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OB/gyn Week 4a

OB/gyn Week 4a. Gynecologic Infxns. Normal Vaginal Ecosystem. pH ~ 4.0 Estrogen stimulates glycogen Glycogen metabolized to lactic acid by lactobacillus (healthy vaginal flora) Many aerobic, anaerobic, and fungal organisms present Normal vaginal secretions (vary with cycle)

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OB/gyn Week 4a

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  1. OB/gyn Week 4a Gynecologic Infxns

  2. Normal Vaginal Ecosystem • pH ~ 4.0 • Estrogen stimulates glycogen • Glycogen metabolized to lactic acid by lactobacillus (healthy vaginal flora) • Many aerobic, anaerobic, and fungal organisms present • Normal vaginal secretions (vary with cycle) • White, floccular, odorless • Present in fornix, not usually on vaginal walls

  3. Vulvovaginitis • Vaginal discharge is the most common symptom in gynecology • Three common infectious causes • Bacterial Vaginosis (BV) • Trichomonas vaginalis • Candida albicans • Common non-infectious causes • Atrophic vaginitis • Desquamative inflammatory vaginitis

  4. Vulvovaginitis • Bacterial Vaginosis (BV) • Most common vaginal infection • Associated with PID, endometritis, premature rupture of membranes during labor, post-op infections of upper genital tract • Can occur with or without sexual activity (treat partner if infection is recurrent or stubborn) • Trichomonas • Not associated with upper tract infections • May be a vector for other bacterial or viral diseases • Sexually transmitted • Candida • Not strictly considered an STI • Not associated with upper tract infections • Symptoms may be hypersensitivity related

  5. Vulvovaginitis • Less common causes of vulvovaginitis • Cytolytic Vaginosis (CV) • Not an STI • Not associated with upper tract disease • Cells lyse, which is painful. • Lactobacillosis (LB) • Same as above • Cells don’t lyse.

  6. Evaluation of Vaginal Discharge • History – Problem focused • HPI, PMHx, PFSHx, ROS, use of irritants or allergens • PE • vulvar inspection, speculum exam, bimanual exam • Lab/Diagnostic testing • pH • Wet mount • Cultures if appropriate • PAP if appropriate • Serology and other blood tests as appropriate

  7. Desquamative Inflammatory Vaginitis • Cause unknown - may be autoimmune • Sx’s – purulent discharge, burning, dyspareunia • Vagina and vulva erythematous • pH > 4.5 • Absence of lactobacilli

  8. Atrophic Vaginitis • Common in peri, post-menopausal women • Result of decreased estrogen activity • Less glycogen, less lactic acid, pH rises • Sx’s – vaginal pruritus, burning, spotting • Discharge minimal • Vaginal walls thin, lack rugae • pH >5 • Wet mount – decreased lactobacillus, parabasal cells, WBC’s

  9. Cytolytic Vaginosis & Lactobacillosis • Cause unknown • Sx’s – from thin/watery to thick/curdy discharge, burning, dyspareunia • pH 3.5-4.5 (Lower than normal pH ) • Overgrowth of lactobacilli • In CV, cytolysis of vaginal epithelial cells

  10. TREATMENT OF VULVOVAGINITIS • Bacterial Vaginosis • Conventional • Metronidazole (oral and/or topical) • Clindamycin (oral and/or topical)

  11. Bacterial Vaginosis • Naturopathic treatment • Strategies • Lower pH • Promote immune response • Restore flora balance • Reduce inflammation • Provide anti-microbial activity

  12. SAMPLE TREATMENT REGIMEN FOR BV • Nutrition • Avoid refined CHO (carbos) • Live culture yogurt • Vitamin A and/or E vaginal suppositories • Lactobacillus – 1 capsule vaginally X 7 days • Boric acid – 600 mg vaginal suppository – 1 daily X 7 days

  13. TRICHOMONAS • Conventional treatment • Metronidazole • Treatment of partner may be indicated

  14. TRICHOMONAS • Naturopathic treatment • Strategies – same as BV • Sample treatment regimen for trichomonas • Immune and anti-inflammatory support as indicated • Melaleuca oil (tea tree) suppositories 1 vaginally X 7-10 days – this is 40% tea tree oil • Lactobacillus vaginal suppositories

  15. CANDIDA VULVOVAGINITIS • Conventional treatment • Topical imidazoles or triazoles – creams or suppositories 1, 3, or 7 days OR • Nystatin 100,000 unit vaginal tablet X 14 days OR • Fluconazole oral 150 mg single dose

  16. CANDIDA VULVOVAGINITIS • Naturopathic treatment • Same as BV except no pH lowering • Sample treatment regimen for candida • Nutrition • Avoid refined CHO • Live culture yogurt • Immune and anti-inflammatory treatments as indicated • Boric acid suppositories 600 mg vaginally qD X 3-7 days • Lactobacillus suppositories 1 vaginally qD X 3-7 days • Vitamin A and E vaginal suppositories

  17. Treatment for CV (Cytolytic Vaginosis ) • Conventional • Increase vaginal pH • Douche or sitz bath in Na bicarbonate • 1 tsp. In 1 pint H2O 1-2 X week OR • 2-4 TBSP in 2 inches warm bath water 15 min. 2-3 X week • Discontinue tampon use for at least 6 months • Naturopathic • Same as above • (don’t use probiotics to treat these!)

  18. Treatment for Desquamative Vaginitis • Conventional • Intravaginal corticosteroids OR • 2% clindamycin cream – anti-inflammatory • Recurrence rate 30% - treat again if necessary • Naturopathic • Strategies –soothe tissue and restore flora • Calendula herbal douche or suppositories daily X 7 days • Saline douche? • Probiotic suppositiories X 7 days

  19. ATROPHIC VAGINITIS • Conventional treatment • Topical estrogen cream (vaginally) OR • Oral estrogen OR • Transdermal estrogen OR • Vaginal lubricants PRN - Replens

  20. Atrophic Vaginitis • Treatment Strategies • Support endogenous estrogen activity • Supply exogenous estrogen • Provide anti-inflammatory support • Sample treatment regimen • Soy and other phytoestrogens in diet • Vitamin E suppositories 400 iu vaginally 1 X week • Oral phytoestrogens as indicated • DHEA may help treat vaginal atrophy • Stimulate vaginal epithelium but not uternine endometrium • Increased bone density [From Natural Medicines Comprehensive Database]

  21. Vaginitis:General Preventative Measures • Avoid sexual activity during treatment • Wear loose fitting clothing • Wear cotton underwear • Do not douche routinely • Wash/bathe with gentle, non-irritating soaps • Barrier contraceptive techniques may reduce recurrence and transmission (partner to partner) • Eat a whole foods diet

  22. CERVICITIS • Cervix is made up of two epithelial cell types • Squamous and columnar • Squamous epithelium is the ectocervix • BV, trich, candida, HSV, HPV can infect • Columnar epithelium is the endocervix • between them is transitional zone • Mucopurulent cervicitis (MPC) is an infection of the columnar epithelium of the cervix • Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) are primary infectious agents

  23. Diagnosis of MPC • Symptoms • Vaginal discharge • Dyspareunia (pain with sex) • Postcoital bleeding • Spotting UP TO 60% OF WOMEN WITH CT or GC ARE ASYMPTOMATIC • Signs • Hypertrophy and/or edema of cervix • Mucopurulent, yellow discharge from cervix • Diagnosis confirmed by gram stain of discharge • Organism ID’d by culture or PCR test of endocervical or urine sample

  24. Treatment of MPC • Conventional treatment is antibiotics (CDC has current recommendations) • Naturopathic treatment • Conventional antibiotic AND • Immune support • Oral probiotic support • COMPLICATIONS OF UNTREATED CT/GC INCLUDE PID, SALPINGITIS, INFERTILITY

  25. KEY CONCEPTS • Appropriate Hx critical to providing diagnostic information • Vulvovaginitis • BV, Trich, Candida, CV, LB, DIV, atrophic vaginitis • Diagnosed with characteristics of discharge, pH, wet mount • Naturopathic treatments effective • Cervicitis • CT, GC main causes • Often asymptomatic, or mucopurulent discharge • Dx by culture or PCR of endocervical sample • Antibiotics with adjunct support is optimum tx approach • Ineffective treatment can result in PID, infertility

  26. Infestations: Crab Lice • Pediculosis Pubis: crab louse (Phthirus pubis) infestation • Different species than head or body louse • Transmitted by close (usually sexual) contact, MAY also be via infected towels, or bedding • Most contagious of all STDs • Eggs deposited on base of pubic hair

  27. Pubic Lice • Symptoms: • Itching in pubic area • Allergic sensitization develops over at least 5 days to weeks • Definitive diagnosis via microscopic visualization of louse

  28. Pubic Lice Crab louse:

  29. Infestations: Scabies Scabies: parasitic infection of itch mite (Saroptes scabiei) Transmitted by close contact and infected bedding/ clothes Widespread over body (no predilection for hairy areas as lice) Travels rapidly over skin, but able to survive only a few hours away from warmth of skin Predilection for warm, moist areas (folds of skin or under elastic bands) Not exclusively a gynecological infection

  30. Scabies • Symptoms • Severe, intermittent itching • Onset of itching may be up to 3 weeks after infection • Red, thin, burrow under skin surface • May imitate any other itchy dermatological condition

  31. Scabies

  32. Infestations: Treatment Conventional • Pediculosis pubis: Permethrin 1% cream rinse applied to pubic area, rinsed off after 10 minutes • Scabies: Permethrin 5% cream applied all over body (except face) overnight (8-14 hours), then washed off *Permethrin is neurotoxic and carcinogenic Natural treatments take more time and care to achieve results - wash all bedding/clothes/etc, apply mix of tea tree oil and olive oil to area

  33. Viral infections: Molluscum Contagiosum • Molluscum Contagiosum • In children may appear all over body • In adults it is an asymptomatic viral disease of primarily the vulvar skin • Appear as small nodules or domed papules, have “umbilicated center” • Caused by poxvirus • Mildly contagious; spread via sexual and nonsexual contact and auto-inocculation

  34. Molluscum Contagiosum

  35. Molluscum Contagiosum • Molluscum contagiosum treatment: • Cryosurgery • Electrocautery • Excision • Trichloroacetic acid or Ferric subsulfate or iodine

  36. Viral Infections:Genital Warts • Condyloma acuminatum: genital warts • HPV • Clinically recognizable, macroscopic lesion in only 30% of cases • Prevalence as high as 50% in sexually active teenagers with multiple partners • Several morphologic types • May occur singularly or in clusters • Usually asymptomatic but may cause pain, itching, tendency to bleed depending on size and location

  37. Genital Warts

  38. Genital Warts • Treatment of external genital warts • Cryosurgery • Surgical excision • Laser surgery • Chemical applications • Podofilox 0.5% solution • Podophyllin resin 10%-25% • Imiquimod 5% cream • Natural therapies • Immune support • Topical thuja oil

  39. Viral Infections: HSV • Genital herpes • Herpes simplex virus HSV I (classically oral) and HSV II (classically genital) • Recurrent, incurable epidemic disease • 60 million individuals in US infected • 80% unaware • Asymptomatic transmission • Not physically debilitating but overwhelming psychologic burden

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