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FacultyFaculty Assessment and Management Beth Allen, MSN, CRNP of Women with Benign Senior Nurse Practitioner Conditions, Abnormal Uterine Bleeding and STIs Deborah Davis, MSN, CRNP Senior Nurse Practitioner

Satellite Conference and Live Webcast Neysa Hernandez, MSN, CRNP Thursday, November 19, 2015 Senior Nurse Practitioner 9:00 – 11:00 a.m. Central Time Bureau of Family Health Services Produced by the Alabama Department of Public Health Alabama Department of Public Health Video Communications and Distance Learning Division

Program Objectives Benign • Discuss and define benign breast • Benign breast disease is a disease with emphasis on heterogeneous group of conditions pathophysiology and clinical including congenital anomalies, management inflammatory lesions, • Outline clinical presentation of varied discharge, and palpable and non- benign breast diseases and needed palpable abnormalities assessment, plan, and follow – up

Benign Breast Disease Benign Breast Conditions • Clinical Presentation: • Benign breast conditions may – Palpable mass represent subclinical breast therefore is always the – diagnosis for exclusion or – Mastalgia confirmation – Inflammatory process – Non-Palpable Abnormality

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Breast Benign Breast Disease • Each breast has 8 to 10 sections • Congenital Anomalies consists of: (lobes) arranged like the petals of – Aberrant breast tissue daisy – • Inside each lobe are many smaller structures called lobules – ItdilInverted nipple

• At the end of each lobule are tiny sacs (bulbs) that can produce milk

Benign Breast Disease Benign Breast Disease • Adolescent Development Disorders : • Mastalgia is that is – Asymmetry classified by history as cyclical or noncyclical breast pain – Macromastia • Differential diagnosis should include – Hypoplasia medical non-breast related problems, – Tuberous breast development inflammatory/infections and –

Mastalgia (Continued) Benign Breast Disease • Differential Dx(s): • Fibrocystic Change is a benign • Costochondritis Irritation of pleura condition that includes formation of , hyperplasia of ductal • Cervical Radiculopathy without atypia or • Rib fracture Shingles malignancy, and stromal changes, • Myocardial Ischemia including fibrosis • Pneumonia Esophageal Spasm

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Mammography Voucher Benign Breast Disease Inflammatory Lesions

Mastitis – Lactational Infections – Nonlactational Infections

Benign Breast Disease Benign Breast Disease • Nipple Discharge • Hyperplasia – , Physiologic, and – Ductal Hyperplasia Pathologic – Lobular Hyperplasia • Intraductal – Atypical Hyperplasia • Ectasia

Benign Breast Disease Benign Breast Disease Palpable Breast Masses Palpable

• • Fibromatosis • • Lactating • Hamartoma • • Phyllodes Tumors • Sclerosing Adenosis • Granular Cell Tumors

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Benign Breast Disease Benign Breast Disease • Documentation of CBE mass • Diagnosed Benign Breast Conditions findings: Left or right breast with where patient is not under surgical location by clock-face position and care yearly and lesion remains centimeters(cm) from the , size clinically unchanged, continue in cm, shape, mobile or fixed, tender annual u/s, biannual clinical breast or non-tender, associated skin exam, and monthly self breast changes and lymphadenopathy exams.

Red Flags of CBE Findings Mammogram Assessment • Skin changes(erythema, Peau d’ Categories orange, , scaling/excoriation, • Category 0 - Incomplete, needs retraction, dimpling, puckering, nipple additional imaging discharge, palpable mass, • Categgyory 1 -Negative lymphadenopathy, persistent breast • Category 2 - Benign Findings pain • Category 3 - Probably benign CANCER UNTIL PROVEN OTHERWISE findings- short term follow-up suggested

MMG Categories ACOG Breast Screening (Continued) • Breast Screening starts 40 years old • Category 4 - Suspicious abnormality- and annually thereafter indicated, subcategory - 4 A - • CBE at 19 years old low suspicion for malignancy, 4 B - itintermedi ditate, an d4Cd 4 C -modtderate • Breast Self Awareness has the potential to detect breast cancer and • Category 5 - Highly suspicious of can be recommended malignancy • Category 6 - Known biopsy proven malignancy

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References • Objectives - ACOG, Benign Breast Alabama Breast and Disease, Clinical Updates In Women’s Health Care, Vol XIV, No.3, July 2015 Cervical Cancer • Green, V. and Weiss, P. Breast Disorders, Program’s 10 -year Breast Clini c Rev iew Ar tic les, Elsev ier Inc. Vo l. 40, No.3, September 2013, pp 459-473. Cancer Screening Stats • Centers for Disease Control (CDC), National Breast and Cervical Cancer Early Detection Program, August 2015.

References ReferenceReference • Center for Disease Control (CDC). National • Medscape,emedicine.medscape.com/articl Breast and Cervical Cancer Early e/1253816. Benign and Malignant Soft Detection Program, August 2015. Tissue Tumors, Jan. 27, 2015. • Georgia Breast and Cervical Cancer PHlthPtiDiProgram Health Promotion Disease Prevention Program, Department of Public Health, September 2010, pp 10-27.

Abnormal Bleeding and Differential Diagnosis • Define the descriptive terms used to characterize abnormal menstrual bleeding patterns Differential Diagnosis • Demonstrate utilization of differential diagnosis in development of a plan of care in a woman with abnormal uterine bleeding

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Differential Diagnosis Differential Diagnosis • Two Important Components 1. Communication with Patients 2. Eliciting Reliable History Bridge The Gap Between . . .

Differential Diagnosis Differential Diagnosis

Chief Complaint and Step By Step Formulation of the Correct Diagnosis

Differential Diagnosis Differential Diagnosis 1. Complaint 2. History of Complaint A. Symptoms B. Directed questions to ask

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Differential Diagnosis Differential Diagnosis • Onset • Aggravating or triggering factors • Location / Radiation • Alleviating factors • Duration / timing • Effects on daily life • Character • Associated Symptoms

Differential Diagnosis Differential Diagnosis C. Assessment, Cardinal Signs D. Medical History: General medical and Symptoms history (Subjective), History specific to complaint (Directed)

Differential Diagnosis Differential Diagnosis • Relevant past medical history 3. Physical Examination • Family history Vital signs and general appearance • Social history

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Differential Diagnosis Differential Diagnosis • Physical Examination should be • Physical Examination may reveal directed toward Chief Complaint unsuspected findings, or • Physical Examination may provide • NO findings are revealed to support the diagnosis without need for the origgginal diagnosis further testing

Differential Diagnosis Differential Diagnosis • Testing • Lab Testing – Initially in Public Health – Basic Tests – Hcg – Move from screening to elaborate – Hgb testing, if needed – TSH – Thyroid Function Studies – Cervical Cancer Screening – Cervical or Urine Cultures (CT/GC/TV)

Differential Diagnosis Differential Diagnosis 4. History and Physical 5. The Differential Diagnosis Examination findings compares typical symptoms of medical conditions with the results of the patients history and physical examexam

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Differential Diagnosis 6. The Practitioner can then decide if additional testing is needed in order to facilitate arriving at the correct diagnosis Re - Evaluate

Differential Diagnosis Differential Diagnosis 7. Clinical decision making • The depth of one’s differential (most likely diagnosis) diagnosis is determined by the breadth of knowledge by the provider

Differential Diagnosis Abnormal Uterine Bleeding • Abnormal Uterine Bleeding (AUB) • Terms no longer used – OLD, OLD – Menorrhagia – Metrorrhagia – Polymenorrhea – Oligomenorrhea – Dysfunctional uterine bleeding

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Abnormal Uterine Bleeding Abnormal Uterine Bleeding • Abnormal Uterine Bleeding (AUB) • PALM – Structural Causes • Heavy Menstrual Bleeding • COEIN – Nonstructural Causes (AUB/HMB) • Inter-menstrual Bleeding (AUB/IMB)

Classification AUB Abnormal Uterine Bleeding PALM-COEIN PALM-COEIN P - polyp (AUB - P) C - (AUB - C) A - Adenomyosis (AUB - A) O - Ovulatory dysfunction (AUB - O) L - Leiomyoma (AUB - L) E - Endometrial (AUB - E) Submucosal myoma (AUB - Lsm) I - Iatrogenic (AUB - I) Other myoma (AUB - Lo) N - Not yet classified (AUB - N) M - Malignancy & Hyperplasia (AUB - M)

Abnormal Uterine Bleeding Abnormal Uterine Bleeding • Medications contributing to AUB – Ginko – Warfarin – Ginseng – Heparin – Motherwort – Non-Steroidal Anti-inflammatory – St. John’s Wort (NSAIDs) – Hormonal Contraceptives

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Abnormal Uterine Bleeding Anovulatory Bleeding • Patient can have more than one • Characterized by heavy, irregular cause for abnormal uterine bleeding unpredictable bleeding

Anovulatory Bleeding Anovulatory Bleeding • Causes Physiologic 1. Physiologic • Adolescence 2. Pathologic • Peri-menopause • Lactation •

Anovulatory Bleeding Anovulatory Bleeding Pathologic • Primary Pituitary disease • Hyperandrogenic anovulation, • Premature ovarian failure adrenal hyperplasia, or andogen- • Latrogenic (ie. Secondary radiation ppgroducing tumors or chemotherapy) • Hypothalamic dysfunction (anorexia) • Medications • Hyperprolactinemia • Thyroid disease

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Ovulatory Cycle Menstrual Cycle • Normal Menstrual Cycle • Abnormal Menstrual Cycle – Interval lasts between 21 - 35 days – Interval less than 21 days or (mean 28 days) greater than 35 days – Duration 4 - 6 days (mean 5 days) – Duration less than 2 days or (most blood lost the first 3 days) greater than 8 days – Volume variable - approx. 30 - 35 ml – Volume greater than 80 ml

Abnormal Uterine Bleeding Ovulatory Bleeding • It is excessive bleeding when she • Characterized by amenorrhea to says it is excessive! heavy irregular menstrual periods

Abnormal Uterine Bleeding Abnormal Uterine Bleeding • One-third of all patient visits to the • 20% of women presenting with gynecologist are related to abnormal abnormal uterine bleeding have uterine bleeding some type of bleeding disorder • 70% are during the ppperimenopausal / menopausal years

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Abnormal Uterine Bleeding Abnormal Uterine Bleeding • Endometrial ablation does not • Post-coital bleeding results from: provide contraception

Postcoital Bleeding Postcoital Bleeding • Benign growths • Infection – Endometrial polyps – Cervicitis – Cervical polyps – Pelvic Inflammatory Disease – Cervical ectropion – Endometritis – Vaginitis

Postcoital Bleeding Postcoital Bleeding • Genital/vulvar lesions • Benign Conditions – Herpes simplex virus – Vaginal atrophy – Syphilis – Pelvic organ prolapse – Chancroid – Benign vascular neoplasms – Lymphogranuloma venereum – Endometriosis – Condyloma accuminata

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Postcoital Bleeding Postcoital Bleeding • Malignancy • Trauma – Cervical Cancer – Sexual abuse – Vaginal Cancer – Foreign bodies – Endometrial Cancer

Abnormal Uterine Bleeding Abnormal Uterine Bleeding Age-Based Common Differential Diagnosis Age-Based Common Differential Diagnosis

• 13 - 18 years • 19 - 39 Years – Persistent anovulation – Pregnancy – Hormonal contraception use – Structural lesions – Pregnancy – Anovulatory cycles – Pelvic infection – Hormonal Contraception – Coagulapathies – Endometrial hyperplasia / – Tumors

Abnormal Uterine Bleeding Case Study # 1 Age-Based Common Differential Diagnosis • 16 year old with c/o prolonged heavy • 40 Years to Menopause menstrual flow with increased cramping over the last 8 days – Anovulatory bleeding • Past menstrual periods reported as – Endometrial hyperplasia / Carcinoma normal • Periods were usually 26 – 28 days; – Endometrial atrophy varied sometimes with some clots – Leiomyoma

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Case Study # 1 Case Study # 1 • Physical Examination Specific to – Bimanual exam – enlarged uterus OB/GYN was normal with exception of: approximately 8 week size; noted tenderness with palpation – Abdomen – deep palpation suprapubic tenderness – Pelvic /speculum exam – large blood clots and heavy bleeding noted. Cervix is closed, vaginal mucosa appears normal, CMT positive for tenderness

Case Study # 1 Case Study # 1 • What is the differential Diagnosis? • What other tests need to be done? – PID or pelvic infection – sexually – CT/GC/TV? transmitted infection – Hcg.? – Missed AB? – Hgb.? – Clotting Disorder? – Urinalysis? – Possible UTI? – Other? – Other?

Case Study # 1 Case Study # 1 • Tests reveal: • Heavy Menstrual Bleeding Causes:

– Positive Hcg. - Hormonal Imbalance - Contraceptives – Hgb. 7.2 - Uterine Fibroid - Pregnancy • What is your Clinical Decision? - EdEndomet tilPlrial Polyps - Coagul opa thies - Infection - Endometrial Cancer - Intrauterine devices

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Case Study # 1 Case Study # 1 • Directed Questions to ask: • Relevant questions: – A good way to ask this question – Sexual activity? related to her bleeding is: “Tell me – Vaginal discharge? about yypypour periods” – History of pregnancy, or ?

Case Study # 1 Case Study # 1 • Cardinal Signs for this patient: • General Medical – Heavy bleeding X 8 days – Family History - Others with – Cramping with clots problems of heavy bleeding? – Nausea – Medical history - Specific to complaint – No contraception (denies having sex)

Case # 22Case Case Study # 2 • 33 y/o G1P1 in for FPA. BP 108/60, • Nonsmoker HR 76, BMI 28, weight 147, non- • No medications; took thyroid smoker, current on OrthoTricyclen medication in past but quit taking it Lo and wants to continue. 2 or 3 yygears ago • Chief complaint – irregular spotting • Hcg - negative on this pill for last six months

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Case Study # 2 Case Study # 2 • Physical Examination • The patient’s Thyroid Function tests – Overweight BMI 28 – weight 147 returned abnormal with elevated TSH and low serum free T4 – H/O ? abnormal thyroid – self d/c meds • Clinical Decision – Hypoth yroidism – Thyroid - Mildly diffuse/no nodular (referral warranted) lesions – Pelvic - speculum and bimanual exam unremarkable

Case Study # 2 Case Study # 3 • Differential Diagnosis? • 48 y/o BF Gravida 3 Para 1 into clinic • Break through bleeding on COCs for annual exam. Complains of irregular bleeding between periods • Possible thyroid disorder and prolonged periods. Periods last about 8 days, heavy, with a little cramping.

Case Study # 3 Case Study # 3 • BP 144/94, weight 178 with BMI 35. • Physical Examination Patient states had BTL. Last pap – Cervix parous, no gross lesions; no 2013 negative with HPV negative CMT • H/O HTN on medication but out X – Bimanual exam – anteverted;15; 15 – 16 1 week1 week week size, irregular shaped – smooth – No adnexal mass palpated bilaterally

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Case Study # 3 Case Study # 3 – Recto-vaginal exam was confirmatory • What is your differential diagnosis with a small hemorrhoidal tag: FIT for AUB? was given and reviewed (pt with no insurance and high risk category – counseldthtFITdled that FIT does not repl ace the need for colonoscopy as that is the specific diagnostic test for colorectal cancer and polyps: FIT is screening test only)

Case Study # 3 Case Study # 3 • Anovulatory bleeding • AUB in this patient is the result of • Endometrial hyperplasia/Carcinoma Leiomyoma • Endometrial atrophy • Leiomyomas

Case Study # 4 Case Study # 4 • 30 year old Gravida 4 Para 3 in for • Physical examination: examination and requesting oral – Abdomen – soft; nontender contraceptives. The patient states her – External genitalia – no gross lesions periods are “normal and lasts two weeks.” She has previously used COCs & Depo. – Speculum exam – vagg;pina; pink & rugae Last Depo use 2 years ago. without lesions; cervix without lesions • Last sexual intercourse two days ago with – Bimanual exam – retroverted; NSSC use of condom but it broke. She does not – Adnexa – without masses/nontender desire pregnancy and wants better – Recto-vaginal – deferred contraception. Smokes ½ ppd

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Case Study # 4 Case Study # 4 • Hcg negative • What is your differential diagnosis? • Thyroid function studies not done • Structural lesions like polyps, or • No wet mount obtained fibroids • CT/GC/TV cult ures d one • Anovulatory cycles (like PCOS) • Pap smear with HPV obtained • Use of hormonal contraceptives • Endometrial hyperplasia/Carcinoma

Case Study # 4 Case Study # 4 • An abnormal pap smear was • What are her options for returned contraception? • HGSIL with Atypical glandular cells (AGC)

Case Study # 5 Case Study # 5 • 59 y/o Gravida 8 Para 2 presented for • Medical History for this patient is: Cancer Detection Initial visit – Non contributory • Reports LMP 10 – 15 years ago • States spotted 2 weeks ago X 1 day – had some pain on right side and the next day spotted again

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Case Study # 5 Case Study # 5 • Family medical history: • Physical examination findings were: – Mother had ovarian cancer – Bimanual exam was normal with (age 70s) the exception of: • Vagina - Pale atrophic mucosa; creamy pink tinged discharge

Case Study # 5 Case Study # 5 • The assessment and plan: • The patient returns for examination – Normal gyn exam with atrophic at age 61 vaginitis • She states she wears a pad daily due – Patient was instructed to f/u for to vaginal bleeding X 4 months evaluation of atrophic vaginitis with PMD

Case Study # 5 Case Study # 5 • Physical Examination: • What is the Differential Diagnosis? – The exam was normal with the exceptions of: Erythematous vulva – Atrophic vagina with erythematous mucosa; pooling of blood tinged serous fluid seen in vaginal canal

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Case Study # 5 Case Study # 5 • This patient was referred and found • Endometrial cancer is one of the most to have on common diagnosed gynecologic endometrial biopsy

Case Study # 5 Case Study # 5 • Epidemiology and risk factors • Clinical Presentation – The most common symptom of endometrial cancer is abnormal uterine bleeding - either irregular menses or intermenstrual bleeding, or post menopausal bleeding

References References • Diagnosis of Abnormal Uterine Bleeding in • Hatcher,R.,Trussell, J., Nelson, A., Cates, Reproductive-Aged Women." ACOG W., Jr., Kowal, D., & Policar, M. Practice Bulletin No. 128. American College Contraceptive Technology. 2011. Ardent of Obstetricians and Gynecologists. July Media, Inc., New York, New York. 2012 (()Reaffirmed 2014). • "Management of Abnormal Uterine Bleeding • “Endometrial Cancer.” ACOG Practice Associated with Ovulatory Dysfunction." Bulletin Number 149, American College of ACOG Practice Bulletin No. 136. American Obstetricians and Gynecologists. April 2015 College of Obstetricians and Gynecologists. July 2013.

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References ICD – 10 Codes • "Endometrial Cancer." ACOG Practice • AUB – I N921 Bulletin No 149. American College of Obstetricians and Gynecologists. April 2015. • AUB – Ovulatory, intermenstrual • “Postcoital Bleeding: A review on etiology, N923 diagg,nosis, and manag ement. Tarney, C.M. • AUB – irregular cycle or periods and Han, J. N925, N926 http://dx.doi.org/10.1155/2014/192087. • Rhoads,J. & Jensen, M., Eds. Differential • Postmenopausal bleeding N950 Diagnosis for the Advanced Practice Nurse. • AUB (dysfunctional uterine bleeding) 2015. Springer Publishing Co., LLC. New N925, N938 York, New York.

2015 STI Treatment 2015 STI Treatment Guidelines Guidelines • Objective: • This information updates the – To identify treatment Sexually Transmitted Disease recommendations for the Treatment Guidelines from 2010 management of sexual health and • We as health-care providers have clinical issues according to the daily opportunities to help promote 2015 CDC guidelines behavioral changes with our patients to help prevent STIs

STI Treatment Guidelines 1. Alternative Treatment • These recommendations are to be Regimens for Gonorrhea used as guidance, they are tools not • Second most commonly reported rules infectious disease – As health care providers we need • In 2013 Ala bama ha d the secon d to tailor this to each patient highest rate of Gonorrhea in the according to their specific clinical nation per CDC presentation

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Gonorrhea Epidemiology (Cont) • Gonorrhea treatment is complicated • Four of the five states with the due to the ability of Neisseria highest prevalence of Gonorrhea Gonorrhoeae to develop resistance infections are in the south. against antimicrobials • 2007 Fluoroquinolones • 2010 Dual therapy • 2015 Azythromycin over Doxycycline

Tx of Uncomplicated GC treatment Gonorrhea Pregnant Females

• Ceftriaxone 250 mg IM single dose Ceftriaxone 250 mg IM single dose PLUS PLUS Azythromicin 1 g PO single dose Azythromicin 1 g PO single dose OR Retest 3-4 weeks Doxycycline 100 mg PO BID x 7 days

GC Treatment GC Treatment (cont) Pregnant Female Alternative Regimen True PCN or Cephalosporin allergy Azythromicin 2g PO single dose Ceftriaxone 250 mggg IM single dose Gentamicin 240 mg IM PLUS PLUS Amoxicillin 500 mg PO TID Azithromycin 2g PO single dose (Repeat test 3-4 weeks) OR

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GC treatment True PCN or (Cont) Cephalosporin Allergy • Call your designated physician or Gemifloxacin 320 mg PO Central Office: PLUS • PHA 1: Dr. Karen Landers - 256-383-1231 Azithromycin 2g PO • PHA 2: Dr. Scott Harris - 205-340-2113 • PHA 3-11: Dr. Albert White - 205-554-4500 • Central Office: - 334-206-5350

2. Updated Treatment for Chlamydia Treatment Chlamydia Infection During Pregnancy

• Most frequently reported infectious Azythromycin 1g PO disease in the United States OR • Prevalence higher in persons less Doxycycline 100 mg PO BID x 7 days than 25 years old • Annual screening recommended

Chlamydia Treatment 3. Use of Nucleic Acid Pregnant Females Amplification Test for the diagnosis of Trichomonas NAAT Azythromycin 1 g PO single dose OR • Higgyhly sensitive and specific test Amoxicillin 500 mg PO TID x 7 days Repeat test in 3-4 weeks

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Test Sensitivity and TestsTests Specificity • Aptima Test • Sensitivity Sensitivity 95.3-100% – Ability of the test to correctly identify Specificity 95.2-100% those patients with the disease For vaginal, endocervical or urine • Specificity specimen – Ability of the test to correctly identify • Wet Mount Poor sensitivity 51-65% those patients without the disease

Trichomonas treatment If Pregnant

• Treatment remains the same Metronidazole 2g PO single dose • Metronidazole 2 g PO single dose OR Repeat test 3-4 weeks Tinidazole 2g PO single dose • Alternative Tx: Metronidazole 500 mg PO BID x 7 days

Mycoplasma genitalium • First identified early 1980’s 4. Role of Mycoplasma • Can be a sexually transmitted genitalium in pathogen urethritis/cervicitis and • Cause of male urethritis treatment related implications • Pathogenic role in women is unclear but may play a role in cervicitis and PID

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Mycoplasma genitalium Treatment Urethritis and (Cont) Cervicitis • Slow growing organism • Single dose of oral Azithromycin 1 g • Culture can take up to 6 months is currently the recommended treatment, but resistance is rapidly • Only a few laboratories in the world are able to recover clinical isolates emerging • NAAT is the preferred method • Moxifloxacin 400 mg PO x 7,10 or 14 days • FDA approved test not commercially available

5. An aditional Treatment Option for Genital Wart • Imiquimod 3.75% cream has been added to the list of recommended 6. Updated HPV vaccines patient applied treatment regimen for recommendations and genital warts counseling messages • Podophyllin resin is now alternative regimen rather than recommended treatment for external genital warts

HPV Vaccines HPV Vaccines Schedule • Bivalent 2vHPV (Cervarix) 2009 • Routinely vaccinate females & males Type 16 and 18 F 11 or 12 years old • Quadrivalent 4vHPV (Gardasil) 2006 – May begin the series as early as 9 Types 16 , 18 , 6 and 11 M/F years old • 9vHPV (Gardasil) 12/2014 M/F • Females 9-26 years old Types 6,11,16,18,31,33,45,52 and 58 • Males 9-21 but can be given up 26 years old

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HPV Vaccine Schedule Tips for Talking with • HPV vaccine is given in a 3 dose Parents About HPV Vaccine series • Recommend HPV vaccine the same way you recommend other adolescent 1st Dose Now vaccines 2nd Dose 1-2 months after 1st dose • The “HPV vaccine is cancer 3rd Dose 6 months after 1st dose prevention” is a message that resonates with parents • Parents ask: Why vaccinate at 11-12 years old?

Tips for Talking HPVHPV with Parents • As of 2014 according to CDC survey • Parents may be concerned that 60% of adolescent girls and 42% of vaccination may be perceived by the boys had received one or more dose child as permission to have sex of HPV vaccine

HPVHPV 7. Screening • Remember: Recommendations, Including Hepatitis C, for MSM – Vaccination is not a substitute for • Recommended to screen annually for cervical cancer screening Hepatitis C if HIV positive or any – This vaccine does not protect othhikfer risk factors against all HPV types that can cause cervical cancer – Women should still get regular Pap tests

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8. Information on the References Clinical Management of • CDC 2015 STD Treatment Guidelines Transgender Individuals – http://www.cdc.gov/std/tg2015/ • New section for transgender individuals was added to the special populilation secti on – Trans-women – Trans-men

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