GYN - A little bit of everything

Ms. V is a 21 year old who gave birth to her first child 8 weeks ago. She comes in for her postpartum GYN exam with a multitude of questions and problems. First, she asks about birth control options. Next, she mentions that she thinks she has a UTI; she has been treated for the UTI “few times” but it never seems to go away. She also thinks she may have a yeast infection, which she treated with Monistat 7, but it never completely went away. Ms. V also has had a lump in her right breast for almost 2 years; her provider told her “not to worry about it.”

We started with a discussion about birth control. She used to use Depo but wants to try the patch. Then we did the breast exam. She has a 1.5 cm solid, movable, painless mass in her right breast at about 1200. Next, I do the PAP. It is obvious that she has a yeast infection. She has the typical “cottage cheese” discharge but I also smell “something fishy.” We process slides to check for Candida and BV; the slides confirm both.

The plan for Ms. V is:
 Referral to the breast clinic – a lump that remains after 2 years and is bothering the patient should be checked out.
 UA/C&S – The UTI has not resolved probably due to the persistent BV/Candida.
 Miconazole cream x 7 days to treat the Candida.
 Metronidazole x 7 days to treat the BV.
 Miconazole and metronidazole to be taken concurrently to maximize treatment. My preceptor states that the yeast infection never resolved because the BV was never treated. Both need to be treated at the same time.
 Contraceptive patch – Start on the Sunday after the start of next menses.

I thought this was an interesting case because there was a little bit of everything – a breast mass, BV, Candida, a PAP, contraception, and a UTI – all in one 30-minute appointment.

GYN ISSUE-Susan Frisbie-posted 13 June 2010

Twenty-four year old female, G1P1, six weeks postpartum, presents with complaints of recurring right Skene’s gland cysts and urinary incontinence with gaping urethra. She has an unremarkable medical, surgical and family history. PNV’s only and no allergies. Height and weight appropriate. 1) Right Skene’s gland drained 4 times while pregnant. Placed on antibiotics initially but culture negative. Today with complaints of painful intercourse due to the Skene’s gland. Examination revealed a mildly inflamed right Skene’s gland with minimal tenderness on palpation. Patient states it has improved tremendously on its own. Discussed conservative management to wait and see if remains a problem, initiated referral to Gynecology and talked about the potential role of the Skene’s glands in intercourse. 2) Patient states urinary incontinence occurs about 10 times throughout the day and it is not related to coughing, sneezing or the urge to urinate. She wears a minipad 24/7 to catch the urine and changes it about 5 times a day. Concerned it is not getting better since delivery. No incontinence issue prior to pregnancy. Urethra visualized on exam but not remarkable. When performing bimanual after Pap 2-3cc of urine was expressed. Treatment consisted of conservative management with Kegels 10 times every time she urinated intentionally or accidentally, referral to Gynecology and I educated her on the role of the Pelvic Floor Physical Therapist if conservative management failed.

HSIL CIN III & HPV

GYN Case:

I had a 21-year old present to the clinic for a repeat Colposcopy. The patient had an abnormal pap and colposcopy over a year ago in a civilian facility and wanted a second opinion as her results showed that he LSIL had progressed to HSIL CIN III and HPV. The patient waited over a year to follow up. Patient states that she is sexually active with multiple partners and refused to use protection while having sex as she does not want to break the heat of the moment.” She was also a smoker who smoked almost 1 pack of cigarettes per day. She was scheduled for a LEEP and She was advised to abstain from sex since she was high risk HPV. The patient was advised to quit smoking as smoking can increase your risks for cervical cancer and yet the patient refused. When asked if she was interested in quitting smoking the patient said no and that her current boyfriend ‘Dips’ and she does not want to quit smoking as this would give her something to do while he dips. MAJOR education was given to this young patient as she was not playing with a “full deck”. I could not believe that someone would continue to smoke and perform such risk taking behaviors after being diagnosed with CIN III and HPV. She was given a consult/referral to psychiatric care.