinical presentation and a routine biopsy Need to rule out concomitant malignancy Topical steroids Clobetasole ointment 0.05% bid x 1 mo, daily x 1 mo, then 1-3 x/week prn Intralesional steroids for thickened plaques Follow-up 3 months Education - chronic vulvar diseaseLichen SclerosusIf > 2cm in diameter surgery is indicated Marsupialization (suturing wound edges to keep wound open) I&D with Word catheter in outpatient settingBartholin's AbscessRisk Factors for _________________: - Presence of HPV (types 16, 18, 31, 33, 45) - Multiple sexual partners - Early sexual activity & early childbearing - "High-risk" consort of partners; other - STDs - Socioeconomic status and race - Immune status - Intrauterine DES exposure - Oral contraceptives - Cigarette smokingCervical DysplasiaSquamous intraepithelial lesion (SIL) is used to describe Pap test results. "Squamous" refers to the type of cells that make up the tissue that covers the cervix. - SIL is not a diagnosis of precancer or cancer. The Pap test is a screening test. - It cannot tell exactly how severe the changes are in cervical cells. A ________________ is needed to find out whether precancer or cancer actually is present.cervical biopsy_________________________ means that changes in the cervical cells have been found. The changes are almost always a sign of an HPV infection. M/C abnormal Pap test result.Atypical squamous cells of undetermined significance (ASC-US)________________________: means that the cervical cells show changes that are mildly abnormal. - Usually is caused by an HPV infection that often goes away on its own.Low-grade squamous intraepithelial lesion (LSIL)__________________: Suggests more serious changes in the cervix than LSIL. It is more likely than LSIL to be associated with precancer and cancer.High-grade squamous intraepithelial lesion (HSIL)___________________: means that changes in the cervical cells have been found that raise concern for the presence of HSIL.Atypical squamous cells, cannot exclude HSIL (ASC-H)Atypical glandular cells (AGC)—Glandular cells are another type of cell that make up the thin layer of tissue that covers the inner canal of the cervix. Glandular cells also are present inside the uterus. An AGC result means that changes have been found in glandular cells that raise concern for the presence of precancer or cancer.IF PAP Abnormal...... - Repeat Pap test or co-test is recommended as a follow-up to some abnormal test results. Done in 1 year or in 3 years depending on your initial test result, your age, and the results of previous tests. - HPV test - Colposcopy, biopsy, and endocervical samplingTreatment depends on etiology and extent: - Treat underlying infection; electrocautery; cryotherapy; laser vaporization; loop electrosurgical excision (LEEP); cone biopsy; chemotherapeutics - Requires close follow-up directed by results and patient demographics, especially HPV statusAbnormal Pap SmearA colposcope is a large, electric microscope that is positioned approximately 30 cm from the vagina A bright light on the end of the colposcope makes it possible for the gynecologist to clearly see the cervix Acetic acid (like clear vinegar) is applied to the cervix Taken up by dysplastic cells The whiter the uptake, the more dysplasticColposcopyGo review Slide 106 in Lec 6 Vulvovaginal Disorders...Done, let's finish this- 20 to 30 mins in-office procedure - Excised tissue is sent to the lab for further evaluation - Ensures that the lesion was completely removed - Allows for a more accurate assessment of the abnormal area Cryo does not allow for pathological analysis!Loop Electrosurgical Excision Procedure (LEEP)______________: Cone-shaped wedge of tissue is removed from the cervix and examined by pathologist - Removes abnormal tissue that is high in the cervical canal - A small amount of normal tissue around the cone-shaped wedge of abnormal tissue is also removed so that a margin free of abnormal cells is left in the cervix - Used to diagnose and sometimes to treat abnormal cervical tissue - Laser or scalpel (Cold Knife) can be used to make the "cone" incision.Cone Biopsy - Conization______________________ is used to report cervical biopsy results. - CIN describes the actual changes in cervical cells. - CIN is graded as 1, 2, or 3. - CIN 1 is used for mild (low-grade) changes in the cells that usually go away on their own without treatment. - CIN 2 is used for moderate changes. - CIN 3 is used for more severe (high-grade) changes. These can progress to CA.Cervical intraepithelial neoplasia (CIN)________________: - Mild dysplasia - Confined to the basal 1/3 of the epithelium - Corresponds to infection with HPV - Typically will be cleared by immune response in a year or so (can take several years to clear)CIN 1 (Grade I)__________________: - Moderate dysplasia - Confined to the basal 2/3 of the epithelium - Usually the threshold for intervention (except in adolescents)CIN 2 (Grade II)_____________: - Severe dysplasia - Spans more than 2/3 of the epithelium - May involve the full thickness - Also now referred to as cervical carcinoma in situCIN 3 (Grade III)