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Gynie Goodies for the Generalist. Kathleen J. Wilder, MD, MHS Chief, Department of Ob/Gyn Northern Navajo Medical Center Shiprock, NM October 30, 2010. Objectives. Learn to rapidly recognize the top 3 causes of vaginitis and know how to treat

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gynie goodies for the generalist
Gynie Goodies for the Generalist

Kathleen J. Wilder, MD, MHS

Chief, Department of Ob/Gyn

Northern Navajo Medical Center

Shiprock, NM

October 30, 2010

objectives
Objectives
  • Learn to rapidly recognize the top 3 causes of vaginitis and know how to treat
  • Learn a quick and dirty work-up for menorrhagia and who needs it
  • Review the best treatment options for uncomplicated (female) UTIs
  • Make a case for perimenopausal hormone therapy
  • AMA contraception – see why it’s an urgent need and learn the best options
  • Wrap up with late/recent breaking tidbits
vaginitis vulvitis
Vaginitis/Vulvitis
  • Itching, burning, irritation, abnormal discharge, dysuria, postcoital bleeding…
  • Most common:
    • Candidiasis 17-39%
    • Baterialvaginosis 22-50%
    • Trichomoniasis 4-35%
  • Also:
    • Other STIs
    • Atrophic vaginitis
  • Undiagnosed 7-72%

Vaginitis, ACOG practice bulletin #72, May 2006

the itch
The Itch
  • Diagnosis
    • Microscopy – 50% sensitivity
    • So really….the story w/or w/o exam
    • Vagina and/or vulva
    • No vaginal bacterial cultures!
  • Etiology
    • Candida albicans
    • Anything that disturbs the normal vaginal pH balance
      • Douche, sex, late luteal phase…
    • Poorly controlled comorbidities -> DIABETES!!!

Vaginitis, ACOG practice bulletin #72, May 2006

slide5

Standard treatment

    • Antifungal cream PV QHS x 1 wk
    • Apply directly to affected area
  • “Complicated” infection (recurrent, severe, pregnancy, comorbidities, non-albicansCandida)
    • Diflucan 150mg po x 1 +/- antifungal cream
    • Diflucan x 2 - 72hrs apart +/- antifungal cream
      • Tx success increased from 67% to 80%
  • Recurrent
    • Fungal culture to check for non-albicansCandida

Vaginitis, ACOG practice bulletin #72, May 2006

the odor
The Odor
  • BV most common
  • Diagnosis – 2 or 3 of Amsel’s Criteria
    • Homogeneous grayish noninflammatory d/c (note missing LB)
    • Clue cells >20%
    • pH >4.5
    • + Amine test -> Fishy odor w/KOH (frequently appreciated w/o)
  • Could also be other vaginitis – ex. Trich
    • Microscopy 50-60% sensitivity
    • Also pH >4.5
    • Culture and Antigen tests have high sensitivity/specificity
  • Treatment – luckily the same!
    • Metronidazole 500mg po BID x 7 days

Vaginitis, ACOG practice bulletin #72, May 2006

a brief note about the vulva
A brief note about the vulva…
  • Thickening, pebbling, hypopigmentation, hyperpigmentation, thinning of the epithelium, lesions, non-healing lesions…
  • Anything irregular appearing needs biopsied

Diagnosis and management of vulvar skin disorders, ACOG Practice Bulletin #93, May 2008.

my periods are so heavy
My periods are so heavy!
  • Menorrhagia =
    • >80ml/menstrual cycle OR
    • lasts for more than 7 days
  • Menometrorrhagia =
    • frequent menstrual bleeding that is excessive and irregular in amount and duration
  • Anovulatory Bleeding =
    • noncyclic menstrual blood flow that may range from spotty to excessive, is derived from the uterine endometrium, and is due to anovulatory sex steroid production specifically excluding an anatomic lesion
    • menstrual bleeding arising from anovulation or oligo-ovulation

Management of anovulatory bleeding, ACOG practice bulletin #14, March 2000, reaffirmed 2009.

pathophysiology of anovulatory bleeding
Pathophysiology of Anovulatory Bleeding
  • No corpus luteum
  • No progesterone
  • Continued estrogen production

Continuous unopposed estrogen stimulation

Unsustainable endometrial growth

special case becoming the norm
Special Case Becoming the Norm:

Obesity

Androgens → Estrogens

Chronic Anovulation

what s the big deal
What’s the big deal?
  • Endometrial cancer- based on 1995 data
    • 0.1/100,000 15-19yo
    • 9.5 19-35yo
    • 2.3 30-34yo
    • 6.1 35-39yo
    • 36.2 40-49yo

SEER data 1973-1996

slide12

Basic work-up:

    • Pregnancy test, TSH, prolactin, FSH
    • Ultrasound to r/o structural defect
  • Amenorrhea + negative/wnl results

→ Anovulation

  • Better to do the EMB than not do the EMB
but don t stop there
But don’t stop there…
  • Need therapy to
    • Prevent future episodes of acute hemorrhage
    • Prevent non-cyclic bleeding
    • Prevent future complications (i.e. cancer)
    • Improve quality of life
  • Initially HEAVY bleeding
  • May take ~3 cycles
  • Treatment options (depending on age) include:
    • Hormonal contraception - ex. COCs
    • Mirena IUD
    • Surgical intervention – endometrial ablation*, hysterectomy
uti in females
UTI (in females)
  • Diagnosis
    • Pyuria (>10) + bacteriuria
    • Don’t overdiagnose based on leukocyte esterase alone
      • FP due to dirty specimen or other infection such as yeast

Treatment of urinary tract infections in nonpregnant women, ACOG Practice Bulletin #91, March 2008.

uti in females1
UTI (in females)
  • It’s not just me, but a lot of really smart people say 3 days is enough…even if > 65 yo
    • Bactrim – totally great drug if resistance in your area is <15-20% --- 94% eradication rate
    • Fluoroquinolones – effective but not preferred first line tx
    • Amoxicillin/Ampicillin – NOT first line tx
    • 3 days is sufficient!
    • If macrobid (ex. pregnancy)—7 days
  • Resistance >15-20% necessitates change in antibiotic
in order of preference
In order of preference:
  • TMP-sulfa DS 1 tab po BID x 3 days
  • Nitrofurantoin monohydrate macrocrystals 100mg po BID x 7 days
  • Ciprofloxacin 250mg po BID x 3 days
  • Levofloxacin 250mg po daily x 3 days
perimenopausal issues
Perimenopausal Issues
  • Transitional hormone therapy
  • AMA contraception

Pazol K, Gamble, SB, Parker WY, et al. Abortion Surveillance –United States, 2006. In: Surveillance Summaries, November 27, 2009;58(S S08);1-35.

unwanted pregnancies among our ama patients
Unwanted pregnancies among our AMA patients
  • Abortion rate among women aged <15 = 1.2/1000 women
  • Among women >40 = 2.6 per 1,000 women
  • Among women 35-39 = 7.8 per 1,000 women
  • Abortions among women >35yo account for 12.1% of all abortions
    • Slow but persistent increase over study period in women >35yo (up from 10.8%)
  • Abortion ratios highest at extremes of age
perimenopausal hormone management
Perimenopausal Hormone Management
  • Yes, there are some risks to HT
  • But for majority of women – it’s more good than bad!
who when and how
Who, When and How
  • Symptomatic
    • Hot flashes, vaginal dryness, poor sleep, poor moods
    • Menometrorrhagia → OLIGOovulatory bleeding
  • Combined hormonal birth control
  • Weigh pros and cons of risks and benefits
    • Take into account comorbidities
  • A word about botanicals…

Schifren JL, Schiff I. Role of hormone therapy in the management of menopause. Obstet Gynecol 2010;115:839-55. Use of botanicals for management of menopausal symptoms. ACOG practice bulletin #28, June 2001, reaffirmed 2010.

transitional ht
Transitional HT…
  • …Kill two birds with one stone:

Perimenopausal estrogen withdrawal

AND

Prevent unplanned/unwanted pregnancy

  • If and when patient chooses hormone therapy after OCPs:
    • Smallest dose for shorter time
    • When decide to stop, do it slowly
in summary
In Summary…
  • Better to biopsy than be biopsied (via wallet)
    • Vulvar and Endometrial biopsies
  • 3-2-1 Done!!!
  • The examined life is worth living and the unexamined and unmanaged postmenopausal life may NOT be worth living!
  • Help prevent unwanted AMA babies: Plan B + effective perimenopausal BCM
late or recent breaking gyn goodies
Late or Recent Breaking Gyn Goodies:
  • No paps under 21yo
  • Every 2 – 3 years unless contraindicated
    • (HIV, hx CIN 2 or 3, immunocompromised, etc.)
  • New US based medical criteria for contraception
    • www.cdc.gov/mmwr
  • HPV vaccines – quadrivalent and bivalent
    • Approved for males and females 9 – 26 yo
  • Preconceptual mgmt of Diabetics - Folic acid 4mg/day
  • CDC STD treatment guidelines to come…
  • New recommendations for diagnosis of GDM to come…
  • …….