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4/20/2015
“EVERYTHING I WANTED TO KNOW
ABOUT GYNECOLOGY….BUT
WAS AFRAID TO ASK!”
T. Watson Jernigan, MD MA
Associate Dean of Clinical Affairs
Quillen COM/ETSU
“The good physician treats the disease; the great physician treats the patient who has the disease”….Sir William Osler
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Disclosure Statement of Financial Interest
• I, T. Watson Jernigan, DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation. Disclosure Statement of Unapproved/Investigative Use
I, T. Watson Jernigan, DO anticipate discussing the unapproved/investigative use of a commercial product/device during this activity or presentation.
OBJECTIVES
• 1.) To appreciate the common causes of Vulvovaginitis and the specific treatment for each
• 2.) To understand the etiology and treatment for Abnormal Uterine Bleeding (AUB)
• 3.) To Up‐to‐Date practices regarding contraception and contraceptive modalities
• 4.) To understand the latest information regarding estrogen deprivation symptoms and current thinking regarding treatment
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INTENT OF LECTURE
• The intent of this lecture is to give you, the participant in this review, a generalized view of my world
• My hope is that I will give you a few answers for your upcoming test AND possibly inform you of what is happening in my world
• At the end of our hour together, I wish that you have a greater appreciation for some of the finer points of my chosen profession
OUTLINE OF LECTURE
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VULVOVAGINITIS
ABNORMAL UTERINE BLEEDING (AUB)
MENOPAUSE
CONTRACEPTION
GUIDELINES FOR PAP SMEARS
GUIDELINES FOR PRE‐CONCEPTION COUNSELING
VULVOVAGINITIS
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BACTERIAL VAGINOSIS
• ETIOLOGY: vaginal inflammation resulting from overgrowth of normal bacteria in vagina
• PRESENTATION: “fishy odor” which may increase after intercourse; dysuria; thin, white/grayish vaginal discharge
• WET‐MOUNT: clue cells; increased WBCs; decreased lactobacilli
• TREATMENT: Metronidazole/Clindamycin
BACTERIAL VAGINOSIS
• RISK FACTORS: natural lack of Lactobacilli bacteria; douching; multiple sexual partners
• VAGINAL pH: >4.5
• RECURRENCE: COMMON (especially within 3 to 12 months)
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TRICHOMONAS VAGINALIS
• ETIOLOGY: Anaerobic, flagellated Protozoan
• PRESENTATION: frothy, greenish vaginal discharge; dysuria; dyspareunia; vulvar pruritus; “musty” malodorous smell
• WET‐MOUNT: normal epithelial cells; increased WBCs; trichomonads
• TREATMENT: Metronidazole/Tinidazole
TRICHOMONAS VAGINALIS
• RISK FACTORS: multiple sexual partners
• VAGINAL pH: >4.5
• APPEARANCE: “strawberry cervix” which is capillary dilation as a result of the inflammatory response
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CANDIDIASIS
• ETIOLOGY: Yeast/fungus generally Candida albicans
• PRESENTATION: vulvar and vaginal pruritus; thick, white, curdy discharge; “cottage cheese‐
like”; absent KOH “whiff test”
• WET MOUNT: hyphae and buds [seen best when slide has KOH added]
• TREATMENT: oral fluconazole/intravaginal imidazoles
CANDIDIASIS
• RISK FACTORS: antibiotic use; oral contraceptive use; dietary items
• VAGINAL pH: Normal (4.0‐4.5)
• RECURRENCE: COMMON especially in patients on long term antibiotics; difficult to treat in some patients (long intermittent RX)
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ATROPHIC VAGINITIS
• ETIOLOGY: loss of estrogen in menopausal patients with loss of cellular glycogen with resulting loss of lactic acid
• PRESENTATION: vaginal irritation with clear discharge; sensation of persistent burning • WET MOUNT: findings of parabasal cells OR lack of cellular debris of any type
• TREATMENT: topical vaginal estrogen
ATROPHIC VAGINITIS
• RISK FACTORS: loss of estrogen by any means‐
aging; chemotherapy [breast cancer]; surgical menopause
• VAGINAL pH: >4.5 (generally elevated 4.7)
• SPECIAL ISSUES: patient may have signs and symptoms of acute U.T.I. with atrophic vaginitis; may be best to treat with estrogen than antibiotics
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ABNORMAL UTERINE BLEEDING
ABNORMAL UTERINE BLEEDING
• Polymenorrhea: frequent menstrual bleeding which means less than 21 days Day 1 to Day 1
• Menorrhagia: prolonged or excessive uterine bleeding that occurs at regular intervals (the loss of 80 mls or more of blood that lasts from more than 7 days)
• Metrorrhagia: irregular menstrual bleeding or bleeding between periods
• Menometrorrhagia: frequent menstrual bleeding that is excessive and irregular in amount and duration
ABNORMAL UTERINE BLEEDING
• Abnormal uterine bleeding is the new classification of bleeding by a patient which is considered abnormal
• This term replaces such terms as menorrhagia; menometrorrhagia; metrorrhagia
• There are two types of AUB:
– Heavy Menstrual Bleeding (AUB/HMB)
– Intermenstrual Bleeding (AUB/IMB)
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PALM‐COEIN
PALM: STRUCTURAL CAUSES
• POLYP (AUB‐P)
• ADENOMYOSIS (AUB‐A)
• LEIOMYOMA (AUB‐L)
• MALIGNANCY AND HYPERPLASIA (AUB‐M)
COEIN: NONSTRUCTURAL CAUSES
• COAGULOPATHY (AUB‐C)
• OVULATORY DYSFUNCTION (AUB‐O)
• ENDOMETRIAL (AUB‐E)
• IATROGENIC (AUB‐I)
• NOT YET CLASSIFIED (AUB‐N)
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ABNORMAL UTERINE BLEEDING
• Treatment of AUB should be to ensure regular shedding of the endometrium and consequent regulation of uterine bleeding
• Only after determination of the etiology of the AUB should treatment be considered
• Therapy will vary depending upon the outcome of the workup
MENOPAUSE
MENOPAUSE
• Baby Boomers (1946‐1964) are “coming of age” at this time
• 6,000 Baby Boomer women reach Menopause Ag (51) each and every day
• By 2020, the number of women who will be older than 55 is estimated to be 46 million
• Given a life expectancy of 83, US women live nearly 40% of their lives without estrogen
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What is menopause?
• Menopause is a normal, natural event, defined as the final menstrual period (FMP), confirmed after 1 year of no menstrual bleeding
• Represents the permanent cessation of menses resulting from loss of ovarian follicular function, usually due to aging
When is menopause?
• Naturally (spontaneously) average age 51
• Prematurely from medical intervention (eg, bilateral oophorectomy, chemotherapy, radiation)
• At any time from impaired ovarian function
Manson JE In: Harrison’s Principles of Int Med, 17th ed. NY: McGraw‐Hill, 2008:2334‐9 Menopausal symptoms & signs
Classic symptoms:
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Change in menstrual cycle pattern (during perimenopause)
Vasomotor symptoms (hot flashes & night sweats)
Vulvovaginal symptoms, dyspareunia
Sleep disturbances
Other symptoms sometimes associated with menopause:
• Cognitive concerns (memory, concentration)
• Psychological symptoms (depression, anxiety, moodiness)
Avis et al Am J Med 2005;118 Suppl 12B:37‐46; NIH Ann Intern Med 2005;142:1003‐
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Weight gain
• Many women gain an average of 5 lb (2.27 kg) at midlife related mostly to aging and lifestyle, not menopause or hormone therapy (HT)
• However, menopause may be related to changes in body composition and fat distribution
Brown WJ Obes Res 2005;13:1431‐41; Milewicz A Climacteric 2004;4:273‐83; Crawford SI Menopause 2000;7:96‐104 12
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Serum hormone levels at menopause
Circulating estrogens
Ratio of estrogen to androgen
Sex hormone‐binding globulin secretion
Peripheral aromatization of DHEA to estrone Reversal of estradiol (E2) to estrone (E1) ratio
No significant change in testosterone levels
POST‐WHI MENOPAUSE
• After the 2002 WHI study was published approximately 65% of women on HT stopped therapy
• In 2003, there were just over 76 million HT prescriptions dispensed
• By 2008, this number had dropped to approximately 42 million prescriptions for HT in USA (29 million were for estrogen only RXs)
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A FINAL THOUGHT
• RELATIVE RISK
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CHARACTERISTIC
14 2 FAMILY MEMBERS WITH BREAST CA
2.2
1 FAMILY MEMBER WITH BREAST CA
1.8 OBESITY
1.6 YOUNG AGE AT MENARCHE
1.3 >30 AT BIRTH OF FIRST CHILD
0.7
MENOPAUSE <49 YEARS OF AGE
– 1.3 HORMONE THERAPY (E+P)<5 YEARS
Archer, David. “Postmenopausal HRT: What is fact, what is fiction” OBG MANAGEMENT; June 2009: 76‐85.
CONTRACEPTION
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PREGNANCY‐RELATED OR METHOD‐RELATED
DEATHS PER 100,000 FERTILE WOMEN
• METHOD
PREGNANCY
ABORTION
IUD
BCPs
BARRIER METHOD
IMPLANTS
TUBAL LIGATION
VASECTOMY
15‐24
5.1
2.0
0.2
1.1
1.0
0.4
1.2
0.1
25‐34
5.5
1.8
0.2
1.5
1.3
0.6
1.1
0.1
35‐44
13.4
13.4
0.4
1.4
2.0
0.5
1.2
0.1
CONTRACEPTION
• 50% of all pregnancies and 30% of all live births are either unplanned, mistimed or unwanted
• Of the 50% unintended pregnancies, ½ of those women were using some form of contraception at the time of conception
• Unplanned pregnancies are associated with lack of prenatal care; low birth weight; increased incidence of alcohol and smoking use in pregnancy
CONTRACEPTION
• Top‐Tier/First‐Tier Methods
– Most effective and easiest to use
– Minimal user motivation or intervention
– Unintended rate < 2/100 users in first year of use
– Longest duration of contraception after initiation
– Require fewest number of return visits
– Examples: Intrauterine Devices (IUDs); Contraceptive Implants
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CONTRACEPTION
• Intrauterine Devices (IUDs) more prevalent today especially with progestin containing IUD
• Use in 2002 was 2% while in 2008 it was 10%
• Two types of IUDs are available today: (1) Levonorgestrel containing and (2) Copper containing
• Indications for wider age group; nulliparity; vaginal bleeding has increased use
CONTRACEPTION
• Levonorgestrel containing IUDs are marketed as Mirena and Skyla
• Daily dosing of 20 mgs qd of Levonorgestrel
• Mirena is placed into endometrial cavity and is good for 5 years*
• Skyla is good for 3 years with its smaller size being used mainly in adolescents
CONTRACEPTION
• Mechanism of Action for IUDs:
– Render the endometrium atrophic
– Stimulates thick cervical mucus that blocks sperm penetration into the uterus
– Decreases tubal motility that thereby prevents an ovum and sperm union
– Inhibits ovulation [due to amount of progestin released some believe there is a systemic effect of the Mirena as opposed to just a local one
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CONTRACEPTION
• Copper Containing IUDs are marketed as ParaGard IUD [Copper T‐380A IUD]
• Contains 380mm2 of Copper
• Effective for 10 years
• Mechanism of Action:
– Intense local inflammatory response leads to lysosomal activation & other inflammatory actions that are spermicidal
– Endometrium becomes hostile for implantation
CONTRACEPTION
• IUD MYTHS
– Modern IUDs do not increase risk for Pelvic Inflammatory Disease or Infection
– Available for use in adolescents and in Perimenopausal patients as well as nulliparous females
– Can be used in Postpartum Patients and Patients who have abortions
– IUDs may be used in HIV+ patients
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CONTRACEPTION
• Contraceptive Implants contain Progestin in the form of Etonogestrel
• Historical Nomenclature: Norplant; Implanon; and Nexplanon
• Nexplanon contains 68 mgs of Etonogestrel and is good for 3 years
• Nexplanon is implanted in the subq tissue on the inner aspect of the upper arm
CONTRACEPTION
• Contraceptive Implants Mechanism of Action
– Progestin released continuously causes ovulation suppression – Increased cervical mucous viscosity decreasing the sperm penetration through the cervical canal
– Continuous Progestin release causes endometrial tissue to become atrophic and hostile to implantation
CONTRACEPTION
• Second‐Tier Methods
– Expected failure rate is 3‐9/100 users in the first year of use
– Examples are Oral tablets; Transdermal patches; Transvaginal Rings; IM injections of Progestin
– Failure rate is related to failure to redose at the appropriate interval (daily; weekly; q3 weeks; q3 months)
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CONTRACEPTION
• Evaluation prior to use of oral bcps
– Complete history including evaluation for:
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Migraine headache
Personal history of breast cancer, DVT/PE
History of Tobacco use especially smoking
Cardiovascular Risk
Family history of Sudden death
Family history of thrombophilia/blood dyscrasias
CONTRAINDICATIONS TO THE USE OF ORAL BIRTH CONTROL PILLS
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PREGNANCY
UNCONTROLLED HYPERTENSION
SMOKERS OLDER THAN 35 YEARS OF AGE
DIABETES WITH VASCULAR INVOLVEMENT
THROMBOGENIC HEART ARRHYTHMIAS
MIGRAINES WITH ASSOC. FOCAL NEUROLOGICAL DEFICITS
UNDIAGNOSED ABNORMAL GENITAL BLEEDING
KNOWN OR SUSPECTED BREAST CARCINOMA
HISTORY OF DVT OR THROMBTIC DISORDERS
ACTIVE LIVER DISEASE INCLUDING HEPATITIS OR CIRRHOSIS
CONTRACEPTION
• Third‐Tier Methods
– Expected failure rate is 10‐20/100 users in the first year of use
– Barrier methods for Men & Women
– For men this would be use of condoms
– For women this would be use of Diaphragm with Spermicide; Cervical Cap with Spermicide; Female Condom; Fertility Awareness‐Based (Rhythm)
– More effective rates with experience
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CONTRACEPTION
• Fourth‐Tier Methods
– Expected failure rate is 21‐30/100 users in the first year of use
– Examples would be Spermicides (used alone) and the Female Sponge
– These are available over the counter
– Active Ingredient in these methods is Nonoxynol‐9 or Octoxynol‐9
CERVICAL SURVEILLANCE
PAP SMEARS
SCREENING METHODS FOR CERVICAL CANCER
• POPULATION
– UNDER 21
– 21 TO 29
– 30‐65
– 30‐65 (*)
– >65
– S/P TOTAL HYST
– VACCINATED
SCREENING METHOD
NO SCREENING
CYTOLOGY ALONE Q3 YRS
CYTOLOGY ALONE Q3 YRS
CYTOLOGY/HPV Q5 YEARS
NO SCREENING NECESSARY
NO SCREENING NEEDED#
FOLLOW AGE‐SPECIFIC 20
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PRE‐CONCEPTION
COUNSELING
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PRE‐CONCEPTION COUNSELING
• Medication Classification in Pregnancy
– Class A: Controlled studies show no risk
– Class B: No evidence of risk in humans or Negative human studies or no human but Negative animal studies
– Class C: Risk cannot be ruled out; no human studies; animal studies positive or lacking
– Class D: Positive Evidence of Risk
– Class X: Contraindicated in Pregnancy
PRE‐CONCEPTION COUNSELING
• Some common medications:
– Isotretinoin for acne: X
– Warfarin: X
– Statin: X
– Bisphosphonates: C
– Fluroquinolones: C
– Valproic acid: D
– ACE inhibitors and ARBS: C (first trimester) and D (second and third trimesters)
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“Example is leadership….I don’t know
what your destiny will be but one
thing I know. The only ones among you who will be really happy are those who have sought and found how to serve.”
….ALBERT SCHWEITZER
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