Repro: Disorders Of Vagina And Vulva

Front 1

Vaginal pH, Normal levels, maintenance

Back 1

Healthy pH in premenopausal women is 3-4.5. Over 5 is abnormal, Gray zone from 4.5-5.0.

As age, pH rises

At puberty, Lactobacillus acidophilus dominates flora and contributes to vaginal pH by lactic acid synthesis and hydrogen peroxide by glycogen breakdown

protects against anaerobic bacteria

Front 2

Vaginal Squames, Estradiol and pH

Back 2

Mature Vaginal Squame - large, glycogen rich, creates lower pH (3-4.5) and has higher serum estradiol. Higher risk for yeast infection but kills anarobes

Intermediate vaginal squame - estrogen decreases, lactobacilli drop, pH rises, glycogen less and cells smaller

Parabasal vaginal squame - post menopausal, looks like bulls-eye. Little glycogen. pH > 5.0. LOW estrogen

Front 3

High vaginal pH possible causes

Back 3

Bacterial vaginosis
Trichomonas vaginalis - inflammatory rxn, serum oozing into vagina, cytokines
Menopause on no HRT - always have elevated pH unless obese (more estrogen)
Presence of blood (blood pH is 7.4)
Breastfeeding - suppresses ovarian function
Topical vaginal medications
Recent intercourse with semen in vagina - semen is alkaline/neutral

Front 4

Vaginal Candidiasis Presentation, Causes, Dx, Treatment

Back 4

Presentation - Vaginal irritation and discharge, itching and burning. Sexually active, history of normal menstruation cycles

thrush-like patcheson vulva, labial edema, clitoral edema, sore, itchy bottom; don't need saline wet mount to dx

Causes
a) Candida albicans - most common
b) Candida glabrata - second most common
Others in immunosuppressed pts

Dx - saline wet mount
a) C. albicans - 90% - BRANCHING YEASTS, replicate via germ tube extension, CHITINOUS framework. Pseudohypae and mycelia. KOH will wash all but chitin framework
b) C. glabrata - BUDDING yeasts

Treatment
a) C. albicans - sensitive to azoles and triazoles, tablet
b) C. glabrata - resistant to azoles but sensitive to triazoles (fluconazole)

FLUCONAZOLE gets both

Front 5

Risk Factors for Recurrent/Persistent Vaginal Candidiasis

Back 5

Broad spectrum Abx - alters normal vaginal flora, yeast opportunistic infection

Pregnancy - more sugar due to high estrogen leading to higher glycogen in vagina

Oral contraception - progesterone may slightly lower T cell function (1st line against fungi), right before periods may be at more risk

Diabetes - high glycogen, altered immune function

Immune compromise - HIV pos

Front 6

Vulvovaginal Candidiasis Therapy Uncomplicated vs Complicated vs Pregnancy

Back 6

Uncomplicated - Fluconazole or intravaginal miconazole, clotrimazole, terconazole

Complicated/Recurrent/Persistent - Fluconazole, need culture for positive identification and sensitivity if no response. Better for uncontrolled diabetics, etc.

Pregnancy - NOT OK TO TREAT WITH ORAL FLUCONAZOLE. Use topical clotrimazole, miconazole, butoconazole, terconazole

Front 7

Vaginal Trichomoniasis Presentation, Causes, Dx, Treatment, MOA, ASE

Back 7

Presentation - Vaginal irritation with BURNING and FOUL SMELLING discharge. Dyspareunia (painful intercourse) Multiple partners, STD history. Can be asymptomatic but usually not

MOST COMMON NON-VIRAL STD in world. Vector for HIV transmission

Cause: Trichomonas vaginalis - flagellated protozoa

Dx - Flagellated organism on wet prep

Therapy -
Metronidazole first line, MOA - diffuses in and converted to free radicals to kill
ASE of bitter taste, nausea, vomiting esp. with alcohol. Rarely pancreatitis, blood dyscrasias, anaphylaxis, need to treat partners

Alternative Therapy -
Some metronidazole resistant trichomonas, but usually pts just undertreated.
If resistant though TINIDAZOLE or CLOTRIMAZOLE (intravaginal suppository)

Front 8

Bacterial Vaginosis Presentation, Cause, Association, Diagnosis

Back 8

Presentation - RECURRENT problem, FOUL SMELLING DISCHARGE, multiple visits and dx's of bacterial vaginitis (itis means fighting, osis means not), Cyclic

Cause - High levels of anaerobic bacteria with absent lactobacilli. pH > 4.5. Often Bacteroides, prevotella, preptostreptococci, mobiluncus, gardnerella, mycoplasma

Associations - no known cause or predisposition but if have likely to get:
a) Poor pregnancy outcome - premature rupture of membranes, preterm labor, chorioamnionitis, postpartum endomyometritis, post cesarean wound infection
b) Pelvic inflammatory disease
c) Post hysterectomy vaingal cuff cellulitis

Diagnosis - Vaginal pH>4.5; abnormal, malodorous discharge, amine odor on KOH addition, Presence of clue cells (squamous cells with indistinct borders due to bacterial lode) on saline wet mount. LACK of lactobacilli and leukocytes (not fighting infection)

Front 9

Therapy, Persistence/Recurrents and Alt. Therapy for bacterial vaginosis

Back 9

Therapy - same as for trichomonas b/c treating anaerobes. METRONIDAZOLE or CLINDAMYCIN

Peristence/Recurrent BV - Recurs in 40%, no evidence that is a STI. Due to biofilm of dense slime of bacterial polysaccharides. Resistant to Abx, pH, and host defense

Recurrent BV treat with longer courses of Metronidazole, consider Tinidazole

Alt therapy - acidic douching, lactic acid gels, probiotics are INEFFECTIVE

Front 10

Vulvar Diseases with Red Lesions, Treatment

Back 10

a) Contact Dermatitis - usually symmetrical eruption. Dry if chemical/perfume, wet if environmental like poison ivy. Eczematoid. Treat with corticosteroids and antihistamines for itching

b) Seborrheic Dermatitis - OILY red lesions, symmetric, RARELY ONLY IN VULVA, often on SCALP, FACE, and NASAL CREASE. cause in increased sebum. Treat with Selenium sulfide, oral contraceptives to decrease androgens (less oil)

c) Coital Trauma - Honeymoon vulvitis - red, painful posterior aspect of vestibule. Just outside hymenal ring. Superficial fissuring that burns on urination. Treat with pelvic rest, topical steroid

d) Tinea Cruris - Jock itch by dermatophyte, symmetric red rash, dry with scaly raised margin. Aggravated by heat and humidity. Usually tricophyton rubrum or epidermophyton fluccosum. Treat with Terbinafine (lamisil)

Front 11

Vulvar Diseases with White Lesions, Treatment

Back 11

a) Intertrigo - hyperkeratosis of skin, waterlogged keratin that itches. Extends into thigh creases secondary to chronic wetness in obese or clothes. Treat with ZINC OXIDE for diaper rash, astringent baby wipes after urination, defecation. Steroids if itch, less occlusive clothing

b) Vitiligo - AD depigmentation of skin, whitening

c) Lichen Sclerosus - Parchment-like, atrophic change. EPITHELIAL THINNING. More in peri-menopausal or menopausal. Can get labial fusion. May get vulvular pruritis. Lichen Sclerosus is NOT in vagina (never on mucous membranes) but Lichen Planus can be. Also on neck, trunk, eyelids. Treat with Clobestasol propionate (corticosteroid), then drop to betamethasone or triamcinolone (medium steroids)

d) Lichen Simplex Chronicus - HYPERPLASTIC DYSTROPHY, SQUAMOUS HYPERPLASIA. Thick, inflammed hyperkeratotic skin 2ndary to INFLAMMATORY PROCESS. VELVETY SKIN. chronic pruritis. Systemic steroids

e) Condyloma Acuminata - warty, cauliflower growths, can be multiple. Flesh colored. Associated with HPV 6 and II. Beware if sessile and pigmented b/c may be carcinoma in situ so biopsy. Treat with acetic acid (make sure not carcinoma), podophyllin or CO2 laser, cryotherapy

Front 12

Ulcerous Disease Lesions of Vulva, Dx and Treat

Back 12

a) Syphilis - primary chancre is PAINLESS, Secondary syphilis ulcers have rash on palms of hands and feet. Dx with FTA-ABS or PRP/VDRL. Penicillin to treat

b) Herpes Simplex - Vesicles, usually multiple lesions, inflammation and itching. Tends to recur in same location but less severe later. Treat with Acyclovir, famcyclovir or valcyclovir

c) Crohn's Disease - "Slit like" lesions involving lateral aspect of vulva extending into thigh crease, wet, oozy, secondary to CHRONIC NON-CASEATING GRANULOMATOUS PROCESS, abdominal pain and weight loss. Treat with Methotrexate, prednisone, excise lesions

Front 13

Paget's Disease in Vulva

Back 13

Tumor that can be in vulva

Raised, velvety red lesion with islands of hyperkeratosis, locally invasive. Recurrence, 25% have underlying adenocarcinoma of apocrine glands. Widely excise and ensure no adenocarcinoma of Bartholin's glands. If adenocarcinoma then do radical vulvectomy with nodes

Front 14

Melanoma in Vulva

Back 14

Biopsy highly pigmented, especially with ulceration and irregular borders, prone to distant metastasis, early or late

Radical vulvectomy with nodes

Front 15

Vulvar Intraepithelial Neoplasia (VIN) in Vulva

Back 15

Diffuse plaques of white epithelium. PCR for HPV 16,18 (HIGH RISK); may be warty, sessile, hyperpigmented or not, solitary or multifocal. Biopsy before initiation of therapy. Wide excision, CO2 laster for small involvement

Can progress to squamous cell carcinoma if do not treat

Front 16

Most common reason for pt visits to ob/gyn in US

Back 16

Vaginitis

Front 17

Wet mount with lack of WBC and lactobacilli

Back 17

characteristic of bacterial vaginosis

Front 18

How to treat vulvar condyloma that are hyperpigmented or sessile

Back 18

IF NOT carcinoma in situ or carcinoma usually can just do topical rx like TCA and podophyllin and a biopsy not necessary

High risk HPV 16,18 more likely to cause cancer