Sexually Related Diseases/Problems in Women

Sexually Related Diseases/Problems in Women: Vaginitis, PID, Unintended Pregnancy
By:Sarah Guerry, MD
Medical Director, LAC STDP
UCLA

Vaginitis:
What is it?
* Clinical syndrome caused by inflammation/infection of the vagina
* Characterized by abnormal vaginal discharge
* Sometimes caused by an STD

Vaginitis: Who Cares?
Vaginitis Etiologies
Differential diagnosis:
* Irritant Dermatitis
* Foreign body
* HSV
* MCP from GC or CT
* Atrophic vaginitis
* UTI
* Desquamative vaginitis

Vaginitis Epidemiology
* Most common reason for doctors visit

Microbiology of the Vagina
Normal Vaginal Physiology
Factors Adversely Affecting Normal Vaginal Flora
* Douching
* Antibiotic and antifungal therapy
* Hormonal changes: pregnancy, OCs
* Spermicides, lubricant
* Foreign bodies: tampons, IUD, diaphragm
* Intercourse, semen
* Menses


Effects of Estrogen Status on Vaginal Microflora
Infection as a Cause of Vulvovaginitis Across the Lifespan
Vaginitis: Clinical Presentation
* Abnormal vaginal discharge
* Vulvar itch
* Odor
* Discomfort
* Burning with urination
* Painful intercourse

Clinical Evaluation of Vaginitis Physical Exam
* Characteristics of vaginal discharge
* Appearance of the vulva
* Appearance of vaginal mucosa
* Appearance of cervix
* Abdominal/bimanual exam

Diagnostic Evaluation of Vaginitis
* Vaginal pH
* Whiff test (amine test)
* Microscopy
* Chlamydia and GC tests

Vaginal pH Measurement
Bacterial Vaginosis A sexually-associated disease
Bacterial Vaginosis
Clinical Presentation of BV
BV: Diagnostic Criteria
BV: Treatment
BV: Complications
BV: Complications in Pregnancy
BV: Screening in Pregnancy
BV: Treatment Criteria
BV: Recurrent Infection
What’s Wrong with Douching?
Vulvovaginal Candidiasis (VVC)
VVC: Risk Factors
VVC: Clinical Manifestations
Yeast Colonization Study
Most Common Misdiagnoses among Women Reported to Have Recurrent VVC
Diagnosis of VVC
VVC: Diagnosis
Uncomplicated VVC: OTC Treatment
Topical Therapies:
Oral Therapy:
Trichomoniasis
Trichomonas: A Pathogen Over Lifetime
Trichomoniasis Clinical Presentation
Trichomoniasis: Diagnosis in Women
Trichomoniasis: Diagnosis in Men
Trichomonas vaginalis
Seattle STD/HIV Prevention Training Center
Trichomoniasis: Treatment
PID Clinical Presentation
Reproductive Anatomy & Spread of Infections
Pelvic Inflammatory Disease (PID):Magnitude of the Problem
PID Diagnostic Considerations
CDC Diagnostic Criteria for PID and much more

Sexually Related Diseases/Problems in Women.ppt

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Vaginitis

Vaginitis
* pathophysiology
* etiology
* diagnosis
* treatment

The dynamic vagina
* vaginal secretions, exfoliated cells, cervical mucosa
* lactobacillus acidophilus
* estrogen
* glycogen
* vaginal pH
* metabolic byproducts of flora and pathogens

Causes of vaginitis
* antibiotics
* contraceptives
* sexual intercourse
* douching
* stress
* hormones
* allergies and chemical irritation

Bacterial vaginosis
* proliferation of Gardnerella vaginalis, Mobiluncus species, Mycoplasma hominis, Peptostreptococcus species
* most common cause
* 1/3 to 2/3 asymptomatic
* 15 to 19% of all women
* 10 to 30% pregnant women

BV misc.
* role of sexual transmission unclear
* risk for preterm labor and PROM
* increased frequency of abnl PAPs, PID, endometritis
* Sxs: profuse malodorous discharge
* Exam: thin grayish discharge, seldom vaginal or vulvar irritation

Risks associated with BV
* Early sexual ‘debut’
* new or multiple sex partners
* IUD (50% contract it over 2y)
* OCP
* Lesbians/receptive oral sex
* no RCT’s but association with douche, c-section and around time of menses

Amsel’s criteria
* thin, homogenous discharge
* positive “whiff” test
* “clue cells” present on microscopy
* vaginal pH > 4.5

BV treatment
* metronidazole 500 mg BID x 7 days
* clindamycin 2% cream qhs x 7 days
* metrogel 0.75% BID x 5 day (vs. QD)
* metronidazole 250 mg TID x 7 days
* metronidazole 2 g po single dose
* metrogel (no previous PTL)

Vulvovaginal Candidiasis
* second most common in U.S.
* Candida albicans predominates
* increasing frequency of non-albicans species (C. glabrata)
* Risks: OCPs, diaphragm, IUD, early intercourse, >4X/month, receptive oral sex, diabetes, recent antibiotics.
* endogenous vaginal flora in 50% women
* not sexually transmitted nor related to number of sexual partners
* treatment of male partner of no benefit
* c/o pruritis, vaginal irritation, dysuria
* vulvovaginal itching not normal in healthy women (lichen sclerosis, vulvar cancer)
* exam: thick white discharge, no odor, normal pH
* vulvar and vaginal erythema

diagnostics
vulvovaginal candidiasis Rx
Trichomoniasis
Evaluation
Trich treatment
Atrophic Vaginitis
Other considerations

Vaginitis.ppt

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VASCULITIS SYNDROMES

VASCULITIS SYNDROMES
By:Emily B. Martin, MD
Rheumatology Board Review

KAWASAKI SYNDROME
Mucocutaneous lymph node syndrome
KAWASAKI DISEASE
* Diagnostic criteria:
CLINICAL MANIFESTIONS
* Arthritis and arthralgia
* Urethritis
* CNS involvement
* GI symptoms

DIFFERENTIAL DIAGNOSIS
* Viral infections
* Toxin mediated illnesses
* Rickettsial or spirochete infections
* Drug reactions
* JRA
* Mercury hypersensitivity reaction

LABORATORY EVALUATION
* Markers of systemic inflammation
* Anemia (normocytic, normochromic)
* Sterile pyuria (urethral origin, don’t do a cath)
* Transaminase elevation (mild to moderate)
* CSF findings
* Synovial fluid inflammation
* Hyponatremia (increased risk for coronary aneurysms)

TREATMENT
* Mainstay of treatment is IVIG 2 gram/kg over 8-12 hours.
* IVIG may need to be repeated in refractory cases.
* Several studies have shown that IVIG + aspirin decreases the risk of coronary aneurysms compared to aspirin alone.
* High dose aspirin during acute illness then low dose for about 2 months.

FOR THE BOARDS…
* Know the clinical manifestations of Kawasaki syndrome.
* Know the differential diagnosis of KD.
* Know the laboratory abnormalities seen in KD.
* Recognize the value of high-dose IVIG in treatment of KD.

QUESTIONS
HENOCH-SCHONLEIN PURPURA

* Most common systemic vasculitis in children.
* Immune mediated
* Often a self-limited disease.
* Occurs more often in fall, winter, and spring.
* About 50% of cases are preceded by URI’s.

CLINICAL PRESENTATION
* Classic tetrad
GI SYMPTOMS
* HSP can cause edema and submucosal hemorrhage of GI tract.
* May be the presenting symptom of HSP.
* Symptoms typically develop within 8 days of the rash.
* Intussusception is the most common GI complication.

RENAL DISEASE
* Occurs in up to 50% of patients.
* Ranges from hematuria to end-stage renal disease (<1% of patients).
* Usually presents within four weeks of onset of HSP.
* Overall prognosis is very good, but there is some long-term risk of progressive renal impairment.

LABORATORY FINDINGS
* There is NO definitive diagnostic test.
* IgA levels may be elevated in 50-70% of patients.
* Platelet counts and coag studies should be normal.
* Inflammatory markers may be elevated.
* Urinalysis
* Negative RF and ANA.
* Recognize the typical presentation of HSP.
* Recognize that HSP may present initially with ABDOMINAL PAIN OR JOINT COMPLAINTS.
* Know the typical laboratory findings in HSP.

MOST likely diagnosis is
* Henoch-Schonlein purpura
* Immune thrombocytopenic purpura
* Juvenile rheumatoid arthritis
* Parvoviral infection
* Post-streptococcal arthritis

VASCULITIS SYNDROMES.ppt

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