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152 Cards in this Set
- Front
- Back
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Stages of Adolescence
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Early: age 11-14 elementary and middle
Middle: age 15-17 high school Late: age 17- 21 college or employed |
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Early Stage of Adolescence
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Concerns with physical changes, normality
Exaggeration of physical complaints Self-centeredness, feelings of being “center stage” Strong sense of invulnerability, omnipotence |
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Middle Stage of Adolescence
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High school
Puberty almost complete Testing/showing off “new body” Strong independence; independence conflicts Shift of attachments from adults to PEERS |
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Late Stage of Adolescence (college)
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Post high school to early 20’s
Adult functional role achieved or approaching Position in family seen as an adult not child Independent decisions, actions Realizations of limitations, vulnerability |
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Obtaining History
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Interview (HEADSS-“Is Very Good”
Home, Education, Activities, Drugs, Sexuality, Suicide, Internet, Violence, Gangs |
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Data on Sexual Activity
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Nearly half of American high school students report sexual activity before graduation
15 million identified STI’s annually in US, 25% in adolescents 4% of females reported initiating sexual activity before age 13 (possible abuse) |
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Age of First Pelvic Exam
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Within 3 years after initiation of sexual activity
Annually in sexually active adolescents 21 for pap smear |
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Relaxation Techniques for Pelvic Exam
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Deep rhymthic breathing-relaxes pelvic muscles and distracts patient
Progressive muscle relaxation-alternate tensing and releasing of major muscle groups Guided imagery-using mental imagery to visualize a pleasant memory of favorite activity |
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Speculum Exam
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Place one finger inside the vaginal
Gently push on pubococcgygeal muscle as you insert the speculum Direct speculum in downward direction 45 degrees |
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The Cervix Inspection
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Adolescents have darker, more erythematous area surrounding the cervical os
Cervical ectopy – columnar epithelial cells will appear as a red concentric ring surrounding the os |
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SMR Females
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Breast Examination and Pelvic exams, education
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21, with pap smear
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Adol IMZ
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Primary Dysmenorrhea
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Menstrual pain without pathology
-Within 1-2 years of menarche After ovulatory cycles -Myometrial contractions induced by prostaglandins originates in secretory endometrium -Begins a few hours prior to or just after onset of menses and lasts 48-72 hours. |
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Primary Dysmenorrhea S/S
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Pain (usually colicky)
Suprapubic cramping (intense, labor-like) Radiating pain (anterior thigh, lumbo-sacral) Systemic symptoms Prostaglandin release into systemic circulation Mild uterine tenderness on exam During menses N/V/D-prostaglandin release Headache Syncopal episodes (rare) VS, Pelvic exam: normal Mild suprapubic tenderness Systemic symptoms Prostaglandin release into systemic circulation Mild uterine tenderness on exam During menses |
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Confirm Dx of Primary Dysmenorrhea
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Rule out other pathology
NL pelvic exam NL vital signs Not pregnant No acute/chronic abdominal pain No chronic pelvic disorders (non-cyclic) adhesions, salpingo-oophoritis, cancer No GI, GU, Neurologic problems |
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Primary Tx of Primary Dysmenorrhea
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Prostaglandin inhibitors
Ponstel (Mefenamic Acid) 500mg Stat, 250mg q6 Ibuprofen 400mg q4-6 Naproxen sodium 550mg Stat, 275mg q8 80% effective take prior to or at onset of pain every 6-8 hours prevents re-formation of prostaglandin byproducts Take with food Try NSAID’s x4-6 months change after 2-4 cycles if no relief OCP’s 90% of women have at least some relief of symptoms If nothing helps REFER : will probably need laparoscopy. |
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Education of Primary Dysmenorrhea
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-Medication compliance
-Exercise Very helpful - especially when pain is worst! (endorphins) 1st thing to do -Heating pads/warm baths -Relaxation -Good diet -Follow-up |
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% of Dysmenorrhea: 2 types
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50%
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Rule of 4s
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. Rule of 4s: 4 days before period starts-load up Cox receptors with ibuprofen, 400mg q4h (before period begins)
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Secondary Dysmenorrhea
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Menstrual pain with PATHOLOGY
Imperforate hymen (blood backs up) Transverse vaginal septum Cervical stenosis Uterine anomalies Endometrial polyps Adenomyosis Uterine leiomyomas (Fibroids) -Endometriosis -IUD -Atypical problems chronic ectopic: ectopic pregnancy doesn’t go away, keeps producing low levels of HCG, always 10 ex. chronic functional cyst -Differential: GI, GU, Neuro, GYN Adhesions, infection |
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Secondary Dysmenorrhea S/S
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Pain frequently begins 1-2 weeks PRIOR to menses and PERSISTS until after menses stops
NSAIDS/OCP’s not as helpful |
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Endometriosis
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Presence of endometrial tissue outside the uterus
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Endometriosis Sites
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-Often includes glands & stroma
-Most frequent sites of implantation pelvic viscera & peritoneum -Extra-pelvic sites intestines (Colon and Rectum) ureteral lungs umbilicus |
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Endometriosis Retrograde menstruation
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Lying down for the rest of our life. Retrograde menstruation, flows outside to tubes and peritoneal cavity. Every woman has potential for endometriosis. Immune system goes in and cleans up.
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Endometriosis Etiology
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Estrogen dependent
Ectopic transplantation of endometrial tissue (retrograde menses) Host immune system factors changes in immune response antibody formation |
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Genetic Component of Endometriosis
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7x’s greater risk if mother/sister effected
75% incidence in homozygotic twins |
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Endometriosis Incidence and Symptoms
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Up to 7% of menstruating women
Postmenopausal women on HRT Associated Symptoms dysmenorrhea pelvic pain (wide range) infertility dyspareunia Pain: abdominal, back GI and GU problems |
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Endometriosis Evaluation
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History & PE
many women asymptomatic w/ normal exam Exam abnormalities (if present) uterosacral/cul-de-sac nodularity ovarian enlargement/mass rectovaginal septal swelling and pain uterus fixed and non-mobile CA 125 elevated in mod/severe disease (careful!) |
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Diagnosis of Endometriosis
Endometriosis Management |
-Dx: Laparascopy
-Surgery laser ablation hysterectomy w/ oophrectomy -Continuous OCP’s -Depo Provera 104mg SQ FDA approved for pain management -GNRh Agonists (Lupron) -Danazol |
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Common Causes of Vaginitis
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Vulvovaginal candidiasis
Bacterial vaginosis Trichomoniasis Dual infections Vaginal Atrophy |
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Physiologic Discharge
Normal vaginal flora ? and functions? |
lactobacilli
Colonize the vaginal epithelium Maintain normal ph at 3.8 to 4.4 Quantity and quality vary in same woman in cycles |
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Factors that influence physiologic discharge
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-Age
Prepubertal Reproductive Post-menopausal -Local Factors Menstruation Post partum Malignancy Semen Personal habits and hygiene -Hormones The pill Cyclical hormonal changes Pregnancy |
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Pathological vaginal discharge
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Candidiasis and bacterial vaginosis– most common
50% of BV is asymptomatic |
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Questions to ask women who complain of vaginal discharge
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-Discharge
Onset Duration Amount Color Blood staining Consistency Odor Previous episodes |
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Associated s/s of Vaginal discharge
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Associated symptoms
Itching Soreness Dysuria Intermenstrual or post-coital bleeding Lower abdominal pain Pelvic pain Dyspareunia –superficial and deep |
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Physical examination should include
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-Complete pelvic exam
To determine source of discharge (cervical or vaginal) Check for foreign bodies (sometimes the white mouse gets lost) -Gross evaluation of the discharge for consistency -Adherence of discharge to the vaginal wall or cervix -Wet mount preparation Saline – clue cells, WBC and Trichomoniasis KOH – for yeast Amine testing=+fishy odor |
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Less Common Infectious Causes of Vaginitis
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Streptococcoal infections
Cytolytic vaginosis/vaginal lactobacillosis Recurrent herpes simplex Genital warts Cervicitis |
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Noninfectious Causes of Vaginitis
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Contact dermatitis
Erosive lichen planus Diabetic vulvodynia Lichen sclerosis Vulvar hyperplasia Other dermatologic conditions Carcinoma |
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Vulvovaginal Candidiasis
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A fungal infection
Usually caused by Candida albicans, but can be caused by other yeast forms 75% of all women report at least 1 episode of VVC, and 40-45% will have 2 or more occurrences About 10% of women will have recurrent/complicated VVC |
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Precipitating factors of VVC
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Immunocompromised
Diabetics or high sugar intake Recent antibiotic use Douching Diaphragm/cervical cap users Spermacide users Chronic conditions or poor diet Pregnancy |
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Clinical Presentation and Diagnosis
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Pruritus and erythema in vulvovaginal area
White discharge, may be “cheesy” or “curd like” in consistency Diagnosed via pH<4.5 (Normal pH) 10% KOH prep will show peudohyphae, yeast spores Can culture for a yeast species, if recurrent |
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Common Intravaginal VVC Treatments
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"Azoles"
Miconazole 2% (5g) qHS X 7 days Miconazole 100 mg vag supp, 1qHS X 7 days Butaconazole 2% (5g) qHS X 3 days, or single dose (OTC) Clotrimazole 1% (5g) X 7-14 days Clotrimazole 100 mg vag tab qHS X 7 days |
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Intravaginal Treatments of VVC
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Clotrimazole 100 mg vag tab, 2 tabs X 3 days
Clotrimazole 500 mg vag tab X 1 dose Clotrimazole 1% Vaginal Cream, 1 applicatorful into vaginal hs x 7 days Tioconazole 6.5% ointment vag X 1 dose Terconazole 0.4% (5g) qHS X 7 days |
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Oral Regimen for VVC
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Fluconazole (Diflucan) 150 mg po X 1 dose
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Helpful VVC Measures
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2% Hydrocortisone cream for pruritis
Loose fitting clothing, + cotton underwear Treat before menses and before antibiotic rx in selected patients Decrease sugary foods Acijel (0.921% glacial acetic acid) or “boric acid” suppositories |
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Bacterial Vaginosis
Characterization? Most frequent causes? |
-Caused by replacement of normal vaginal flora with anaerobic micoorganisms
-Characterized by vaginal discharge, vulvar itching and irritation, and vaginal odor -Most frequent causes: Gardnerella vaginalis Mycoplasma |
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BV associations
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Associated with new sexual partner and frequent change of sexual partners (Ask about internet partners)
Reduced rate in monogamous relationships, can also occur in virginal women Increased incidence in women who douch (upset the flora) Can also be associated with concurrent STI commonly Trichomonas |
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Dx of BV
3 out 4 to Dx |
Requires 3 out of 4:
Homogenous, white, noninflammatory D/C coating the walls of the vagina Vaginal pH of >4.5 Fishy odor (+Whiff/Amine test) Clue cells on microscopic exam |
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Dx adjuncts of BV
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DNA probe for high levels of G.vaginalis (Affirm VPIII- Manuf. By Becton Dickinson, Sparks, MD)
Fem Exam Card, which detects pH and trimethylamine. This has proven effective in combat operations. |
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BV Tx First Line
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First Line:
-Metronidazole gel 0.75% (5g), 1 app. Vag QHS X 5 days (antiparasitic) -Metronidazole 500 mg po BID X 7 days (NO ALCOHOL for three days prior to or after treatment) -Clindamycin Cream 2% (100 MG / 5 g), 1 app Intravaginally x1 or QHS x 7 days |
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In pregnancy
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In pregnancy Oral metronidazole preferred over gel and clindamycin.
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BV Treatments During Pregnancy
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Metronidazole 250 TID X 7 days
Clindamycin 300mg BID X 7 days If woman at high risk for preterm delivery, consider follow-up evaluation 1 month after completion of therapy |
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Trichomoniasis Background
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-Results from infection with Trichomonas vaginalis, a flagellated protozoan
-3-5 million women infected annually -Comprises 15% of STI clinic visits -Non-sexual transmission rare, but possible |
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Trichomoniasis S/S
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Malodorous yellow vaginal D/C
Vaginal soreness Vulvar itching Dyspareunia ,dysuria 10% may have abdominal symptoms Asymptomatic infection is not uncommon Incubation 5-10 days, range 1-28 days |
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Dx Trichomoniasis
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-Copious, thin, homgenous pools of yellow or green D/C
-D/C may be frothy, since this is an anaerobe -May be confused with candidiasis or mucopurulent cervicitis -Wiping the cervix clean to see if D/C is oozing from the cervix may be helpful -Abdominal and bimanual exams may show mild lower quadrant discomfort, but focal tenderness, guarding or masses should not be detected pH>4.5 Positive amine test Wet prep demonstrates protozoa in only 60% of women Pear-shaped with undulating flagella Increased WBCs "Strawbery Cervix" |
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Tx Trichomoniasis
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Metronidazole 2 g po X 1 dose
Treat the partner !!!!!!!! Alternative Regimen: Metronidazole 500 mg BID X 7 days Treat systemetically. can be in the bladder |
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Trichomoniasis in Pregnancy
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-Trichomoniasis associated with:
PROM Preterm delivery Low birth weight -Metronidazole 2 gm in 1 dose (Class B drug) -Treat the partner !!!!!!! |
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Causes of Recurrent and Persistent Vaginitis
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Reappearance of trichomoniasis (Partner not treated)
Sexually transmitted diseases of the cervix (GC, Chlamydia, Syphilis) Atrophic vaginitis Irritant or allergic contact dermatitis |
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PID Definition
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“Acute infection of the upper genital tract in women involving any or all of the uterus, oviducts, and ovaries.”
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What is the Cardinal Rule for PID
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Any woman of reproductive age who presents with abdominal pain has an ECTOPIC PREGNANCY until proven otherwise!!!!!!!!!!!
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PID Epidemiology
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Community acquired infection initiated by a sexually transmitted agent.
Accounts for approximately 2.5 million outpatient visits annually Accounts for approximately 200,000 hospitalizations per year. |
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Clinical Evaluation of PID
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Lower abdominal pain is the cardinal presenting symptom in women with PID, although the character of the pain may be quite subtle.
Abnormal uterine bleeding occurs in about one – third or more of patients with PID. New vaginal discharge, urethritis, proctitis, fever, and chills can be associated signs. |
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Risk factors of PID
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Age less than 35 years
Non barrier contraception New, multiple, or symptomatic partners Previous episode of PID Oral contraceptives African – American ethnicity (higher reported incidence) |
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Physical Exam of PID
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Only about 50% of patients have fever
Diffuse lower quadrant abdominal tenderness which may or may not be symmetrical Purulent endocervical discharge and / or acute cervical motion tenderness and adnexal tenderness by bimanual examination is highly suggestive of PID Rectovaginal examination should reveal the uterine adnexal tenderness Rebound tenderness and decreased bowel sounds are common Right upper quadrant tenderness does not exclude PID (10% have perihepatitis) |
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Dx of PID
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The index of suspicion should be high, especially in adolescent women
CDC minimum criteria for empiric treatment: lower abdominal tenderness, adnexal tenderness, cervical motion tenderness CDC minor determinants (signs that may increase the suspicion of PID: Fever > 101 degrees F, Vaginal discharge, Documented STD, Increased Sed Rate (ESR), C-Reactive protein, Systemic signs (pt looks sick), Dyspareunia |
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When to Use Empiric Tx in PID
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Pregnancy test is negative
The examination suggests PID Demographics (risk factors) are consistent with PID |
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Lab Eval of PID
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Pregnancy test !!!!!
Microscopic exam of vaginal discharge Complete Blood Count (CBC) Test for Gonorrhea and Chlamydia Urinalysis Fecal Occult Blood C-reactive protein (optional) Gram stain is only useful if it stains positive for Gram negative intracellular diplococci (Gonorrhea) |
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Dx Tool of PID
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Ultrasound
Should be reserved for the acutely ill patient with PID in whom a pelvic abscess is suspected |
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Recommendations for PID
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Maintain a low threshold of suspicion for the diagnosis of PID
Sexually active young women with lower abdominal pain, adnexal and cervical motion tenderness should receive empiric treatment If clinical findings suggest PID then initiate empiric treatment |
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Differential Dx of PID
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Ectopic Pregnancy !!!!!!!!!!!!!!!!!!!!!
Appendicitis Hemorrhagic ovarian cyst Ovarian torsion Endometriosis Urinary tract infection Irritable Bowel Syndrome Gastroenteritis Cholecystitis Nephrolithiasis Somatization (Don’t be afraid to ask about rape, incest, sexual abuse, domestic violence) |
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Tx of PID
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Gonorrhea and Chlamydia are the most common initiators of PID
Treatment coverage should also include Streptococcus Group A and B, Gram negative enteric bacilli (E. coli, Klebsiella, and Proteus), and anaerobes (“2 inch no man’s land, rectum & vag”) |
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Inpatient PID Tx
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Recommended Parenteral Regimen A Cefotetan 2 g IV every 12 hours OR Cefoxitin 2 g IV every 6 hours PLUS Doxycycline 100 mg orally or IV every 12 hours
Recommmended Parenteral Regimen B : Clindamycin 900 mg IV every 8 hours PLUS Gentamicin loading dose IV or IM (2 mg/kg of body weight), followed by a maintenance dose (1.5 mg/kg) every 8 hours. Single daily dosing may be substituted. |
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Outpatient PID Tx
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Recommended Oral Regimen Ceftriaxone 250 mg IM in a single dose PLUS Doxycycline 100 mg orally twice a day for 14 days WITH OR WITHOUT Metronidazole 500 mg orally twice a day for 14 days
Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally administered concurrently in a single dose PLUS Doxycycline 100 mg orally twice a day for 14 days WITH OR WITHOUT Metronidazole 500 mg orally twice a day for 14 days Other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime) PLUS Doxycycline 100 mg orally twice a day for 14 days WITH OR WITHOUT Metronidazole 500 mg orally twice a day for 14 days |
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If parenteral cephalosporin therapy is not feasible, use of what is feasible?
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If parenteral cephalosporin therapy is not feasible, use of fluoroquinolones (levofloxacin 500 mg orally once daily or ofloxacin 400 mg twice daily for 14 days) with or without metronidazole (500 mg orally twice daily for 14 days) may be considered if the community prevalence and individual risk for gonorrhea is low
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PID other considerations/tests
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Women with PID should also have serology testing for HIV, Hepatitis B & C, and Syphilis
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Provisional STD Statistics 2009 As of 26 Sep 2009
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Chlamydia: 816,901
Gonorrhea: 194,369 Syphilis (Primary & Secondary): 9,544 |
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STD: Biological Factors
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Gender – females at greater risk
Preexisting STDs including HIV Lack of conspicuous signs and symptoms Long lag time for symptom presentation Women infected more than men Other factors: circumcision, douching, oral contraceptives, IUD’s |
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STD: Social Factors
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Poverty
Inadequate access to health care Substance abuse Lack of education Sexual abuse and violence Secrecy |
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STD: REPORTABLE
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Syphilis
Gonorrhea AIDS Chlamydia Chancroid Other STDS (Varies by State) Reporting may be provider and/or lab based |
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STD: HX
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History of Present Illness: onset, duration, timing of symptoms
Gyn Hx: Previous STD, Lesions, Treatment Sexual HX: Practices, Number of partners, New partner, Partner symptoms Medications: Contraceptives, OTC’s Review of Systems |
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The Five P's
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Partners
Prevention of Pregnancy Protection from STD’s Practices Past History of STD’s |
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STD Workup
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Cardinal Rule: ANY woman of reproductive age with a complaint of abdominal / pelvic pain has an ectopic pregnancy until proven otherwise!!
Always test for other STDs DNA probe (Nucleic Acid Amplification Tests) Gonnorhea and Chlamydia Cultures RPR HIV HBSAg Wet mount |
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Chlamydia Background
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#1 STD in USA
15-28% of Sexually Active Adol |
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Chlamydia Manifestations & Serious Sequelae
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Clinical Manifestations
Cervicitis-MOST COMMON IN FEMALES pharyngitis Bartholinitis-bartholin’s gland Proctitis-male or female Endometritis-can head towards PID Urethritis-can head towards PID PID-scarring in the tube, sperm goes anywhere but ECTOPIC PREGNANCY INFERTILITY |
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Chlamydia Risk Factors
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young age (15 – 21 highest prevalence)
multiple sex partners non-white race low Socioeconomic status cervical eversion-show columnar OCP’s New partner Unprotected sex |
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Chlamydia S/S
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asymptomatic
abnormal vaginal discharge postcoital or intermenstrual spotting/bleeding dysuria, frequency-urethritis d/t chlamydia infection dyspareunia pelvic / abdominal pain Signs* General-usually wnl Elevated temp Abdominal – usually wnl RUQ pain Pelvic-r/t PID CERVIX (+swab test): may be friable with mucopurulent discharge FUNDUS: may be tender if endometritis present ADNEXAE: may be tender; mass may be present |
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Chlamydia Dx
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DIAGNOSIS*
Nucleic Acid Amplified Tests (NAATs) are the most sensitive test for endocervical and male urethral swab specimens Sensitivity: 80 – 100% Specificity: near 100% |
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Chlamydia Tx
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RECOMMENDED REGIMENS
Azithromycin 1 GM po x 1 dose, OR Doxycycline 100mg po bid x 7 days ALTERNATIVE REGIMENS Erythromycin base 500 mg po qid for 7 days Erythromycin ethylsuccinate 800 mg po qid for 7 days Ofloxacin 300 mg po bid for 7 days Levofloxacin 500 mg po qd for 7 days FOLLOW-UP: except in pregnancy (retest 3-4 weeks after completing therapy) test of cure is not indicated |
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Chlamydia Sexual Partners
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Management of Sexual Partners:
Partners should be referred for evaluation, testing, and treatment. All partners with sexual contact 60 days prior to onset of symptoms should be evaluated The most recent sexual partner should be evaluated even if contact > 60 days Treated before next intercourse |
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Abx Contraindicated in Pregnancy with Chlamydia
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Doxycycline (Tetracylcines), Ofloxacin, and Levofloxacin (Quinolones) are CONTRAINDICATED in pregnancy
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Recommended Regimens for pregnant women
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Azithromycin 1 gm po in a single dose (macrolide) OR
Amoxicillin 500mg po tid x 7 days (penicillin) |
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Gonorrhea Facts
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“Clap, Drip, Dose, Gleet, Whites”
ORGANISM - Neisseria gonorrhoeae 300,000 new cases in USA each year May not be symptoms in women until PID Incubation: 1 – 14 days 20 – 40% co-infected with Chlamydia Males have “drippy” discharge Extremely painful to urinate (finger impressions in the side of the urinal) |
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Gonorrhea Transmission
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Sexual
Typical is Men to Women or Men to Men 80-90% transmission from male to female with a single act of intercourse |
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Gonorrhea Sites of Infection
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Endocervix - primary site in women
Urethra – primary site in men. Usual site in hysterectomized pt Skene’s and Bartholin’s Rectum – women and men Pharynx –women and men |
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Gonorrhea Serious Sequelae
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PID - 15-20%
INFERTILITY ECTOPIC PREGNANCY DISSEMINATED GONOCOCCAL INFECTION (DGI) |
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Gonorrhea S/S
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SYMPTOMS
asymptomatic vulvar pruritis, irritation, labial edema abnormal vaginal discharge abnormal vaginal bleeding Other: dysuria, urgency/ frequency, dyspareunia, dysmenorrhea SIGNS GENERAL temperature may be increased ENT pharyngeal injection, cervical nodes SKIN volar aspects of arms, hands, fingers EXTREMITIES joint tenderness, swelling, erythema, effusion ABDOMEN usually WNL; tender if PID PELVIC EXTERNAL GENITALIA - erythema, edema, excoriation VAGINA - abnormal discharge, blood, pus CERVIX - purulent/mucopurulent discharge; friable UTERUS - tender if PID ADNEXIA - tender, mass if PID |
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Gonorrhea Dx
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GRAM STAIN: high specificity and high sensitivity (polymorphonuclear leukocytes with Gram negative, intracellular diplococci in symptomatic males)
Nucleic Acid Amplified Tests (DNA / RNA) tests both GC Can be co-infected with Chlamydia |
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Tx for Uncomplicated Gonorrhea of Cervix, Urethra and Rectum
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Recommended Regimens (Cephalosporins Only)
Ceftriaxone 125 mg IM in a single dose OR Cefixime 400 mg orally in a single dose or 400 mg by suspension (200 mg/5ml) PLUS TREATMENT FOR CHLAMYDIA IF CHLAMYDIAL INFECTION IS NOT RULED OUT |
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Tx for Gonorrhea and Chlamydia
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Treatment for Chlamydia if concurrent infection not ruled out: Gonorrhea regimen PLUS
Azithromycin 1 gram po in a single dose, OR Doxycycline 100mg po bid x 7 days |
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Tx for Gonorrhea Partner
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Sex partners with sexual contact 60 days prior to onset of symptoms should be evaluated and treated for Gonorrhea and Chlamydia
Most recent sexual partner should be treated even if sexual contact was over 60 days prior to onset of symptoms |
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Tx for Gonorrhea Pregnancy
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NO Quinolones, tetracyclines
Use recommended or alternate cephalosporin If cephalosporin intolerant, then Spectinomycin 2 gm single dose IM Either Azithromycin or Amoxicillin is recommended for treatment of presumptive Chlamydia |
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STDs Characterized by LESIONS
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GENITAL HERPES* most prevalent
SYPHILIS CHANCROID Frequency varies by geographic location and patient population All three are associated with an increased risk for HIV infection -ULCERS GENITAL HERPES CHANCROID SYPHILLIS GRANULOMA INGUINALE LYMPHOGRANULOMA VENEREUM -WARTS HPV (condyloma) Diagnosis based only on HPI, PMH, and PE is often inaccurate Serology testing should be done on all patients with genital lesions |
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Genetic Ulcer Test
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Darkfield examination or direct immunofluorescense test for Treponema pallidum
Culture or antigen test for HSV, and Culture for Haemophilus ducreyi (where chancroid is prevalent) HIV testing! |
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Genital herpes
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Recurrent, incurable viral disease; latent in the spinal root ganglia
Serotypes: HSV-1 and HSV-2 HSV-2 diagnosed in at least 45million USA |
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Genital Herpes Transmission
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Mucosal contact with HSV-infected secretions
Asymptomatic viral shedding Human reservoir |
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Hormone Therapy
What is Rate? Relative Risk? |
Rate:
Number of events per number of individuals per time interval: 44 events in 10,000 people per year Relative Risk (Ratio) Rate of disease in exposed group divided by rate of disease in unexposed group. |
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Risk of DVT
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2.0
Annual rate of DVT in postmenopausal women Oral ET: 22/10,000 No ET: 11/10,000 Risk for DVT in women using ET twice that of non ET users |
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How do you Interpret Relative Risk?
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RR <1.0: exposure appears to Decrease risk
RR 0.50 = 50% Decrease risk for exposed group RR 0.3 = 70% Decrease risk for exposed group RR >1.0: exposure appears to Increase risk RR 1.2 = 20% Increase risk for exposed group RR 2.0 = risk is doubled for exposed group RR = 1.0 exposure/non-exposure = risk |
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What is Absolute Risk and why should you use it with your patients?
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More clinically useful than RR in explaining risk to patients
Addresses number of new cases Quantifies the impact on Public Health Difference between incidence rates in exposed and unexposed groups (risk difference) |
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Absolute Risk Example
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22/10,000 - 11/10,000=11/1000
For every 10,000 ET users 11 additional cases of DVT per year of ET use |
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Difference between Rare and Very Rare
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1998 CIOMS risk levels:
RARE: < or = 10/10,000/year VERY RARE: < or = 1/10,000/year |
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Menopause Background: Longevity and Population Expansion
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Longevity
1/3 of lifetime postmenopausal Population expansion By 2020: 45 million American women >50 |
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Why is the Nachtigall study significant?
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First randomized controlled trial in postmenopausal women
1965-1987 = 22 years 84 matched pairs (chronically hospitalized) Wide array of clinical endpoints MI, CA, Thromboembolism, Gall Bladder etc. First 10 years Placebo or CEE 2.5mg & MPA 10mg Next 12 years CEE to 0.625mg patients free to stop or switch |
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Nachtigall Results?
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Higher incidence Gall Bladder disease
No difference: MI, Uterine CA, Thrombophlebitis Lower incidence of Breast CA 0 cases in HRT group (N=116) 6 cases in placebo group |
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What is the Coronoary Drug Project?
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The first E2 Clinical Trial
Question: Is estrogen cardioprotective in men? Men given 2.5 or 5 mg/day of CEE Stopped prematurely Early excess VTE & Heart Disease What did it tell us? E2 in high doses is NOT good for men… |
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What is the HERS I and HERS II Study?
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Heart & Estrogen-Progesterone Replacement Study
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What were the HERS I results?
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Treatment group had more CHD events in the first year, and fewer years 3-5.
Probable that prothrombotic/arrhythmic/ ischemic effects in first year counterbalanced lipid improvements |
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What was the HERS II study? and its results?
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Confirm trend toward improvements in cardiovascular profile in treatment group
No Improvement! Estrogen in women with documented heart disease is Not Good! No Benefits even after 6 years If no evidence of heart disease with smoking, obese, on bcp..not a good idea to start estrogen. Although she has a hx of hormone use with bcp. |
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What is the Bottom Line of the WAVE, ERA and WELL HART Studies?
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WAVE: Women’s Angiographic Vitamin & Estrogen
ERA: Estrogen Replacement and Atherosclerosis WELL-HART Women's Estrogen/Progestin & Lipid Lowering Hormone Atherosclerosis Regression Bottom line: No change in progression or outcomes of CVD |
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WHI clinical endpoints?
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CHD (Non-fatal MI & Death)
Invasive Breast Cancer Global Index: Balance of risk/benefit 2 primary outcomes + Stroke Pulmonary Embolism Endometrial Cancer Colorectal Cancer Hip Fracture Death due to other causes WHI: told us there are a difference between combine and estrogen only, and difference with Women’s Age. The earlier, the more benefit. |
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WHI CEE only findings?
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12 more women with stroke.
44 in CEE vs. 32 in placebo group. ? Increase in clots 6 fewer women with hip fractures. Possibly 7 fewer breast cancers Bottom line: CEE should not be used to prevent chronic disease overall and heart disease in particular |
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WHI CEE vs CEE/MPA findings?
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Similarities
Increased stroke and decreased fractures similar to CEE/MPA Differences CEE did not increase breast cancers or decrease colorectal cancers Possible explanations: Different health factors for women with hysterectomy MPA changes disease risks and benefits |
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Findings of Rossouw etal (2007) - 2ndary Analysis if WHI?
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Effect of age & yrs since menopause
Primary endpoints: CHD & Stroke Age groups: 50-59 60-69 70-79 Years since menopause <10 10-19 >10 |
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Findings of Rossouw etal (2007) - 2ndary Analysis if WHI? (continued)
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50-59 yrs: overall in mortality
<10 yrs, CHD reduced (not significant) CHD risk in ET vs HT (not significant) If <10 yrs since menopause No differences in total mortality or CHD If >20 years, HT CHD risk Stroke risk across all categories |
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Findings of Hsia (2006) & Manson (2007)?
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ET between 50 & 59 significantly reduced coronary artery plaque & prevalence of subclinical coronary artery disease
Consistent with observational studies ET may be protective in younger women |
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What is NAMS Position Statement?
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“The benefit-risk ratio for menopausal hormone therapy (HT) is favorable for women beginning HT close to menopause but decreases in older women and with time since menopause in previously untreated women”
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NAMS 2010 Summary?
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Absolute risks for use of HT are low,
-particularly for the women on ET only -considerable safety for 0.625 mg/day of oral CE. Risks rare except for stroke Absolute risk or benefit small for women <50 At low risk of CHD, stroke, osteoporosis, breast cancer, or colon cancer, Type of hormones , administration routes and timing of doses have distinct beneficial and adverse effects (po vs cream) |
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Risk Factors related to hormone therapy?
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Risk factors related to
Baseline disease risks Current age & age at menopause Time since menopause Cause of menopause Prior hormone use Types, routes, and doses of HT Emerging medical conditions |
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Hormone Therapy Terminology
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ET: Estrogen therapy
EPT: Combined estrogen-progestogen HT: Hormone therapy (ET + EPT) Progestogen: Progesterone & Progestin Systemic therapy: HT resulting in serum levels high enough to produce clinically significant effects: Local therapy: Vaginal ET therapy that does not result in clinically significant effects. |
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Terminology:
Spontaneous/Natural Menopause Induced Menopause Perimenopause/menopause transition |
Spontaneous/natural menopause:
The final menstrual period (FMP), confirmed after 12 consecutive months of amenorrhea with no obvious pathologic cause Induced menopause: Permanent cessation of menstruation after bilateral oophorectomy (ie, surgical menopause) or iatrogenic ablation of ovarian function (eg, by chemotherapy or pelvic radiation therapy) Perimenopause/menopause transition: Span of time when menstrual cycle and endocrine changes occur a few years before and 12 months after the FMP resulting from natural menopause |
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Terminology
Premature menopause Early menopause Premature ovarian failure Early post menopause |
Premature menopause:
Menopause reached at or under age 40, whether natural or induced Early menopause: Natural or induced menopause that occurs well before the average age of natural menopause (51 y), at or under age 45 Premature ovarian failure: Ovarian insufficiency experienced under age 40, leading to permanent or transient amenorrhea Early postmenopause: The time period within 5 years after the 1FMP resulting from natural or induced menopause |
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What is the Primary indication for HT?
What are vasomotor symptoms? |
Primary indication for HT = moderate to severe vasomotor symptoms
ET (w/ or w/o progestogen) most effective treatment for menopausal vasomotor symptoms & side effects Hot flashes & night sweats Diminished sleep quality, irritability & lower QOL Systemic products all approved for this indication |
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How bout Vaginal symptoms?
Local or Systemic? |
ET most effective treatment for mod-severe vulvar & vaginal symptoms
Dryness, dyspareunia, atrophic vaginitis Many systemic products & all vaginal products approved for this indication If ONLY vaginal c/o – consider local treatment only |
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What are the effects of HT on Sexual Function?
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Vaginal sx relief (local or systemic HT) can improve sexual function
Local E2 may blood flow & sensation 1 oral product approved for treatment of pain with intercourse HT not recommended as sole treatment for other sexual problems e.g. decreased libido |
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Effects of HT on Urinary Health?
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Urge: Local ET may help (vaginal atrophy)
Overactive bladder: Benefit unclear Stress UI: -Unclear about local -Systemic HT can provoke Change in uterine volume or periurethral collagen Local HT may help with recurrent UTI Proliferative effect on urethra & bladder epithelia Restores pH and vaginal flora No drugs FDA approved |
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What are the BMI changes and HT?
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Peak BMI between 50 and 59
-Changes in exercise & diet patterns -Decreased metabolic rate Menopausal hormonal changes may add to this tendency for weight gain. No statistically significant differences between women on HT vs off HT |
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HT and Osteoporosis
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HT fracture risk even in women w/o osteoporosis
Extended HT use an option for women with osteoporosis or osteopenia Prevents further bone loss and fracture if other treatments not useful/tolerable Optimal initiation time: immediately post menopause Benefits dissipate rapidly after stopping |
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HT and CHD
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Timing of initiation
Observational studies: younger women (2-3 years postmenopause) RCTs: older women 63-64 years old (>10 years post menopause) When age matched, RCTs = Observational results HT may reduce CHD risk if initiated at younger age (recently postmenopausal) Duration of HT use Observational studies: longer use = risk for CHD and related mortality Short term: HT associated with increase in CHD risk in older women Coronary artery calcium may be the reason…HT may slow the development of CA calcium. |
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HT and Stroke
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HT NOT effective in
dec risk of recurrent stroke in women with established cardiovascular disease (CVD) Preventing a first stroke NOT recommended as stroke prevention HT may INC rate of 1st stroke particularly in women over age 60 Stroke not INC in 50 to 59 in overall WHI analysis BUT stroke risk nearly doubled in ET group >10 years post menopause. Why? Possibly due to Relatively few events Difficulty in accurately timing onset of menopause in the ET group. |
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HT and VTE
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All studies show risk with oral HT
WHI Effect emerges early (1-2 years), with time Excess risk lower in women <60 years 7/10,000/year EPT; 4/10,000/year ET (“Rare”) BMI >30, risk 3 fold higher Prior history of VTE or factor V Leiden at INC risk on HT Lower doses and transdermal route may decrease risk (no RCT data) |
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Bottom Line: Cardiac
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HT NOT recommended as sole or primary indication for coronary protection: irrespective of age
HT does not seem to INC risk for CHD events in women 50-59 or initiated w/in 10 years of menopause HT initiation in early postmenopause may DEC CHD risk |
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HT and Diabetes
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RCT suggests that HT DEC new onset Type II DM
WHI Women on HT 21% reduction in DM (15/10,000/year) ? Mechanism Lower weight gain, DEC insulin resistance No evidence for recommending HT as sole or primary indication for prevention of DM in peri or postmenopausal women Women who have Type II Transdermal ET may be better Trigylceride levels don’t increase with transdermal BP changes only reported with oral ET, not with transdermal delivery methods |
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HT and Endometrial Cancer
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USE PROGESTOGEN IF INTACT UTERUS
Unopposed systemic ET: risk dose & duration related Risk persists after discontinuation 3 years = 5 fold risk 10 years = 10 fold risk Early bleeding to early diagnosis; minimal impact on life expectancy |
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HT and Breast Cancer
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Hormones breast cell proliferation, pain & density on mammogram
Br Ca with EPT use >3-5 years Rare (4 to 6/10,000/year) ? If sequential vs continuous is worse Br Ca not with ET use 6 fewer cases/10,000/year (not statistically significant) Decrease seen across all age groups 50-59, 60-69, 70-79 ET use <5 years little impact on risk |
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HT and Mood/Depression
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Progestogens may worsen mood
History of PMS/PMDD/Clinical depression RCT’s in depressed peri/post menopausal women HT antidepressant effect (2 studies) HT no effect 5-10 years post (1 study) Controversial: does ET augment SSRI? Evidence does not support HT use to treat depression |
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HT and Cognitive decline/Dementia
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No association between age at menopause & AD
Case/control study bilateral oophorectomy before menopause associated with dementia & risk increased with younger age at oophorectomy |
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HT and Premature Menopause
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Distinctly different population
Limited data but possibly: risk breast cancer, risk for CHD Earlier onset osteoporosis HT may be more protective Don’t extrapolate WHI data to these women No trial data, but risks potentially smaller & benefits possibly greater |
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HT and Total Mortality
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WHI = to observational studies
DEC total mortality if HT initiated soon after menopause total mortality DEC 30%; statistically significant if ET/EPT data combined Not associated with DEC mortality if initiated >60 |
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Prescribing HRT: Estrogens
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Primary indication: vasomotor instability
Secondary: vaginal symptoms NOT considered cardioprotective E2 receptors are everywhere Endometrium Breast, Brain, Vagina, Skin SERM: turns OFF some, ON others VAGINAL ET: Not SYSTEMICALLY absorbed |
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Prescribing HRT: Progestogens
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Primary indication: DEC endometrial cancer risk
INTACT UTERUS, using systemic ET needs adequate progestogen NO UTERUS: No progestogen Vaginal ET: No progestogen Vasomotor symptoms may improve more if E + P |
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WHI results comprehensive
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Compared with the placebo, estrogen plus progestin resulted in:
* Increased risk of heart attack * Increased risk of stroke * Increased risk of blood clots * Increased risk of breast cancer * Reduced risk of colorectal cancer * Fewer fractures * No protection against mild cognitive impairment and increased risk of dementia (study included only women 65 and older) Compared with the placebo, estrogen alone resulted in: * No difference in risk for heart attack * Increased risk of stroke * Increased risk of blood clots * Uncertain effect for breast cancer * No difference in risk for colorectal cancer * Reduced risk of fracture (Findings about memory and cognitive function are not yet available.) |
