OBGYN Oral Exam Cases

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OBGYN Oral Exam Cases by Mind Map: OBGYN Oral Exam Cases

1. Abnormal Uterine Bleeding

1.1. Normal Cycle

1.1.1. 21-35 days (avg 28d)

1.1.2. Menses 3-5 days

1.1.3. Avg blood loss 30-50 mL

1.2. Definition

1.2.1. Any departure from the normal amount/duration of bleeding whether too much or too little

1.3. Types of AUB

1.3.1. Menorrhagia >80 mL/cycle or >7d bleeding or >1 pad/hr Usually due to fibroids, adenomyosis, or polyps

1.3.2. Hypomenorrhea Regular periods but very light flow Usually HPA dysfunction (e.g., exercise, anorexia) or birth control

1.3.3. Oligomenorrhea Cycles >35d apart Usually PCOS, pregnancy, chronic anovulation, thyroid disease

1.3.4. Polymenorrhea Cycles <21d apart Usually a type of anovulation

1.3.5. Metrorrhagia Bleeding between periods Consider cervical cancer or polyps

1.3.6. Secondary Amenorrhea Cessation of cycles for 6 mo after previously normal cycles

1.3.7. Primary Amenorrhea No menses by age 16 or 4 years after breast development

1.4. DDX

1.4.1. Dysfunctional Uterine Bleeding Refers to AUB w/o identifiable cause Thought to be related to chronic anovulation resulting in endometrial proliferation that never sheds as part of a cycle. As it grows, it slowly outgrows its blood supply and you get random bleeding. Most often happens around periods that are commonly anovulatory, such as menarche, pregnancy, breastfeeding, perimenopause. Diagnosis of exclusion so r/o thyroid, abnormal prolactin levels, POI Workup Treatment NSAIDs (1st line) OCPs (1st line) Surgery if needed

1.4.2. PALM COEIN Polyps Pathophys Risks Symptoms Treatment Notes Adenomyosis Pathophys Risks Symptoms Treatment Notes Leiomyomas Pathophys Risks Symptoms Treatment Notes Malignancy Pathophys Risks Symptoms Treatment Notes Coagulopathy Pathophys Risks Symptoms Treatment Notes Ovulatory Dysfunction Pathophys Risks Symptoms Treatment Notes Endometrial dysfunction Pathophys Risks Symptoms Treatment Notes Iatrogenic Pathophys Risks Symptoms Treatment Notes Not otherwise specified

1.5. General Workup

1.5.1. H&P History When it started Associated symptoms Medical/Surgical history Family history ObGyn History (paps, pregnancies, etc.) Medications Allergies Social history Physical/ROS Signs of anemia B-symptoms Pelvic Exam

1.5.2. Tests Pap smear Biopsy anything suspicious (r/o cancer) Pelvic/TV US Mass = f/u sonohysterogram or hysterosalpingogram

1.5.3. Labs ß-hCG (pregnancy and malignancy) CBC Prolactin TSH FSH STI panel Hyperandrogenism? Total testosterone Early morning 17-hydroxyprogesterone

2. Vulvar/vaginal Benign Disease

2.1. Infectious

2.1.1. Bacterial Vaginosis Pathophys Decreased lactobacilli results in increased anaerobes like gardnerella and bacteroides Risks Smoking Douching New sexual partner Recent BSA Symptoms Most common cause of vaginal discharge (grey, thin) Fishy odor 50-75% are asymptomatic Does not generally cause inflammatory symptoms by itself (book says ~25% will have vulvar irritation) Treatment Metronidazole 500mg BID for 7 days Alternatively topical clindamycin Notes Potential Complications of Untreated BV No need to treat partner "Gold standard" for diagnosis is gram stain, but diagnosis is more often made clinically

2.1.2. Trichomoniasis Pathophys Protozoan STI Risks Multiple sex partners Symptoms Frothy, copious discharge that is foul smelling and sometimes green Itching Burning Dyspaerunia Dysuria Vulvar edema/erythema "Strawberry" cervix Petechiae (uncommon) Often asymptomatic Treatment Metronidazole 2 grams, PO, once; or 500mg BID for 7 days Treat partner also Re-test in two weeks or so (NAAT) Notes Left Untreated During pregnancy Diagnostics

2.1.3. Candidiasis Pathophys Typically due to candida albicans Candida is part of normal vaginal flora in ~25% of women Not typically due to opportunistic infection Risks Multiple sexual partners Diabetes Recent antibiotic use (loss of lactobacillus) Increased estrogen levels Immunosuppression Genetic predisposition Obesity Tight clothing/panty liners Symptoms Vulvar Itching Vulvar Erythema Cottage cheese/white discharge (but sometimes thin, watery, loose) Soreness Vulvar excoriation/fissures Dyspaerunia Treatment Uncomplicated Complicated Pregnancy Notes Specific Diagnostics Boric acid tablets are used in some specific types of candidal infections, but are used vaginally. Taking these orally can be fatal! Oral Fluconazole associated with miscarriage at high doses, but is safe for pregnant women at the low therapeutic dose used for candidiasis

2.1.4. Pelvic Inflammatory Disease Pathophys Acute and subclinical infection of upper genital tract (fallopian tubes) Spectrum of infection, no single diagnostic gold standard Can lead to tuboovarian abscess May lead to scarring or Fitz-Hugz Syndrome Risks Sexual activity Prior history of PID Prior/current history of STD First 12 weeks of pregnancy Anything that increases risk of infection Symptoms Lower abdominal pain Dyspareunia AUB Lower abdominal tenderness Acute cervical motion, uterine, and adnexal tenderness on bimanual pelvic exam Purulent discharge Fitz-Hugh Curtis Syndrome (perihepatitis) Infertility Pelvic organ tenderness is a defining symptom of acute PID Fever WBCs on microscopy Treatments Ceftriaxone/Cefoxitin + Doxycycline (10-14d) = "Foxy Doxy" F/u within 48-72 hours if treating outpatient If pregnant, use azithromycin instead of doxycycline ("Foxy Zee at the Metro") Notes Specific Diagnostics Indications for Hospitalization Permanent Complications

2.1.5. General Workup Swab + wet prep Swab + KOH slide pH test UA + culture + microscopy Vaginal discharge culture + gram stain NAAT

2.1.6. STI Screenings <25 screen for gonorrhea/chlamydia >25 screen if new/multiple partners or partner w/ new confirmed STI Pregnant = screen for syphilis, gonorrhea, chlamydia, HIV, and HBV in 1st trimester Repeat 3rd trimester for high risk patients Age 13-64 screen for HIV at least once, repeat annually if high risk Men who have sex w/ men = annual gonorrhea/chlamydia screen Injection drug use or unsafe sex = screen for HIV annually

2.1.7. Herpes Simplex Virus HSV1 Oral or genital lesions HSV2 Genital lesions Symptoms Pain + Urinary retention Treatment Acyclovir, Famciclovir, or valacyclovir

2.2. Noninfectious

2.2.1. Lichen Sclerosis Symptoms White, thin skin Shrinkage of labia +/- pruritis Complications 10-15% risk to turn into cancer in postmenopausal women Diagnostics Biopsy, always Treatment Potent topical corticosteroids Topical antihistamines

2.2.2. Lichen Planus Symptoms Multiple shiny, flat, purple papules Pruritis Adhesions Vaginal stenosis Wickham striae Dyspaerunia Treatment Potent topical steroid (sometimes systemic steroids), applied nightly, is first-line Estrogen cream No cure, so education/support important F/u in 3-4 weeks Diagnostics Biopsy

2.2.3. Lichen Simplex Chronicus Pathophys Reactive change to chronic itching, typically only one side Symptoms Severe itching, worse at night Thick white skin w/ scaling Treatment Topical steroids

2.2.4. Adenosis Pathophys Extracervical lesion consisting of columnar epithelium, often associated with DES exposure Symptoms Palpable red spots/patches in upper third of vagina Otherwise asymptomatic Treatment None Management Biopsy to rule out cancer

3. Abnormal Pap Smear

3.1. Stats

3.1.1. HPV implicated in almost all cases

3.2. Notes

3.3. Abnormal Results

3.3.1. Atypical Squamous Cells of Unknown Significance (ASCUS) Do HPV DNA test (+) (-)

3.3.2. Atypical Squamous Cells, Cannot Exclude High Grade Squamous Intraepithelial Lesion (ASC-H) Colposcopy

3.3.3. Low-grade Squamous Intraepithelial Lesion Colposcopy

3.3.4. High-grade Squamous Intraepithelial Lesion Colposocpy

3.3.5. Over 35 years old or risk factors for endometrial cancer? Get endometrial biopsy

3.4. Consequences

3.4.1. HPV usually causes squamous cell carcinoma of the cervix (typically at the transition zone)

3.4.2. Many pap smear abnormalities (ASCUS, ASCH, and LSIL) may regress over the next year

3.5. Colposcopy

3.5.1. Looking for acetowhite epithelium (turns white with acetate wash), mosaicism, punctuations, and atypical vessels Biopsy these areas CIN I CIN II CIN III = all the way through from basal cells to surface Squamous Cell Carcinoma in Situ (all the way through the basement membrane)

3.6. Cervical Cancer Risk Factors

3.6.1. HPV Detectable in 99.7% of cervical cancers

3.6.2. Low SE status

3.6.3. OCP use

3.6.4. Smoking (squamous specifically)

4. Preterm Labor

4.1. Definition

4.1.1. Delivery from 20-37 weeks of EGA

4.1.2. Labor = contractions + cervical changes

4.2. Stats

4.2.1. Contributes to 35% of 1st year of life mortalitiy

4.2.2. 70% of neonatal demise

4.3. Newborn Complications

4.3.1. Respiratory Distress

4.3.2. Infection

4.3.3. Intraventricular Hemorrhage

4.4. Risk Factors

4.4.1. Prior h/o preterm birth

4.4.2. Short cervical length <2.5 cm

4.4.3. Cervical surgery

4.4.4. Smoking

4.4.5. Drinking

4.4.6. Low maternal BMI

4.4.7. Adolescence

4.4.8. Chorioamnionitis

4.4.9. Preeclampsia

4.5. Clinical Features

4.5.1. Often PROM Always start antibiotics if PPROM (ampicillin)

4.6. Treatment/management

4.6.1. 24-34 weeks EGA Corticosteroids Short-term tocolytics CCBs NSAIDs ß-agonists Magnesium sulfate Contraindications Magnesium sulfate if <32 weeks Goal is to try to make it to 34 weeks if possible, otherwise reduce risk of RDS

4.6.2. >34 weeks EGA Admit for potential delivery If stable and no labor progression, d/c home w/ close followup If progresses, go ahead and deliver

4.6.3. Progesterone Therapy Inhibits cervical ripening Can give to women w/ h/o preterm birth or short cervix

4.6.4. GBS If PPROM or GBS unknown, start penicillin prophylaxis

5. Preeclampsia

5.1. Criteria (Uncomplicated PreE)

5.1.1. New onset, 20 wk+ BP of 140/90 or higher (either SBP or DBP) on two separate readings 6 hours apart + any of the following: New onset proteinuria (>300 mg in 24 hours or urine protein:Cr ratio >0.3) Any other sign of end organ damage Thrombocytopenia Impaired LFTs Renal Insufficiency (Cr >1.1) Pulmonary Edema New Onset Cerebral or Visual Disturbance

5.2. Criteria (Severe PreE)

5.2.1. Systolic BP 160 or higher or diastolic 110 or higher on two occasions 4 hours apart

5.2.2. Any other sign of end organ damage Also may see severe epigastric/RUQ pain AMS Dyspnea Stroke (hemorrhagic)

5.3. Risk Factors

5.3.1. Nulliparity

5.3.2. AMA

5.3.3. African American

5.3.4. Prior h/o preeclampsia or family h/o

5.3.5. Chronic HTN

5.3.6. Chronic renal disease

5.3.7. Obesity

5.3.8. Antiphospholipid Syndrome

5.3.9. Diabetes

5.3.10. Multifetal pregnancy

5.4. Routine Workup

5.4.1. Establish baseline BP and urine protiein Get BP and protein at first visit Record BP at every visit Urine dipstick at every visit for protein and signs of infection Repeat any high BP reading to confirm

5.4.2. Detailed H&P Screen for PreE symptoms (HA, abdominal pain, visual disturbances) Personal history of HTN and CVD issues Family history of HTN and CVD issues Risk factors (smoking, drugs, lifestyle, etc.)

5.4.3. Prevention Low dose ASA from 12 weeks

5.4.4. Normal routine screenings and perinatal care

5.5. Management of Preeclampsia

5.5.1. Uncomplicated Preeclampsia Close observation Are baby and mom stable? Regular checks Deliver at term ~37 weeks Consider magnesium sulfate on case-by-case basis Note: Magnesium is eliminated by the kidneys and should be stopped 24 hours postpartum

5.5.2. Severe (Complicated) Preeclampsia Stabilize maternal status BP > 160 SBP or > 110 DBP Assess for maternal/fetal threats PulseOx, Labs, Fetal Strip Review of symptoms Assess fetal weight, FHR pattern, and/or BPP Assess for potential delivery window 34 weeks or more GA = give magnesium and deliver Less than 34 weeks

5.6. Complications

5.6.1. Maternal Complications End organ damage AKI Liver damage Coagulopathy Seizure Stroke

5.6.2. Fetal Complications IUGR Preterm birth

5.7. DDX

5.7.1. Chronic HTN BP 140/90+ before pregnancy or at less than 20 weeks, or persisting more than 12 weeks postpartum Risk of IUGR, fetal demise, placental abruption, and preeclampsia

5.7.2. Gestational HTN HTN w/o proteinuria or other features of preeclampsia at > 20 weeks gestation

5.7.3. Eclampsia PreE + seizures

5.7.4. HELLP Syndrome Hemolysis, Elevated Liver enzymes, Low Platelets, thought to be a subset of severe PreE

5.7.5. Posterior Reversible Encephalopathy Syndrome

5.7.6. Superimposed Preeclampsia Preeclampsia in a patient with preexisting chronic HTN

5.7.7. Superimposed Preeclampsia with Severe Features Preeclampsia w/ severe features in a patient with preexisting chronic HTN

5.7.8. Preeclampsia with Severe Features Worsening vasospasm results in end organ damage usually requiring delivery of the baby regardless of GA

5.8. Stats

5.8.1. 90% of cases occur late in pregnancy (>34 weeks)

5.8.2. 10-25% of Gestational HTN cases go on to become preeclampsia

5.8.3. Overall incidence rate of preeclampsia in the US is ~5%

5.8.4. ~25% of women with preeclampsia develop severe features

6. 3rd Trimester Bleeding

6.1. Generally

6.1.1. RhoGam recommended if mom is RhD(-)

6.1.2. If bleeding is severe IV access Type & Screen Notify blood bank of need for tfx IVF resuscitation RhoGam KB test can tell you how much is needed Prepare OR for possible delivery/lap

6.2. DDX

6.2.1. Placenta Previa (or vasa previa) Risk Factors Prior c-section Uterine surgery Multiparity Smoking AMA Prior previa Symptoms Sudden and profuse painless vaginal bleeding in 3rd trimester Diagnostics DO NOT DO A VAGINAL EXAM UNTIL PLACENTAL LOCATION CONFIRMED BY ULTRASOUND TAUS/Pelvic US --> TVUS (if dx early, get another one in 3rd trimester as some spontaneously resolve) Treatment/Management Fetal distress Stable

6.2.2. Placental abruption Risk Factors Chronic HTN Preeclampsia Cocaine H/o abruption Meth Trauma Rapid decompression of an overdistended uterus Elevated AFP in 2nd trimester Symptoms Severe abdominal pain Vaginal bleeding +/- strong contractions Abnormal FHT Diagnostics Often clinical TAUS/TVUS Confirmed by placental exam after delivery (retroplacental clot + placental necrosis) Treatment Small and Asymptomatic Big or Symptomatic

6.2.3. Uterine Rupture Risk Factors Prior C-section (especially classical) Overuse of oxytocin External cephalic version Ehlers Danlos Syndrome Symptoms Sudden, severe abdominal pain Vaginal bleeding Abnormal FHT Regression of fetal parts Treatment/Management Immediate laparotomy for repair + c-section delivery UAE and hysterectomy if bleeding can't be controlled

7. Adnexal Mass

7.1. Ovarian

7.1.1. Cancer Notes Most lethal gynecological cancer 3rd most common gynecological cancer Pathophys Originate from epithelial cells (most common), germ cells, or ovarian stroma Risk Factors BRCA 1/2 (biggest risk) Other FHx (1st degree relative) H/o breast cancer Early menarche Late menopause Nulliparity Late 1st pregnancy Protective Factors OCPs Breastfeeding Multiparity Chronic anovulation Hysterectomy Tubal ligation Diagnostics Pelvic US Labs Treatment/Management Surgery Chemo in some cases

7.1.2. Cyst Types Follicular cyst Corpus luteum cyst Theca lutein cyst Complications Torsion (waxing and waning pain and nausea) Rupture (acute abdominal pain) Diagnostics Pelvic US Pelvic exam Treatment/Management Premenarchal/Postmenopausal Otherwise

8. Ectopic Pregnancy

8.1. Pathophys

8.1.1. Extrauterine pregnancy, 96% of the time in the fallopian tube

8.2. Risk Factors

8.2.1. IVF

8.2.2. Prior ectopic pregnancy

8.2.3. PID or other genital infections

8.2.4. Infertility

8.2.5. Tubal surgery

8.2.6. Prior sterilization w/ sterilization failure

8.2.7. Smoking (dose-dependent)

8.2.8. In utero DES exposure

8.2.9. Vaginal douching

8.2.10. Advanced age

8.3. Symptoms

8.3.1. 1st trimester vaginal bleeding w/o apparent intrauterine pregnancy

8.3.2. abdominal pain

8.3.3. may be asymptomatic!

8.3.4. amenorrhea

8.3.5. hemodynamic instability + acute abdomen not otherwise explained

8.3.6. other pregnancy signs/symptoms

8.4. Workup

8.4.1. TVUS Looking for Intrauterine/extrauterine mass or pregnancy Intraperitoneal bleeding Confirm location of extrauterine pregnancy if present

8.4.2. ß-hCG If the patient is stable, repeat in two days. If ß-hCG has risen <35% then likely ectopic pregnancy.

8.4.3. Uterine aspiration w/o products of conception (ancillary diagnostic)

8.4.4. Type & Screen

8.4.5. CBC

8.5. Treatments

8.5.1. Stable First-line Methotrexate Second-line Laparoscopic Surgery

8.5.2. Unstable Transfer to hospital for resuscitation and stabilization May need to stabilize there and then w/ IV access, IV fluids, blood products Emergent laparoscopic surgery Salpingostomy Salpingectomy Type & Screen + RhoGam if RhD(-) FAST If (-) then unlikely to be a ruptured ectopic

8.5.3. Follow-up Must track ß-hCG post-treatment/surgery weekly to confirm that levels decline If ß-hCG fails to decline, treat with methotrexate until resolved

8.6. Notes

8.6.1. Almost all spontaneous pregnancies following surgical treatment of ectopic pregnancy occur in the first 18 mo following the procedure

8.7. DDX

8.7.1. Physiologic (actual pregnancy w/ implantation bleeding)

8.7.2. Spontaneous abortion

8.7.3. Other pathology like a polyp

8.7.4. Subchorionic hematoma

8.7.5. Gestational trophoblastic disease

9. Endometriosis

9.1. Pathophys

9.1.1. Endometrial glands outside the uterus (often ovaries, peritoneum, pelvis)

9.1.2. Frequent cause of pelvic pain of women in 30s

9.1.3. Retrograde menstrual flow

9.1.4. Estrogen-dependent

9.2. Risk Factors

9.2.1. FHx

9.2.2. Nulliparity

9.2.3. Prolonged exposure to exogenous estrogen

9.2.4. Early menarche

9.2.5. Late menopause

9.2.6. Short menstrual cycles (<27 days)

9.2.7. Heavy menstrual bleeding

9.2.8. Obstructions to menstrual outflow

9.2.9. Physical/Sexual abuse in childhood/adolescence

9.2.10. Trans unsaturated fats

9.2.11. Atherosclerotic disease

9.3. Symptoms

9.3.1. Endometrioma Ovarian cyst ("chocolate cyst") made of ectopic endometrial tissue filled with old blood

9.3.2. Pelvic pain (dysmenorrhea or dyspareunia) Often, but not always, cyclic Tenderness on physical exam

9.3.3. Infertility

9.3.4. Urinary/GI symptoms

9.3.5. "Powder burn" lesions

9.3.6. Often subside during pregnancy But increases risk of preterm birth

9.4. Diagnosis

9.4.1. Definitively diagnosed by histology of laparoscopic biopsy

9.4.2. Can achieve presumptive diagnosis based on symptoms, signs, and imaging

9.4.3. TVUS/Pelvic US

9.4.4. Visual inspection

9.4.5. Staged I-IV by severity

9.4.6. Bimanual pelvic exam

9.5. Treatment

9.5.1. Mild-moderate pain but no evidence of endometrioma NSAIDs + OCPs for medical management as long as possible Reassess 3-4 mo after start of tx If still symptomatic, consider oral northindrone or depot medroxyprogesterone

9.5.2. Severe pain interfering with daily life or that is refractory Trial of GnRH analog (leuprolide) + hormonal therapy If still refractory, only then try aromatase inhibitors Offer laparoscopic diagnosis and treatment OCPs afterward to suppress recurrence Hysterectomy + BSO and excision of extrauterine lesions is definitive, but consider ablation + local excision for more conservative management (esp. if fertility is at issue)

9.5.3. Endometriomas Symptomatic or expanding endometriomas should be surgically removed Asymptomatic and small endometriomas can be left in place w/ medical management

9.6. Notes

9.6.1. Affects ~10% of women

9.6.2. Increases risk of epithelial ovarian cancer (EOC)

10. Contraception

10.1. Progestin Only Birth Control

10.1.1. Progestin Side Effects Irregular uterine bleeding/spotting Amenorrhea Weight gain Mood changes Bone loss (w/ long-term depot medroxyprogesterone)

10.1.2. Progestin IUD Contraindications Pregnancy Endometrial or cervical cancer/hyperplasia Unexplained vaginal bleeding Gestational trophoblastic disease Distorted endometrial cavity Acute pelvic infection Active liver disease Active breast cancer

10.2. Combined Hormone Contraception

10.2.1. Combined Estrogen-Progestin Side Effects Nausea Breast tenderness Headache Unscheduled bleeding Amenorrhea Mild BP increase Increased VTE risk (3x-5x) MI and Stroke Increase triglycerides

10.2.2. Contraindications Age 35+ and smoking 2 or more CV disease risk factors (old age, smoking, diabetes, HTN) HTN (sys 140+ or dia 90+) Prior hx of VTE Known thrombogenic mutations Prior MI/Stroke or complicated heart disease Breast cancer Cirrhosis Migraine w/ aura Hepatocellular adenoma or malignant hepatoma

10.2.3. Notes Works by increasing estrogen and progesterone so HPA axis is inhibited, resulting in less LH/FSH which normally trigger ovulation Most effective if taken at the same time every day

10.3. Non-hormone Contraception

10.3.1. Copper IUD Contraindications Wilson Disease Pregnancy Endometrial or cervical cancer/hyperplasia Unexplained vaginal bleeding Distorted cavity Acute pelvic infection

10.4. Plan B

10.4.1. Big dose of progesterone that prevents ovulation and alters the lining of the uterus to make implantation less favorable

10.4.2. Must be taken within 72 hours to work

11. Normal Prenatal Care

11.1. Vaccines

11.1.1. Flu (IM) okay during pregnancy

11.1.2. Hep B okay during pregnancy

11.1.3. MMRV (most important to get before pregnancy, cannot be given during!)

11.2. Scheduled Visits (Uncomplicated)

11.2.1. Visit Schedule q4w until 28 weeks q2w from 28-36 weeks q1w from 36w-delivery

11.2.2. 1st Trimester 10 week visit (initial prenatal encounter) Baselines

11.2.3. 3rd Trimester Gestational DM High risk patients screen earlier 1-hr GTT 140 or higher Alloimmunization Type & Screen Maternal Anemia Low-end of Normal Maternal Hgb at 28 weeks is 10 Usually iron deficiency anemia Get iron studies w/ ferritin Tx is iron supplement Infectious GBS Screen at 35w

12. Preventative Care/Maintenance

12.1. Breast

12.1.1. Stats 2nd most common malignancy in women 2nd most common cause of cancer death

12.1.2. Risk Factors #1 Age Lifetime risk 1 in 8 FHx and Genetics 1st degree relative Early menarche / late menopause Nulliparity Radiation Dense breasts

12.1.3. Screenings Start mammograms at 40yo, annually (ACOG)

12.2. GU

12.2.1. Contraception

12.2.2. STI Screening <25 = chlamydia/gonorrhea screen HPV typically transient, do NOT screen under age 30 (unless good reason) Cervicitis then test for: PID Chlamydia Gonorrhea Trichomoniasis HIV HBV and HCV if at risk population

12.2.3. Cervical Cancer Risk Factors Immunosuppression HPV Smoking Early coitarche Screenings Pap w/ cytology from 21-30 every 3 years Pap w/ cytology + HPV from 30-65 every 5 years (cytology alone every 3) 65+ w/ 3 normal paps in the last 10 years = stop screening Prevention HPV vaccine given between ages 9-26

12.2.4. Pap smears Remember that endometrial cells are not reported until age 45, at which point they are an abnormal finding

12.3. Other

12.3.1. Domestic Violence

12.3.2. Colorectal Disease Start colonoscopies at 50, every 10 years (45 if AA)