CPD II: gynecology week 2 cont'd

the second lecture of the second week of gynecology in CPD II: vaginitis, PID, GC/chlamydia.

here are some keywords for the different conditions:
BV: risky sexual practices, clue cells, thin white discharge. gardnerella.
candida: thick cottage cheese discharge, redder tissue.
atrophic: low estrogen, thin clear discharge, thin / dry walls, high pH, basal cells.
trichomonas: copious yellow / green, tender perineum, strawberry cervix.
cytolytic: overgrowth of lactobacillus. candida symptoms. atypical clue cells, baking soda.
PID: save the tubes in 36 hours! fever / discharge. high WBC's. inguinal lymphs. fitz-hugher-curtis.
GC: greenish yellow discharge, swelling of glands, 7-21 days prodrome, increased ESR/WBC/pH.
chlamydia: similar to GC. flourescent antibody test. increased pH.

questions
vaginitis...
1. what are the signs and symptoms of vaginitis?
2. when is vaginal discharge normal?
3. what effect does progesterone have on cervical discharge?
4. what are some common etiologies for vaginitis for children?
5. vaginitis in reproductive age women is usually from...
6. what is a factor that protects against bacterial overgrowth in the vagina?
7. what are some non infectious causes of vaginitis in reproductive age women?
8. what is the pathogenesis of vaginitis in menopausal women?
9. how might crohn's disease lead to a sequelae of vaginitis?
10. what is the most likely cause of vaginitis for symptoms that occur before vs. after menses?
11. what are some distinct morphological signs for vaginitis from candidia?
12. if the WBC count on a wet prep is below 50 per HPF, vaginitis is likely due to...
13. if the WBC count on a wet prep is above 50 per HPF, vaginitis is likely due to...
14. what is a differential diagnosis for vaginitis related to dermatology?

bacterial vaginosis...
15. what is a microscopic finding that can point to BV?
16. name some risk factors for bacterial vaginosis.
17. what are the potential complications for a woman with BV?
18. what are the criteria for diagnosis of BV?
19. the WBC count is usually...
20. what is the quality of the vaginal discharge in BV?

vaginitis due to candida...
21. what are some risk factors for candida infection?
22. what is the quality of the vaginal discharge in candida?
23. what are some other symptoms of a candida infection?
24. how does symptom severity relate to time during the menses cycle in a candida infection?
25. compared to other types of vaginitis, vaginal tissue with candida infection is generally more...
26. how is the diagnosis of candida vaginitis made?
27. if there is a candida infection without the positive sign in question 26, what does this indicate? how is this treated?
28. what are some ddx's for vaginitis due to candida?

atrophic vaginitis...
29. what is the cause of atrophic vaginitis?
30. what is the quality of the vaginal discharge and vaginal walls in atrophic vaginitis?
31. what is a differential diagnosis for atrophic vaginitis?
32. what is the pH of atrophic vaginitis?
33. what is seen on the wet prep for atrophic vaginitis?

trichomonas...
34. what are the signs / symptoms of a trichomonas infection?
35. what is the morphological sign on the cervix for a trichomonas infection?
36. what is the conventional treatment for a trichomonas infection?

cytolytic vaginosis...
37. what is cytolytic vaginosis?
38. what is a common cause of cytolytic vaginosis?
39. what are the signs / symptoms of cytolytic vaginosis?
40. what might be present in the wet prep of cytolytic vaginosis?
41. what is an effective and simple treatment for cytolytic vaginosis?

PID...
42. how long is the window of time before the uterine tubes might be irreversibly damaged by a PID infection?
43. what are the common etiologies for women under 35yo with PID?
44. what are the common etiologies for women over 35yo with PID?
45. what are some risk factors for PID?
46. what are the signs/symptoms for PID?
47. what are some PE findings for PID?
48. what are three main diagnostic criteria for PID?
49. what are some complications of PID?
50. what is fitz-huges-curtis syndrome?
51. what are the differential diagnoses of PID?

GC...
52. what is the quality of the discharge in a gonorrhea infection of the vagina?
53. what are some other symptoms in a gonorrhea infection?
54. how long does it take for symptoms to appear after exposure to GC?
55. what are the lab tests used to diagnose GC?

chlamydia...
56. what is the most common presentation of a chlamydia infection?
57. what is the test used to diagnose a chlamydia infection?

answers
1. abnormal vaginal discharge
irritation / swelling / pruritis
erythema
dysuria / dyspareunia
2. before ovulation due to high estrogen levels.
3. causes it to become thick and sticky, forming a plug in the cervix that can remain in place in conception occurs.
4. poor perianal hygeine
bath chemicals / soaps
foreign bodies
5. infection: trich, candida, or BV.
6. lactobaccilus (keeps pH low)
high estrogen levels (maintains wall thickness)
7. factors that raise pH in the vagina: semen, menstrual blood,
tight clothing
frequent douching
foreign bodies
8. lower estrogen levels leads to thinning of the vaginal wall which might lead to decreased lactobacillus which could lead to increased pH and greater vulnerability to infection.
9. through a fistula that connects the vaginal and the GI tracts.
10. before: chronic candida. after: BV.
11. paper cut-like fissures on the labia majora / minora.
12. normal flora imbalance.
13. staph, strep, ecoli, GC, chlamydia.
14. lichen sclerosis.

15. clue cells.
16. IUD's
risky sexual practices
uncircumcised male partner
17. PID if not pregnant
post partum, premature complications if pregnant
18. Amsel's criteria:
higher than 4.5 pH
fishy odor
gray/white discharge
clue cells
[your clue: 4.5 gray fishes]
19. below 50hpf.
20. thin, copious, white.

21. diabetes, antibiotics, pregnancy, chronic yeast infections, some contraceptives.
22. thick white cottage cheese discharge that adheres to vaginal wall.
23. pruritis, erythema, dryness
dyspareunia
24. symptoms increase before menses.
25. red.
26. the presence of hyphae / buds / spores on wet prep.
27. candida glabradae, as opposed to candida albicans. treat with boric acid.
28. contact / allergic / chemical irritation
paget's disease of the vulva

29. low estrogen levels due to menopause or primary ovarian insufficiency.
30. clear vaginal discharge, thin and dry vaginal walls.
31. erosive lichen planus.
32. greater than 6, because less lactobacillus.
33. increased WBC
decreased lactobacillus
increased parabasal cells
increased cocci

34. copious yellow / green discharge
tender perineal area
dysuria
35. "strawberry cervix".
36. antibiotics.

37. an overgrowth of the normal lactobacillus strain in the vagina.
38. increased stress.
39. similar to candida.
40. atypical clue cells.
41. baking soda.

42. about 36 hours.
43. STI, from GC and CT.
44. overgrowth of endogenous flora.
45. unsafe sex
age, economic factors
nulliparous
46. lower abdominal pain that radiates to the back / sternum
fever
discharge
abnormal bleeding
47. inguinal lymphadenopathy
fever
mucopurulent discharge
enlarged Skene's glands
easily friable, erythematous cervix
cervical motion tenderness
48. elevated wbc's on CBC
WBC's over 50hpf on wet prep
sed rate over 15mm/hr
49. fitz-hughes curtis
tuboovarian abscess
adhesions
infertility
hydrosalpinx
50. infective exudate leaving the fimbrae and travelling between liver and diaphragm.
51. endometriosis
adenomyosis
ectopic pregnancy
cysts

52. greenish mucopurulent discharge.
53. bartholin/skene gland swelling
urinary symptoms
54. 7-21 days.
55. increased ESR, WBC
increased pH
DNA probe

56. similar presentation to GC infection, or asymptomatic.
57. flourescent antibody testing, increased pH on wet prep.

pathology III: uterine pathologies part I

lecture 1 / 2 of the pathology of the uterus.

questions
overview...
1. the uterus is composed mostly of...
2. what are menorrhagia and metrorrhagia?
3. what are anovulatory cycles generally caused by?
4. what can anovulatory cycles also be caused by?
5. when do anovulatory cycles most commonly occur?
6. what is an "inadequate luteal phase"
7. what are some symptoms that often accompany an inadequate luteal phase?
8. what is the test used to diagnose inadequate luteal phase? what does it show? when is it performed?

endometritis...
9. acute endometritis is associated with...
10. what are the etiologies of chronic endometritis?
11. what is seen in endometrial tissue in acute and chronic endometritis?

endometriosis and adenomyosis...
12. what is endometriosis?
13. what age does endometriosis generally occur?
14. where in the body does endometriosis commonly affect?
15. what is adenomyosis?
16. what are the histological characteristics of adenomyosis?
17. how common is adenomyosis?
18. what are the clinical symptoms of adenomysosis?
19. what are the signs/symptoms of endometriosis?
20. what is "retrograde/implantation" etiology theory for endometriosis?
21. what is the "metaplastic" theory for endometriosis?
22. what is the "vascular or lymphatic" theory for endometriosis?
23. the vascular/lymphatic theory could explain...
24. what are three "non standard" theories of etiology for endometriosis?
25. what is the morphology of endometriosis implants?
26. what is a "chocolate cyst"?

endometrial polyps...
27. what is an endometrial polyp?
28. how big are endometrial polyps?
29. what are the two histological types of polyps? which one does not respond to progesterone?
30. what is a serious potential complication of endometrial polyps?

endometrial hyperplasia...
31. endometrial hyperplasia is related to...
32. what is the general cause of endometrial hyperplasia?
33. what are estrogen producing factors implicated in the pathogenesis of endometrial hyperplasia?
34. what is "PTEN" and how is it related to endometrial hyperplasia?
35. describe the morphology of simple hyperplasia.
36. simple hyperplasia of the endometrium reflects...
37. what percentage of simple hyperplastic endometrium progresses to adenocarcinoma?
38. what is the morphology of complex hyperplasia of the endometrium.
39. complex hyperplasia is usually associated with...

PID...
40. PID is associated with...
41. statistically, what are the causes of PID in younger vs. older women?
42. what are the clinical manifestations of PID?
43. in PID, where does gonococcal inflammation begin?
44. what other areas are involved in gonococcal inflammation?
45. how else might infection travel to the tubes and ovaries?
46. what are the morphological characteristics of gonococcal derived PID 2-7 after infection?

answers
1. smooth muscle (myometrium)
2. excess bleeding during menses, and between menstrual cycles.
3. excess estrogenic stimulation, lack of progesterone, no corpus luteum development.
4. endocrine disorders, metabolic disorders, ovarian tumors.
5. puberty and perimenopause.
6. inadequate luteal function and low progesterone output with an irregular ovulatory cycle.
7. infertility, increased bleeding, or amenorrhea.
8. endometrial biopsy performed at postovulatory time shows immature secretory endometrium.

9. bacterial infection or incomplete miscarriage.
10. chronic PID
retained gestational tissues
IUD's
TB
[CE PID IUD TB RGT] [iCPTR] [I, COMPUTER]
11. acute: PMN. chronic: plasma cells, macrophages, lymphocytes.

12. presence of endometrial glands and stroma in ectopic locations.
13. 3rd and 4th decades.
14. endometrial tissues found in:
ovaries
uterine ligaments
rectovaginal septum
pelvic peritoneum
laparotomy scars
[oh... your butt has a poo poo scar]
15. presence of endometrial tissue in uterine wall.
16. irregular nests of endometrial stroma within myometrium.
17. in up to 20% of uteri.
18. menorrhagia, colicky dysmenorrhea, dyspareunia, pelvic pain
[add men dys dys pelvic] [the ADD man: "this- this pelvic pain!!!!"]
19. infertility
dysmenorrhea
pelvic pain
deep dyspareunia
pain with BM, urine
[endo infertility dys pelvic deep BM] [end this infertility with this deep pelvic shit]
20. retrograde menses through the fallopian tubes spreads endometrial tissue in the peritoneal cavity.
21. coelemic epithelium produces endometrial tissue directly.
22. dissemination of endometrial tissue through veins or lymph nodes.
23. lesions in lungs / lymph nodes.
24. GI dysbiosis (candida in particular), hereditary influences, aromatase cytochrome P450, dioxin / PCB exposure.
25. nodules with red-blue to yellow-brown appearance on or below serosal surfaces, sometimes with fibrous adhesions.
26. endometrial tissue on the ovaries.

27. a sessile mass projecting into the endometrial cavity.
28. 0.5-3cm.
29. functional and hyperplastic (doesn't respond to progesterone).
30. adenocarcinoma.
31. carcinoma.
32. prolonged estrogen stimulation of endometrium by anovulation or increased estrogen production.
33. menopause, PCOS, ovarian tumors, ERT.
[hyper men hurt because of tumors]
34. a tumor suppressor gene that, when inactivated, can contribute to endometrial hyperplasia by increasing endometrial sensitivity to estrogen.
35. irregular gland shape, similar to proliferative endometrium without mitotic figures.
36. persistent estrogen stimulation.
37. 1-8%.
38. increased number and size of endometrial glands with irregular shape
scalloped or tufted surface on epithelial lining
mitotic figures
39. altered PTEN gene expression.

40. STI's, endogenous vaginal flora.
41. younger: STI. older: endogenous flora.
42. pelvic pain
adnexal tenderness
fever
vaginal discharge and bleeding
nausea / vomiting
back pain
CMT
dysuria
deep dyspareunia
43. Bartholin glands and periurethral glands.
44. cervix, uterus, uterine tubes, ovarian region.
45. through procedures such as abortion, D+C.
46. inflamed glands
acute suppurative inflammation of superficial mucosa
spared endometrial tissue
lumen filled with purulent exudate
tubo-ovarian abscesses
hydrosalpinx
[PID glands superficial spared lumen tubo salpinx] [stuPID glands: spared the superficial tubs of lemons instead of the minx]