1. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Vulvar / Vaginal Disease Ch 19, 23, 41 2009-2010 Academic Year MSIII Ob/Gyn Clerkship Self-Directed Study

2. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Case Study 63 yo GP3 postmenopausal woman, not on hormone replacement therapy, presents to clinic with complaints of vulvar pruritus. The patient has concerns as she is a diabetic and does not want to have an infection. Please discuss this patient’s evaluation in clinic and diagnosis.

3. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Questions to Consider 1. How would this change if she were 22? –Decreased risk of malignancy 2. Differentiate bacterial vaginosis and yeast infection by history. –BV – fishy odor, yellowish frothy discharge –Yeast – white clumpy discharge, pruritus 3. What if you see lesions? What if you see lesions in a 33 yo vs. an 80 yo? –Increased risk of malignancy with age –In a 33 yo, differential diagnosis includes infection and neoplasm

4. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies APGO Educational Topic 35: A. Diagnose and manage a patient with vaginitis. B. Interpret a wet mount microscopic examination. C. Describe dematalogic disorders of the vulva. D. Evaluate a patient with vulvar symptoms.

5. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies APGO Educational Topic 51: A. Define the risk factors for vulvar neoplasms. B. Describe the indications for vulvar biopsy.

6. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Vaginitis Inflammation of the vagina (+/- vulva) Evaluation of Vaginal Discharge –Whiff Test: KOH on slide or speculum with vaginal discharge produces “amine” or fishy odor with BV or Trichomoniasis. –Wet-Mount: Vaginal discharge on slide, mixed with normal saline or mixed with KOH. Evaluated under microscope. –Characteristic of discharge, pH also helpful.

7. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Wet Mount (Normal Saline) Microscopic view (high power) of a Trichomonad in a saline wet-mount preparation. The organisms are usually motile in this type of preparation. Trichomonas Bacterial Vaginosis Microscopic view of clue cells in a saline wet-mount preparation. Note the irregular or serrated cell walls.

8. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Wet Mount (KOH) Mycelial tangles of yeast pseudohyphae in KOH wet-mount preparation. Candidiasis (Yeast Infection)

9. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Cevical Images associated with vaginitis “Clumpy” “Cottage-cheese-like” discharge Consistent with Yeast infection Frothy discharge consistent with Trichomonas.

10. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Dermatologic Conditions of Vulva Squamous Hyperplasia Lichen Sclerosis Lichen Planus Pemphigus Bechet’s Syndrome Crohn Disease Acanthosis Nigricans

11. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Squamous Cell Hyperplasia Local thickening of epithelium Associated with prolonged itch-scratch cycle

12. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Lichen Sclerosis Pruritus, Dyspareunia, burning Most common in menopausal women Skin is thin, inelastic, white, crinkled “tissue paper” Potent topical steriods (0.05% Clobetasol)

13. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Lichen Planus Purplish, polygonal papules Can be erosive Vagina, vulva, mouth Topical and systemic steroids Ulcerated lesions Lacy reticulated pattern, scarring www.mdconsult.com

14. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Derm disorders of vulva that can be found on other parts of body Several dermatologic findings can also affect vulva/vagina. –Pemphigus: autoimmune blistering disease of vulva/vagina, conjunctival areas. –Behcets: ulcerations of genitals, mouth, ocular lesions. –Crohn’s: slitlike “knife-cut” ulcers of vulva, edema (often precedes GI sx’s) –Acanthosis Nigricans: intertriginous areas, axilla, nape of neck. Darkly pigmented velvety or warty surface. Associated with insulin resistence.

15. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Pemphigus oral lesions. www.mdconsul.com Bechet’s Syndrome www.bestpractice.bmj.com Acanthosis Nigricans www.dermatologistsnyc.com

16. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Vulvar Biopsy When to biopsy –If you don’t know what it is –If it is persistent despite treatment or recurrent –When in doubt, biopsy. YOU ARE NEVER WRONG TO BIOPSY!!!