1. When Good Vaginas Go Bad Susan H. Oakley, MD January 23 rd, 2013

2. HOT TOPICS  Background Info  Normal Female Parts  Menstrual Cycle  Abnormal Menstruation, Diagnosis & Treatment  Pregnancy and Prevention  Sexually Transmitted Infections (STIs/STDs) and Prevention  Pelvic Exam

3. Background  Average age of MENARCHE = 12yo  Typical Menstrual Cycle = 21 to 35 days  Bleeding lasts < 7days

4. Abmaet al., Vital Health Stat, 2010

5. Background Young Women…..  Seen in a variety of clinical practice settings by providers with different backgrounds and training  Account for ¼ of sexually active population aged 15-44 years, but  Acquire nearly ½ of all new STIs  88% of new STI cases are from 3 infections: HPV, trichomonas, and chlamydia Weinstock et al., Persp Sex Reprod Health, 2004

6. Background  First Visit to Ob/Gyn @ 13-15yo  First Exam when SEXUALLY ACTIVE  First PAP smear for cancer screening @ 21yo - every 2 years from 21-29 - every 3 years from 30+ - may discontinue at age 65-70 ACOG Practice Bulletin 109, December 2011

7. Background  High Adolescent Pregnancy Rates in the USA  Adolescents = highest rates of HPV  Adolescents can legally give consent to be tested for and treated for STIs  Adolescents need parental consent for “procedural” contraceptive methods

8. NORMAL ANATOMY & HORMONES

9. Normal Female Anatomy

12. HORMONES  ESTROGEN  PROGESTERONE  TESTOSTERONE  SHBG

13. NORMAL AND ABNORMAL MENSTRUATION

14. MENSTRUATION

16. Abnormal Menstruation  Menorrhagia  Metrorrhagia  Menometrorrhagia  Polymenorrhea  Oligomenorrhea

17. Diagnosis of Abnormal Bleeding  History and Physical Exam  20% of all AUA due to bleeding disorder  UPT  CBC  TSH  PAP*  Chlamydia  +/- TVUS ACOG Practice Bulletin 128, July 2012

18. How to Make Bleeding Better!  OCP  Patch  Ring  Injection  Implant  IUD  Non-hormonal  NSAIDs

23. PREGNANCY AND PREVENTION

24. PREGNANCY STATS  National Youth Risk Behavior Surveillance System - ↓in high school students who have ever had sex 1991- 2009: ↓54% to →46% - ↓in high school students reporting sex with >4 persons 1991-2009: ↓19% →14%  6/10 teen girls have had sex < 18 yo  1/3 of adolescents wait 1 year after initiating intercourse to obtain contraception  Most popular = OCPs and condoms  Failure rates can  15-18% in adolescents

25. Pregnancy Prevention  Non-hormonal - Paraguard (copper based) IUD - Condoms - Rhythm method (~basal body temperature)  Hormonal - OCP - Patch - Ring - Mirena (progesterone) IUD - Implanon (subdermal implant) - Depo-Provera

26. SEXUALLY TRANSMITTED DISEASES

27. Sexually Transmitted Diseases  HPV  HIV  HSV  Chlamydia  Gonorrhea  Hepatitis  Syphilis  Trichomoniasis

31. 31 Chlamydia — Positivity among 15- to 24-year-old women tested in family planning clinics by state: United States and outlying areas, 2003 Chlamydia Note: Includes states and outlying areas that reported chlamydia positivity data on at least 500 women aged 15-24 years screened during 2003. SOURCE: Regional Infertility Prevention Projects; Office of Population Affairs; Local and State STD Control Programs; Centers for Disease Control and Prevention

32. 32 Gonorrhea — Positivity among 15-24 year old women tested in family planning clinics by state: United States and outlying areas, 2003 *States reported gonorrhea positivity data on less than 500 women aged 15-24 years during 2003. Note: Includes states that reported gonorrhea positivity data on at least 500 women aged 15-24 years screened during 2003 except for Minnesota which submitted gonorrhea positivity data for July-December 2003 only. SOURCE: Regional Infertility Prevention Program; Office of Population Affairs; Local and State STD Control Programs; Centers for Disease Control and Prevention Gonorrhea

34. 34 Primary and secondary syphilis — Rates by state: United States and outlying areas, 2003 Note: The total rate of primary and secondary syphilis for the United States and outlying areas (including Guam, Puerto Rico and Virgin Islands) was 2.5 per 100,000 population. The Healthy People year 2010 objective is 0.2 per 100,000 population. Source: CDC/NCHSTP 2003 STD Surveillance Report Syphilis

36. The GYT campaign is a youthful, empowering social movement to reduce the spread of STDs among young peopleVisit the web sites for provider resources, tools, and GYT materials to help support your local STD prevention efforts: http://provider.gytnow.org www.cdcnpin.org/stdawareness www.findstdtest.org www.itsyoursexlife.com/gyt

37. THE GYNECOLOGIC EXAM

38. The GYN Exam

40. ANY QUESTIONS??? THANK YOU!!!