womens health

pap

CELLS SCRAPED FROM CERVIX

EXAMINED UNDER MICROSCOPE

LOOK FOR HPV NUMBER ONE CAUSE OF CERVICAL CA

WOMEN 21-29

PAP EVERY 3 YEARS

HPV TESTING NOT RECOMMENDED

WOMEN 30-65 YEARS

PAP TEST ONLY - NORMAL =3 YEARS

HPV NORMAL =5 YEARS

HPV + PAP ( PREFERRED) NORMAL =5 YEARS ODGERS SLIDES

CERVICAL CANCER SCREENING DECREASED CERVICAL CANCER BY 70%

EXFOLIATED CERVICAL CELLS FOR CYTOLOGIC STAINING AND EXAM

2.1% REVEAL CYTOLOGIC ABNORMALITIES

MAJORITY OF WOMEN W CERVICAL CANCER DID NOT HAVE PAP OR DID NOT HAVE IN LAST 5 YEARS

HPV TYPES 16 AND 18 CAUSE 70% OF ALL CERVICAL CANCERS

HPV 6 AND HPV 11 CUASE GENITAL WARTS

MOST COMMON STI

DO NOT NEED PENETRATIVE INTERCOURSE , CAN BE TRANSMITTED THROUGH DIRECT SKIN AND MUCOUS MEMBRANES TO PARTNER

ONLY A SMALL PROPORTION OF WOMEN WITH HPV PROGRESS TO CERVICAL CANCER

NOT PRESENCE BUT PERSISTENCE OF HPV INFECTION IS THOUGHT TO LEAD TO CANCER

NOT DURING MENSES

NOT WITHN24-48 HOURS OF SEX

NOT WHEN TOPICAL VAGINAL MEDS USED

OBTAIN FROM THE TRANSFORMATION ZONE OF THE CERVIX

XTERNAL CERVIX (ECTOCERVIX) IS STRATIFIED SQUAMOUS EPITHELIUM

INTERNAL ( ENDOCERVIX) IS MUCUS SECRETING COLUMNAR EPITHELIUM

METAPLASIA -NORMAL CELL METAMORPHOSIS FROM COLUMNAR TO SQUAMOUS - IS THE SQUAMOCOLUMNAR JUNCTION-THIS IS TRANSFORMATION ZONE -THIS IS WHERE YOU TAKE THE SAMPLE FROM

. Cervical neoplasias most often occur at the squamocolumnar junction (SCJ) and affect squamous epithelial cells (80-90% of cervical cancers)

PAP IS SCREENING TEST

BIOPSY IS DIAGNOSTIC TEST

BETHESDA CLASSIFICATION

TWO SYSTEMS

LOW GRADE-SQUAMOUS INTRA EPITHELIAL LESION( LSIL)

AND HIGH GRADE (HSIL)

NOTE: HSIL IS A PRECURSOR LESION THAT HAS THE POTENTIAL TO DEVELOP SQUAMOUS CA

PRECANCEROUS STATE IS CALLED CIN cervical intraepithelial neoplasia

ASYMPTOMATIC EARLY STAGES

ABNORMAL VAGINAL BLEEDING 80-90%

WATERRY PURULENT MALODOROUS VAGINA DISCHARGE

DYSPAREUNIA

POSTCOITAL BLEEDING

BLADDER OUTLET OBSTRUCTION

PELVIC BACK ABDOMINAL PAIN ( TUMOR INVASION)

SWELLING OF LEGS 2/2 OBSTRUCTION LYMPHATIC OR VASCULAR

CONSTIPATION

SEVERE CERVICITIS

POLYP OR NABOTHIAN CYST

ENDOMETRIAL CA

VAGINITIS

PID

ENDOMETRIOSIS

CERVICAL ECTROPION

PAP TEST W HPV W TRANSORMATION ZONE COMPONENT FOUND

HPV TESTING >5

STD TESTING WET MOUNT

COLPOSCOPY W ENDOCERVICAL CURETTAGE(ecc)

LOOP ELECTROSURGICAL EXCISION PROCEDURE

COLD KNIFE CONE BIOPSY

ENDOMETRIAL BIOPSY >34 YO

CBC

CHEM

RENAL AND HEPTIC FUNCTION TESTS

MRI, CT CXR PET

CIN 1 AND CIN 2 COLPSOCPY AND CLOSE OBSERVATION UNTIL RESULTS NORMAL

EXPEDITED SURGICAL RX FOR HSIL -EXCISION OVER ABLATION

• Gynecologist

• Surgical oncologist

• Gynecologic oncologist

• Radiation oncologist

• Radiologist

• Pelvic floor physical therapist

• Psychologists, social workers

PROTECTS AGAINST OROPHARYNGEAL AND RECTAL CANCERS FROM HPV

PRE TEEN VACCINE, 11-12 YEARS

TEENS -> 26 YEARS WHO DIDNT START OR FINISH VACCINE SHOULD HAVE VACCINATION

GUIDELINES:

11-12 YO TWO DOSES HPV V 6 -12 MONTHS APART

9-14 YO TWO DOSES

15-26 3 DOSES

9-14 <5 MONTHS APART 3RD DOSE

9-26 WEAK IMMUNE - 3 DOSES

2018 FDA

MALE AND FEMALE UP TO 45 CAN GET VACCINE, COVERS ALL NINE TYPES

LIKELY TO HAVE BEEN EXPOSED TO SOME STRAINS BUT NOT ALL

VACCINE DOES NOT TREAT EXISTING DISEASE

SCREENING CONTINUES EVEN IF VACCINATED

MAY NEED:

BIOPSY R/O DYSPLASIA /CA

TEST FOR OTHER STI

TREATMENT

PODOFILOX GEL 0.5 %

TRICHLOROACETIC ACID TCA BCA

CRYOTHERAPY OR SURGICAL EXCISION

avERage age 51 in us (45-55)

1 YEAR NO PERIOD

AGE OF ONSET FACTORS

NATURAL DECREASE IN HORMONES

CHEMO/RADX

PRIMARY OVARIAN INSUFFICIENCY (POI)

HYSTERECTOMY

SLEEP DISTURBANCE EARLY M. 32-40%

LATE M 38-46

DEPRESSION

>2.5X

ANXIETY

VAGINAL DRYNESS

ATROPHIC VAGINA

SEXUAL DYSF

HEADACHE /FATIGUE

DYSPAREUNIA

HAIR LOSS

DRY EYES

GINGIVAL THINNING

BONE AND JOINT PAIN

SKIN THINNING

SPONTANEOUS

NATURAL

OVARIAN FOLLICULAR FUNCTION ENDS

PERIMEN

TRANSITIONAL PERIOD TO MENOPAUSE

CAN BE MANY YEARS: IRREGULAR PERIODS, NIGHT SWEATS, SHORTER PERIODS

PREMATURE

GENETIC AUTOIMMUNE METABOLIC

AGE 40 OR YOUNGER

POI

<AGE 40

ABSENT SKIPPED INCONSISTENT PERIODS

PREGNANCY

THYROID DEFICIENCY

HYPOTHALAMIC DYSFUNCTION

HYPERPARATHYROIDISM

POI

PITUITARY ADENOMA

PCOS

DM

DETAILED HISTORY

MENSTRUAL CALENDAR

SYMPTOMS HOT FLASH DRYNESS ETC

SEX HISTORY OF DYSPAREUNIA, REDUCED LIBIDO

VAGINAL EXAM FOR ATROPHY DRYNESS

LABS

VARIES BY AGE AND PRESENTATION

PREGNANCY TEST

FSH

PROLACTIN

TSH

PERIMENOPAUSE

ESTROGEN NORMAL FSH GETS HIGHER

MENOPAUSE < ESTROGEN> FSH >LH

NO PERIOD FOR YEAR AND FSH > 30 = MENOPAUSE DX( ALTHOUGH HISTORY SUFFICES AS DX)

FSH >30 PERIMENPAUSE

FSH >70-90 COMMON POST MENOPAUSAL

>45 YO NO LABS NEEDED

40-45 LABS TO EXCLUDE OTHER DX

PREGNANCY, PROLACTIN. TSH

<40 ??POI

PREGNANCY , PROLACTION,TSH FURTHER TESTING

UTERUS + ESTROGEN AND PROGESTERONE OR > RISK UTERINE CA

ORAL ESTROGEN

LOW COST GOOD EFFECT ON LDL HDL CHOL

> RISK THROMBOSIS STROKE > TRIGLYCERIDES, CRP < LIBIDO

TRANSDERMAL AND TOPICAL ESTROGEN

AVOID FIRST PASS SO LESS S/E LIVER TRIG, CRP LIBIDO REDUCTION, GI S/E

COSTLY PATCH SENSITIVITY, TRANSFER HORMONES

VAGINAL ESTROGEN

VAGINAL BENEFIT ONLY

PROGESTERONE

RELAXES HELPS SLEEP

INCREASE BREAST CA RISK - CHECK LATEST ACOG GUIDELINES ON THIS

BLOATING DYSPHORIA CAN OCCUR

PORPHYRIA CUTANEA TARDIS- ABSOLUTE CONTRAINDICATION

PREGNANCY

BREAST CA PAST OR PRESENT

ESTROGEN SENSITIVE MALIGNANCY

ENDOMETRIAL HYPERPLASIA

UNDIAGNOSED VAGINAL BLEEDING

ACTIVE LIVER DX

UNTREATED HTN

VENOUS/ARTERIAL THROMBOEMBOLISM.

FDA APPROVED

SSRI PAROXETINE 7.5MG

OFF LABEL

SSRI SNRI

GABAPENTIN NIGHTLY TO 4 X DAY

CLONIDINE FOR HOT FLASHES 0.005MG OD S/E PROFILE NOT GOOD

VITS AND MINERALS

IRON

CALCIUM

VIT D

HOT FLASH

NO SPICY HOT CAFFEINE DRINKS

WICKING CLOTHING

LOW FAT HIGH CALCIUM DIET

BED FAN

ANX AND DEP

YOGA

MEDITATION

BIOFEEDBACK

CBT ACUPUNCTURE REFLEXOLOGY

VAGINA

KEGELS

WEIGHT AND EXERCISE

F/U AND EDUCATION

1-2 MONTHS AFTER DRUG THERAPY FOR EFFECTIVENESS

EDUCATION-LIGHT SPOTTING NORMAL

CONTINUE WITH NORMAL SCREENINGS

RED FLAGS

POST MENOPAUSE BLEEDING - UTERINE LINING ABNORMALITIES OR CA

CHIEF COMPLAINT FOR MOST VULVAL DISORDERS

OFTEN MISDIAGNOSED OR PT NOT EXAMINED

COMMON CAUSES

VAGINITIS

STI

NEOPLASM

BARTHOLIN DUCT CYSTS

CANDIDA(ME)

OTHER CONDITIONS

TB

VULVAR PSORIASIS-UNUSUAL PRESENTATIONS-LOOK FOR NORMAL PRESENTATION ELSEWHERE ON BODY

CROHNS

ENDOMETRIOSIS

IMPORTANCE OF FULL VAGINAL EXAM, MAGNIFYING GLASS OR COLPOSCOPE MAY BE NEEDED

AUTOIMMUNE WEAK LINK ASSOC W DM TYPE 1 VITILIGO PERNICIOUS ANEMIA,ALOPECIA AREATA,THYROID DX

WOMEN : MEN 10:1

MENOPAUSEAL

AND PRE PUBERTY GIRLS-ESTROGEN RELATED THEORY NOT PROVEN

SEVERE VULVAR PRURITUS

DYSPAREUNIA

KEYHOLE EFFECT/FIGURE 8 APPERANCE

NARROWED INTROITUS

OBLITERATION OF LABIA MINORA

WHITE PAPULES

THN WHITE EPITHELIUM-PARCHMENT

CAN RESEMBLE HYPERPLASIA

FISSURES AND TELANGIECTASIA CAN OCCUR

THROUGH HISTORY

TIMING ONSET LOCATION AND DURATION

ALLEVIATING/AGGRAVATING

PHYSICAL EXAM WITH MAGNIFYING GLASS OR COLPOSCOPE

PUNCH BIOPSY FOR DIAGNOSIS AND RR/O ATYPIA

(PUNCH BIOPSY FINDINGS:

HYPERKERATOSIS

EPITHELIAL THINNING

CYTOPLASMIC VACUOLATION OF BASAL LAYER CELLS

FOLLICULAR PLUGGINGHOMOGENOUS SUBEPITHELIAL LAYER

INFLAMMATORY CELL INFILTRATION W LYMPHOCYTESAND FEW PLASMAN CELLS)

CBC- F INFECTION SUSPECTED

THYROID FUNCTION TESTS

ANA

B12 LEVEL ( PERNICIOUS ANEMIA)-AUTOIMMUNE TESTING MAY NOTT BE DONE AS WEAK LINK

LICHEN PLANUS

ATROPHIC VAGINITIS

CONTACT/ALLERGIC DERMATITIS

FUNGAL INFECTION

VITILIGO

ULTRA POTENT CORTICOSTEROIDS 4-6 WEEKS

CLOBETASOL

HALOBETASOL

BETAMETHASONE DIPROPIONATE AUGMENTED 0.05% OINTMENT

THIN LAYER 1-2 X DAILY 2-4 WEEKS THEN 3 X WEEK FOR MAINATENANCE

INTERESTING THAT VULVA IS NOT SUSCEPTIBLE TO LONG TERM TOPICAL CCS ATROPHY AND SKIIN THINNING-VULVA CAN TOLERATE LONG TERM SUPERPOTENT STEROIDS

IF RECURS SWITCH TO MILDER

EG BETAMETHASONE VALEARATE 1% HIGH POTENCY

OR TRIAMCINOLONE 0.1 %

OR FLUOCINOLONE ACETONIDE 0.025% ( MODERATE POTENCY )LONG TERM MGT

ABX TOPICAL-

MILD INFECTION

TOPICAL ESTROGEN

ORAL ANTIHISTAMINE

HYDROXYZINE 25-50 MG OR BENADRYL

IMMUNOSUPPRESSANT -TOPICAL CALCINEURIN INHIBITORS, RETINOIDS- ACITRETIN

COOL COMPRESSES

COTTON CLOTHING

LOOSE FITTING CLOTHES

REFERRAL

PUNCH BIOPSY RESULTS INDICATE HYPERPLASIA OR APLASIA ONC GYN

SURGICAL CONSULT FOR SEVERE ARCHITECTURAL CHANGES OR SCARRING

SLIGHT INCREASED CHANCE OF SQUAMOUS CELL CARCINOMA

GYN DERMATOLOGY IF NO RESPONSE TO TOPICAL STEROIDS

LIFETIME DX

WILL GET EXCACERBATION

SEXXUALLY ACTIVE PAIN

https://www.thevpfoundation.org/

https://www.nva.org/

AFFECTS SKIN SCALP MUCOUS MEMBRANES OF MOUTH VAGINA AND VULVA

WOMEN

MOSTLY MIDDDLE AGED,

TCELL MEDIATED DX

CLASSIC

WLL DEFINED WHITE RETICULATED PLAQUES

EROSIVE

ERYTHEMATOUS EROSIVE LESIONS

CAN LEAD TO LEUKORRHHEA AND STENOSIS INTROITUS

MAY BE ARCHITECTURAL CHANGES

PAIN PRURITUS

BURNING DYSPAREUNIA DYSURIA

THOROUGH HISTORY

PHYSICAL MAGNIFYING GLASS , COLPOSCOPY MAY BE NEEDED

BIOPSY:

FINDINGS

CHRONIC INFLAMMATION

LYMPHOCYTES W FEW PLASMA CELLLS

ACANTHOSIS AND THINNING EPITHELIUM

R/O HSV

PCR

AND BECHETS DISEASE-AUTOIMMUNE TESTING

LICHENI SCLEROSUS

ULCERATIVE STI HSV OR SYPHILLIS CHANCROID

BECHETS DX

CONTACT ALLERGIC DERMATITIS

ATROPHIC VAGINITIS

FUNGAL

EXACTLY SAME AS LS

PETROLATUM BARRIER OINTMENT ADDED

OTHERWISE THE SAME

REFER TO PAIN MGT AND GYN DERM IF NO RESPONSE

AGE >30 AND MENOPAUSE

PRURITUS IS HALLMARK SYMPTOM

LSC OR SQUAMOUS CELL HYPERPLASIA- VERY ITHCY , HISTOLOGIC ECZEMATOUS HYPERKERATOTIC,LICHENIFICATION. CHRONIC SCRATCH ITCH

RX CCS TOPICAL TOPICAL BARRIER PETROLATUM

ANTIHISTAMINES DOXEPIN BENADRYL Q NOCTE

TCA-AMITRYPTILLINE FOR ITCH

REFERRAL SAME GYN DERM

MOIST SKIN

URINE

ERYTHEMA AND EDEMA ARE HALLMARK SIGNS

USU NOT VAGINAL DISCHARGE

RX

REMOVE ALLERGEN

CCS TOPICAL

ANTIHISTAMINE - HYDROXYZINE

SITZ BATH EMOLLIENT

BURROWS COMPRESS DOMEBORO ANTIBACTERIAL AND ANTIFUNGAL WRUNG OUT OTC SOLUTION BID

Tight clothing, spandex clothing, synthetic underwear, latex and elastic in clothing

2. Laundry detergent, fabric softener, dryer sheets, bleach

3. Rough, scented, or colored toilet paper; personal wipes

4. Menstrual hygiene and incontinence products including pads, panty liners, and tampons (especially if scented

5. Personal hygiene products including soap, shampoo, conditioner, bubble bath, and shower gel

6. Perfumes, body sprays, deodorants, douches, powders, lotions, creams, hair removal products (wax, razors, shaving cream, depilatories)

7. Urine, feces (especially if incontinent), seminal fluid, sweat

8. Commercial vaginal lubricants, condoms, spermicide

PSORIASIS - LOOK FOR SYMPTMS EXTENSOR

INHERITED NEW SKIN CELLS PRODUCED TOO QUICKLY RED AND SCALY OR SILVER WHITE

NEW PSORIASIS CAN DEVELOP AT AN AREA OF INJURY ( KOEBNER PHENOMENON)

AFFECTS LABIA NOT MUCUS MEMBRANES

CAN PRESENT AS SMOOTH ERYTHEMA NON SCALY INITIALLY

ECZEMA

USUALLY RESULT OF ITCHING

LOOK FOR ECZEMA ELSEWHERE

SEVERE PRUTRITUS LASTING FEW WEEKS

RED RASH ERYTHEMA INDISTINCT BORDERS

IF LEFT UNTREATED CAN LEAD TO LSC AND THICK SCALY PLAQUES SEEN IN SQUAMOUS CELL HYPERPLASIA

OCCURS ACROSS THE LIFE SPAN

SYMPPTOMS WORSE WITH LOWER ESTROGEN AND ATROPHY

LICHEN SCLEROSIS

LICHEN PLANUS

CONTACT DERMATITIS

FUNGA’

USUA CLINICAL EXAM AND HISTORY

PUNCH DIOPSY IF OTHER THINGS RULED OUT

TOPICAL AND INJECTABLE STEROIDS

SEVERE ECZEMA:

POTENT CCS CLOBETASOL 1-2 X DAY FOR 2-4 WEEKS ,TAPER TILL SYMPTOMS RESOLVE

CAN USE LOW POTENCY STEROIDS WHEN APPROPRIATE

TRIAMCINOLONE ACETONIDE INJECTIONS FOR RECALCITRANT

ORAL ANTIHISTAMINES

BENDADRYL

DOXEPIN IS H1 AND H2 RECEPTOR ANTAGONISTANTIHISTAMINE

HYDROXYZINE

DOVONEX OR CALCIPOTRIENE OINTMENT ( VITAMIN D3 PREP ) IS EFFECTIVE

COOL COMPRESES

BURROWS SOLTUION

ULTRAVIOLET TREATMENT- QUESTIONABLE NEED LOW DOSE

LOOSE CLOTHING

AVOID HARSH CLEANSERS

COTTON

REFERRRAL'

DERM GYN PHYSICIAN

VVS

CHRONIC INFLAMMATORY CONDITION

REPRODUCTIVE AGE AND SEXUALLY ACTIVE

8-16% WOMEN UNDER 40

PRIMARY -ONSET AFTER 1STT INTERCOURS OR TAMPON

2NDRY VAGINITIS TREATMENT, POSTPARTUM, HPV

PAIN IN VESTIBULE

EV

VULVAL BURNING AND PAIN, NOT LIMITED TO VESTIBULE

CAN BE NEUROPATHIC -PUDENDAL NEURALGIA , REFLEX SYMPATHETIC DYSTROPHY

TRIGGER EVENT

SUGGESTED FOR BOTH, VULVAR AND VAGINAL YEAST INFECTIONS FREQUENTLY TREATED,CANDIDA AUTOIMMUNE RESPONSE)

INTERSTITIAL CYSTITIS CAN BE CAUSE

ESTABLISHED THAT NOT PSYCHOGENIC

VVS SEVERE PAIN INTROITAL PENETRATION, VIA SEX OR TAMPON, BICYCLE OR HORSEBACK TIGHT CLOTHES

PAIN SECONDS TO DAYS

HX OF FREQUENT CONSULTATIONS

IMPROTANT HISTORY

TRIGGER

IMPACT ON DAILY LIFE

BACK PAIN

BOWEL AND BLADDER FUNCTION

PRIOR VAGINOSIS , CANDIDA INFECTIONS, CYSTITIS

RECTAL PAIN

USU UNREMARKABLE FINDINGS VVS ERYTHEMA AROUND VESTIBULAR GLANDS

SALINE MOISTENED Q TIP TEST FOR SENSITIVITY TO TOUCH

TIP ON CLITORIS LABIA MINORA URETHRA VESTIBULE - BURNING TENDERNESS LEVEL OF DISCOMFORT

NO COLPOSCOPY UNLESS HPV SUSPECTED

INITIAL

COTTON SWAB TEST

LAB

GONORRHEA

CHLAMYDIA

UREAPLASMA

B HEMOTLYIC CUTLRES

KOH FOR YEAST AND VAGINOSIS

STI

CANDIDA

UREAPLASMA

B HEMOLYTIC STREP

NO STANDARD PAIN MEDS OR OPIATES- DO NOT WORK

ANTIDEORESSANT

INTERFERE WITH NEGATIVE PAIN FEEDBACK LOOP

TCA AND SSRI

NOT PRESCRIBED FOR DEPRESSION, PRESCRIBED FOR PAIN

TOPICALS

XYLOCAINE FOR PAIN DURING INTERCOURSE

ESTROGEN CREAM IF MENOPAUSAL

ANTIFUNGA

IF RECURRENT CANDIDA CAN TRY FLUCONAZOLE 150 MG WEEKLY FOR 2 MONTHS THEN BIWEEKLY FOR 2 MONTHS -CAERFUL EVAL FOR DRUG INTERACTIONS EG ORAL HYPOGLYCEMICS, ANTICOAGULANTS

NO TOPICAL ANTIFNGALS- WILL AGGRAVATE

PFE BID BIOFEEDBACK EXERCISES

CHRONIC PAIN MGT

GUIDED IMAGERY

ACUPPUNCTURE

PELVIC FLOOR MUSCLE CAN HAVE INCREASED TONE OR BE ASYMMETRIC IN VVVS ND EV

SEXUAL THERAPIST

MENTAL HEALTH PROVIDER

AVOID VULVAR IRRITANTS

COMMERCIAL LUBRICANTS

4.5 - 8 DAYS

FREQUENCY 24-38 DAYS

IRRGULAR IS A VARIABILITY GREATER THAN 20 DAYS

NORMAL BLOOD LOSS 5-80 ML

80 MLS IS EQUIVALENT TO THREE SOAKED PADS OR SIX TAMPONS A DAY FOR 3 OR MORE DAYS

UTERINE STRUCTURAL ABNORMALITIES

P POLYPS

A ADENOMYOSIS

L LEIOMYOMA

M MALIGANCY AND HYPERPLASIA

UTERINE NON STRUCTURAL ABNORMALITIES

C COAGULOPATHY

O OVULATORY

E ENDOMETRIAL

I IATROGENIC

N NOT OTHERWIE XLASSIFIED

NSAIDS AS PROSTAGLANDIN INHIBITORS

PROSTAGLANDIN PROLONGS UTERINE CONTRACTIONS CAN BE CALLED UTERINE ANGINA AS IT CAN CUASE UTERINE ISCHEMIA

OVARIAN

ENDOMETRIAL

UTERINE

OVARIAN:

ADNEXAL MASS

PELVIC OR ABDOMINAL SYMPTOMS

BLEEDING IS UNCOMMON

UTERINE

AVERAGE AGE IS 60 YO

ADENOCARCINOMAS

TYPE 1

ESTROGEN EXCESS

NO PROGESTERONE TOS USTAIN VASCULARITY OF THICK ENDOMETRIAL WALL SO BLEEDS COMMON

RISK FACTORS

OBESITY-CONVERT TESTOSTERONE TO ESTROGEN

HLD

LOW PARITY

LATE MENOPAUSE

FAVORABLE PROGNOSIS

TYPE 2

NORMAL WEIGHT

POOR PROGNOSIS

BLEEDING POST MENOPAUSE MOST IMPORTANT SIGN

FULLNESS /PRESSURE IN PELVIS

PAINFUL URINATION

DDYSPAREUNIA

PELVIC PAIN

POST COITAL BLEEDING

BIMANUAL PELVIC EXAM

TRANSVAGINAL USS

REFER FOR BIOPSY ENDOMETRIUM

BLEEDING IN POST MENOPAUSAL WOMEN SHOULD BE ASSUMED TO BE CANCER UNTIL PROVEN OTHERWISE

5TH LEADING CAUSE OF DEATH

RISK FACTORS

63 OR OLDER

WHITE

MOST COMMON TYPE IS EPITHELIAL

RISK FACTORS

BRCA 1 AND BRCA 2 GENE MUTATIONS ASSOCIATED WITH OVARIAN CANCER

LYNCH SYNDROME

PEUTZ JEGHERS SYNDROME

LATE MENOPAUSE

NULLIPARITY

EARLY MENARCHE

OBESITY

RED FLAG SIGNS

PELVIC PAIN

ABDOMINAL PAIN

URNIARY URGENCY AND FREQUENCY

INCREASED ABDOMINAL SIZE/BLOATING

EARLY SATIETY

DIFFICULTY EATING

EXAM WONT YIELD ANYTHING

TRANSVAGINAL USS

IF PELVIC MASS REFER

transient or permanent

primary or secondary

PRIMARY

ABSENCE OF SPONTANEOUS UTERINE BLEED AND DELAYED PUBERTY AT AGE 14 OR BY 2 YEARS AFTER SEXUAL MATURATION,BY 16

AVERAGE RANGE 9-16 YEARS AGE 12.7

AGE OF PARENT AT MENARCHE,BODY FAT, NUTRITIONAL STATUS

SECONDARY

MORE COMMON, 1-3 %

25% FEMALE ATHLETES HAVE THE TRIAD: AMENORRHEA,OSTEOPOROSIS AND AN EATING DISORDER

STRUCTURAL-OUTFLOW PROBLEMS

IMPERFORATE HYMEN, CERVICAL STENOSIS, TRANSVERSE VAGINAL SEPTA

CHROMOSOMAL WOMEN NEED TWO X CHROMOSOMES

PRESENCE OF A Y OR FRAGMENT OF Y RESULTS IN GONADAL FAILURE OF SOME TYPE

HYPOTHALAMUS

PROBLMS WI SYNTHESIS OR RELEASE OF GnRH-hypogonadism

HYPOTHALAMUS-PITUITARY-OVARIAN AXIS DISORDERS

LEPTIN PRODUCED BY ADIPOSE TISSUE MAY CONTROL SEX STEROIDS, GONADOTROPHINS ,GNRH WHEN ENERGY DEFICIENT….INTENSE EXECRICSE, EATING DISORDERS,STRAVATION, PSYCHOGENIC STRESS CAN CAUSE DEFICIENT HORMONES AT HYPOTHALAMIC LEVEL 2/2 LO LH THEREFORE LOW ESTEROGEN

ESTROGEN

LOW ESTROGEN LEVEL IN AMENORRHEA

PROLACTIN

HIGH PROLACTIN ANENORRHEA

BREAST FEEDING

PITUITARY TUMORS

RENAL FAILURE

BENZODIAZEPINES

COCAINE

AMITRYPTTILLINE

CAISES ANOVULATION DUE TO IMPAIRED GONDAOTROPHIN PULSATILITY ( LOOK IT UP) WHICH LEADS TO DERANGEMENT OF LH AND ESTROGEN

DRUGS-CHEMO, GABAPENTIN, HEROIN

AUTOIMMUNE-SLE, ADDISONS THYROID LOW OR TOXICITY

HISTORY

AGE AT MENARCHE

FREUQNECY

DURATION

FLOW

LMP

HISTORY OF MISSED MENSES

SEXUAL HX, LAST INTERCOURSEE, BIRTH CONTROL, PARA GRAVIDA

SX HISTORY

FAM HISTORY AGE OF MENARCHE /INFERTILITY

LOOK FOR PAST OVULATORY CYCLES: BREAST TENDERNESS, ABD PAIN, BLOATING, CHANGES IN CERVICAL MUCUS

PMH FOR DM AUTOIMMUNE, RADIATION OR CHEMO , SIGNS OF OSTEOPOROSIS,THYROID AND ADRENAL FUNCTION

EATING DISORDERS -LANUGO, THIN, LOW TEMP, LO BP , DRY SKIN CHIPMUNK CHEEKS ,CHVOSTEK SIGN -IPSILATERAL FACE TWITCH

DRUG USE ESP OTC

RECENT WEIGHT LOSS /GAIN

LOOK FOR SIGNS OF HYPERANDROGENISM ( HAIRY, TRUNCAL OBESITY, DEEP VOICE) OR GALACTORRHEA ( PITUITARY /HYPOTHALAMUS

HYPOESTROGEN ( HOT FLASHES VAG DRY DEPRESSION, DYSPAREUNIA)

LIFE STRESSORS

LOOK FOR ANDROGEN INSENSITIVITY -NO PUBIC OR AXILLA HAIR

GALACTORRHEA = HIGH PROLACTIN

ASSESS ALLA BOVE

BODY

VAGINA EPITHELIUM AND MUCUS

AXILLAE -ACANTHOSIS NIGRICANS OR LACK OF HAIR

THYROID AND PARATHYROID , NODULES MASSES

BREASTS-GALACTORRHEA

EYES, ACUITY AND FUNDUS- RETINAL ABNORMALITITIES -MAY REFLECT IC MASS

ABDOMINAL STRIAE ON NULLIPAROUS WOMEN -HYPERCORTISOLISM

SKIN TAGS, FISSURES FOBT MAY BE IBD

EXCLUDE PREGNACY OR BREAST FEEDING

LABS

SERUM HUMAN CHORIONIC GONADOTROPIN

THYROID PROFILE

FSH , LH

PROLACTIN

FURTHER LABS

DHEA->700 mg/dL+ ADRENAL CAUSE

SERUM GLUCOSE , ELECTROLYTES BUN AND CR

ESR -AUTOIMMUNE

HGBAIC

URINARY FREE CORTISOL

IMAGING

CT OR MRI -SELLAR BODIES

OTHER DIAGNOSTICS

CLOMIPHENE CHALLENGE TEST

HYSTEROSALPINGOGRAM

ANOVULATION

CUSHINGS

ADRENAL OR OVARIAN TUMORS

PCOS -OST COMMON

FSH >20IU/L IS PCOS

FSH >30 IU/L IS MENOPAUSE

PITUITARY AND HYPOTHALAMIC -LH PLUS MRI OF SELLAR REGION-

ARE ALL THE CAUSES

REFER TO APPROPRAITE SPECIALIST

FIRST TOW YEARS OF PERIODS NORMAL

DISCONTINUATION OF ORAL CONTRACEPTIVES -RETURNS 6 MONTHS

DEPO PROVERA-RETURNS 6-14 MONTHS

PCOS HYPERANDROGENIC

OBESITY RELATED

DO HORMONE LEVELS TO RULE OUT AND IN

TSH LH FSH PROLACTIN

REFER

NUTRITION COUNSELLING

VITAMIN D

HOSPITALIZATION ANOREXIA NERVOSA 30% WEIGHT LOSS

ANDROGEN EXCESS >RISK CAD AND LIPID ABNORMALITIES

MOST COMMON CANCER IN WOMEN,2ND LEADING CANCER DEATH CAUSE

A WOMANS LIFETIME RISK IS 12 %,CURRENT SURVIVAL RATE 90%

OLDER AGE

FAMILY HISTORY

BRCA GENE MUTATION

BLACK WOMEN 40% MORE LIKELY TO DIE FROM BREAST CANCER THAN WHITE WOMEN

EARLY MENARCHE AND LATE MENOPAUSE

AGE 30 FIRST BIRTH SAME RISK AS NULLIPAROUS WOMEN

<30 FIRST BABY, SUBSEQUENT BABIES AND LENGTH OF BREAST FEEDING ALL REDUCE BC RISK

HRT FOR MENOPAUSE

OBESITY

ALCOHOL

SMOKING

RADIATION TO CHEST

USPTSF

FIRST DEGREE RELATIVE W BC =2 FOLD INCREASED RISK

TWO FIRST DEGREE RELATIVES BC= 3FOLD RISK

FIRST DEGREE RELATIVE <40YO =3FOLD RISK

PERSONAL HISTORY OF DUCTAL CARCINOMA IN SITU, INVASIVE BREAST CA OR LOBULAR CARCINOMA= VERY HIGH RISK FOR NEW-4-5 FOLD

RISK ASSESSMENT TOOL BCRISKTOOL

https://bcrisktool.cancer.gov/calculator.html

USPSTF

START BREAST CANCER SCREENING AT AGE 40

EVERY OTHER YEAR MAMMOGRAMS AGE 40-74-OTHER ORGANIZATIONS -ACOG AND AMERICAN CANCER SOCIETY RECOMMEND YEARLY MAMMOGRAM

ACOG 2017

• Use shared decision-making to select screening choices

• Clinical breast examination may be offered every 1-3 years for women aged 29-39 years and annually for women aged ≥ 40 years

• Start offering mammography at age 40 years; initiate after counseling, if patient desires

• Recommend starting mammography screening by no later than age 50 years

• Mammography may be annual or biennial; biennial screening is particularly reasonable after age 55 years

• Continue mammography until age 75 years, then discuss discontinuation, with the woman's health status and longevity as considerations

INSURANCE IN US MUST COVER ANNUAL MAMMOGRAPHY

CBE Q 3YEARS TO AGE 40

CBE ANNUALLY OVER AGE 40

MAMMOGRAPHY ANNUALLY AGE 40 OR 10 YEARS BEOFRE DIAGNOSIS IN WOMEN WITH FIRST DEGREE RELATIVE

PREVENTION

CBEEVERY 3 YEARS TO AGE 40 AND ANNUALLY OVER AGE 40

MAMMOGRAPHY ANNUALLY BEGINNING AT AGE 40 or 10 YEARS BEFORE AGE OF DIAGNOSIS IN FIRST DEGREE RELATIVE

TERTIARY PREVENTION

REFER TO ONC TEAM

DEPENDENT ON TUMOR STAGE, PRESENCE OF HORMONE RECEPTORS AND PT SYMPTOMS/PREFERENCES

mammo 40-75 every 1-2 years. earlier if risk - gail guideline

dense breasts- acog do not need extra testing ( uss) if no risk factors

note: germline cancer risk includes breast and pancreatic

fda 2023 must notify pt that dense breast mammogram is not as sensitive to discern cancer or not

SHOWN NOT TO REDUCE MORTALITY EVEN WITH APPROPRIATE TRAINING AND CAUSED UNNECESSARY BIOPSIES

ACOG REMOVED RECOMMENDATION FOR BSE AND RECOMMEND BREAST SELF AWARENESS

BSA

ATTUNEMENT TO NORMAL FEEL AND LOOK OF HER BREASTS, NOTIFY PROVIDER IF NEW PAIN, MASS , NIPPLE DISCHARGE AND REDNESS

ACOG RECOMMENDS CBE - CLINICAL BREAST EXAM ESP IN WOMEN UNDER 40 YEARS

ESTROGEN RECEPTOR MODULATORS(TAMOXIFEN)

AROMATASE INHIBITORS

PROPHYLACTIC MEASTECTOMY

OVARIAN ABLATION

EXERCISE

estrogen-receptor negative

progesterone negative

ERBB2-negative [formerly HER2/Neu-negative]).

CBE

BSA

MAMMOGRAM 3D FEWER FALSE POSITIVES

GENETIC TESTING/COUNSELLING

FOR WOMEN WHO HAVE FAMILY MEMBERS WITH BREAST OVARIAN OR PERITONEAL CANCERS ( LOOK OUT FOR GERMLINE PANCREATIC CANCER- ASSOCI WIHT BRCA GENE)

ODGERS:

MAMMOGRAPHY

USS

REFER T BREAT SPECIALIST FOR

NEEDLE BIOPSY- EXCISIONAL BIOPSY IS MOST RELIABLE DIAGNOSTIC TEST WHERE STAGING OF TUMOR IS DONE

20-25% WOMEN W BREAST COMPLAINTS

PHYSOIOLGIC

PATHOLOGIC

;GALACTORRHEA

COMMON IN PRE MENOPAUSAL AND PREGNANT WOMEN

USU BILATERAL

PATHOLOGIC IS SPONTANEOUS BLOODY SEROUS ONE DUCT 1/3 CANCER

GALACTORRHEA = PITUITARY ADENOMA OR HYPOTHYROIDISM

OTHER S/S LETHARGY COLD INTOLERANCE, DRY SKIN ,AMENORRUEA

PROLACTIN LEVEL AND BRAIN MRI

PHYSIOLOGIC

BILATERAL, MULTIPLE DUCTS,EXPRESSION NOT SPONTANEOUS -CLEAR YELLOW DARK GREEN COLOR

HORMONE RELATED , GROWTH,ADRENAL , INSULIN

COMMONEST CUASE INTRADUCTAL PAPILLOMA

IF MASS PRESENT ALSO , > RISK CANCER

THOROUGH BREAST EXAM

COMPRESS AREOLA BETWEEN FINGER AND THUMB TO MILK DUCTS -IS IT ONE OR A FEW?

FUNDOSCOPY IF GALACTORRHEA ( RETINAL ABNORMAL IC MASS)

EOM VISUAL ACUITYVISUAL FIELDS - COMMON IN PARAPITUITARY LESIONS

NEUROLOGIC EXAM

THYROID EXAM

FULL PMH

ENDOCRINE AND REPRODUCTIVE HISTORY

DISCHARGE FOR OB IF SEROUS OR WATERY

NO CYTOLOGY ( DOESNT RULE OUT MALIGNANCY)

MAMMOGRAM

USS PREIAREOLAR

PREGNANCY TEST

SERUM PROLACTIN ( PITUITARY OR CNS ORIGIN)

THYROID PROFILE

MRO BRAIN IF SYMPTOMS OF IC MASS

GALACTORRHEA WITH AMENORRHEA

OR ELEVATED PROLACTIN LEVEL

DUCT ECTASIA

NON PUERPERAL MASTITITIS

INTRADUCTAL PAPILLOMA

BREAST CA

TREAT UNDERLYING CAUSE

IF DUCT ECTASIA IT IS BENIGN, NO TREATMENT

IF RECURRENT BREAST SURGEON

IF INTRADUCTAL PAPILLOMA BREAST SURGEON

TREATMENT PUNCH BIOPSY AS OFFICE PROCEDURE OR REFER TO DERM OR SURGEON

ECZEMA

USU BILATERAL

INTERMITTENT HX WITH RAPID PROGRESSION

MOIST INITIALLY

INDISTINCT BORDER

AREOLA INVOLVED NIPPLE MAY BE SPARED

ITCHING COMMON

PAGETS

UNILATERAL

CONTINUOUS HX WITH SLOW PROGRESSION

MOIST OR DRY

IRREGULAR BUT DISTINCT BORDER

NIPPLE ALWAYS INVOLVED AND DISAPPEARS IN ADVANCED STAGE

ITCHING COMMON

UP TO 85% WOMEN WITH NO HISTORY WILL DEVELOP BREAST CANCER

90% BREAST MASSES ARE BENIGN CYSTS FIBROADENOMAS FIBROCYSTIC CHANGES-PREMENOPAUSAL

DIFFERENT <30 FIBROCYSTIC CHANGES BENIGN

31-50 YO USU CYSTS - BENIGN FLUID FILLED

AND >50 YO

FIBROADENOMAS PAINLESS WELL CIRCUMSCRIBED FREELY MOVABLE MASSES ROUND OR LOBULAR , RUBBERY , MAY BE HARD CALCIFIED, HORMONALLY RESPONSIVE -MOST COMMON IN 20S AND 30S-BENIGN

BENIGN PHYLLODES - RAPIDLY GROWING BREAST MASS,

FOCAL AREAS OFTEN BIOPSIED AND ARE BENIGN STROMAL FIBROSIS

DUCTAL CARCINOMA NOT USU FOUND AS A LUMP BUT DETECTED ON MAMMOGRAM AS ABNORMALITY SUCH AS CALCIFICATION

GALACTOCELE-MILK CYST IN PREGNANT WOMEN

HISTORY DURATION

PAIN

ASSOC SKIN CHANGES

PRESENCE OF AXILLARY, SUPRA OR INFRACLAVICULAR ADENOPATHY

CHANGE IN SIZE OR TEXTURE OVER TIME

RELATIONSHIP TO MENSTRUAL CYCLE

NIPPLE DISCHARGE

RECORD

SIZE

LOCATION

SHAPE

MOBILITY

LYMPH NODES

DISCHARGE

CBE IS NOT AN INDEPENDENT DIAGNOSTIC TEST

MAMMOGRAPHY + USS IF >25 YO

USS <25 YO

15-18% MAMMOGRAMS APPEAR NEGATIVE IN PRESENCEE OF PALPABLE CANCER

ADDITIONAL BIOPSY

DISCRETE MASS ALWAYS REQUIRES SURGICAL REFERRAL FOR BIOPSY

NEEDLE BIOPSY -EXCISIONAL BIOPSY IF MOST RELIABLE DIAGNOSTIC TEST

CYST CAN BE ASPIRATED FOR RELIEF OF PAIN AND CYTOLOGY-4-6 WEEK FOLLOW UP FOR RECURRENCE OF CYST

ANY DISCRETE SOLID MASS REQUIRES TISSUE BIOPSY R/O CANCER

SOLID MASS

SMALL DOUBLE STRANDED DNA THAT CAN BE ONCOGENIC

MOST HAVE NO CONSEQUENCES

CANCER

UROGENITAL

CERVICAL FOR WOMEN

OROPHARYNGEAL FOR MEN

6 AND 11 CAUSE ANOGENITAL WARTS

INCIDENCE

MOST SEXUALLY ACTIVE MEDN AND WOMEN WILL ACQUIRE HPV INFECTION

90% WILL RESOLVE SPONTANEOUSLY WITHIN 2 YEARS + CLINICALLY SILENT

CDC

13 MILLION NEW HPV CASES IN 2018, ONLY 12% IN MSW, 41% WOMEN

ANOGENITAL WARTS INCUBATION 3-6 (wOMEN) -11 MONTHS(MEN) BEFORE SEEN

OROPHARYNGEAL CANCER

CERVICAL CANCER PRE CANCER OCCURS YEARS AFTER AND CANCER OCCURS DECADES AFTER INITIAL INFECTION

ANAL CANCER

PRECANCERS CAN REGRESS AND PROGRESS

SEXUAL PARTNER NUMBER,

EARLY AGE OF SEXUAL DEBUT

ORAL SEX

IMMUNOSUPPRESSION

LONG TERM ORAL CONTRACEPTIVE USE

TOBACCO SMOKING

COINFECTION WITH HIV, CT HSV 2

SMALL NON ENVELOPED DOUBLE STRANDED DNA VIRUS, CREATES A SHELL THAT LINKS TO THE HPV DNA

HPV IDENTIFIED BY DETECTION OF HPV DNA OR HPV mRNA

MORE THAN 70 TYPES IN HUMAN GENITAL TRACT-HAVE AN AFFINITY FOR THIS TRACT

INFECTION AT BASAL LAYER OF STRATIFIED SQUAMOUS EPITHELIAL CELLS

LOW RISK

HPV 6 AND HPV 11( NONONCOGENIC) CAUSE 90-95% ANOGENITAL WARTS

HIGH RISK

CAUSE LOW GRADE + HIGH GRADE CERVICAL CELLULAR CHANGES ,SOME HIGH RISK TYPES CAUSE CULVA VAGINA ANAL PENIS AND OROPHARYNX CANCERS

TWELVE TYPES

16-18-31-33-35-39-45-51-52-56-58-59

65-705 CAUSED Y 16 + 18

TRANSMISSION FROM FRICTION INDUCED MICROABRASIONS IN SKIN TO SKIN

VISIBLE ANOGENTIAL WARTS USU MULTIPLE HPV TYPES

CANB EC ONFUSED

CONDYLOMATA LATA-SECONDARY SYPHILLIS

MOLLUSCUM CONTAGIOSUM

HERPES VEGETANS

SQUAMOUS CELL CA

VESTIBULAR PAPILLAE

SKIN TAGS

BOWENS DISEASE

NEOPLASMS

HSV CONDYLOMA ACUMINATA-CAULIFLOWER

SMOOTH PAPULES DOME SHAPED

FLAT PAPULES

KERATOTIC WARTS

BLEEDING

TUMORS ULCER MASS

ANOGENITAL WARTS

CLINICAL FINDINGS

ONLY BX IF ATYPICAL-BLEEDING OR ULCERATED

IMMUNOCOMPORMOISED HOST

NOT RESPONSIVE TO THERAPY

WORSEEN DURING RX

CERVICAL CA

PAP-COLLECT FROM EDOCERVIX AND ECTOCERVIX

ENDOF BROOM

ECTOSPATULA-CYTOLOGY SLIDE OR LIQUID BASED TEST

PAP IS NOT AN STI SCREENING TEST

FROM 10-20 DAYS AFTER MENSES CONVENTIONAL TEST

LIQUID TEST ANYTIME DURING MENSTRUAL CYCLE

IF HAS OTHER STI S REPEAT PAP AFTER THEY ARE TREATED

MUCOPURULENT DRAINAGE CAN BE PUSHED ASIDE TO COLLECT PAP

CAN STILL COLLECT OTHER CERVICAL STI SPECIMENS AT SAME TIME AS PAP

BASIC OR PRIMARY -TESTS HPV ALONE

HPV ASSAYS DETECT FULL RANGE (HRHPV)

USU USED FOR HIGH RISK OR ABNORMAL PAP SMEAR

DONT USE TO DETECT WARTS TYPES <25 YEARS AS PART OF ROUTINE SCREEENING PAP

COTESTING ALLOWED OVER CERTAIN AGE

PAP

I-V

BETHESDA

CIN SCALE

-SQUAMOUS LESIONS ,BASED ON FRACTION OF NORMAL EPITHELIAL CELLS REPLACED BY UNDIFFERENTIATED CELLS

CIN 1 MILD DYSPLASIA

CIN 2 MODERTAE

CIN 3 SEVERE DYSPLASIA PREMALIGANT

LAST SCALE

SQUAMOUS LESIONSTWO TIERED

LSIL LOW GRADE SQUAMOUS INTEREPITHELIAL LESIONS -CORRESPOND TO CIN 1

HSIL CORRESPOND TO CIN 3

FRO CINI 2 THEY DO IMMUNOHISTOLOGICAL STAINING OF BIOMARKER P16 -IF NEGATIVE DOWNGRADED TO LSIL, IF POSITIVE UPGRADED TO HSIL

FIRST DARE - DIGITAL ANORECTAL EXAM

ANAL PAP INSERT FINGER 2-3 INCHES INTO ANAL CANAL, SWAB CIRCULAR -GLASS SLIDE OTR LIQUID

NO HPV ANAL TESTS ON MSM NOT FDA APPROVED AS MOST MSM HAVE HPV

USE ANOSCOPY

AGE 21-65 YEARS

21-29 PAP Q 3 YEARS

30-65 3 OPTIONS

PAP Q 3YEARS

HRHPV Q 5 YEARS

COTESTING Q 5 YEARS

<21 NO SCREENING

> 65 NO SCREENING IF NO ABNORMALITIES

HPV VACCINE SCREENING IS SAME

HYSTERECTOMYAND CERVIX REMOVAL + NO HISTORY OF DYSPLASIA-NO SCREENING

REDUCES DOES NOT ELIMINATE TRANSISSION,OR REDUCE CANCER RISK

PROVIDER APPLIED TREATMENTS-WORK QUICKER AND FEWER TREATMENTS

PATIENT APPLIED, PRIVACY OF OWN HOME

PROVIDER:

CRYOTHERAPY + SURGICAL REMOVAL REFER

TCA-TRICHLOROACETIC ACID

BCA BICHOLORACETIC ACID

NO TCA BCA OR PODOPHYLLIN FOR URETHRAL WARTS

PATIENT:

IMIQUIMOD 3.75%CREAM Q NOCTE X 8 WEEKS-CAN WEAKEN CONDOMS AND DIAPHRAGMS

IMIQUOD 55 3XWEEK X 16 WEEKS

PODOFILOZ 0.5% GEL BID X 3 DAY THEN OFF FOR 4 DAYS , REPEAT CYCLE X SINECATECHINS 15%OINTMENT TID UPT TO 16 WEEKS

FOLLOW UP IN 3 MONTHS

CONDOM USED REDUCEDS 70%

LIKE VIRUS THE VACCINE USED RECOMBINANT TECHNOLOGY PRODUCING l1 PROTEINS THAT SLF ASSEMBLE INTO VIRAL LIKE PARTICLES

HPV 6-11-16-18-31-33-45-52-58

ONLY ADVERSE S/E IS IMMEDIATE POST INJECTION SYNCOPE

11-12 YEARS ( CAN START AT AGE 9)

>13 YEARS-26 YEARS CAN GET CATCH UP VACCINATION

27-45 SHARED DECISION MAKING

DOSING:

9-14 2 DOSE HPV 6 MONTHS APART MINIMAL 5 MONTHS APART OR GET THIRD DOSE

15 AND OVER 3 DOSE 0, 1-2 AND 6 MONTHS

INTERRUPTED SCHEDULE : COMPLETE THE SERIES WITHOUT REPEATING DOSES

NO PREGANCNY TEST REQUIRED

HIV -ALL GET 3 DOSE VACCINE

MOST COUPLES SHARE HPV HISTORY

DOES NOT MEAN PARTNER IS HAVING SEX OUTSIDE RELATIONSHIP

MOST PEOPLE CLEAR INFECTION SPONTANEOUSLY WITHOUT HEALTH PROBLEMS

IF INFECTION PERSISTS

CERVIX ANAL PENIS VULVA VAGINA HEAD NECK CANCERS AND PRE CANCERS AND WARTS MAY DEVELOP

PARTNER NO TESTING- BUT COUNSELLING ON IMPLICATIONS- HIGHLY CONTAGIOUS , CONDOM USE