Hello, in this lecture, we'll be discussing
sexually transmitted infections in women.
In the United States, sexually transmitted infections
traditionally called STDs, now called STIs, are a problem.
You can see here, that we have high
rates of human papilloma virus
as well as HSV or herpes
Half of the infections are in men
and about half are in women
which make up about a hundred
million types of infections.
Why are STIs so important to discuss?
Well, they facilitate HIV transmission.
They do this by disrupting the epithelial mucosal
barriers that are important in protecting the body.
They can also increase the number of
HIV targets in the genital tract.
They also increase expression
of HIV co-receptors.
They induce secretion of cytokines
and increase HIV shedding
and also, HIV alters the
natural history of some STIs.
So essentially, STIs and HIV work together
to make the patient sicker.
I now want to bring your
attention to two classifications
recommended by the CDC
or the Centers for Disease Control.
Sores or ulcers are actually caused
by syphillis, HSV-1 and HSV-2.
As you might have read, HSV-1 is traditionally
oral while HSV-2 is traditionally genital
but they can affect each body part.
Other uncommon causes
of sores in the US
include LGV, chancroid
or granuloma inguinale.
Now let's talk about drips,
the second classification.
These are discharges, so
women usually would present
with some type of vaginitis or
an abnormal discharge.
Commonly, gonorrhea and
chlamydia are the culprits.
You can also have nongonococcal
urethritis or cervicitis.
Trichomonas vaginitis or urethritis
also cause an abnormal discharge.
You can get a discharge with a yeast
infection or Candidiasis, this is non-STD.
You can also have bacterial vaginosis
which is not sexually transmitted
but can be sexually associated.
We'll discuss that in a little bit.
The major concerns though
are genital HPV
especially type 16 and 18
and cervical, anal and oral cancer.
Let's now talk about a case.
A 30-year old woman presents to your clinic
with the following physical finding:
What's your diagnosis?
We'll, if you've read here,
it's herpes simplex.
Well, what else do we need to know?
It could be syphillis.
It could be a zipper cut but unlikely,
or it could be granuloma inguinale.
What do you need to do to differentiate?
So you need to ask the patient
if the sores are painful.
This is usually indicative of chancroid.
or it could be very painful,
associated with herpes.
presents as a painless sore.
LGV is also traditionally painless
as well as granuloma inguinale.
Let's talk about primary syphillis.
This is rare to see but in any
this may be present, especially
a patient with HIV or AIDS.
Primary syphillise has
a 10-90 day incubation,
On average, three weeks.
You can see a chancre on examination and
early on you may see a macule or papule
that tends to lead to
erosion around the edges.
Usually, the base is clean, painless and
indurated with smooth, firm borders.
It can go unnoticed in a large
percentage of the population
and it typically resolves on
one to five weeks.
This stage is highly infectious
and therefore, their sexual
partners are at risk.
Let us now review what it
looks like in a female.
If you were to do a speculum exam,
you should always wear gloves.
If you put the speculum in, you may see a
large papule as you see here in this picture.
Externally, you may see a sore on the outside,
on the labia minora or majora.
Here you see it pictured on the labia
minora, on both sides or bilaterally.
Let's now talk about secondary syphillis.
This represents a dissemination of the
spirochetes throughout the blood.
This usually takes two to eight weeks after
the initial presentation of the chancre.
The rash is usually a whole body rash and
does include the palms and the soles,
which is unusual for rashes as the palms
and the soles are usually spared.
You sometimes can have
mucus patches in the mouth
and you may see a condyloma lata
which is highly infectious.
This is not to be confused with condyloma accuminata
which is seen on the cervix and other scenarios.
The patient may have constitutional
symptoms such as fever
and usually signs and symptoms
resolve in two to ten weeks.
Early diagnosis of syphillis is very important
especially in a reproductive age woman
as she is at risk for pregnancy.
Clinical presentation should alert you
to the diagnosis of syphillis
but you can use skin lesions to obtain
spirochetes to do darkfield microscopy
also serology with an RPR is
important in diagnosing syphillis.
These are often tested on your exam and you
may wanna go over these in some detail.
Let's now talk about the treatment.
Especially in a pregnant woman, Benzathine
Penicillin 2.4 million units is very important.
If a patient has an allergy,
then she would need to be desensitized
but that's beyond the scope of the USMLE.
But just remember,
penicillin is the treatment.
Let's now discuss genital herpes.
This is usually caused by HSV-2
but can be caused by HSV-1.
Transmission is usually through direct contact,
usually during asymptomatic shedding.
That means, the partner may not have
any lesions but can still shed virus.
Primary infection is
Symptomatic cases sometimes can be very severe,
prolonged and have systemic manifestations.
Vesicles errupt and cause painful
ulcerations and crusting.
There is a definitive recurrence potential
and patient should be made aware of this.
Let's now talk about the
diagnosis of HSV-1 or HSV-2.
Typically, we do PCR.
Culture was an older method that we
did utilize, and we also do serology.
Typically you will do PCR from a
lesion that you see upon presentation.
Culture was done traditionally but serology can be
done quickly in the office with just a blood test.
Let's now talk about treatment.
Since herpes simplex virus is a virus,
we need to use antivirals.
We typically use acyclovir,
valcyclovir and famciclovir.
These may potentially show up on
some of your examination questions.
Just to remind you, we had a case
from earlier in the lecture.
This patient did in fact have
These are what the
ulcerations may look like.
These can be very painful
and lead to dysuria.