Gynie Goodies for the Generalist

1. Gynie Goodies for the Generalist Kathleen J. Wilder, MD, MHS Chief, Department of Ob/Gyn Northern Navajo Medical Center Shiprock, NM October 30, 2010

2. Objectives • Learn to rapidly recognize the top 3 causes of vaginitis and know how to treat • Learn a quick and dirty work-up for menorrhagia and who needs it • Review the best treatment options for uncomplicated (female) UTIs • Make a case for perimenopausal hormone therapy • AMA contraception – see why it’s an urgent need and learn the best options • Wrap up with late/recent breaking tidbits

3. Vaginitis/Vulvitis • Itching, burning, irritation, abnormal discharge, dysuria, postcoital bleeding… • Most common: • Candidiasis 17-39% • Baterialvaginosis 22-50% • Trichomoniasis 4-35% • Also: • Other STIs • Atrophic vaginitis • Undiagnosed 7-72% Vaginitis, ACOG practice bulletin #72, May 2006

4. The Itch • Diagnosis • Microscopy – 50% sensitivity • So really….the story w/or w/o exam • Vagina and/or vulva • No vaginal bacterial cultures! • Etiology • Candida albicans • Anything that disturbs the normal vaginal pH balance • Douche, sex, late luteal phase… • Poorly controlled comorbidities -> DIABETES!!! Vaginitis, ACOG practice bulletin #72, May 2006

5. Standard treatment • Antifungal cream PV QHS x 1 wk • Apply directly to affected area • “Complicated” infection (recurrent, severe, pregnancy, comorbidities, non-albicansCandida) • Diflucan 150mg po x 1 +/- antifungal cream • Diflucan x 2 - 72hrs apart +/- antifungal cream • Tx success increased from 67% to 80% • Recurrent • Fungal culture to check for non-albicansCandida Vaginitis, ACOG practice bulletin #72, May 2006

6. The Odor • BV most common • Diagnosis – 2 or 3 of Amsel’s Criteria • Homogeneous grayish noninflammatory d/c (note missing LB) • Clue cells >20% • pH >4.5 • + Amine test -> Fishy odor w/KOH (frequently appreciated w/o) • Could also be other vaginitis – ex. Trich • Microscopy 50-60% sensitivity • Also pH >4.5 • Culture and Antigen tests have high sensitivity/specificity • Treatment – luckily the same! • Metronidazole 500mg po BID x 7 days Vaginitis, ACOG practice bulletin #72, May 2006

7. A brief note about the vulva… • Thickening, pebbling, hypopigmentation, hyperpigmentation, thinning of the epithelium, lesions, non-healing lesions… • Anything irregular appearing needs biopsied Diagnosis and management of vulvar skin disorders, ACOG Practice Bulletin #93, May 2008.

8. My periods are so heavy! • Menorrhagia = • >80ml/menstrual cycle OR • lasts for more than 7 days • Menometrorrhagia = • frequent menstrual bleeding that is excessive and irregular in amount and duration • Anovulatory Bleeding = • noncyclic menstrual blood flow that may range from spotty to excessive, is derived from the uterine endometrium, and is due to anovulatory sex steroid production specifically excluding an anatomic lesion • menstrual bleeding arising from anovulation or oligo-ovulation Management of anovulatory bleeding, ACOG practice bulletin #14, March 2000, reaffirmed 2009.

9. Pathophysiology of Anovulatory Bleeding • No corpus luteum • No progesterone • Continued estrogen production Continuous unopposed estrogen stimulation ↓ Unsustainable endometrial growth

10. Special Case Becoming the Norm: Obesity ↓ Androgens → Estrogens ↓ Chronic Anovulation

11. What’s the big deal? • Endometrial cancer- based on 1995 data • 0.1/100,000 15-19yo • 9.5 19-35yo • 2.3 30-34yo • 6.1 35-39yo • 36.2 40-49yo SEER data 1973-1996

12. Basic work-up: • Pregnancy test, TSH, prolactin, FSH • Ultrasound to r/o structural defect • Amenorrhea + negative/wnl results → Anovulation • Better to do the EMB than not do the EMB

13. But don’t stop there… • Need therapy to • Prevent future episodes of acute hemorrhage • Prevent non-cyclic bleeding • Prevent future complications (i.e. cancer) • Improve quality of life • Initially HEAVY bleeding • May take ~3 cycles • Treatment options (depending on age) include: • Hormonal contraception - ex. COCs • Mirena IUD • Surgical intervention – endometrial ablation*, hysterectomy

14. UTI (in females) • Diagnosis • Pyuria (>10) + bacteriuria • Don’t overdiagnose based on leukocyte esterase alone • FP due to dirty specimen or other infection such as yeast Treatment of urinary tract infections in nonpregnant women, ACOG Practice Bulletin #91, March 2008.

15. UTI (in females) • It’s not just me, but a lot of really smart people say 3 days is enough…even if > 65 yo • Bactrim – totally great drug if resistance in your area is <15-20% --- 94% eradication rate • Fluoroquinolones – effective but not preferred first line tx • Amoxicillin/Ampicillin – NOT first line tx • 3 days is sufficient! • If macrobid (ex. pregnancy)—7 days • Resistance >15-20% necessitates change in antibiotic

16. In order of preference: • TMP-sulfa DS 1 tab po BID x 3 days • Nitrofurantoin monohydrate macrocrystals 100mg po BID x 7 days • Ciprofloxacin 250mg po BID x 3 days • Levofloxacin 250mg po daily x 3 days

17. Perimenopausal Issues • Transitional hormone therapy • AMA contraception Pazol K, Gamble, SB, Parker WY, et al. Abortion Surveillance –United States, 2006. In: Surveillance Summaries, November 27, 2009;58(S S08);1-35.

18. Unwanted pregnancies among our AMA patients • Abortion rate among women aged <15 = 1.2/1000 women • Among women >40 = 2.6 per 1,000 women • Among women 35-39 = 7.8 per 1,000 women • Abortions among women >35yo account for 12.1% of all abortions • Slow but persistent increase over study period in women >35yo (up from 10.8%) • Abortion ratios highest at extremes of age

19. Perimenopausal Hormone Management • Yes, there are some risks to HT • But for majority of women – it’s more good than bad!

20. Who, When and How • Symptomatic • Hot flashes, vaginal dryness, poor sleep, poor moods • Menometrorrhagia → OLIGOovulatory bleeding • Combined hormonal birth control • Weigh pros and cons of risks and benefits • Take into account comorbidities • A word about botanicals… Schifren JL, Schiff I. Role of hormone therapy in the management of menopause. Obstet Gynecol 2010;115:839-55. Use of botanicals for management of menopausal symptoms. ACOG practice bulletin #28, June 2001, reaffirmed 2010.

21. Transitional HT… • …Kill two birds with one stone: Perimenopausal estrogen withdrawal AND Prevent unplanned/unwanted pregnancy • If and when patient chooses hormone therapy after OCPs: • Smallest dose for shorter time • When decide to stop, do it slowly

22. In Summary… • Better to biopsy than be biopsied (via wallet) • Vulvar and Endometrial biopsies • 3-2-1 Done!!! • The examined life is worth living and the unexamined and unmanaged postmenopausal life may NOT be worth living! • Help prevent unwanted AMA babies: Plan B + effective perimenopausal BCM

23. Late or Recent Breaking Gyn Goodies: • No paps under 21yo • Every 2 – 3 years unless contraindicated • (HIV, hx CIN 2 or 3, immunocompromised, etc.) • New US based medical criteria for contraception • www.cdc.gov/mmwr • HPV vaccines – quadrivalent and bivalent • Approved for males and females 9 – 26 yo • Preconceptual mgmt of Diabetics - Folic acid 4mg/day • CDC STD treatment guidelines to come… • New recommendations for diagnosis of GDM to come… • …….