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Wet smear – pseudophyaeand spores w/ large # WBCMiconazole (Monistat), Clotrimazole (Gyne-Lotrimin), Diflucan, Terconazole (Terazol-3) creamIf patient on antibiotic daily yogurt or lactobacillus pillsBacterialVaginosis (BV)Overgrowth ofanaerobic bacteriain vaginaUnpleasant “fish-like” odor worse afterintercourse. Discharge that is copious andhas milk-like consistency. Exam showslight gray discharge coating on vaginalwalls. No vulvar or vaginal irritationWet smear – clue cells(squamous epithelial cellsw/ lg bacteria), few WBC;Whiff test – KOH applied tosample – smells fishyVaginal pH >4.5Metronidazole (Flagyl), Clindamycin cream, Not STD, no partner treatment neededAbstain from sex until treatment completeTrichomonasVaginitis(Trichomoniasis)Protozoan parasite w/ flagellac/o pruritic, reddened vulvovaginal area,dysuria. Copious grayish-green bubblyvaginal discharge. Partner may have samesymptomsExam: “strawberry” cervixw/ some bleedingMetronidazole (Flagyl)Treat sexual partner; avoid sex until treatment completeAtrophicVaginitisLack of estrogen in tissue of urogenital tractVaginal dryness, itching, pain wintercourse. No discharge, less rugae,pale color, may bleed on physical examPap smear shows atrophicchangesElevated FSH/LHTemporary use of topical estrogen cream, if intact uterus, need progesteroneOsteoporosisLoss of bone density from estrogen def.“Skinny white woman who smokes anddrinks” – seen in Caucasian and Asianwomen.Affects women and menDXA scan: T-score < -2.5(Osteopenia - -1.5 to -2.4)Weight-bearing exercises, calcium w/ Vit D (1200/800mg), bisphosphonates: 1stline – Fosamax (alendronate), Actonel (risedronate), Selective Estrogen Receptor Modulator – Evista (raloxifene) after menopause, Miacalcin (not 1stline)HET/ERT to increase bone density Pap Smears:Bethesda systemAtypical Squamous cells of undetermined significance: Atypical Glandular Cells of Undetermined Significance: Low-grade Squam. Intraepithelial Lesions/<20yo – repeat in 12 months refer for endometrial biopsy High-grade Squamous epithelial lesions:>21 – oder pap with “reflex” (HPV DNA) HPV testing – refer for colposcopy and biopsyOncogenic HPV 16, 18 – refer for colposcopy/biopsy
Oral ContraceptivesCombined oral contraceptivesoMonophasicpills (Loestrin) –21 active pills; placebo last 7doTriphasic(Ortho tri-cyclen) - 21 active pills; placebo last 7d. Hormones wk 3 varies. Good for acneoExtendedCycle(Seasonale)– 84 days active pill w/ 7 free days. 4 periods/yroEthinylEstradiol/Drospirenone (Yaz)– drospirenone as progesterin; great for acne, PCOS, hirsuitism, PMDD. Highrisk for DT/hyperkalemia. Must check K+ levels if on ACEI/ARB/K+ sparing diureticProgestin-OnlyoMicronor– 28 days starting (mini-pill) – safe for breastfeedingoContraindications: hx DVT, smoker over 35, increase for stroke, acute liver infection, known CAD, pregnancy, reproductive cancersWOMEN’S HEALTHContraceptive contraindicationsAbsolutecontraindications“MY CUPLETS”oMigraines w/ focal neurologica auraoCAD/CVAoUndiagnosed genital bleedingoPregnantoLiver tumor/active liver diseaseoEstrogen-dependent tumoroThrombus/embolio