gynecologic challenges of the hiv positive female dr. orville p. morgan consultant...
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Gynecologic challenges of the HIV positive female
Dr. Orville P. MorganConsultant
Obstetrician/GynaecologistVJH
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Gynaecologic Challenges
Infectious Menstrual disorders Neoplasia Reproductive/fertility
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Infectious diseases
Vaginal candidiasis HSV HPV PID Pelvic abscess Endometritis TB
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Vaginal candidiasis Vulvo-vaginitis Fulminant Resists standard treatment Sign of advancing disease Increases risk of virus transmission Inflammatory changes only on Pap
smear with isolation of candida specie Most often candida albicans
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Clinical Diagnosis
Thick white discharge Pruritus Dypareunia Dysuria Ulceration
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Diagnosis
KOH preparation shows yeast Pap smear/culture shows yeast
and the patient has symptoms of a vaginitis
Category B illness
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Treatment
Azole drugs usually topically for 7 days
DS suppositories for 3 days Oral Rx fluconazole 150-200mg stat
or itraconazole 200mg for three days HIV positive patient – topical agents
for 14 days may be appropriate
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Recurrent Candidiasis
Ketoconazole x 6 months
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HSV
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HSV & HIV HSV seropositivity increases the risk
of acquiring HIV x 2 ? Upregulation HIV replication
HSV-2 infection increases the risk of transmitting HIV
HIV positive individuals may have more frequent outbreaks
In severely immunocompromised individuals lesions may be atypical.
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HSV
HSV-1 droplets, kissing, ora-genital contact
HSV- 2 penile- vaginal, anal intercourse
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Diagnosis &Treatment of HSV
Diagnosis clinical Acyclovir 400mg q6h x 10/7, 800mg
bd Valacyclovir(prodrug) 1000mg daily,
500mg daily Famciclovir 500mg daily, 250mg
daily Foscarnet IV tid
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Dietary Management HSV
HSV contains more arginine vs lysine
Foods high in Lysine Fish, chicken, beef, milk, cheese, beans(not peas), vegetables
Lysine 390mg daily Avoid gelatin, chocolate, oats,
soyabeans, peanuts,whiteflour
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HPV
Skin warts Anogenital warts Cervical cancer Vulval cancer Penile ca, respiratory papillomas,
conjunctival papillomas, oral cavity lesions
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HPV & HIV HPV detection in HIV infected women
may be as high as 83%(5x the general population)
20% of dually infected women with no evidence of cervical disease will develop cervical disease within 3 years.
HIV infected women are at greater risk for developing cervical cancer caused by HPV infection.
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HPV & HSV
Immunosupression inhibits the clearance of HPV
Immunosupression promotes HPV reactivation
Patients have greater number of precancerous lesions
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HPV & HIV
More likely to be infected with multiple types.
Correlation between lower CD4 counts and higher number of multiple types of HPV
More likely to have large condylomas More likely to experience treatment
failures for cervical dysplasia
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PID
Patients admitted for PID more likely to be HIV positive
Symptoms may be muted Fortunately responds equally to
standard therapy More likely to have an adnexal
mass on ultrasound.
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Pelvic Abscess
Tubo-ovarian abscess frequent complication of PID
Constitutional symptoms often absent.
Surgical intervention
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Menstrual abnormalities
Related to advanced disease Amenorrhea IMB Shortened cycle Active virus shedding greatest in
luteal phase R/o malignancies, infections incl TB
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Neoplastic challenges
Cervical carcinoma Vulval carcinoma Uterine lymphomas
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CIN & HIV
HGSIL category B Multifocal dyplasia (vagina, anus)
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Treatment of CIN
Colposcopy LEEP Eradication of SIL almost impossible -
goal to prevent progression to HGSIL 5-Fluorouracil vaginal cream has been
shown to be useful in reducing recurrence rates
HAART may lead to “normal” behaviour of CIN
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Reproductive Challenges- Contraception
Condoms Tubal ligation,(Decreased condom
use) IUCD(?contraindicated) OCP, (Decreased condom use) Depoprovera, (Decreased condom
use)
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Reproductive challenges-fertility
Sero-positive male, sero-negative female
Sero-positive female Obstetric outcomes
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Thank you
Neither this man nor his parents sinned……..
..the work of God might be displayed in his life
John 9:3