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175 Cards in this Set
- Front
- Back
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***Gravidity vs Parity
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1. Total number of pregnancies
2. # of times a women has given birth |
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***In terms of Parity what does TPAL stand for?
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1. Term birth = >37 weeks
2. Pre term = 20 - 37 weeks 3. Abortions = < 20 weeks 4. Living children |
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What is meant by this example G5P3113
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-5 pregnancies
-3 term births -1 preterm -1 abortion -3 living children |
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***What is the #1 reason when women come in and she doesn't know why she is hear?
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-Domestic violence
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*What is bleeding after sex an indication of until proven otherwise?
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-Cervical cancer
-tip of penis is hitting the cervix (use colposcopy to investigate) |
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PID: Pelvic Inflammatory Disease
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-inflammation of uterine tubes and uterine structures, fever, uterine tenderness, puss, possibly d/t a STD
-pain is not cyclic it is chronic |
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*Endometriosis
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-abnormal endometrium outside the uterus, estrogen dependent so when estrogen rises in early part of secretory phase, these implants will swell causing painful menses around the period
-in luteal phase the progesterone falls and pain goes away |
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***TQ: What should you do w/ a pt who says she has never had sex but has gone clubbing
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-R/O pregnancy
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If a pt bleeds profusely w/ craps and something like tissue comes out and the pt no longer has bleeding and craps what is this?
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-a spontaneous miscarriage (80% of all pregnancy)
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*If there is pain w/ sex and she is spotting blood, what should you start to think?
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-PID or cancer
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***TQ: Menorrhagia
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excessive or prolonged bleeding
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***TQ: Metrorrhagia
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-irregular, acyclic bleeding
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***TQ: Menometrorrhagia
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-excessive or prolonged bleeding WITH irregular, acyclic bleeding
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***TQ: Hypomenorrheea
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-diminution of flow
-commonly d/t OCPs (OCPs also decrease endometrial cancer) |
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***TQ: Oligomenorrhea
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-reduction in frequency (<6 / year)
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***TQ: Polymenorrhea
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-increase in frequency
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***TQ: What is the most cost effective and reliable method of early cancer detection especially when combined w/ appropriately scheduled mammography?
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-The breast exam by a physician
(important to note that 80% of breast cancer is found by women on self exam so encourage this) |
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*What is the number 1 cause of galactorrhea?
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-trauma to the nipples
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*Bleeding from the nipples is what till proven otherwise?
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-cancer
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***What is the MC area to find breast cancer?
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-in the Upper out quadrant (especially at the 'tail of Spence')
-(if you don't find lumps here you reduce her chances of breast Ca by 80%) -cancer is fast growing, hard fixed and irregular |
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Percussion:
Ascites vs Cyst |
1. Ascites: symmetric contour of abd; shifting dullness w/ change of position; percussion of: flanks, ant. abd, epigastrum = dull, tympani, dull
2. Cyst: Upper abd; seldom shifting dullness; percussion of: flanks, ant. abd, epigastrum = tymp, dull, tymp |
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What are general principles of the Pelvic exam
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-empty bladder
-arms at sides or across chest -verbal cues before tactile cues -avoid sudden movements -warm hands -warn of speculums loud click |
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*Clitoromegaly
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-d/t excess testosterone produced by ovarian cyst/cancer
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***Uterus is palpated for?
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-Position:
-if you can feel it, then uterus is anteroverted -if you can not feel it then uterus is retroverted |
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*What is the technique for:
Bimanual Uterine exam |
-index and middle finger dominant vagina
-thumb folded -fingers inserted deeply to POSTERIOR FORNIX -uterus elevated by vaginal hand |
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*What is the technique for:
Adnexal exam |
-vaginal fingers in LATERAL FORNIX
-adnexa palpated by sliding motion |
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***TQ: Ovaries and palpation
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-ovaries are as sensitive to palpation as testes
-ovaries are only palpable 50% of the time in reproductive age pts |
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*What is the technique for:
Rectovaginal exam |
-feel for uterosacral ligament
-if pt has RETROVERTED UTERUS think about using this -enterocele (bulging of vag into colon) -1 finger in asshole and 1 in vag |
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About what percentage of pregnancies are unplanned?
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-50%
-most of the unplanned are undesired -50% of the undesired will end in abortion |
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***TQ: What is the proper way to use a condom?
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-use a new condom every time
-hold the condom at the base of the penis when withdrawing |
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***TQ: Pts may NOT be aware of the NON-contraceptive benefits of the OCP, it is your role as a physician to let them know...
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-if pt is on pill for a year she gets a 50% reduction of ovarian cancer
-also reduces endometrial cancer -collagen is estrogen dependent, OCP after menopause skin will look younger -helps to tx severe acne |
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*What contraceptive methods work by inhibiting development and release of the egg?
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-OCPs (thickens cervical mucus d/t progesterone, also reduces ovulations)
-Injectable progestins -Patch (evra) -Vaginal ring (NuvaRing) |
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*What contraceptive methods work by imposing a mech, chemical or temporal barrier btwn sperm and egg?
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-Condom
-Diaphragm -Foam (kills sperm and GOOD vag bacteria) -Rhythm (don't have sex 11-16 days after period b/c sperm can live 3 days, and eggs can live 2 days after ovulation) |
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***TQ: What contraceptive is rarely used anymore and why?
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-Diaphragm
-it has INCREASED risk of UTIs |
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*What contraceptive methods work by altering the ability of the embryo to implant and grow?
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-IUDs
-Morning after pills -RU 486 (new abortion pill that induces menses) |
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***TQ: Which Contraceptives are EXTREMELY EFFECTIVE?
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-IUDs
-DMPA -Implants -Sterilization |
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***TQ: Which Contraceptives are VERY EFFECTIVE
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-OCPs
-Patch -Ring |
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***TQ: Which Contraceptives are LESS EFFECTIVE?
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-Male and female condoms
-cervical cap -diaphragms -withdrawal -fertility awareness |
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Pills contain synthetic steroids similar to estrogen and progesterone. What do each of these do?
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-Progesterone is what helps NOT get prego
-Estrogen stops breakthrough bleeding |
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How is Progesterone an antic cancer drug?
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-causes mitotic figures in endometrium to die
-DOWN regulates rapidly growing cells |
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What are some of the advantages of Progesterone in the OCP?
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-Decreased risk of endometrial and ovarian cancer
-reduced incidence of benign breast disease -Decreased risk of PID -Eliminates the risk of ectopic pregnancy |
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*What are disadvantages of the OCP?
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-noncompliance remains the major problem
-time and cost of obtaining a prescription |
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*What is a COMPLETE contraindication for the OCP?
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-Clotting Hx
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What pill is the newest progestins combined w/ lowest effective dose of estradiol?
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Yazmin
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***TQ What are ABSOLUTE CONTRAINDICATIONS of the OCP?
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-Smokers > 35 y/o
-current thrombophlebitis or embolic disorder -undiagnosed abnL vag bleeding -Hx of DVT, cholestatic jaundice of prego, or jaundice w/ prior use -Hepatic adenomas, carcinomas -known/suspect prego, or breast Ca (ANY estrogen depend Ca) -Migraine w/ focal aura -Leiden factor V deficiency -CAD or cerebrovascaular disease |
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***TQ: What is the unique progesterone in Yazmin?
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-Drospirenone plus EE
-1st pill w/out androgen derivative -DOES NOT CAUSE WT GAIN LIKE OTHER PROGESTERONES |
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***TQ: Warning sings of possible pill related illnesses
ACHES |
1. Abd pain (clotting in abd vasc)
2. Chest pain or SOB 3. H/a or migraines 4. Eye or vision problems (stroke) 5 Swelling or severe pain in leg (DVT) |
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***TQ: MOST available emergency contraception in the pharmacy?
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-Progestin ONLY (Plan B)
-if already pregnant will NOT work |
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*Depo provera (Medroxyprogestroen Acetate injection)
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-Effective up to one year
-irregular bleeding, amenorrhea -every 3 months, but if use for more than 3 years will decrease bone density |
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*Patch (Ortho Evra)
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-contains norelgestromin (NGMN) and ethinyl estradiol (EE)
-patch for 3 weeks and then 1 week off |
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***TQ: Why is it effective for a teenage girl to wear the patch?
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-She does not have to remember to take the pill everyday
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*NuvaRing
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-ENG and EE
-put in and take out yourself every 21 days |
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*What is the classic presentation of Imperforate hymen?
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-firs period w/out blood, complaining of extreme pain
-big bulge looks like fluid behind vagina -have to make an incision and release the blood sac |
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*Inherent growht potential of reproductive tract is female (default development) and does NOT require the presence of ___?
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an ovary
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*Masculinization of a genetically male reproductive system DOES require the presence of ___?
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-androgen (from fetal testis)
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*target organ response is as important as ____?
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-gonadal fxn
-ex. androgen insensitivity syndrome (testicular feminization) ***gonads are totipotent up to 5 wks |
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***Abnormal chromosomal sex determinination
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-mainly from non-disjunction (during oocyte MEIOSIS results in a female gamete w/ no X or one w/ an extra X)
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*If a female gamete w/ extra X is fertilized by male gamete Y chromosome what is the result?
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-47XXY = Klinefelter's syndrome
-prisoners -Stigmata: mental retardation, infertile, gynecomastia, hypogonadism |
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*If a female gamete w/ an extra X is fertilized by a male gamete w/ X chromosome, what is the result?
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-47XXX = superfemale
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***If a female gamete w/ an NO X is fertilized by a male gamete w/ X chromosome, what is the result?
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-Turner's Syndrome = 45 X
-Stigmata: webbed neck, increased carrying angle, coarction of aorta, atrial septal defect |
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*Mosaicism
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-form of chromosomal variation d/t non disjunction in the early MITOTIC division of the embryo in which cells of different chromosomal consitution exist together in a single individual
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***If zygote has no Y and at least 2 X chromosomes what will happen?
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-the gonad will differentiate into an ovary
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**Agenesis vs Dysgenesis
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1. NO growth (hypogonadism)
-rare, usually a/w other genital tract abnormalities 2. Dysgenesis: some degree of degradation (ex Turner's)*** |
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***What are the 4 categories of abnormal mullerian Duct development?
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1. Failure of fusion (MC*** = double vag)
2. Failure of formation 3. Failure of dissolution 4. Failure of complete atrophy of the mesonephric system |
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*Normal development of the Vagina
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-prim cloaca divided into urogentital sinus and anorectal canal
-utero-vaginal primoridium contacts the urogenital sinus and a solid mass of cells (VAGINAL PLATE) is formed--> central cells of this disappear forming the lumen of the vagina, and periph cells from the vaginal epithelium |
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***TQ: What are the 2 MC manifestations of androgen excess?
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-ambiguous genitalia
-primary amenorrhea |
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***TQ: What is the MC source of excess androgen affecting the female fetus?
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-congenital adrenal hyperplasia
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What is the most important pelvic plane and why?
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-plane of least pelvic dimensions
-area where most arrest of progress occurs |
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***What are the 4 parent types of pelvic shape?
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1. Gynecoid (best and MC)
2. Android 3. Anthropoid ("face to pubes" deliveries) 4. Platypeloid (NO vaginal delivery) |
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***Gynecoid
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-best prognosis for fetal passage
-MC 40-50% -inlet is rounded, side walls straight, sacrum well curved and sacrosciatic notch is adequate |
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***What happens when a women is 10 cm dilated?
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-they are totally dilated, time to start pushing baby out
-if Platypelloid pelvic shape, cannot get dilated so need C section -if cannot get C section will die during birth |
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*What is a serious complication of hysterectomy?
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-clamping and ligation of female ureter
-so make sure you pull up on the bladder so you get around the ureter -on autopsy of women w/ hysterectomy may see this, they have kidney failure of 1 kidney |
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*What is Endometriosis?
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-benign disorder resulting from the presence and growth of endometrial glands and stroma OUTSIDE OF THE UTERINE CAVITY
-CYCLIC PELVIC PAIN |
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*Endometrioma
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-an area of endometriosis, usually in the ovary, big enough to be called a tumor
-increased estrogen causes cyclic pain** |
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*Chocolate Cyst
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-an endometrioma or other cystic structure, filled w/ old blood which grossly resembles chocolate syrup
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***Sites of Endometriosis
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1. Ovary - 60% MC***
-typically B/L, if only on ovary may not have pain and thus may be found accidentally 2. other pelvic sites - 30% -Utero-sacral ligaments -Recto-vaginal septum -Fallopian tubes |
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*What is the Direct Implantation Theory (Sampson's Theory) of endometriosis
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-viable fragments of endometrium are carried to intraperitoneal sites by RETROGRADE REGURGITATION thru the oviducts
-sex during menstruation increases the risk of endometriosis (by increasing retrograde flow) |
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***What are 4 evidences of cyclic estrogen action dependency?
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1. uncommon before menarche and rare after menopause
2. ovarian ablation results in complete and prompt regression 3. Rare in amenorrheic individuals 4. Improves/stabilizes during phyiologic (prego) or induced (hormonal) amenorrhea (hallmark!) -Tx w/ NSAIDs and OCPs |
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*Incidence?
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-1-2% of general pop (appear to have genetic predisposition)
-30-50% of infertile females (there is a relationship) -Incidence INC d/t 1. Deferred child bearing 2. Better diagnostic methods |
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***TQ: Classic microscopic Findings
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1. Endometrial Epithelium
2. Glands 3. Stroma (dx often based on this alone) -***all these found outside the uterus -also may have hemorrhage |
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***What is the classic gross visual appearance?
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-"Powder-Burn" lesion --> looks like splattered w/ gun powder
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***What makes endometrial cyst of an ovary surgery very difficult?
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-it is difficult b/c it is highly hemorrhagic and dissection is difficult
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***Clinical features
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-asymptomatic or wide variety
-dysmenorrhea -dysapareunia (usually pain w/ 'deep thrust') -infertility, pelvic pain, abnormal bleeding -dysuria/hematuria/painful defecation (at time of menses) |
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**Signs that suggest but do not confirm dx
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1. Fixed retroverted uterus
2. Thickened, nodular uterosacral ligaments 3. Thickedned rectovag septum 4. Induration of cul-de-sac**** 5. Fixed adnexal mass |
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***What is the GOLD STANDARD for dx of Endometriomas?
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-BIOPSY --> endometrial stroma and glands
-for endometriosis need lapartomy/laparoscopy for confirmation |
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***What is counter intuitive regarding endometriosis?
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-visible appearance of endometriosis does NOT predict the severity of symptoms
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*Tx of pts who present w/ persistent adnexal mass
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-surgical removal is diagnostic and therapeutic
-60% recurrence and the 2nd surgery is harder than the first-> scar tissue -tx empirically w/ OCPs and NSAIDs |
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*How does Moderate to severe endometriosis cause infertility?
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-mild caused by (inc peritoneal fluid, PGs, and phagocytosis of sperm by peritoneal macros)
-NOW ADD mechanical tubal and ovarian obstruction -infertile pts w/ stage III-IV endometriosis should have surgery to attempt to remove implants and adhesions |
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**Surgery short of total abd hysterectomy or B/L salpingoophrectomy will result in?
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-recurrence UNLESS followed up by long term hormonal control
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*What are Medical therapies of Endometriosis?
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-this is a steroid responsive ds
-estrogen promotes growth and development of endometriotic implants while ANDROS and PROGESTINs induce atrophy -use combo of NSAIDs and OCPs ***use continuous therapy (skip placebos) to cause amenorrhea |
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Depo MPA (Provera)
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-down regulation of pituitary gonadotrophs and DEC ovarian steroidgenesis
-SE: irreg uterin bleeding, wt gain, fluid retention, unpredictable return of menstrual fxn (~1 year) |
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Danazol
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-Speeds up "pulse generator" hypothalmus
-creates a hypoestrogenic hyperandrogenic state (also affects immune system may play role) -SE: anabolic effects, hirsutism, acne, wt gain, pigmentation change |
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GnRH agonist therapy
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-Leuprolide acetate -> daily subQ injection or monthly IM inj
-Naferelin acetate-> BID,TID, Intranasal -Goserelin acetate--> Implants -SE: 2ndary to estrogen def, early menopause, vag dryness, arthralgia, myalgia, dec libido |
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***Surgical Tx
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-more effective for INFERTILITY
-allows for definitive diagnosis w/ the option of simultaneously perform definitive tx -INVASIVE and EXPENSIVE |
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*Lapartomy and conservative surgery
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-getting rid of as many lesions as possible but preserving uterus and other repro organs
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*Laparotomy and definitive (extirpative) surgery
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-uterus and ovaries taken out, plus removal of all visible implants
-TX of choice for ADVANCED disease w/ NO desire to preserve child bearing -after surgery: Provera 1030mg/day x 6 months, followed by Premarin/Provera |
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***SAMPLE TQ:
Pt w/ "cyclic pelvic pain" and nodules in recutm most likely has? |
-endometriosi
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***SAMPLE TQ:
Post coital bleeding (trauma from deep thrusting) |
-Cervical Cancer until proven otherwise but very likely ENDOMETRIOSIS causing uterus to be stuck posteriorly (Retroverted)
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***SAMPLE TQ:
Complication of 2nd C section? |
-more likely to injure bladder (but make repair at time of surgery)
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***SAMPLE TQ:
Pt no longer desires child bearing, has sever endometriosis and is refractory to drugs, how do you tx? |
-Hysterctomy
-***Laprotomy and definitive (extirpative surgery) |
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*When should you get your first pap smear?
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-21 y/o or 3 yr after 1st sex (b/c can acquire HPV)
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***TQ: What percentage of 14 y/o having unprotected sex? 15 y/o?
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1. 40%
2. 50% -takes teens about 12 months after having unprotected sex before seeing a doctor |
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*What should you always ask about when interviewing an adolescent?
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-FDLMP (1st day of last menstrual period)
-NEED A CHAPERONE IN ROOM -never imply disapproval, pts are scared usually -if mom in the room, NO NON-VERBAL CUES |
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*What is extinction of stimuli?
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-mean to decrease anxiousness
-distract pt while inserting the speculum, take a deep breath or touch another party body |
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*What is a Pederson speculum
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-1/2 size of normal adult
-if sexually active sometimes too small |
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*Gardasil?
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-HPV vaccine to prevent cervical Ca and vaginal warts
-now approved for men 9-26 y/o (16, 18 cause penile CA and anal CA in men) |
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***Abnormal Bleeding
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-Von Willebrands (MC coagulopathy that causes spotting)
-Prego -Trauma -Borrowed OCPs -Thyroid disease -Clear cell adenocarcinoma |
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***TQ: What is the MCC of abnormal bleeding in a PRE - adolescent?
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-Foreign body
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***TQ: A girl comes in and has had a few, skipped periods last year. Also for past 6 months no period. Prego test and serologies were negative. What do you do?
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-WAIT
-this is NORMAL in adolescents |
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*What is Asherman's syndrome
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-uterine synechiae
-adhesions or fibrosis d/t scars left by surgery |
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***TQ: How do OCP decrease pregnancy?
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-by CERVICAL MUCOUS THICKENING
(also slightly protects against Chlamydia infx) **OCP does NOT encourage promiscuity |
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***TQ: What are 2 Non-contraceptive benefits of the OCP?
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-acne reduction
-reduces abnormal bleeding |
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***TQ: Absolute CI of the OCP?
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-Estrogen (+) Ca (breast, uterine)
-Undx abnormal uterine bleeding -Clot hx (Anti-thromb 3, hyperhomocysteinemia) -HCC or abnl liver fxn -pregnancy -Hx of jaundice -CAS or cerbrovascular disease |
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***TQ: Why should you always use condoms even if on OCP?
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-because it does not protect against STDs
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***TQ: What is 10x more common in female adolescents than adults?
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-PID
-this is b/c teens are less likely to succumb to complaint and women who have had disease previously know how to recognize it |
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*What is Gestational Trophoblastic Disease (GTD)?
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-a spectrum of tumors, representing a rare variation of pregnancy, resulting from the abnormal proliferation of the trophoblast, limited in most instances to a BENIGN disorder called molar pregnancy
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*Quick general overview of Gestational Trophoblastic Disease (GTD)?
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-dx w/ US
-monitor w/ beta hCG -tx w/ chemo MTX -"Snow storm pattern" -"vesicles/grapes coming out of uterus" -failure to recognize and tx GTD in early stage can lead to untoward and even fatal consequences |
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*Hydatiform mole
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-represents a transformation of the placenta of blebs of edematous, fluid containing trophoblastic cells
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*Hydatiform mole incidence
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-varies w/ geographical location
-etiology unknown -frequency is greater at beginning and end of reproductive life -recurrence rate is ~2% |
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***What is a COMPLETE MOLE?
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-"Daddy's Girl" (46XX)
-dispermic fertilization of oocyte -replace nL placental tissue by hydrophobic placental villi -proliferation from synctiotrophoblast -NO FETUS is formed -Malignancy rate 15-20% |
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***What is a PARTIAL MOLE?
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-fetus is triploidy, 69XXY (90%)
-prolif from cytorophoblast -composed of one haploid set of maternal chromosomes and 2 haploid sets of paternal, secondary to dispermic fetilization -malig trans less than COMPLETE |
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*Invasive mole (chorioadenoma destruens)
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-local uterine invasion of molar vesicles in trophoblast
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***Choriocarcinoma
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-only CA a/w Pregnancy!!!
-in 50% of cases, antecedent event is primary molar gestation -rapid hematologic spread is hallmark of the disease |
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***Risk factors for GTD?
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1. Dietary deficiency (Folic acid: remember give this up to 3 months before trying to get prego)
2. Age (extremes) 3. Prior hx 2% |
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*Clinical presentations?
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-most previously dx as prego and then bleed suggesting early spontaneous abortion
-uterine size/date discrepency -exaggerated sx of prego -preeclampsia in 1st or early 2nd trimeester -passage of "grape like" tissue fragments -***SNOWSTORM on US |
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*Presentation of a partial mole?
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-similar to GTD but usually later in pregnancy
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*What is the dx tool of choice?
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-TV or Trans abd US
***remember prego until proven otherwise and Rh- until proven otherwise |
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*Tx
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-Suction curettage, post op oxytocin and gentle post op curettage to R/O myometrial invasion
-Hysterectomy for older pt not concerned w/ future fertility |
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*Tx for a partial mole?
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-PG vaginal suppositories for >24 week
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***Tx for enlarged ovaries (Theca-lutein cysts)?
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-do not need removal and will normalize when markedly elevated gonadotrophin levels return to baseline
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***Post evacuation management
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-Periodic exams including serial Beta subunit hCG radioimmunoassay for 2 weeks until normalize, then monthly for 1 year
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***Diagnosis of metastatic or malignant GTN?
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-dx by hCG level that rises or plateaus
-careful H and P -pelvic US -CT of head and abd-pelvic cavity |
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*How do you tx malignant Non metastatic GTD?
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-it is confined to uterus
-use MTX |
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*How do you tx malignant metastatic GTD with good prognosis?
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-MTX or actinomycin-D
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*How do you tx Choriocarcinoma?
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-Tx w/ MTX
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*What should you be suspicious of if a pt presents w/ pruritis of the vulva?
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-vulvar cancer or infx (always want to R/O cancer)
-DX is limited to hx, inspection and BIOPSY |
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*Biopsy technique
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-1. Culposcopic guided biopsies
2. Keyes punch or scalpel 3. Hemostatis w/ AgNO3 or suture |
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***What are 3 non-neoplastic epi disorders of the vulva?
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1. Lichen simplex chronicus (LSC)
2. Lichen planus 3. Lichen sclerosis |
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*Lichen Simplex Chronicus (LSC)
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-diffuse redness w/ patches of hyperpig and hyperkeratotic (leather thickening) ridges of epidermis
-sx= itching and burning -tx = benadryl, hydrocortisone, Triamcinolone (for hyperkeratosis) |
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***Lichen Planus
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-vulvular burning/pruritis and insertional dysparenuia
-"Classic" - sharply demarcated, flat-topped plaques on oral and genital membranes -"Erosive" - extending vag canal |
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***TQ: Lichen planus is a disorder of ???
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-CMI
-check mouth, may confirm dx -Whitish lacy bands of keratosis adjacent to reddish, ulcerated lesions (Wickhamn striae) are classic sign -Most difficult to tx, cyclosporin, steriods, retinoids |
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***TQ: What is the morphology/appearance of Lichen Sclerosis?
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-depigmentation, loss of mucocutaneous markings, loss of nL architecture, stenois of introitus
-"cigarette paper" or "onion skin" appearance, ecchymoses -"Figure 8" appearance -Tx w/ Clobetasol (Temolate) |
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***TQ: How do you tx Seborrheic dermatitis?
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-this is red/pink and covered by oily appearing scaly crust
-***Tx w/ Burrow's solution (domeboro) |
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***Friedrich's Criteria for dx of Vestibular adenitis (vestibulitis)?
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1. Severe pain on vestibular touch or attempted vag entry
2. Tenderness localized w/in the vestibule 3. Physical findings of erythema Tx:surgical removal after 6 m of trigger point inj of Kenalog and Marcaine |
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*Vulvar Neoplasia
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-Squamous cell hyperplasia
-acanthosis and hyperkeratosis -mainly post meno women, pruritis -pink-white or white raised lesions, nL labia and clit (in contrast to lichen Sclerosis) -Tx essential same as L. Sclerosis |
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Vulvar intraepithelial neoplasia (VIN)?
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-ID by naked eye after application of acetic acid (white rxn)
-Tx: local incision is now mainstay |
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***Paget Disease
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-infrequent neoplastic condition, symptomatically a/w w/ itching, burning, and bleeding
-extensive intra-epi ds, histo identical to Paget ds of the breast -well-demarcated, eczematoid lesion, red to bright pink, with scattered white islands of hyperker -Tx = wide local excision |
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**Level 1 Melanomas
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-5% of vulvar maligs are melanomas but 8% of melanomas occur in the vulva
-ALL pig lesions of vulva require wide excision for Dx and stagin -local excision adequate only if lesion is superficial |
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***Vulvar Cancer
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-rare
-menopausal female w/ 1. Vulvar pruritis 2. Red/white exophytic or ulcerative lesion commonly on posterior 2/3 of labium majora 3. bleeding, discharge, dysuria |
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***Why should you avoid petrolatum/petroleum based lubricants when using a condom?
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-because they cause breakage or leakage of condom
-remember to withdraw while still erect and holding the base of condom at base of penis |
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***What is a negative SE of using spermicides?
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-they are also bacteriocidal so they can cause VULVOVAGINITIS through lactobacilli killing
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***What is the MOST EFFECTIVE way of preventing pregnancy (other than abstinence)?
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-Intrauterine Contraceptive Devices (IUCD) = failure rate of 5/1000 = .5%
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***What are the 2 types of IUCDs?
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1. CuT380A - Copper, last 10 yrs
2. LNG IUS = Mirena, last 5 yrs -both are long term, reversible and breast feeding safe -prevent ectopic preg d/t reduction of preg risk in general |
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***MOA of Copper IUCD?
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-copper toxicity --> toxi to sperm and bacteria, which is why it can sometimes lead to inc infx risk
-relative CIs for this include menorrhagia and Wilson's disease |
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***MOA of Mirena IUCD
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-progesterone release --> making it better for breakthrough bleeding
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***Overview of Vaginal Neoplasms
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-rare
-generally F >65 (this number is falling d/t prevalence of HPV 16 and 18) -dx is generally late and most are from metastasis from nearby |
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***What is VAIN?
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-Vaginal intraepithelia Neoplasia --> the precancerous from
-must differentiate between this and true neoplasia -dx made by colpscopy and biopsy |
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***How is invasive vaginal carcinoma tx?
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Radiation
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***What happens if there is a lack of lactobacillus?
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-can cause discharge from vagina
-d/t pH changes in the microenvironment, leading to an ALKALOTIC infx and VULVOVAGINITIS |
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*Intertrigo
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-rash of body folds
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*Folliculitis/furunculosis
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-usually from sharing razors
-folliculitis is superficial -tx by antiseptic or abx (dicloxacillin) |
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***Pediculos pubis (Phthirus pubis)
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-Crabs
-pruritis of mons pubis is MC presentation |
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***Scabies (Sarcoptes scabiei)
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-lesion in webs and sides of fingers and toes
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***Hidradenitis suppurativa
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-chronic ds from blockage and infx of APOCRINE GLANDS OF VULVA, AXILLAE
-tx is surgical "unroofing" for proper drainage |
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***Fox-Fordyce Disease
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-ds of reproductive age
-from blockage and chronic inflammation of sweat glands -NON BACTERIAL |
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***Why do most pts fail to get permanent relief of vaginitis or vulvovaginitis?
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-d/t DIAGNOSTIC ERROR
-also caused by vaginal washing w/ soap, reinfxn, or immunocompromising diseases |
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What does normal physiologic discharge from vagina look like?
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-white, non-homogenous, oderless and pH of 3.5 - 4.2
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What are signs of infx?
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-"Wetness"
-itching and irritation -ODOR (esp. the "fishy" smell in bact vaginosis and sometimes trichomoniasis vaginosis) |
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***What is the leading cause of vulvovaginitis complaints?
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1. bacterial vaginitis
2. vulvovaginal candidiasis |
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***pH paper is important for differentiating between alkalotic and acidic vulvovaginitis. Which are alkalotic and which are acidic?
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1. Alkalotic: Trichomoniasis and Bacterial Vaginosis
2. Acidic: Candidiasis |
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***Bacterial Vaginosis
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-gardnerella or aneorbes
-"fishy" odor (alkalotic) -clue cells -"cup of milk" discharge -Tx: Metronidazole |
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***Trichomoniasis vaginosis
|
-T. vaginalis (STD)
-'Strawberry Cervix" = pathogonomic -frothy, gray green discharge -motile flagellated organisms |
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***TQ: What is the tx for Trichomoniasis Vaginosis?
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Metronidazole
1. 250 mg TID x 7 2. 400 mg BID x 5 3. 2000mg single dose |
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***Candidiasis Vaginosis
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-90% is C. albicans
-RF include Abx -vulvar erythema and "cottage cheese" discharge -hyphae w/ KOH stain, acidic -Tx: Topical "azoles" |
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Atrophic Vaginitis
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-diminished estrogen
-post menopausal -Tx is topical estrogen |
