Week # 14

Brief description of the following Gynecological concerns and genitourinary male/female tract dysfunction where their management is described.

Please make sure to provide citations and references (in APA, 7th ed. format) for your work.

Management of Gynecologic Concerns

MSN5600

Amenorrhea

Absence or abnormal cessation of menstrual bleeding

Primary amenorrhea

The absence of both spontaneous uterine bleeding and secondary sexual characteristics (delayed puberty) at the age of 14 years

Or, by 2 years after sexual maturation or the absence of menarche at the age of 16 years regardless of the presence of secondary sexual characteristics

Secondary amenorrhea

The absence of menstrual bleeding in a woman with prior menstruation (e.g., pregnancy, endurance sports, anorexia )

Amenorrhea (Cont.)

Physiologic amenorrhea

Results from:

Constitutional delay

Pregnancy

Lactation

Menopause

Additional mechanisms for amenorrhea

Generally involve:

Disorders of the sex chromosomes

Hypothalamic-pituitary-ovarian axis and hormone-related causes

Amenorrhea (Cont.)

Clinical Presentation

Obtain a thorough menstrual history

A complete sexual history

Age at menarche and menopause for family members and any family history of infertility PMHx

Medication Hx

Nutritional Hx

Exercise Hx

ROS + Soc Hx

P.E.

General growth and development assessment

Thorough P.E. focusing on

Visual acuity

Thyroid assessment

Pelvic exam

Amenorrhea (Cont.)

Diagnostics

R/O pregnancy

Labs

FSH, LH, and TSH

Prolactin

MRI

CT scan

CMP, serum electrolytes, urinary free cortisol, thyroid antibodies, ESR, HbA1c

Differential Diagnoses

Turner’s syndrome (45, X) mosaicism

Abnormal X chromosomes

Chromosomal deletions

Structural abnormalities

Malnutrition

Systemic illness

Tumors

Early menopause

Pregnancy

Primary ovarian insufficiency

PCOS

Medication-related amenorrhea

Amenorrhea (Cont.)

Management

Psychiatric counseling (when indicated)

Medication

Challenge – medroxyprogesterone

Restoration of the hypothalamic-pituitary-adrenal and the hypothalamic-pituitary-thyroidal axes

Anorexia-related D/O

Increased nutritional intake

Reduced exercise

Therapies – pulsatile GnRH, recombinant human leptin

Bartholin’s Gland Cysts and Abscesses

Bartholin’s gland cysts

Usually, non-infectious cyst enlargements related to ductal obstruction

Causes

Inflammation

Mucus

Congenitally narrower ducts

Bartholin’s gland abscesses/bartholinitis/Bartholin’s adenitis

Causes:

Acute infection followed by obstruction

Bartholin’s Gland Cysts and Abscesses (Cont.)

Result of

Trauma

Parturition

Episiotomy

Inflammatory scarring, epithelial metaplasia, or inspissated secretions

Infection due to inflammation of the gland’s acinus (abscess)

Clinical Presentation

Often asymptomatic or painful (sign of abscess) or tenderness on walking, dyspareunia

Chronic or recurrent

Generally unilateral

Range in size from 1 to 3 cm (0.4 to 1.2 inches)

Bartholin’s Gland Cysts and Abscesses (Cont.)

P.E.

Obtain vital signs

Inspect the affected area

Assess accompanying inguinal node involvement

Speculum or bimanual examination may be too painful until the cyst or abscess has been treated

Diagnostics

Culture of cystic contents and the cervix for STIs

CBC

Bartholin’s Gland Cysts and Abscesses (Cont.)

Differential Diagnoses

Solid benign tumors

Adenocarcinomas

High-grade squamous intraepithelial neoplasias

Carcinomas

Sarcomas

Mixed tumors

Leiomyomas

Adenofibromas

Mucinous cystadenomas

Myxoid leiomyosarcoma

Papillary tumors

Primary neuroendocrine carcinoma

Management

Empirical antibiotic treatment targeting both aerobic and anaerobic organisms

Surgical Tx

Incision and drainage

Excision of the Bartholin’s gland

Breast Disorders

The evaluation of breast complaints is common − complaints include

Breast pain, breast masses, and nipple discharge

Evaluation should include risk factors for breast disease

Risk Groups

Family Hx/Genetic, reproductive/hormonal, proliferative benign breast disease, and mammographic density

Screening

Genetic

Clinical breast exam

Mammography

MRI

Breast Disorders (Cont.)

Risk Reduction

Prophylactic mastectomy

Chemoprevention

Types:

Mastalgia, Mastodynia

Nipple Discharge, Galactorrhea

Paget’s Disease of the Nipple

Breast Masses

Cysts, fibroadenoma, fibrocystic changes

Breast cancer (breast masses)

Gynecomastia

Breast Disorders (Cont.)

Management

Based on the underlying condition

May involve:

Pharmacotherapy

Lifestyle (e.g., dietary changes)

Surgical intervention

Ongoing surveillance as indicated

Chronic Pelvic Pain

A continuous or episodic, non-menstrual pain of at least 6 months’ duration affecting both men and women

May be sudden or gradual in onset

Occurs at or below the umbilicus

Severe enough to interrupt normal activities of daily life

May involve gastroenterologic, urologic, gynecologic, oncologic, musculoskeletal, and psychosocial systems

The cause is often multifactorial, making it challenging for patients and providers

In up to 60% of patients, the cause is unknown

Chronic Pelvic Pain
(Cont.)

Subset of the population who are at increased risk for CPP are patients with Hx of

Physical and Sexual Abuse

Pelvic Inflammatory Disease

Endometriosis

Interstitial Cystitis

Irritable Bowel Syndrome

Musculoskeletal D/O

Post-Surgical Pain

Chronic Pelvic Pain
(Cont.)

Clinical Presentation

May require multiple visits before the chief presentation is defined

Obtain a thorough med/surg Hx with the PQRST of pain

Assess the relationship of the pain to each organ system

Identify associated events, including complaints of fever, sweats, fatigue, anorexia, nausea, vomiting, and constipation

P.E.

Perform a detailed abdominal, pelvic, and back exam

Chronic Pelvic Pain
(Cont.)

Diagnostics

Evaluation should include vaginal and cervical cultures, urinalysis, urine culture, complete blood count (CBC), pregnancy test, and erythrocyte sedimentation rate (ESR)

A transvaginal/renal ultrasound and/or laparoscopy, CT scan, or MRI may be indicated

Differential Diagnoses

Musculoskeletal

Gastrointestinal

Urologic

Gynecologic

Psychologic

Chronic Pelvic Pain (Cont.)

Management

Supportive Care – counseling

Pharmacologic – NSAIDs, tricyclic antidepressants, anticonvulsants

Interventional – neurostimulation, laparoscopy

Complementary and Alternative Medicine

Dysmenorrhea

Painful menstruation

Very common condition

Types

Primary

Painful menses despite normal pelvic anatomy and ovulation occurring within 6 to 12 months after menarche, when ovulatory cycles are established

Secondary

Usually appears later in life, following painless menses associated with endometriosis, uterine fibroids, adenomyosis, PID infertility problems, ovarian cysts, polyps, intrauterine adhesions, cervical stenosis, other pelvic pathologic conditions, or IUD use

Dysmenorrhea (Cont.)

Causes

Excess or imbalance of prostaglandins, vasopressin, and chemical substances originating from phospholipids

Resulting in uterine contractions, cramping, nausea, vomiting, and diarrhea

Risk factors

Adolescence

Anxiety

Depression

Stress

BMI less than 20 or greater than 30 kg/m2

Menorrhagia

Metrorrhagia

Nulliparity

Smoking

Dysmenorrhea (Cont.)

Clinical Presentation

Clinical features and detailed Hx with PQRST of Sxs

Obtain a detailed pain assessment

P.E.

Careful Hx and P.E.

Focus on abdominal and pelvic exams

Dysmenorrhea (Cont.)

Diagnostics

Tests are ordered as indicated:

Pelvic exam

Pelvic ultrasonography

CT scan

Labs:

CBC

ESR

Genital cultures

Laparoscopy

Hysteroscopy

Dilation and curettage

Differential Diagnoses

Intrauterine causes include

Myomas, adenomyosis, polyps, an IUD, infection, cervical stenosis, and cervical lesions

Extrauterine causes include

Endometriosis, tumors (myomas or malignant), inflammation, sexually transmitted infections, adhesions, psychogenic causes such as pelvic congestion syndrome, and nongynecologic causes

Pregnancy should be R/O

Dysmenorrhea (Cont.)

Management

Pain relief and menses regulation

NSAIDs

Hormonal contraceptives

Calcium channel blockers

Tocolytics

Dietary changes

Vitamin and mineral supplementation

TENS unit

Behavioral intervention

Hysterectomy

Dyspareunia

Common condition causing recurrent or persistent genital pain associated with sexual intercourse in women

It can develop secondary to other vulvar problems, such as localized provoked vulvodynia (LPV), vaginismus, or vulvodynia

Sxs include:

Pain, heightened contact sensitivity, spasm, among other Sxs

Other related factors include

Spontaneous and postabortive PID

Early postpartum or perimenopausal status

Generalized urogenital sensitivity

Hx of sexual abuse or cervical cancer

Psychosocial factors, such as rigid religious upbringing, low physical and emotional satisfaction, decreased general happiness, or previous painful sexual experience

Dyspareunia (Cont.)

Clinical Presentation

Inquire about Sxs of discomfort during sexual intercourse

PQRST of Sx

Med Hx

Gyn Hx

Sexual Hx

P.E.

Thorough pelvic exam

Inspection

Palpation

Q-tip test

Dyspareunia (Cont.)

Diagnostics

Vaginal KOH and wet mounts

Endocervical Pap smear

Chlamydia trachomatis and Neisseria gonorrhoeae cultures

The Q-tip test

CBC

Erythrocyte sedimentation rate (ESR)

HCG

Differential Diagnoses

Psychological and pathophysiologic factors

Focus diagnoses based on findings from a thorough P.E. and Hx and supportive diagnostic findings

Dyspareunia (Cont.)

Management

Based on underlying etiology

Psychological counseling

Lubrication

Pharmacotherapy

Topical estrogen

Botulinum toxim A

Other therapies

Pelvic floor exercises

Alternative sexual positions

Ectopic Pregnancy

Occurs when a fertilized ovum implants anywhere outside of the uterus

Mortality remains high

Second leading cause of maternal mortality and the leading cause of pregnancy-related death in the first trimester

Clinical Presentation

Sxs can be vague and subacute

Most common Sxs abdominal pain with/without vaginal bleeding or spotting, dizziness, and shoulder pain

Sxs generally appear between 6 and 12 weeks of gestation

Amenorrhea for 1 to 2 months and the usual early signs of pregnancy (nausea, fatigue, breast heaviness) are often part of the initial presentation

May have generalized or unilateral pelvic or abdominal pain

Pain to the shoulder (ruptured ectopic sign)

Ectopic Pregnancy (Cont.)

P.E.

Obtain a thorough Hx and P.E.

Postural vital signs

Speculum examination (a bulging cul-de-sac (indicative of hemoperitoneum in rupture), uterine enlargement occurs in roughly one fourth of women with ectopic pregnancy, but its size may be less than expected according to dates

Check for abdominal tenderness

Adnexal mass, involuntary guarding, and peritoneal signs

Diagnostics

The slope of a rising human chorionic gonadotropin (hCG) titer has been found to be a useful determinant of early ectopic pregnancy below the ultrasonographic discriminatory zone

CBC, blood type, and Rh determination and serum progesterone

Transvaginal US

Ectopic Pregnancy (Cont.)

Differential Dxs

Appendicitis, salpingitis, cholecystitis, PID, intrauterine pregnancy with inaccurate dates, corpus luteum cyst, gestational trophoblastic neoplasm, incomplete or missed spontaneous abortion, endometriosis, pelvic mass, ureteral calculi, and adnexal torsion, twisted cystic teratoma or a ruptured malignant ovarian tumor

Management

Emergent referral (ED) for a positive test result for serum human chorionic gonadotropin (hCG), abdominal pain, and vaginal bleeding/ruptured EP

Pharmacotherapy with guided US

Folic acid antagonist

Methotrexate or potassium chloride

Uterine immobilization

Surgical laparoscopy or laparotomy treatment choice for ruptured ectopic pregnancy

Fertility Control

The most common types of contraception are oral contraception, female sterilization and condoms (U.S.)

Discussion of contraceptive options should include information about the risks and benefits, potential side effects, rate of efficacy, and effects on future fertility

Oral Contraceptives

Hormonal (Progestin-only – Minipills)

Injectable Contraception

Contraceptive Implants

Contraceptive Patch

Post-Coital Contraception

Barrier Methods

Condoms

Diaphragms, cervical caps

Spermicides

Cervical Sponge

IUD

Vaginal Ring

Surgical Sterilization

Natural Family Planning

Genital Tract Cancers

Gynecologic Cancers

Cancers of the endometrium, ovary, fallopian tube, vulva, vagina, and cervix

Of the gynecologic cancers, cervical cancer is the only one with a standardized screening tool – the Pap smear

Endometrial

Most prevalent type in U.S. Age 55 and greater

Ovarian

5th leading cause of ca death, typically age 65 years and greater, genetic factors, pelvic pain, fullness, early satiety, or urinary frequency

Fallopian Tube

Vulvar

4% of cancer cases, vulvar irritation, burning or pain, pruritus, local discomfort, excoriation, fissuring, painful irritation, bleeding and discharge, or painful vulvar lump

Vaginal

1% of cancer cases, painless vaginal discharge that is often bloody

Cervical

Dxd in women 50 to 65 years, abnormal uterine bleeding (postmenopausal, postcoital, after douching, or intermenstrual), and foul vaginal discharge

Genital Tract Cancers (Cont.)

Clinical Presentation and P.E.

DUB

Pelvic, abdominal pain

Leg edema

Urinary and rectal symptoms

Symptoms and P.E. vary based on location and clinical assessment techniques specific to gynecologic organ

Genital Tract Cancers (Cont.)

Diagnostics (as indicated)

A pelvic examination that includes a rectovaginal examination

Pap smear of the cervix and vagina

HPV reflex

Colposcopy

Transvaginal US

Pelvic CT scan or MRI

Serum CA antigen testing

Biopsy

Differential Dxs

Sigmoid diverticulitis

Pregnancy

Distended bladder

Low-lying distended cecum

Stool in the sigmoid colon

Pelvic kidney

Fallopian tube, uterine, or gastrointestinal tumor

Crohn’s disease

Genital Cancers (Cont.)

Management

Surgery

Chemotherapy

Radiation

Close Surveillance

Gyno-Oncologic Management

Genetic Testing

Infertility

Defined as

A couple’s inability to conceive after 1 year of regular, timed, unprotected intercourse or therapeutic donor insemination

Impaired fecundity

Physical difficulty in getting pregnant or the inability to carry a pregnancy to live birth

Infertility affects one couple in six, and prevalence increases dramatically with paternal and maternal age

Clinical Presentation

Genetic, anatomic, endocrine, and behavioral factors

Interview both members of couple, then individually to assess medical Hx, gynecologic Hx, social Hx, occupational Hx

Infertility (Cont.)

P.E.

Male exam

Inspection of genitalia

Testicular size

Female exam

Thyroid, breast, vaginal exam

Assess visual acuity

Diagnostics

Semen analysis (assessed early in the workup)

Menstrual calendar

Basal thermometer tracking

Urinary LH

If women is >35 a day-3 FSH level and an estradiol level should be taken

Additional tests as tailored to the patient

Infertility (Cont.)

Differential Dxs

Genetic, structural, and endocrine disorders

Acquired infections (Trichomonas, Chlamydia organisms)

Treatment of other conditions with radiation therapy or chemotherapy

Body mass index

Personal behaviors like alcohol consumption and maternal cigarette smoking

Medications

Sexual dysfunction

Antisperm antibodies

Previous genital or pelvic surgery, among others

Management

PCPs manage basic preconceptual education

Health promotion − prenatal focus

Counseling

Referral as indicated to a reproductive endocrinologist

Assisted reproductive technologies (ARTs), such as in vitro fertilization (IVF)

Pharmacotherapy

Gonadotropin or GnRH therapy (male)

Various meds to induct ovulation

Estrogens, anti-estrogens

Menopause

A normal life event that every woman will experience if she lives past age 50

Average of menopause (U.S.) is 52.54 years

Clinical Presentation

Sxs may vary

Associated with a dramatic decline in estrogen levels causing a number of short- and long-term physical changes

Cycle irregularity

Vasomotor symptoms (hot flashes)

Urogenital atrophy (vaginal dryness, urinary incontinence, pelvic floor dysfunction)

Mood changes

Poor sleep and sexual functioning

Menopause (Cont.)

P.E.

Regular physical and preventive health examinations

Menopause (Cont.)

Smoking cessation

Weight-bearing exercise

Healthy diet

Limiting alcohol intake

Maintaining a normal body weight

Reducing stress levels

Vitamins and minerals: a balanced diet rich in fruits and vegetables

Address manage as needed on an individual basis

Vasomotor

Vaginal atrophy

Pharmacotherapy

Contraceptive Therapy

Hormones

Non-Hormonal Therapy

Bio-Identical Products

Pap Test Abnormalities

Papanicolaou (Pap) is a screening test for cervical cancer

2.1% of findings show abnormal results (U.S.)

13 HPV subtypes are correlated with high risk for cervical dysplasia

Especially types 16 and 18 (account for 70% of all cervical cancers )

HPV is the most common STI in the U.S.

Cervical cancer risk factors include:

Older age

Infection with particular high-risk HPV types

Vaginal pH changes

Hormonal changes

Cellular trauma

Long-term use of combined hormonal contraception

Young age at coitarche

Multiparity

Hx of STIs: sexual partner with a Hx of STIs, more than five lifetime sexual partners, younger age at first pregnancy, and cigarette smoking

Pap Test Abnormalities (Cont.)

Clinical Presentation

Cervical Pap abnormalities are not visible by routine speculum exam

However, frank cervical cancer may appear as a lesion on the cervix

Dx Tests:

HPV/Pap test

Cytologic brush

Broom liquid-based medium

Guidelines

Begin Pap screening for all women at age 21 years

HPV testing is indicated for women ages 30 to 65

P.E.

Currently, screening by HPV alone, without a Pap done simultaneously, is not recommended

Pap and HPV screening every 3 years in the 30- to 65-year age range

No Pap or HPV screening for women over 65 who have had 3 normal consecutive Paps

Women who have a Hx of CIN II or greater should continue screening past the age of 65 for a minimum of 20 years

Women who have had a hysterectomy and had their cervix removed should have screening discontinued unless they have a history of CIN II or greater in the past 20 years or have ever had cervical cancer

Women who have had DES exposure, immunosuppressed HIV, or CIN II or greater require closer monitoring

Pap Test Abnormalities (Cont.)

Specialty Focus

Patients with ASC-US lesions, with a concurrent positive HPV DNA test result should be referred for colposcopy, unless they are under 24 years of age

Repeat cytology in women under 24 years of age in 12 months

Can choose to have a reflex HPV test run after the initial or repeat cytology in 12 months, without running a reflex HPV test

Women over the age of 24 positive for ASC-US HPV should be referred for colposcopy

Gynecologic consultation is indicated for abnormal Pap findings – colposcopy diagnostics

Pelvic Inflammatory Disease (PID)

Spectrum of inflammatory disorders of the upper genital tract in women may include:

Any combination of endometritis, salpingitis, tubo-ovarian abscess (TOA), and pelvic peritonitis

Often asymptomatic

Most common reason for gynecologic emergency room visits and hospitalizations

Leading cause of infertility

Pelvic Inflammatory Disease (PID) (Cont.)

Risk Factors:

Young age less than 25 years

Having multiple sexual partners

No current or consistent use of contraception

Living in an area with a high prevalence of STIs

Strong correlation between the incidence of STIs and PID in any given population

Other risk factors for PID include penetration of the cervical mucous barrier during medical procedures, including the insertion of an intrauterine contraceptive device, vaginal douching

Cigarette smoking

Reduced Risk:

A woman’s risk for PID is decreased if she uses barrier contraception, takes oral contraceptives, or has had a tubal sterilization

Pelvic Inflammatory Disease (PID) (Cont.)

Clinical Presentation

Often asymptomatic, and remain undiagnosed because of their mild or nonspecific signs and symptoms

Sxs vary based on the pathogen responsible

Fever or chills, cramping, dysuria, low back pain, nausea and vomiting, abnormal vaginal bleeding (post-coital, inter-menstrual bleeding)

P.E.

Lower abdominal pain

Elev. temp 38.3° C (101° F)

Abnormal cervical or vaginal mucopurulent discharge

Presence of white blood cells (WBCs) on saline microscopy of vaginal secretions

Elevated ECRP

Cervical infection with N. gonorrhoeae or C. trachomatis

Mucopurulent cervical discharge or WBCs on microscopic evaluation of vaginal fluid

Pelvic Inflammatory Disease (PID) (Cont.)

Diagnostics

Tests

HCG

Pelvic US

RPR

HIV

Endometrial Bx

MRI

Doppler studies

Laparoscopy

Differential Diagnoses

Ectopic pregnancy

Acute appendicitis

Ovarian torsion

Ovarian cyst

Endometriosis

Corpus luteum bleeding

Pelvic adhesions

Benign ovarian tumor

IBD

IBS

Diverticulitis

Pyelonephritis

Nephrolithiasis

Cystitis

Pelvic Inflammatory Disease (PID) (Cont.)

Management

Empirical therapy

Broad-spectrum antimicrobial coverage including:

Anaerobic coverage

Combination therapy is necessary

Imperative to empirically treat sexual partner(s) esp. those within 60 days preceding onset of Sxs

Health monitoring/Education/Monitoring

Sexual Dysfunction – Female (FSD)

Types

(1) Female sexual interest/arousal disorder

(2) Female orgasmic disorder

(3) Genito-pelvic pain/penetration disorder

FSD based on duration:

Lifelong versus acquired

Generalized versus situational

Etiologic origin and/or treatment

FSD is multifactorial

A complex interaction of psychological, interpersonal, environmental, genetic, biological, and physiological factors that change throughout the life cycle

Sexual Dysfunction (Female) (Cont.)

Clinical Presentation

Obtain Hx

Open, understanding, nonjudgmental attitude is necessary to create a comfortable environment to obtain sexual Hx

Assess sexual function

P.E.

Obtain a thorough health Hx and P.E.

Pelvic exam

Sexual Dysfunction (Female) (Cont.)

Diagnostics

As indicated:

wet mount, testing for gonorrhea and chlamydia, complete blood count (CBC), hormonal studies, fasting glucose concentration, lipid panel, renal panel, and liver function studies. Pelvic ultrasound examination may be performed as indicated to rule out pelvic mass or anatomic anomaly. Screening for depression may also be indicated

Differential Diagnoses

Psychosocial difficulties

Depression

PTSD

Hormonal imbalance

TSH

Adrenal disorders

Liver disorders

Kidney disorders

Diabetes, infection

Injury

Substance abuse

Arterial insufficiency

Medicamentosa

Sexual Dysfunction (Female) (Cont.)

Management

Primary care consult to assess underlying etiology of PFD

Referral to educational resources

Suggestion for lifestyle changes

Referrals for individual or couples counseling

Unplanned Pregnancy

A pregnancy that is undesired or the time of conception is mistimed (occurs earlier than desired)

50% of all pregnancies are unintended

Clinical Presentation

Signs and Sxs of possible pregnancy may include

Missed period

Nausea and vomiting

Breast pain

Dizziness

Fatigue

Provide supportive environment to discuss and guide patient

Unplanned Pregnancy (Cont.)

Management and Counseling

Can be challenging

Respect personal feelings about unplanned pregnancy, the options available, and the fact that an unplanned pregnancy can be a crisis in a woman’s life

Need to understand and accept that a woman’s perspective and her goals and way of achieving them may conflict with their own

Discuss reproductive choices

Vulvar and Vaginal Disorders

Encompass a broad range of dermatologic conditions

Benign vulvar disorders include:

Pruritus, pain, burning, irritation, and a mass and/or growth

Prior to a clinical visit women often use nonprescription remedies

Clinical assessment includes

Inspecting skin with a hand-held microscope or in some cases a colposcope

Vaginitis, cervicitis, and other STIs should be excluded

Vulvar and Vaginal Disorders (Cont.)

Types:

Lichen Sclerosis

Lichen Planus

Lichen Simplex

Contact Dermatitis

Eczema and Psoriasis

Vulvar Pain

Bacterial Vaginosis

Vulvovaginal Candidiasis

Atrophic Vaginitis

Clinical Presentation

Presentations vary

Obtain a detailed clinical Hx

Review of previous Tx

Vulvar conditions may manifest in other organ systems, including tuberculosis, Crohn’s disease, and endometriosis, e.g., vulvar psoriasis may have an unusual presentation with typical psoriatic lesions elsewhere

Vulvar and Vaginal Disorders (Cont.)

P.E.

Clinical Hx

Clinical exam

Inspection

Palpation

Microscopy

Diagnostics (as indicated)

Clinical exam

Microscopy

Colposcopy

Punch Bx

CBC

Autoimmune labs

TSH and B12 levels

ANA

Diagnostics to consider

Viral culture for HSV if erosive presentation

Hepatitis C antibodies

Autoimmune/allergy testing

Vulvar and Vaginal Disorders (Cont.)

Differential Dxs

Extensive list of associated conditions

Management

Avoidance of irritants

Topical corticosteroids

Topical estrogen/progesterone

Antibiotics

Antifungals, tricyclic antidepressants

Gynecology/surgical referral

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