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GY28 Gynecology
Gynecological Infections
Toronto Notes 2019
Genital Warts During Pregnancy
• Condyloma tend to get larger in pregnancy and should be treated early (consider excision)
• C-section only if obstructing birth canal or risk of extensive bleeding
• Do not use imiquimod, podophyllin, or podofilox
Human Rights in Health Equity: Cervical Cancer and HPV Vaccines
Am J Law Med 2009;35:365-87
• Whilecervicalcancerrateshavedrastically
fallen in developed countries due to effective prevention and treatment, socially disadvantaged women within these countries remain disproportionately more likely to develop and die of cervical cancer.
• Inmostdevelopingcountriescervicalcancer rates have risen or remained unchanged.
• Must recognize that cervical cancer disparities between race groups, urban and rural residence, and high and low socioeconomic status are attributed to disparate screening and vaccination coverage.
• Programs are implemented without sufficient attention to conditions that render screening less effective or inaccessible to disadvantaged social groups including: lack of information, undervaluing of preventive care, opportunistic delivery in limited health care settings, sexual health stigma, and related privacy concerns.
A 9-Valent HPV Vaccine Against Infection and Intraepithelial Neoplasia in Women
NEJM 2015;372:711-23
Purpose: To determine the efficacy and immunogenicity of the qHPV (types 6, 11, 16, 18) vs. 9vHPV (five additional types 31, 33, 45, 52, 58) vaccines.
Method: International randomized, double-blinded phase 2B-3 study of 9vHPV vaccine in 14,215 women between ages of 16-26. Participants were randomized to the 9vHPV vaccine group or the qHPV vaccine group and each received a series of three IM injections (day 1, 2, and 6 months). Swabs of labial, vulvar, perineal, perianal, endocervical, and ectocervical tissue was obtained and used for HPV DNA testing/Pap smear.
Results: Rate of high-grade cervical, vulvar, or vaginal disease was 14.0 per 1,000 person-years in both vaccine groups. The rate of high-grade cervical, vulvar, or vaginal disease related to HPV-31, 33, 45, 52, and 58 was 0.1 per 1,000 person-years in the 9vHPV group and 1.6 per
1,000 person-years in the qHPV group (95% CI = 80.9-99.8). Antibody responses to HPV-6, 11, 16, and 18 were not significantly different between
the two vaccine groups although adverse events related to injection sites were more common in the 9vHPV group.
Conclusions: The 9vHPV vaccine was non-inferior to qHPV vaccine in preventing infection and disease related to HPV-6, 11, 16, and 18 and also covered additional oncogenic types HPV-31, 33, 45, 52, and 58 in a susceptible population.
HUMAN PAPILLOMAVIRUS
Etiology
• mostcommonviralSTIinCanada
• >200subtypes,ofwhich>30aregenitalsubtypes
• HPVtypes6and11areclassicallyassociatedwithanogenitalwarts/condylomataacuminata
• HPVtypes16and18arethemostoncogenic(classicallyassociatedwithcervicalHSIL)
• types16,18,31,33,35,36,45(andothers)associatedwithincreasedincidenceofcervicalandvulvar
intraepithelial hyperplasia and carcinoma
Clinical Features
• latentinfection
■ no visible lesions, asymptomatic
■ only detected by DNA hybridization tests
• subclinicalinfection
■ visible lesion found during colposcopy or on Pap test
• clinicalinfection
■ visible wart-like lesion without magnification
■ hyperkeratotic, verrucous or flat, macular lesions ■ vulvar edema
Investigations
• cytology
• koilocytosis: nuclear enlargement and atypia with perinuclear halo
• biopsy of lesions at colposcopy
• detectionofHPVDNAsubtypeusingnucleicacidprobes(notroutinelydonebutcanbedonein
presence of abnormal Pap test to guide treatment)
Treatment
• patient administered
■ podofilox0.5%solutionorgelbidx3dinarow(4doff)thenrepeatx4wk ■ imiquimod (Aldara®) 5% cream 3x/wk qhs x 16 wk
• provideradministered
■ cryotherapy with liquid nitrogen: repeat q1-2wk
■ podophyllin resin in tincture of benzoin: weekly
■ trichloroacetic acid (TCA) (80-90%) or bichloroacetic acid weekly X4-6wks; safe in pregnancy ■ surgical removal/laser
■ intralesional interferon
Prevention
• vaccination:Gardasil®9,Gardasil®,Cervarix®seeTable27,GY45
• condomsmaynotfullyprotect(areasnotcovered,mustbeusedeverytimethroughoutentiresexual
act)
HERPES SIMPLEX VIRUS OF VULVA Etiology
• 90% are HSV-2, 10% are HSV-1
Clinical Features
• maybeasymptomatic
• initialsymptoms:present2-21daftercontact
• prodromal symptoms: tingling, burning, pruritus
• multiple,painful,shallowulcerationswithsmallvesiclesappear7-10dafterinitialinfection(absentin
many infected persons); lesions are infectious
• inguinallymphadenopathy,malaise,andfeveroftenwithfirstinfection
• dysuriaandurinaryretentionifurethralmucosaaffected
• recurrent infections: less severe, less frequent, and shorter in duration (usually only HSV-2)
Investigations
• viralculturepreferredinpatientswithulcerpresent,howeverdecreasedsensitivityaslesionsheal
• cytologicsmear(Tzancksmear)showsmultinucleatedgiantcells,acidophilicintranuclearinclusion
bodies
• HSVDNAPCR
• typespecificserologictestsforantibodiestoHSV-1andHSV-2(notavailableroutinelyinCanada)