Activate Windows

Go to Settings to activate Windows.

GY26 Gynaecology Toronto Notes 2023

Gynaecological Infections

Physiologic Discharge

• clear, white, flocculent, odourless discharge; pH 3.8-4.2

• smear contains epithelial cells, Lactobacilli

• increases with increased estrogen states: pregnancy, OCP, mid-cycle, PCOS, or premenarchal

• if increased in perimenopausal/postmenopausal woman, consider investigation for other effects of

excess estrogen (e.g. endometrial cancer)

Non-Physiologic Discharge

• etiology

genital tract infection

vulvovaginitis:candidiasis, trichomoniasis,BV, polymicrobialsuperficial infection

chlamydia, gonorrhea

pyosalpinx,salpingitis

• genital tract inflammation (non-infectious)

local: chemical irritants, douches,sprays,foreign body, trauma, atrophic vaginitis,desquamative

inflammatory vaginitis, focal vulvitis

neoplasia: vulvar, vaginal, cervical, endometrial

• systemic: toxic shock syndrome,Crohn’

s disease, collagen vascular disease, dermatologic (e.g.

lichen sclerosis)

IUD,OCP (secondary to progesterone)

Vulvovaginitis

PREPUBERTAL VULVOVAGINITIS

• clinical features: irritation, pruritus, discharge, vulvar erythema, vaginal bleeding (can be due to

(iroup A Streptococcus and Shigella )

• etiology

• non-specific vulvovaginitis is responsible for 25-75% of vulvovaginitis in prepubertal girls

• there are a number of potential factors in children that increase the risk of vulvovaginitis:

lack of labial development

non -estrogenized, thin mucosa

more alkaline pH (pH 7) than postmenarchal girls/women

obesity

poor hygiene (proximity of anusto vagina)

foreign bodies (most commonly toilet paper)

irritation by bubble baths,shampoos,perfumed soaps, and chemicals

localized skin disorders:lichen sclerosis,condyloma acuminata

trauma:accidentalstraddle injury,sexual abuse

infectious

Vulvovaginitis

Vulvar and vaginal Inflammation

Vulvar Hygiene

Recommend wipe front to back,

wash vulva only with water, avoid

daily pantyliners. avoid douching, no

need for "feminine cleansers/sprays/

powders",use gentle laundry detergents

for underwear, cotton underwear, no

underwear at night

pinworms

Candida (if using diapers or chronic antibiotics)

Group A Streptococcus, S.aureus,and Shigella

discovery of STI should raise suspicion ofsexual abuse

Prepubertal and Adolescent

Gynaecological Infections:Legal

Aspects of Confidentiality

. Clinicians who treat adolescents

must be aware of federal, state, and

provincial laws related to adolescent

consent and confidentiality

• Clinicians must be aware of

guidelines governing funding sources

for particular services and be familiar

with the consent and confidentiality

policies of the facility In which they

practice

other

polyps,tumour (ovarian malignancy)

psychosomatic vaginal complaints (specific to vaginal discharge)

endocrine abnormalities (specific to vaginal bleeding)

blood dyscrasia (specific to vaginal bleeding)

other systemic diseases: measles, chickenpox,scarlet fever, Hpstein-Barr Virus, Mycoplasma

pneumonia-induced rash and mucositis, Stevens-lohnson syndrome,Crohn'

s disease, and

Kawasaki disease have all been associated with vulvovaginal signs and symptom

• investigations

• vaginal swab for culture (specifically state that it is a pre-pubertal specimen)

pH, wet

-mount, and KOH smear in prepubertal adults only

• treatment

r > enhanced hygiene and local measures (handwashing, white cotton underwear, use sitz baths, use

mild detergent, urinate with legsspread apart, no nylon tights, no tight-fitting clothes, no sleeper

pajamas, avoid bubble baths, eliminate fabric softener, avoid prolonged exposure to wet bathing

suits) to protect vulvarskin

• infectious: treat with antibioticsfor organism identified

Most common gynaecological problem

in prepubertal girls is non-specific

vulvovaginitis,not yeast

(.j

+

Activate Windows

Go to Settings to activate Windows.

GY27 Gynaecology Toronto Notes 2023

Table 14. Other Common Causes of Vulvovaginitis in Prepubertal Girls

Pinworms Lichen Sclerosis Foreign Body

Diagnosis Cellophane tape test Area of white patches and thinning of skin Careful examination with or without

sedation

Irrigation of vagina with saline,may

require local anesthesia or an exam under

anesthesia

(figure of 8)

empirical treatment with

mchendarole [anthelmintic)

treatment Topical steroid creams

INFECTIOUS VULVOVAGINITIS

Table 15. Infectious Vulvovaginitis

Candidiasis Bacterial Vaginosis (BV) Trichomoniasis

Organisms Condida albicans (90%)

Candida glabrala («5%)

Condida Iropicolis (<5%)

Replacement ofvaginal Lactobacillus

with:

Catdnetello vaginalis

Mycoplasmahomims

Anaerobes:Prevotello. Mobiluncus,

Bacletoides

Immunosuppression (DM.AIDS,etc.) High frequency of vaginal intercourse

Recent antibiotic use

Increased estrogen levels (e.g.

pregnancy,OCP)

Whitish,“cottage cheese,

*minimal Grey, thin,diffuse,fishy smelling

Irichomonas vaginalis (flagellated

protoroan)

Risk Factors Sexual transmission

Smoking

Douching

Discharge Yellow-green,malodourous,diffuse,

frothy

2S% asymptomatic

Petcchiae on vagina and cervix

Occasionally irritated,tender vulva

Dysuria.frequency,dyspareunia

% asymptomatic

Signs/Symploms

20% asymptomatic

Intense pruritus

Swollen, inllamed genitals

Vulvar burning,dysuria. dyspareunia

50- 75% asymptomatic

Fishy odour,especially alter coitus

Absence ol vulvar/vaginal iiritation

pH

-4.5

-

4.5 s4.5

KOH vrel mount reveals hyphae and >20% cluecells * squamous epithelial

cells dotted withcoccobacilli

[Cordnerella]

Paucity of W8C

Paucity of Lactobacilli

Positive whilf test:fishy odour with

addition olKOH to slide (due to

formation ol amines)

Ho treatment it non- pregnant and

asymptomatic,unless scheduled for

pelvic surgery or procedure

Saline WetMount Motile flagellated organisms

Many V/8C

Inflammatory cells (PMNs)

Can have positive whiff test

spores

Clotrimaiolc, butoconacole.

miconarole, terconaiole

suppositories,and/or creams for 1,

3,or 7 d treatments

Only vaginal treatment inpregnancy Metronidazole 500 mg P0 BID x 7 d*

Fluconazole150 mgP0 in single dose Oral treatment is best inpregnancy

Vaginal

Metronidazole 0.75% gel x 5 d once

daily

Clindamycin 2% 5gintravaginally at

bedtime lot 7 d

Probiotics {loctobocillus sp.):oral or

topical alone orasadjuvant

Associated with recurrent preterm

labour,preterm birth,and postpartum

endometritis

Routine treatment of partner(s)

not recommended (not sexually

transmitted)

Treat even if asymptomatic

Metronidazole 2 g P0 single dose or

metronidazole 500 mg BID x 7 d

(alternative)

Symptomatic pregnant women should be

treated with metronidazole 2 g once

Treatment

Oral

Other Prophylaxis for recurrent infection

includes boric acid,vaginal

suppositories,luteal phase

fluconazole

Routine treatmentof partner(s)

not recommended (not sexually

transmitted)

Treat partner(s) (sexually transmitted)

* Need to warn patients on metronidazole nottoconseme alcohol (dlsultlram.like action}

+

Activate Windows

Go to Settings to activate Windows.

GY28 Gynaecology Toronto Notes 2023

Sexually Transmitted Infections IS

• see Family Medicine, 1M46

FALLOPIAN TUBE SPECULUM EXAM

CDC Notifiable Diseases

• Chancroid

• Chlamydia

• Gonorrhea

• Hepatitis A, B.C

. HIV

• Syphilis Pelvic inflammatory

disease (PID )

Gonorrhea

Chlamydia

Risk Factorsfor STIs

• History of previous STI

• Contact with infected person

• Sexually active individual <25 yr

• Multiple partners

• New partner in last 3 mo

• Lack of barrier protection use

• Social factors (homelessness, drug

use)

LABIA MAJORA

.ABIAMINURA

leipes

I

« 1 «

Syphilis HPV warts

1.Chancre sore

2.Condylomatalata

richomomasis

(yellow-green frothy

discharge)

(#)

ANUS

Figure 13. Speculum exam

TRICHOMONIASIS

• see Infections Vulvovaginitis, GY27

CHLAMYDIA

Etiology

• Chlamydia trachomatis

Epidemiology

• most common bacterial STI in Canada

• often associated with N.gonorrhoeac ( patients with chlamydia should also he tested for gonorrhea)

Clinical Features

• asymptomatic (80% of women)

• muco-purulent endocervical discharge

• urethralsyndrome:dysuria,frequency, pyuria, no bacteria on culture

• pelvic pain

• postcoital bleeding or intermenstrual bleeding (particularly if on OCP and prior history of good cycle

control)

• symptomatic sexual partner

Investigations

• cervical culture or nucleic acid amplification test (can present in pharynx, rectum)

• obligate intracellular parasite: tissue culture is the definitive standard

• urine and self vaginal tests now available, which are equally or more effective than cervical culture

Treatment

• doxycycline 100 mg PC) BID for 7 d or azithromycin 1 g PC) in a single dose

Doxycycline is contra-indicated in the 2nd and 3rd trimesters of pregnancy

• reportable disease, test and provide empiric treatment to all sexual partners of the index case within

60 d prior to symptom onset or dale of specimen collection (if the index case is asymptomatic)

• test of cure is recommended 3 wk after completion of treatment when compliance to treatment is

suboptimal, an alternative treatment regimen is used, experiencing persistent symptoms,or the

person is prepubertal or pregnant

Screening

• during pregnancy

• asymptomatic sexually active people under 25 yr

• neonates born to mothers with chlamydia

• any other people with risk factorsfor sexually transmitted and blood-borne infections

ft

STI Testing

• Vaginal swab

• Testsfor bacterial vaginosis,

trichomoniasis. Candida

• Cervical swab

• Tests for gonorrhea and chlamydia

gonorrhoeae

Test of cure for

is

C

not

.trachomatis

routinely indicated

and N. +

Repeat testing if symptomatic, if

compliance with treatment is uncertain,

or if pregnant

Activate Windows

Go tc ttings to activate Window

GY29 Gynaecology Toronto Notes 2023

Complications

• PID: low-grade salpingitis and adhesions resulting in tubal obstruction

• infertility

• ectopic pregnancy

• chronic pelvic pain

• Fitz-Hugh-Curtissyndrome (liver capsule inflammation)

• reactive arthritis (male predominance, HLA-B27 associated), conjunctivitis, urethritis

• perinatal infection:conjunctivitis, pneumonia

GONORRHEA

Genital Warts During Pregnancy

• Condyloma tend to get larger in

pregnancy and should be treated

early (consider excision)

• Removal only if obstructing birth

canal or risk of extensive bleeding

• Do not use imiquimod, podophyllin,

or podofilox in pregnancy

• Baby at risk for juvenile respiratory

papillomatosis, but cone dissection

does not significantly reduce the risk

Etiology

• Neisseria gonorrhoea?

• symptoms and risk factors same as chlamydia

Investigations

• Gram stain shows Gram-negative intracellular diplococci

• cervical, rectal, and throat culture (if clinically indicated)

Treatment

• single dose of ceftriaxone 250 mg IM plus azithromycin 1 g PO

if pregnant: above regimen or spectinomycin 2 g IM plus azithromycin 1 g PO (avoid quinolones)

• also treat chlamydia, due to high rate of co-infection

• treat partners

• reportable disease

screening as with chlamydia

Human Rights in Health Equity: Cervical Cancer

and HPV Vaccines

Am JIdA Med 2009.3S 36S 3B 7

While cervical cancer rates have drastically (alien

In developed countries due lo effective prevention

and treatment,socially disadvantaged women

within these countries remain disproportionately

more lively to develop and die olcervical cancer.

• In most develop ng countries cervical cancer rates

have risen or remained unchanged.

• It must be recognized that cervical cancer

disparities between race groups,urban and

rural residence.and high and low socioeconomic

status are attributed to dispaiate screening and

vaccination coverage.

• Programs are implemented withoutsufficient

attention to conditions that lender screening less

effective ov inaccessible to disadvantaged social

groups including:lack ol information, undervaluing

ol prevenbve care, opportunistic delivery In kmlled

healthcare settings,setual health stigma, and

related privacy concerns.

HUMAN PAPILLOMAVIRUS

Etiology

• most common viral ST'

l in Canada

• >200 subtypes, of which >30 are genitalsubtypes

• HPV types 6 and 11 are classically associated with anogenital warts/condylomata acuminata

• HPV types 16 and 18 are the most oncogenic (classically associated with cervical HSIL)

• types 16, 18, 31, 33,35, 36, 45 (and others) associated with increased incidence of cervical and vulvar

intraepithelial hyperplasia and carcinoma

• HPV is readily transmissible between opposite and same-sex partners through receptive and

penetrative vaginal, anal and oral sex, and non-penetrative sex (digital-vaginal sex and skin-toskin contact)

infection with one HPV type does not appear to provide protection against infection with related

HPV types

Clinical Features

• latent infection

no visible lesions, asymptomatic

only detected by DNA hybridization tests

• subclinical infection

visible lesion found during colposcopy or on Pap test

• clinical infection

visible wart

-like lesion without rnngniAcation (check pharynx too)

hyperkeratotic, verrucous or flat, macular lesions

• vulvar edema

A 9 Valent HPV VaccineAgainst Infection and

Intraepithelial Neoplasia in Women

NEJM 2015:372:711-723

Purpose: lodetermine the efficacy and

immunogen city of the qHPV (types 6,11,16.18)

vs.9vHPV (five Jddtonal types 31.33.45.52. 58)

vaccines.

Method itteinalio-alrandonnted. double-blinded

phase 28-3study of 9vHPV va tc me i n 14215 worn eu

between agesol 16-26. Participants were random it ed

lo the 9rHPV vaccmegroup or the qHPIf vaccine group

and each recerr ed a series of three IM inactions(d

1.2 mo. and 6 mo).Swabs ol labial,valvar, perineal,

perianal, endocenrical.and ectocervical tissue was

obtamedend used for HPV DMA testing/Pap smear.

Results:Pate ol high-grade cervical,vulvar, or

va gi nal disease was14.0 per1000 person-yr in both

vaccinegroups.Tbe rate of bigh-grade cervical,

vulvar, or vagnal disease related to HPV-31,33.45.

52. and 58 was 0.1 per 1000 person-yr in the 9vHPV

group and1.6 per1000 person -yr in the qHPV group

(95% CI-80.9-99.81. Antibody responses to HPV-6,11,

16.and 18 were not sign ficantly different between

the two vaccine groups although adverse events

related lo injection vies weie more common n the

9vHPV group.

Conclusions the9iHPV vaccine was non-inferior

to qHPV vaccine in prevent ng infection and disease

related to HPV-6.11.K.and 18and also coveved

additional oncogen c types KPV-31.33.45.52. and 58

in a susceptible popnlabon.

Investigations

• cervical cytology by Pap test

• koilocytosis: nuclear enlargement and atypia with perinuclear halo

• biopsy of lesions at colposcopy

• detection of HPV DNA subtype using nucleic acid probes (not routinely done but can be done in

presence of abnormal Pap test to guide treatment)

Treatment

• anogenital svarts

• patient administered

podofilox 0.5% solution or gel BID x 3 d in a row (

-1 d off ) then repeat x 4 wk

imiquimod (Aldara*) 5% cream Jx/wk nightly x 16 wk

sinecatechins 10% ointment 0.5 cm strand T ID x up to 16 wk, daily dose 250 mg ( need not

be washed off )

+