OB GYN test 3

Injury to cervix or uterus from IUD

Perforation of the Uterine Fundus: *Potentially serious complications associated with IUD use. Occurs at insertion in about 1/1000 insertions Suspect if a patient reports she cannot feel attached string and doesn't think IUD was expelled. Use x-ray or US to locate device If IUD found outside uterus, must be removed because of complications (adhesions, bowel obstruction)

Fertility Cycle

Phase 1. Relatively infertile phase Phase 2. The Fertile phase Phase 3. The absolutely Infertile phase

Neg factors of NFP

Requires several months of teaching and follow-up to lean to properly evaluate and record the state of cervical mucus. Couples instructed to avoid genital contact during this time to remove variable in charting. Need to evaluates mucus at the vulva

STDs that CDC keeps track of are:

Chancroid, chlamydia, gonorrhea, Hepatitis B, HIV, and syphilis.

Perimenopause causes of AUB/DUB

1. Perimenopause anovulatory menstrual cycles 2. Pregnancy "change of life baby" 3. Infections 4. Medications 5. Systemic disease 6. Polyps, fibroids 7. Endometrial cancer

scabies

(Sarcoptes scabiei): Much quicker than crabs and can be found anywhere on the skin. *Burrows long tunnels in skin to lay eggs Transmitted by close sexual contact but also by NON-sexual contact (sharing clothing or bedding)

ella

(Ulipristal acetate): Progesterone-receptor agonist/antagonist. Similar to mifepristone (Mifeprex). Delays follicular rupture and may cause endometrial changes that could interfere with implantation of a fertilized ovum. Effectiveness remains constant for at least 120 hours Adv effects-headache, nausea, abdominal pain, dysmenorrhea, fatigue and dizziness

progestin and estrogen emergenct contraception

(Yuzpe Regimen): Many brands of the combined daily birth control pill can be used for emergency contraception in the US. Decrease chances of getting pregnant by 75%; more likely to experience side effects (nausea and vomiting). Need to use an anti-emetic Examples-Nordette, Triphasil, Seasonale, Seasonique

HSV Epidemiology:

*Prevalence estimated at 45 million in USA to have HSV-2 *Predominant mode of transmission is sexual intercourse. Incubation time is 3-7 days.

Treatment of primary and secondary syphilus

*Benzathine penicillin G 2.4million units IM single dose If pcn allergic Tetracycline 500mg po aid x 14days or doxy 100mg po 14days Pts with HIV need longer tx

trichomonas vaginalis sx

*Profuse, yellow-grey, frothy malodorous discharge of low viscosity. Vulvar pruritus. Erythematous vulva and vagina. *"Strawberry" cervix-intense erythematous mottling of the cervix

Dx of syphilis

1. Dark field examination 2. Serologic tests

Chance

(no form of contraception): 15% effective!

treatment of HIV/AIDS

*NO effective prophylactic therapy to prevent infection, but try to slow progression with antiviral agents: Entry Inhibitors Fusion Inhibitors Reverse transcriptase inhibitors Integrase inhibitors Protease inhibitors Multi-class combination products

infection from IUD

*Pelvic infection rates are highest in the first 2 weeks after insertion and then decrease. *The risk of developing pelvic infection is greatest in women who have: a. Prior history of pelvic infection b. No children (nulliparous) and who are under age 25 c. Multiple sexual partners. *The incidence of salpingitis is about three times greater in IUD users than diaphragm or OCP users. Treatment: *Remove IUD and give antibiotics.

Tx of C. Granulomatis

* Azithro 1g po one/week or 500mg po daily Alt Doxy 100mg bid for 3 weeks or Ciproflox 750mg po bid for at least 3 weeks or tmpsmx- 1 double strength tablet 3 wks

Cervititis

* GC and chlamydia MCC 50% women infected with both Many ask Sx- vag discharge, dysuria, abnormal vaginal bleeding PE- cervical edema, erythema, friability, discharge Tx both Azithromycin 1g PO single dose or Doxycycline 100mg po BId 7 days * consider bono coal infection if high prevalence in the community

Treatment of GC

* coexisting chlamydia infection * do F/u cultures and exam 3-7days after completion of therapy. *patients with acute PID usually need hospitalization and broad spectrum antibiotics * cant use quinolones in California, Hawaii, Asia, pacific islands ***MAy 2007- CDC no longer reccomends use of fluoroquinolones QRNG tx: ceftriaxone 250mg IM single dose or Cefixime 400mg single dose + azithro po single dose or Doxy 100mg bid 7days GC Ceftriaxone 250mg IM single dose + Azithromycin 1gm po single dose

Von Willebrands disease and menorrhagia

* the MC inherited bleeding disorder Inadequate platelet adhesion and thrombus formation Sx: Easy bruising, freq nose bleeds, bleeding gums, ** heavy menstrual bleeding, prolonged bleeding after cuts or surgery Dx: Dec vWD factor Dec factor VIII activity Prolonged bleeding time Tx: Desmopressin OCs for repeated menorrhagia

Hx of pelvic pain

* very important Consider onset (acute vs chronic), location, quality, duration, and severity of the pain and associated sx (fever, chills, anorexia, N/V or bleeding)

Microbiology of PID

** polymicrobial infection * GC and Chlamydia cause about 2/3 of cases of acute PID; coexist in 25-40% cases.

Common causative agents of PID

**1. Neisseria gonorrhoeae **2. Chlamydia trachomatic 3. Enteric gram neg rods 4. Haemophilus influenzae 5. Streptococcus agalactiae 6. Bacteroides sp. 7. Peptostreptococcus sp 8. Peptococcus 9. Mycoplasma genitalium 10. Mycoplasma hominis 11. Ureaplasma urealyticum 12. CMV 13. Actinomycetes 14. Microorganisms that compromise vaginal flora- anaerobes, Gardner Ella, Haemophilus influenzae, enteric gram neg rods, streptococcus agalatiae

HPV-Related Pre-Cancerous Conditions of Cervix:

**Most important to exclude dysplasia before treatment. 1. Cryotherapy 2. Laser vaporization 3. Surgical excision

Ectoparasites tx

*1% permethrin cream (NIX) OR, *Pyrethrins and piperonylbutoxide (RID) Recommended Regimens Permethrin 1% cream rinse applied to affected areas and washed off after 10 minutes OR Pyrethrins with piperonyl butoxide applied to the affected area and washed off after 10 minutes Alt Regimens for louse infections Malathion 0.5% (Ovide) lotion applied to affected areas & washed off after 8-12 hours can kill lice and some lice eggs but currently has not been approved by the FDA for treatment of pubic "crab" lice. OR Ivermectin topical lotion Both topical and oral ivermectin have been used successfully to treat lice; however, only topical ivermectin lotion currently is approved by the U.S. Food and Drug Administration (FDA) for treatment of lice. Oral ivermectin is not FDA-approved for treatment of lice.

Diagnosis of PID

*Acute PID difficulty to dx because there is a wide variation of signs and sx that are relatively nonspecificMany women with PID have subtle or mild symptoms. Delay in diagnosis and treatment probably contributes to inflammatory sequelae in the upper reproductive tract. *High degree of suspicion essential in making diagnosis.

tubo-ovarian abscess (TOA)

*Admit. Sick. Severe low abdominal pain, nausea, vomiting and diarrhea. Fever up to 1030F Can have ileus Tachycardia Can be hypotensive *Very tender abdominal exam Labs: Elevated WBC, Sed rate. Decreased urine output

Diagnosis of HSV

*Diagnosis typically made by lesion appearance and clinical history. Nucleic acid amplification methods-most sensitive, specific and timely methods for diagnosis of acute lesions (e.g., vesicles, ulcers, inflammation of mucous membranes, cerebrospinal fluid [CSF]) PCR - rapid diagnostic testing that is recommended in certain conditions Viral culture - less sensitive (~50%) compared to PCR; cultures from vesicular fluid or edge of ulcerative lesion Antigen detection tests for HSV - rapid, relatively inexpensive; 80% sensitive for acute vesicular lesions; 60-75% sensitive for resolving lesions or asymptomatic shedding Tzanck smear - rapid; does not differentiate between simplex and zoster; *See multinucleated giant cells-Tzanck smear/cells HSV antibody titers are not useful for rapid diagnosis of acute infections; May be useful in patients with negative cultures

treatment of scabies

*Disinfecting clothing, bedding and the home environment *5% permethrin (Elimite) cream now the DOC OR, Ivermectin 200 mcg/kg po repeated in 2 weeks Rec Regimens: Permethrin 5% cream applied to all areas of the body from the neck down and washed off after 8-14 hours* OR Ivermectin 200ug/kg orally, repeated in 2 weeks * Infants and young children should be treated with permethrin. *Infants and young children aged <10 years should not be treated with lindane.

diagnotic studies for PID

*Dx of PID based on clinical findings. *No single lab test has good sensitivity and specificity. 1. Cervical Gram Stain-look for GNID (GC). Gram stain alone misses ½ of GC cases. 2. Cervical cultures 3.Culdocentesisneedle aspiration of the cul-de-sac thru post vaginal wall; PID purulent fluid; do cultures 4. *Laparoscopy-provides direct visualization of ovaries, uterus, fallopian and tubes but is invasive and carries risks of surgery and anesthesia. Always thought to be the definitive diagnostic method, but not never really validated as such and it is not cost effective. Not readily available. Will not detect endometritis and may not detect subtle inflammation of the fallopian tubes. 5. Transvaginal Uts-may help to define adnexal masses or ectopic pregnancies. Shows thickened, fluid-filled tubes (> 5mm) with or without free pelvic fluid or tubo-ovarian abscess. May also see incomplete septae w/in the tube, fluid in the cul-de-sac and the "cogwheel" sign (a cogwheel appearance on the cross-section tubal view). 6. Endometrial bx w/ histopathologic evidence of endometritis. CDC considers the finding of histologic endometritis on endometrial biopsy to be the most specific diagnostic criteria for acute PID 7. CT pelvis-subtle changes in appearance of pelvic floor fascial planes, thickened uterosacral ligaments, inflammatory changes of tubes or ovaries and abnormal fluid collection. 8. MRI-may see TOA, pyosalpinx, fluid-filled fallopian tube or polycystic-like ovaries with free pelvic fluid. Better than transvaginal US in diagnosing PID with sensitivity of 95% and specificity of 89% but MRI is much more expensive. 9. Serum hCG-rule out ectopic pregnancy

treatment for PID

*Empiric, broad-spectrum coverage. Clindamycin-anaerobes Metronidazole-anaerobes Doxy/TCN-enterics, no anaerobes Aminoglycosides-enterics, no anaerobes PCN and Cephalosporins-aerobes, some enterics, some anaerobes *Avoid fluoroquinolones unless resistance has been excluded. *Must cover N. gonorrhoeae, C. trachomatis, anaerobes, gram-negatives, facultative bacteria and Streptococcus species *Indiv tx Outpatient management with close 48-72 hr follow-up vs. hospitalization. Fluoroquinolone-resistant N. gonorrhea a tx problem in certain geographic areas China, Japan, Korea, the Philippines, Singapore and Vietnam have the highest rates (46 to 92.5%). Also see high rates of resistance in Cali. *Levofloxacin or ofloxacin should not be used unless infection with QRNG has been excluded.

endometrial physiology

*In the absence of normal cycles of progesterone stimulation and periodic desquamation, the endometrium attains an abnormal height without the necessary structural support. Tissue is fragile and has superficial breakdown and bleeding. As one site heals, another site breaks down, resulting in continuous bleeding. *Continuous stimulation of unopposed estrogen to the endometrium can result in excessive proliferation and mitotic activity, which leads to adenomatous hyperplasia, atypical adenomatous hyperplasia, and endometrial carcinoma.

Ectoparasites clinical sx and dx

*Intense vulvar pruritus secondary to an allergic sensitization. 1. See with hand lens inspection-crabs and/or nits on hair follicles.

Mollescum contagiosum tx

*Local excision, cryotherapy, electrocautery, laser vaporization and Retin-A. *When seen in children in genital area, must think sexual abuse.

IUD

*MOA: •Thickens cervical mucus •Causes local, sterile inflammatory reaction in uterus; reversible •Inhibits sperm movement •Thins uterine lining Advantages: 1. High level of effectiveness 2. Lack of associated systemic metabolic effects 3. Single act of insertion required for long-term use. Effectiveness: 99%

Management of DUB

*Must rule out organic causes of DUB before classifying it as endocrine in origin. Management Depends on: 1. Amount of bleeding 2. Cause of bleeding 3. Age of patient 4. Ovulatory status 5. Desire for fertility All women with menorrhagia should be started on iron. Mild cases of DUB are amenable to watchful waiting or treatment with NSAIDS. DUB from anovulation is usually treated hormonally.

HIV

*Retrovirus Epidemiology: Risk populations include male homosexuals, bisexuals, IVDU, female heterosexual sexual partners of infected males, recipients of tainted blood or blood products, neonates born to infected women. *Transmission is both horizontal and vertical. *Incubation or latency time is between 2 months and 5 years. *Prevalence in general population estimated at 9/100,000 people *Men are affected more frequently than women.

more severe stage of HIV

*Symptoms include generalized lymphadenopathy, night sweats, fever, diarrhea, weight loss and fatigue. *Infections with Herpes Zoster and oral candidiasis can occur *30% of cases progress to AIDS in 4-5 years.

pathophysiology

*The pathophysiology of DUB is due to disturbances in the hypothalamic-pituitary-ovarian axis.

Herpes Simplex Virus (HSV):

*Very common STI. Estimated up to 1, 000,000 new cases each year. Highly contagious. *HSV-2 is the predominant genital pathogen (HSV-1 seen in 13-15% genital infections) *Infect mucocutaneous tissues of lower genital tract. *Virus stored in pelvic ganglia for recurrent herpetic genital infection. *Most commonly produces recurrent vesiculoulcerative genital lesions. *HSV-2 has been associated with cervical cancer.

combo hormonal contraceptives

*all CHCs increase the risk of VTE *CHCs with drospirenone may be associated with a higher risk of VTE. Highest risk during 1st yr of CHC use, the VTE risk assoc with pregnancy is much higher.

Chlamydia STIs

*chlamydia trachomatic is a very common STI. MC bacterial cause of STIs. Different types of infections.

Preovulatory follicle

*estrogens rise rapidly. Reach peak approx 24-36hrs before ovulation. LH increases steadily until midcycle , and then there is a surge with a lesser surge of FSH.

antral follicle

*follicle destined to become dominant secretes the greatest amt of estradiol *rising estradiol levels result in neg feedback on FSH secretion levels; this halts dev of other follicles which become atretic. *follicular rise in estradiol causes positive feedback on LH secretion

Side effects of OCs

*freq of SE appears to relate to estrogen dosage. 1. * breakthrough bleeding or amenorrhea- often seen when very low dose preps used. 2. Nausea, HA, weight gain, and breast tenderness- usually disappear or lessen in severity after 2 or 3 cycles of pill use. 3. Negative effects from progesterone 4. Melasma

Pelvic pain neurophys

*hard to differentiate pain that arises from deep pelvic viscera *poorly localized and slowly conducted and persists after a stimulus is removed.

Physiology of DUB: anovulatory bleeding

*most DUB is anovulatory and is from estrogen withdrawal or estrogen breakthrough bleeding

Hemophilia Ducreyi (chancroid)

*small, nonmotile gram negative rod (chaining appearance on gram stain) Rare in US,common world wide Most frequently in young sex active men involved w prostitutes Incubation 3-5days

Reasons to choose NFP

Religious preferences, availability and low cost, complete absence of drugs and exogenous hormones, desire to have a sense of control over their body

Adjunct Treatment for DUB

. Nonsteroidal anti-inflammatory drugs (NSAIDS): *NSAIDS inhibit prostaglandin synthesis. Can reduce menstrual blood loss 20-50% in those with ovulatory DUB. •Mefanamic acid 500 mg tid •Ibuprofen 400 mg pot id •Meclofenamate 100 mg pot id •Naproxen 275 mg po q 6 hours after a 550 mg loading dose

Sx to 2ndary dysmenorrhea

1 *cramping pain-NOT limited to menses 2. Infertility 3. Abnormal bleeding 4. Dyspareunia- not usually seen in primary dysmenorrhea

How many adolescents have an STI?

1 in 4, many go undiagnosed

3 pathways transmit sensations from the pelvic organs

1) Parasympathetic nerves (S2,S3,S4) 2) Thorcolumbar sympathetic nerves (T11, T12, L1) 3) superior mesenteric plexus (T5-T11)

Luteal phase features:

1) fairly constant duration of 12-16days 2) elevated basal body temp over 98F 3. Formation of corpus luterum in ovary, w secretion of progesterone and estrogen 4. Endometrial changes: tortuous glands, secretion, stromal edema and decidual reaction 5. Vaginal epithelium remains thick, marked decrease in secretory changes. 6. Decreased sex desire and decreased sexual enjoyment

Dysmenorrhea primary and 2ndary causes

1- assoc w. Ovulatory cycle 2- endometriosis, adhesions, leiomyomas, congenital anomalies, cervical stenosis

Diagnosis of HPV

1. Direct inspection-confirmed with biopsy 2. Pap smears (see koilocyte or halo cell) 3. Colposcopy-after staining with a weak acetic acid solution (turns lesions white) very helpful in detecting latent or associated precancerous lesions 4. DNA hybridization techniques-new methods

chlamydia diagnosis

1. *Direct immunofluorescence test-test of choice-95% specificity. EIA done on cervical secretions and monoclonal fluorescent antibody done on dried specimens. 2. Cultures-used to confirm diagnosis (take 48-72 hrs)

DDX of PID

1. *Ectopic pregnancy-must rule out 2. Ruptured ovarian cyst or torsion of a cyst-use US 3. Acute appendicitis 4. Endometriosis-usually low WBC and no fever 5. Inflammatory bowel disease 6. Degenerating fibroids 7. Spontaneous abortion 8. Diverticulitis 9. Dysmenorrhea 10. Cystitis, renal colic 11. Ovarian neoplasm 12. Pelvic adhesions 13. Mittelschmerz 14. Incarcerated hernia

ddx of chronic PID

1. *Endometriosis 2. Pelvic Pain Syndrome 3. Tuberculous salpingitis-rare in USA. Think systemic TB. Treat with standard regimens for disseminated TB (isoniazid, rifampin, ethambutol). Presents with adnexal mass. Look for history of: •Family history of TB •Low-level pelvic pain •infertility •Amenorrhea 4. Pelvic malignancies 5. Inflammatory bowel disease 6. Chronic mesenteric ischemia

clinical presentation of chlamydia

1. *Symptoms of urethritis and pyuria and a negative urine culture in sexually active women suggests chlamydia 2. In symptomatic women, see mucopurulent cervicitis. 3. Chlamydia-related acute PID accounts for approximately 30% of cases of acute PID. 4. Asymptomatic form seen in mild cases of cervicitis or PID, but can still --> infertility or ectopic pregnancy.

signs and symptoms of PID

1. *generalized lower abdominal pain 2. *adnexal tenderness and CMT -> chandelier sx 3. Fever 4. N and V 5. Dysuria and urethritis 6. Foul smelling, mucopurulent cervical or vaginal discharge 7. Adnexal masses or fullness 8. Elevated WBC 9. Elevated C- reactive protein and sed rate 10. History of concurrent or just finished menses 10. Hx of concurrent or just finished menses 11. Presence of WBC on saline wet prep from vaginal secretions 12. Back pain 13. Mild, non specific sx-ab bleeding, dyspareunia, vaginal discharge 14. some pts have NO sx

Acute pelvic pain

1. Abortion 2. Ectopic 3. Mittelscherz 4. Ovarian accidents 5. Ovarian hyperstimulation syndrome 6. PID 7. Appendicitis w. Anorexia, N/V below 8. Herpes zoster 9. Ovarian cancer 10. Incarcerated hernia 11. Cystitis 12. Ureterolithiasis 13. Abdominal trauma

Dx criteria for PMS/PMDD

1. At least one of the following w/in 5 days before menses: Affecticve depression, angry outbursts, irritability, anxiety, confusion, social with drawl Asomatic - great tender, abdominal bloat, HA, swelling of extremities 2. Sx must by in 3 consecutive cycles 3. Must be relieves within 4 days of menses, not from meds, hormone ingestion or drugs. Be cause it dysfunction in social or economic performance, occur reproducibly during 2 cycles of prospective recording

Known risk factors for VTE

Smoking, obesity, fam hx of VTE and age over 35

safe sex counseling

1. Avoid contact with partner's menstrual blood and any visible genital lesions 2. Cover sex toys with new condom each time it is used for penetration 3. Dental dam (latex barriers) for oral-genital (anal) sex 4. Use gloves and lubricant for any manual sex that may cause bleeding 5. Consider offering Hepatitis B vaccine to all WSW 6. Women who also have sex with men should always use condoms for penetrative sex and receive periodic screening for HIV and other STIs if condoms are not always used 7. Women who inject drugs should use their own needles and equipment and use bleach to clean needles; receive hepatitis B vaccine 8. Partner notification should follow same protocol as with heterosexuals

Types of contraception

1. Barrier methods- diaphragms, cervical caps, condoms, sponges, and spermicides 2. IUD 3. Hormonal manipulation- OCs, Depo-provera

Types of NFP

1. Calendar 2. Basal body temperature 3. Combined temperature and calendar method 4. Cervical mucus (Billings) method 5. Symptothermal method- cervical mucus and BBT

Postmenopause Causes of AUB/DUB

1. Cancer until proven otherwise (but not the most common cause in this age group)-endometrial, cervical, uterine

cervical cap disadvantages

1. Cervical irritation 2. May be difficult to fit 3. Pap smear abnormalities

Protective factors against PID

1. Cervical mucus barrier 2. Some contraceptive methods- hormonal methods, barrier methods

long term consequences of chronic PID

1. Chronic pelvic pain 2. Irregular periods 3. Dyspareunia 4. Infertility 5. Ectopic pregnancies

Lifestyle modifications of PMS

1. Cognitive behavioral therapy 2. Education 3. Progressive muscle relaxation 4. Relationship skills 5. Self -help groups 6. Stress management 7. Psychiatric evaluation for marked alteration in mood swings, psychotic behavior, severe derpression, mania 8. Diet -eliminates caffeine, tobacco, alcohol, chocolate, complex carbs (whole grains, cereals), good protein (fish, vs red meat), veggies, fruits, dec salty foods, pyridoxine (vit B6) 9. Support bra for mastalgia

Treatment of DUB

1. Combination of Estrogen and Progestin (OCs): Anovulatory Bleeding: Good for adolescents with anovulatory bleeding Acceptable for older patients with chronic anovulation if endocrinopathy ruled out. Do not use in women over 35 who smoke a. Low dose OCs b. Cyclic progestins: *Progestins act as anti-estrogens. Diminish effect of estrogen by inhibiting estrogen receptor replenishment in cell Anti-mitotic and anti-growth effect. Supports use in treatment of unopposed estrogen and endometrial hyperplasia *Progestin supports and organizes the endometrium so there can be organized sloughing of endometrium after its withdrawal. Example: Medroxyprogesterone or norethindrone 5-10 mg/d for 10-12 days/month 2. Estrogens: Estrogen promotes rapid growth of endometrial tissue Can be used for prolonged heavy bleeding needing hospitalization

Causes of AUB/DUB in reproductive years

1. Complications of pregnancy-ectopic, abortion, placental polyps 2. Infections-cervicitis, condyloma, PID (vaginosis does not cause DUB) 3. Complications of contraception 4. Medications-OCs, other hormones, steroids 5. Systemic disease-hyperthyroidism, hypothyroidism, chronic renal failure, leukemia, severe liver disease, malignancy 6. vonWillebrands disease-most common inherited bleeding disorder worldwide. Can lead to heavy menses/menorrhagia. Treat with Desmopressin. OCs effective for repeated, sever menorrhagia due to vWD 7. Endometrial polyps and fibroids *Anovulatory bleeding is the most common cause of menstrual abnormalities in reproductive-age women.

Primary dysmenorrhea sx

1. Cramping pelvic pain prior to menses; may radiate to back and thighs * 2. Dizziness, HA, N and V, fatigue 3. Hypotension 4. Pallor

Treatment of Anal Warts

1. Cryotherapy with liquid nitrogen OR, 2. TCA or BCA 80-90%. Can repeat weekly OR, 3. Surgical removal

Other gonococcal infections

1. Disseminated gonococcal arthritis in man and women 2. Conjunctivitis/gonococcal ophthalmia Neonatology in the newborn 3. *Fitz-Hugh cutis syndrome- perihepatitis as a complication of GC consists of inflammation- locales fibrosis with scarring of ant surface of the liver and adjacent peritoneum. Sx fever, RUQ pain

dx of HIV

1. ELISA (enzyme linked immunosorbent assay)-screening test 2. Western blot analysis-more specific assay, confirmatory test. 3. Viral load 4. p24 antigen

Organic Causes of Chronic Pelvic Pain:

1. Endometriosis- 1/3 cases 2. Adhesions-1/4 cases 3. Ovarian pain-cyst 4. Post tubal ligation-may interfere with blood supply to ovaries; leads to irregular periods, pelvic pain 5. Retroverted uterus-with pelvic congestion syndrome 6. GI-cancer, hernias, irritable bowel syndrome, diverticulitis 7. Psychogenic factors

tx of chronic PID

1. Excision of blockage 2. Tuboplasty-open tube and hope it works 3. Final therapy -->total hysterectomy (TAH) and salpingo oophorectomy (BSO) with replacement therapy (estrogen/progestin)

bleeding patterns of DUB

1. Heavy Bleeding: The heaviest bleeding due to high sustained levels of estrogen and is seen with: •Polycystic ovarian disease •Obesity •Immaturity of the hypothalamic-pituitary-ovarian axis (postmenarchal teenagers) •Late anovulation-perimenopausal women who are in their late forties 2. Irregular, Prolonged and Excessive Flow (menometrorrhagia): Large amount of tissue available for sloughing and bleeding No orderly vasoconstriction of spiral arteries ultimately leads to stasis, ischemia, and degradation of endometrium.

Viral Sexually Transmitted Diseases:

1. Human papilloma virus (HPV) 2. Herpes simplex virus (HSV) 3. Molluscum contagiosum (MC) 4. HIV

ACOG guideline for OC use with chronic conditions*

1. Hypertension- under 35yo; don't smoke; BP well controlled 2. Hyperlipidemia- well controlled; check lipids, monthly until stabilized 3. diabetes- less than 35yo and do not smoke, monitor glucose, BP, weight and lipids 4. Migraine and HA- avoid in those with classic migraines; use low dose OC in women without aura, less than 35yo and doesn't smoke

treatment of TOA- admit!

1. IV hydration, careful monitor I/Os (Foley cath) 2. Pain meds 3. Perform regular exams 4. Antibiotics-combination therapy; must provide empiric, broad spectrum coverage of likely pathogens •*Strong anaerobic agent-Clindamycin, Metronidazole •Strong PCN or cephalosporin-Mezlocillin, Piperocillin, Ampicillin plus sulbactam, Cefotetan, Cefoxitin •Aminoglycoside-Gentamicin, Tobramycin *If not better in 72 hrs, go to OR and do exploratory lap

OC's effects on menstrual cycle:

1. Improves iron deficiency anemia 2. Improves acne, hursutism, PCOD 3. Improves urogenital symptoms

ddx TOA

1. Incomplete septic abortion 2. Ruptured appendix with abscess 3. Ruptured diverticular abscess 4. Torsion of adnexa

Clinical presentation of C. Granulomatis

1. Initial lesion-indolent ulcer w. Pink to beefy red base. 2. Secondary phase beefy red granulation tissue w scar formation. May have inguinal swelling and suppurative abscess 3. Advanced lesions-markedly hypertrophic. Fistula of vagina, bladder and rectum may occur. *Elephantitis of external genitalia may occur.

Pelvic exam

1. Inspect external genitalia and cervix- trauma, infection, hemorrhage or asymmetry 2. Palpate the vaginal wall- tenderness 3. Palpate the cervix- CMT 4. Palpate the annexation-tenderness 5. Bimanual exam- evaluate masses or tenderness

Dx of DUB (dysfcnl uterine bleeding)

1. Lab/Blood studies: •Serum hCG to determine presence of a pregnancy or a hydatidiform mole. •Platelet count and platelet function tests to determine presence of von Willebrand's disease or thrombocytopenia. • (CBC) and differential to determine presence of leukemia 2. Endometrial sampling: •Endometrial biopsy •Endometrial aspiration 4. Dilation and curettage (D & C) 5. Hysteroscopy or direct visualization of the endometrial cavity 6.Hysterosalpingography-provides information about the uterine cavity 7. Sonohysterography-fast; inexpensive; minimally invasive. Saline induced through catheter into endometrial cavity followed by transvaginal US. Can differentiate polyps from myomas 8. MRI 9. Transvaginal US-detects polyps, fibroids, ovarian mass, endometrial thickness •Look for endometrial thickness

Types of OCs

1. Low dose estrogens- less estrogen SE, less breakthrough bleeding 2. Progestin only pills- minipill, take continuously, less estrogen SE. Dec DVT, HA, BP elevation, less depression. Predominantly used by breastfeeding women and those who cant tolerate estrogen. Irregular bleeding is a SE that leas to D;/c of the pill 3. 3rd generation progestins- desogestrel, norgestimate, drospirenone (Yasmin). Synthetic progestin related to spironolactone, least androgenic, greater progestin effects; supposed to lead to less weight gain; careful if on K- spearing dieuretics, ACEI, heparin or NSAIDs; FDA approved for acne A. Yaz B. Orthotricycline low

Mastodynia without Cystic changes

1. Low dose testosterone 2. Danazol 3. Vitamins E 4. Primrose oil

Management of Refractory DUB

1. Medical agents •Gonadotropin release inhibitor (Danazol) •GnRh agonists (Leuprolide)-produces a "medical menopause"; not 1st line 2. Surgery: Refractory, prolonged heavy bleeding may require surgery: •D & C •Endometrial ablation-if done with child-bearing •Transcervical resection of the endometrium (TCRE) •Hysterectomy-if done with child-bearing 3. Uterine Balloon Therapy: Thermal balloon endometrial ablation is a safe, simple, easy &min invasive. done under IV sedation and paracervical block in an office setting. advantages over hysterectomy- preservation of the uterus, avoid surgical incision & pot to perform on an outpatient basis. It is a good alt to hysteroscopic endometrial ablation w a comparable success rate w min risk & no limiting factors except the cost of the balloons.

screening WSW screening for STIs

1. Medical history/sexual history 2. Types of sexual practices of WSW •oral-genital •genital manipulation •vaginal penetration w fingers, hand or sex toy •internal and external use of vibrators •oral-anal contact-less common •sadomasochism-less common •anal penetration with fingers, hand or sex toys-less common

factors associated with onset of PID

1. Menstrual periods- degenerating endometrium good culture medium. 2/3 acute cases begin just after menses. 2. Sexual intercourse 3. Iatrogenic events a. elective abortion b. D and C c. IUD insertion or use d. hystersalpingography 4. endometritis 5. myometritis 6. parametritis

IUD mode of action

1. Non-medicated IUD: Brand Name: ParaGard T (Copper T 380A) Contraception involves a local, sterile inflammatory reaction caused by the presence of a foreign body in uterus. The addition of copper increases the inflammatory reaction. With removal of both copper-bearing and non-copper bearing IUDs, the inflammatory reaction rapidly disappears and the resumption of fertility follows. 2. Medicated IUD: Brand Name: Progestasert Medicated (progesterone) IUD works locally on endometrium and cervix. Progesterone makes endometrium incapable of sustaining an implantation. Also changes cervical mucus and makes passage of sperm difficult.

Dysmenorrhea Hx

1. Onset menarche 2. Frequency menses 3. Flow 4. Pain 5. Meds 6. Sex hx 7. Clots 8. Assoc GI sx 9. PE w rectal sx 10. Fam hx

Non-contraceptive health benefits of OCs: decreased incidence of:

1. Ovarian cancer 2. Endometrial cancer 3. PID 4. Benign breast disease 5. Uterine fibroids 6. Osteoporosis 7. Endometriosis 8. RA 9. Functional ovarian cysts 10. Ectopic pregnancy

Decreases Menstrual Disorders like:

1. PMS 2. Dysmenorrhea 3. Menorrhagia 4. DUB

Management of primary dysmenorrhea

1. Prostaglandins synthetase inhibitors (NSAIDS) *treatment of choice- dec levels of endometrial prostaglandin, lessen uterine contractions, relieve dysmenorrhea *start NSAIDS as early as 24048 hrs before pain begin . 2. OC use- estrogen plus progestin, eliminates ovulation, eliminates natural estrogen-progesterone progression in ovulatory cycles- in absence of ovulation, there is NO dysmenorrhea* 3. IM medroxy progesterone 4. Reassurance in mild cases 5. No narcotics

sequelae of PID

1. Pyosalpinges (tubal abscesses) 2. Hydrosalpinges (fluid-filled, dilated, thin walled, destroyed tubes) 3. Partial tubal obstruction and crypt formation resulting in ectopic pregnancies 4. Tubo-ovarian abscesses 5. Total tubal obstruction 6. Peritubular and ovarian adhesions 7. Pelvic and ovarian adhesions 8. Ruptured abscesses (sepsis, shock) 9. Chronic pelvic pain and dyspareunia 10. Chronic PID 11. Infertility

Contraceptive counseling issues

1. R/o CI 2. Discuss sE 3. Discuss pill components, packaging, dosing 4. Personalize non-contraceptive benefits 5. Dispel myths 6. Look for alternative methods for those who cant tolerate or desire OC's

ACOG guidelines for treating PMS

1. Regular exercise and a balanced diet: dec fats, diary, and caffeine, esp in PMS time. Sx. Walking, biking 2. Vitamin supplementation0 calcium can reduce PMS sx, especially pain, cramping and mood swings, red 1200 mg/day of elemental calcium. Mag helps 3. Nutritional supp- evening primrose oil or vitamin E 400 IU 4. SSRIs* Goos for women w mood sx like anxiety and depression considered 1st line pharmacotherapy (Fluoxetine, sertraline, paroxetine) 5. Diuretics- spironolactone (do NOT have supp K )- would spike K 6. Anti-anxiolytics/ tranquilizers 7. OC 8. Bromocriptine 9. Low dose Danazol 10. GnRH analong/agonists 11. Tamoxifen citrate 12. NSAIDs 13. Surgery- oophorectomy last resort

complications to IUD and pregnancy

1. Spontaneous abortion 2. Ectopic pregnancy 3. Prematurity

Mode of action of OC

1. Suppression of ovulation- primary MOA 2. Cervical mucus is thick 3. Endometrial atrophy, bc flat and inactive and unprepared for implantation of embryo due to progestins.

permanent BC

1. Surgical Sterilization-Female and male sterilization is 99% effective 2. Sterilization Implant-Essure coil. Permanent, non-reversible contraception. Miniature metal coils guided through vagina and uterus and implanted in fallopian tubes. Forms scar tissue and blocks fertilization. Fast, easy, short recovery time. Must use alternative birth control for 12 weeks post procedure. Reliability rate is greater than 99%

chronic PID physical exam

1. Swollen tubes filled with fluid, closed off (hydrosalpinx) 2. Adhesions 3. Frozen pelvis-all organs fixed and fibrosis

Complications of OCS *

1. Thromboembolism 2. Cardiovascular disease/hyperlipidemia 3. Hypertension 4. Post pill amenorrhea 5. Liver tumor-heptatocellular adenoma 6. DM 7. Migraines

other causes of pelvic infection- Granulomatous Salpingitis

1. Tuberculous salpingitis 2. Leprous salpingitis-similar to TB presentation and path 3. Actinomycosis- A. israelii. Associ w/ IUD use. Tx w PCN 4. Schistosomiasis-MC in Far East and Africa 5. Sarcoidosis-very rare 6. Foreign-body salpingitis-follows use of non-water soluble dye material for hysterosalpingography.

Assoc sx with pelvic pain

1. Vaginal bleeding- suggests reproductive tract pathology 2. Fever and chills- pelvic infection that has spread systematically 3. Anorexia, nausea, vomiting- nonspecific but often suggests intestinal tract pathology 4. Synopsis, vascular collapse, shock- suggests intraperitoneal hemorrhage and instability secondary to hypovolemic 5. Frequency, dysuria, flank pain, or hematocrit- urinary tract problems 6. Shoulder pain- irritation of diaphragm by blood or inflammatory fluid 7. Dyspareunia- many causes

tichomonas vaginalis dx

Vaginal pH between 5-6. See motile trichomonads on wet preps. Organisms are twice the size of WBCs

Features of follicular phase

1. Variable length./duration 2. Low basal body temp 3. Development of ovarian follicles 4. Vascular growth of endometrium 5. Secretion of estrogen from ovary 6. +/- uterine cramps on days 1 and 2 from increased prostaglandins 7. Vaginal epithelium thickens and increased vaginal transudation —> lubrication from estradiol

labs for chronic pelvic pain syndrome (none are diagnotic)

1. WBC-normal (increased with infections) 2. ESR-non-specific; increased in any inflammatory condition 3. Urinalysis and C&S 4. +/- ultrasound

Risk factors for PID

1. Young age <30 (70%); sexual intercourse at a young age 2. Early sexual activity 3. Multiple sexual partners 4. Hx of STIs 5. Use of IUD 6. Previous episode of PID 7. Alcohol use 8. Recent genital tract procedures- abortion, IUD, insertion, endometrial biopsy, etc 9. Frequent douching 10. AA and Hispanic race 11. Frequent sexual intercourse

Dx of chancroid

1.gram stain of exudate, aspirate of bubo or * see " school of fish or chaining" of gram neg -rods

adverse effects of IUD use

1.intrauterine bleeding 2. injury to cervix or uterus 3. infection

Menarche

1st menstrual period, avg height 5'2'' True biological marker of puberty Usually 2 yrs after thelarche. Depends on hypothalamus, pituitary, ovcary, fam hx and exposure to exogenous hormones

Phases of menstrual cycle

2 phases: follicular (proliferating phase) and luteral (secretory phase)

Recurrent genital HSV lesions

30% of patients. Similar to primary but usually less severe in intensity, duration of illness and systemic side effects. Usually 2 to 5 days. *Menses and stressful life situations associated with recurrent outbreaks.

Period Blood loss amount normal vs abnormal and what's in it

30-50ml; 80ml< is abnormal bleeding. Blood dark red, non-clotting, mostly arterial blood. Contains tissue debris, prostaglandins, large amounts of fibrinolysin from endometrial tissue. Fibrinolysin lyses clots in menstrual blood unless the bleeds are very heavy.

Tertiary syphilis

33% of untreated patients progress to tertiary syphilis with multiple organ involvement. Transmission unlikely except blood transfusion or placental transfer. See damage to CNS, heart and great vessels. End arteritis leads to aortic aneurysm and aortic insufficiency, tabes dorsalis, optic atrophy and meningovascular syphilis. *Gummas-chronic focal area of inflammatory destruction due to localization of Treponema pallidum in a tissue. Indolent lesion with rubbery, grey-white necrotic center. Vary in size and can involve any organ or tissue. MC in mucocutaneous tissue, liver, bones and testes, dev 1-10 yrs after infection

Effectiveness of condoms depends on

Age of the couple Family income Interest in spacing or preventing pregnancies Education level of the couple

Most important differentiating feature of PMS is

A clear sx -free interval during follicular phase of menstural cycle

Syphilis

Agent is Treopnema pallidum (spirochete) Transmitted by sexual intercourse or intrauterine transmission. Disease stages include: primary, secondary and tertiary syphilis Inc incidence in past several years

GC clinical presentation

40-60% of women with GC dev onset at end of menstruation Sx: 1. Purulent cervical discharge 2. Lower abdominal pain, anorexia, fever 3. Dysuria, urinary frequency 4. Asymptomatic Dx: 1. Gram stain of cervical secretions- gram neg dilococci in PMNs 2. Thayer-MArtin culture medium- provide 80-95% diagnostic sensitivity

Vaginal sponges

72-82% effective Nonoxynol 9 1000mg in each sponge Wait 6 hrs after intercourse before removing sponge, but lo longer than 30hrs Does NOT protect against STIs/HIV

Peak levels of progesterone are at

8-9days after ovulation

Barrier Methods of contraception Condoms

86-885 effective, 79% for female condom. One of the oldest forms of BC Safe, relatively inexpensive and free form side effects *must be used correctly Watch for allergic reaction to latex in some ppl- red irritation and sl. Swelling. To- rest, stop using latex, possible steroid creams

Median time to conception for hormonal injectable D/c

9 months after stopping because it takes time for drug to leave system.

Mandatory written reporting

A report of the disease must be made in writing, ex: are gonorrhea and chlamydia

Molimen

A variety of mild but unpleasant sx preceding menses. (Old term)

evidence based medicine for PID

A" evidence-Screening for and treating asymptomatic lower genital tract chlamydial infection is recommended to reduce the incidence of PID.

Recurrent episodes of hsv tx

Acyclovir 400 mg po tid x 5 days Acyclovir 800 mg po tid x 2 days Acyclovir 800 mg po bid x 5 days Famciclovir 125 mg po bid x5 days Famciclovir 1 g bid x 1 day Famciclovir 500 mg po x 1, then 250 mg po bid x 2 days Valacyclovir 500 mg po bid x 3 days Valacyclovir 1g qd x 5 days

evidenced base medicine definitions

A-Consistent, good-quality patient-oriented evidence B-Inconsistent or limited-quality patient-oriented evidence C-Consensus, disease-oriented evidence, usual practice, expert opinion or case series

Dx of C. Granulomatis

A. * gram stain of the lesion w inclusion cysts called donovan's bodies B. Tissue biopsies show Donovan's bodies

OCPs appear to protect user against PID, thought to be due to *

A. Decreased menstrual flow B. Decreased ability of bacteria to attach to endometrial cells C. Progestin- induced changes in cervical mucus- barrier against bacteria. *barrier methods of contraception-also protect against PID

Medical sequelae develop in 1 in 4 women with acute PID

A. Ectopic pregnancy B. Chronic pain C. Abscess D. Infertility E. Mortality

Risk factors of gonococcal

A. Young age B. Multiple sexual partners C. Failure to use barrier contraception

Mammary Dysplasia

AKA fibrocystic disease; fibrodysplasia Presence of solitary or multiple cystic areas in breast. Dx usually made by aspiration or excisional biopsy Serial mammograms or US used to monitor patients.

severe hsv tx

Acyclovir 5-10 mg/kg body weight IV q 8h for 2-7 days until clinical resolution

ovulatory cycles

Abnormal bleeding can be associated with ovulation and can be characterized by regular cycles of approximately the same duration. 1. Midcycle spotting-scanty intermenstrual discharge, associated with a decrease in estrogen at midcycle, following ovulation 2. Frequent menses (polymenorrhea)-associated with short follicular phase 3. Luteal phase deficiency "defect"-associated with premenstrual spotting. Seen when luteal phase is shortened by prematurely decreased progesterone levels. 4. Prolonged corpus luteum activity-result of persistent progesterone production in absence of a pregnancy. Results in prolonged cycles or protracted menstrual bleeding.

Dysfunctional uterine bleeding

Abnormal endometrial bleeding caused by an endocrine dysfunction related to the circulating levels of estrogen and progesterone. Abnormal uterine bleeding without an organic cause. Bleeding abnormal in amt , duration or timing in female of reproductive age. Must R.o organic causes* (pregnancy, tumor, infection, coagulopathy, systemic dx)

Growth spurt due to

Acceleration in growth rate due to GH and somatomedin- C

2ndary dysmenorrhea

Acquired; unusual before 25-30 yo *onset typically many yrs after menarche * causes by organic or pelvic pathology *endometriosis MC sec cause *other causes- adhesions, infections, adenomyosis, pelvic congestion syndrome, anatomical defects that lead to obstruction of blood flow

initial exposure to HIV*

Acute mono-like syndrome. Usual incubation period is 2-4 weeks. *Symptoms include: febrile pharyngitis, fever, sweats, myalgia, arthralgia, headache, photophobia. *Lymphadenopathy-generalized

Dx of Bartholinitis

Acute pain in region of gland Vulvar pain, dyspareunia, tender, red swelling below posterior part of labia majora

Chlamydia trachomatis

Acute urethritis, cervicitis and acute PID *MC bacterial STI in US *caused by C. Trachomatic stereotypes D, E, F, G, H, I, J, K *coexistence of C. Trachomatic with GC is common. *chlamydia frequnently recovered in women whose partners have non-gonococcal urethritis.

LH receptors are on theca cells at

All stages of cycle and on granulosa cells after follicle matures under influence of FSH and estradiol

Menostasia.menostasis

Amenorrhea

Alternative Parenteral Regimens:

Ampicillin/Sulbactam 3g IV q 6 hours + Doxycycline 100 mg orally or IV every 12 hours Ampicillin/sulbactam plus doxycycline is effective against C. Trachomatis, N. gonorrhoeae, and anaerobes in women with tubo-ovarian abscess.

TX of Bartholinitis

Analgesics Broad spectrum antibiotics Abscess --> I and D

Chronological order of female pubertal events

Andrenache-8yo Gonadarche-8 Thelarche-10 to 11 Pubarche- onset pubic hair 11-12 Max growth 11-12 Menarche 11.5-12.8 Adult pubic hair 13.7 Adult breast 14.6

LH stimulates

Androgen synthesis by theca cells When enough receptors of LH on granulosa cells, LH acts directly on granulosa cells to cause lunteinization and production of progesterone.

Information gained from reported allows the county and state to make informed decisions and laws about activities and the enviornment such as:

Animal control Food handling Immunization programs Insect control STD tracking Water purification

Microbicides

Antimicrobial products that can be applied topically to prevent transmission of HIV and other STIS

DDX in PMS

Anxiety, depression, bipolar, affective dx, dysmenorrhea, endometriosis, hypothyroidism, endocrinopathies, anemia, SLE, hyperkalemia, perimenopause, drug and alcohol abuse

other causes of pelvic infection: non-granulomatous salpingitis

Any other bacterial infection, usually of peritoneal cavity that can cause tubal infection: a. Appendicitis b. Diverticulitis c. Crohn's disease d. Cholecystitis e. Perinephric abscess

Syphilis epidemiology

Approx 30,000 new cases each year in US. Incubation period from 10-90 days Syphilis chancres increase transmission of HIV 2 to 5 fold

clinical presentation of HIV

Approximately 80-90% of infected individuals are asymptomatic carriers.

Tx of neurosyphilis

Aqueous crystalline pcn G 18-24 million units IV/day as 3-4 million units IV q 4h or continuous infusion x 10-14days.

Gonadarches

Around age 8. Leads to stimulation of gonadotropin in anterior pituitary (LH.FSH)

Adrenarche

Around age 8. Secretion of steroid hormones DHEA, androstenedione

% anovulatory in 1st year, 90% will have cycles in what range and how many days

At least 50% of menstrual cycles anovulatory in 1st year but in fairly regular intervals. During first 2 yrs after menarche, cycles somewhat irregular but 90% will have cycles within range of 21 to 42 days with 2 to 8 days of flow. By 7th year of menarche , 90% cycles ovulatory. Once ovulatory, may experience dysmenorrhea

Natural family planning

Avoiding pregnancies by abstaining from sexual intercourse during the fertile phase of the menstrual cycle. (Avg is 8 to 10 days a month. Drugs, devices and surgical procedures not used.

Resistant NGU thought to be mycoplasma genitalium tx

Azithro 1gm po single dose or * azithro 500mgdose followed by 250mg daily for 4 days ( might be sl bar than single dose)

Tx of Chancroid

Azithromycin 1gm po single dose or Ceftriaxone 250mg IM single dose or Cipro 500mg po BID x 3 days or Erythromycin base 500mg po TID 7 days

oral/ IM treatments for PID

Ceftriaxone 250 mg IM in a single dose + Doxycycline 100 mg orally twice a day for 14 days WITH* or WITHOUT Metronidazole 500 mg orally twice a day for 14 days OR Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally administered concurrently in a single dose + Doxycycline 100 mg orally twice a day for 14 days WITH or WITHOUT Metronidazole 500 mg orally twice a day for 14 days OR Other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime) PLUS Doxycycline 100 mg orally twice a day for 14 days WITH* or WITHOUT Metronidazole 500 mg orally twice a day for 14 days

types of IUDs

B/c of medicolegal costs, only the progesterone-releasing device and the copper-containing device are still being produced. 1. Mirena-levonorgestrel (LNG) 52 mg. A progestin. Initially releases 20 mcg LNG/day but decreases to less than half that after 5 years. Can be left in place for 5 years. Good for perimenopausal menorrhagia. Other levonorgestrel (LNG) IUDs include Kyleena (19.5 mg LNG over 5 years), Skyla (13.5 mg over 3 years) 2. Progesterone-releasing T-shaped device-must be replaced each year; reservoir of progesterone becomes depleted after 18 months of use. 3. Copper (ParaGard T)-bearing devices-must be replaced every 6 years because of the constant dissolution of copper 4. CuFIX 330-"frameless"; softer; less pain and bleeding; plastic thread holds 6 Copper tubes; "sewn into myometrium.

Carcinoma of the cervix

Barrier contraception thought to protect the cervix from sexually transmitted agents that promote cervical neoplasia (HSV, papillomavirus, and chlamydia)

Dx of PMS

Based on dx of patients sx to luteal phase Important to have patients do menstrual diary. Nightly recording of sx essential. Chart sx throughout at least 2 successive menstrual cycles. List 5 of the most severe sx that disrupt daily activity. O-3 in severity

The standard days method

Based on timing of fertile window. Uses cycle beads that represent menstrual cycle

Fertility awareness

Based on tracking fertility and avoiding unprotected sex on fertile days.

Clinical findings in dysmenorrhea

Before or after onset of meneses in last 24-48hrs' 2. Pain suprapubic, sharp, colicky; may radiate to back and thighs 3. Multi-sx condition- nausea, vomiting, diarrhea, constipation, dizziness, backache, and HA 4. Dysmenorrhea does not occur in a ovulatory cycles 5. Associated sx- weight gain, breast pain, and fullness, irritability, depression, fatigue, mood swings

Phase 1 the relatively infertile phase

Begins with menstruation and ends with onset of mucus. Sexual intercourse during the first phase is unlikely to result in the conception of a child.

Treatment of latent syphilus

Benzathine pcn G 2. 4million units IM each week for 3 weeks Tetracycline 500mg po aid x 4 weeks or doxy 100mg po bid 4 weeks if pcn allergic.

Intermentrual bleeding

Bleeding btw regular menstrual periods and varies in amt. form of metrorrhagia.

FDA black box warning for drospinernone due to increase risk of?

Blood clots (VTE)

Levonorgestrel Implant

Brand Name: Norplant II *Long acting, reversible, & effective form of birth control. Effectiveness: 99% Admin of Levonorgestrel: 6 flexible silicone rubber implants containing levonorgestrel placed under the skin of woman's arm Sm amts of levonorgestrel released at relatively constant rate for 5 yrs *MOA: •Ovulation suppressed in most users •Cervical mucus changes thick and scanty; prevents migration of sperm •Dev and growth of endometrium suppressed. *SE: Most common side effect is change in bleeding pattern with more frequent and irregular bleeding episodes, spotting between periods and amenorrhea. Many side effects go away after several months.

Laboratory tests

CBC- infection, blood loss Urinalysis-UTI Blood type and antibody screen Pregnancy test- beta HCG Cervical cultures- GC, chlamydia, etc Culdocentesis- posterior cul-de-sac for intraperitoneal blood or free fluid (ascites) Send rate non specific test. X rays- intestinal obs, free air under diaphragm, free fluid- bleeding or ruptured cyst, calcification- stones, gallstones, calcified myomas, dermatitis cysts

PMS

Can exist in women w stable or unstable personalities Over 100 sx but only a small group truely has it Cyclic recurrence Psych piece and somatic piece Restricted to luteal phase only

Lymphogranuloma venereum

Caused by C. Trachomatic stereotypes L1,L2, L3 Produces local and regional ulceration and destruction of genital tissues.

Alt regimens fo rGC

Cefixime 400mg orally in single some plus azithromycin 1g orally in single dose

CDC recommended parenteral regimens

Cefotetan 2 g IV q 12 hours + Doxycycline 100 mg orally or IV q 12 hrs OR Cefoxitin 2 g IV q 6 hrs + Doxy 100 mg oral or IV q 12 hrs (doxy prf orally bc pain w IV) Or Clindamycin 900 mg IV q 8 hrs + Gentamicin loading dose IV or IM (2 mg/kg), followed by maintenance dose (1.5 mg/kg) q 8 hrs. Single daily dosing (3-5 mg/kg) can be substituted.

Cervical changes

Changing concentrations of estrogen and progesterone affect the quantities and quality of cervical mucus . Classified as either: 1. Dry/non-fertile (tacky, sticky, cloudy) 2. Fertile (clear, stretchy, lubrications)

External genital/perianal/vaginal warts:

Chemical destructive techniques-Patient applied: • Podophyllin (Podofilox 0.5%) soln or gel bid X 3 days then off for 4 days; may repeat up to 4 cycles OR, • Imiquimod 5% cream qhs 3x/week for < 16 weeks; wash off after 6-10 hrs OR, • Sinecatechins (Veregen) 15% ointment applied tid for < 16 weeks Chemical destructive techniques-Provider applied: • Cryotherapy with liquid nitrogen, cryoprobe every 1-2 weeks OR, • Podophyllin resin 10% - 25% in tincture of benzoin. Can repeat weekly OR, • TCA or BCA 80%-90%; repeat weekly as needed OR, • Surgical removal o Electrocautery o Laser vaporization o Surgical removal

Ex of reported total number of cases

Chicken pox and influenza Cancer reported to state cancer registry

MC bacterial STD/reportable?

Chlamydia

primary lesions in HSV

Clear vesicles Shallow coalescent painful ulcers with red border, 3-7 days after exposure. Last 2-3 weeks. *Lesions on vulva, vagina, cervix, perineal, perianal skin --> buttocks Can also have dysuria, urinary retention (approx. 10% of primary attacks require hospitalization for urinary complications), mucopurulent vaginal discharge, painful inguinal adenopathy, generalized myalgias and low grade fever.

Causes of false pos results

Collagen disease, mono, atypical pneumonia, malaria, leprosy, some vaccines, drug addiction, old age. False pos usually have low titer and transient, FU with treponema tests.

symptothermal method

Combines cervical mucus and BBT Additional sx to watch for at ovulation including bloating, vulvar swelling, mittelschmerz, breast tenderness. LH most accurate method of determining ovulation.

LH surge stimulates

Completion of reduction division in oocyte Luteinization of granulosa cells Synthesis of progesterone and prostaglandin within follicle

Notifiable (Reportable) Diseases

Considered to be public health importance and track on societal level. Providers required by law to report these diseases.

Combination pills

Contain various amounts of estrogen and one of a variety of progestins. Current preps contain low doses of estrogen. Taken for 22 days with 1 week btw pill packs.

Allergies to sponge?

Contains sodium metrabisulfite which may cause severe allergic rxns

Cramping comes from

Contractions of hollow viscous or intraluminal pressure in hollow viscus

switching to or from copper IUD

Copper IUD becomes effective immediately after insertion. Prevents pregnancy via spermicidal mechanisms up to 5-days after unprotected sex. Switching from copper to progestin IUD or vice versa may do so immediately after first IUD removed but barrier contraception is required for one week when switching from copper to progestin

Progesterone production

Depends on FSH and LH* *needed for implantation of fertilized occyte into endometrium and to sustain pregnancy early on in 1st trimester Production begins 24hrs before ovulation and inc rapidly. Max production is 3-4 days after ovulation and is maintained approximately 11 days. If there is NO fertilization and implantation —> rapid decrease in progesterone *neg feedback on FSH and LH. Decreased FSH and LH in luteal phase

Thelarche

Dev of breast buds

Herpes simplex virus

One of the most prevalent STIs. Most infections are sub clinical, genital HSV infection is NOT at nationally notifiable condition. Most persons with genital HSV infection have not received a dx

LH initiates what

Luteinization and progesterone production in granulosa layer. Preovulatory rise in progesterone causes midcycle FSH surge by enhanceing pituitary response to GnRH and facilitating pos feedback action of estrogen.

Primordial follicle

Covered by single layer of granulosa cells Even w./o gonadotropin stimulation, some primordial follicles dev into prantral follicles. This process occurs during times of anovulation (childhood, pregnancy, OCP use) as well as during ovulatory cycles.

Types of spermicides

Creams, jelly, aerosol foams, and non-foaming and foaming suppositories. Commonly used with other forms of contraception (diaphragms, sponges, and condoms)

Anovulatory cycles

DUB often occurs in the absence of cyclic hormonal changes of the menstrual cycle. *About 85% - 90% of all DUB is anovulatory in nature. *Anovulatory bleeding is common in girls in their early teen years *Anovulatory bleeding from: 1. Unopposed estrogen--> "breakthrough bleed" 2. Relative in circulating estrogen-->"estrogen withdrawal bleeding" 3. Decreased progesterone-in the absence of progesterone production by the corpus luteum, an unpredictable, disorganized shedding of the endometrium occurs.

STD 6

Dec gonorrhea rates

Spinnbarkeit

Degree of stretchiness of cervical mucus

Sx of ovarian accidents

N/V, syncope, shock, shoulder pain

Corpus Luteum lifespan, where it forms and diameter

Development Forms in an ovary at the site of a follicle that has matured and release its egg (ovulation ). The corpus luteum is not permanent; if pregnancy does not occur, the corpus luteum regresses. General: 2.5cm diameter, deep yellow in color, hormone secreting body Lifespan 13-14 days unless pregnancy occurs.

Genital Tuberculosis dx

Diagnosis: Based on clinical suspicion and confirmed by cultures. TB skin test indicates exposure, NOT location.

2 questions for 2 day method

Did i notice secretions today? Did I notice secretions yesterday?

switching pills

Do not need to wait for withdrawal bleed. Switch directly from one pill to another; do not go a day without a pill; may complete current pack or stop and start new pack the next day

Diaphragms

Dome shaped, 50-105mm in diameter and made of latex rubber, base of dome is a rubber-covered metal spring. *rest btw the posterior aspect of the symphysis pubic and the posterior fornix of vagina; they cover the anterior vaginal wall ANS the cervix. 80-82% effective Depends on leaving it in place for 6hrs after

Phase 3- absolutely infertile phase

Drying process extends from 48hrs after ovulation until onset of menstruation. Lasts 10-16days. Munch more consistent than phase 1. Return of the less fertile (tacky) mucus. Less than1% chance of pregnancy during this phase.

Oogenesis

During full reproductive cycle, one oocyte matures before ovulation, in that produces a number of oocyte are stimulated to partial maturation but undergo atresia before reaching ovulation,. Unknown why several oocyte are stimulated but only one is ovulated.

Incidence of PID *

Dx of young woman Peak incidence in late teens to early twenties MC serious infection in women 16-25yo MC in AA and Hispanic women

Most common medical problem in young women

Dysmenorrhea

UTS

Early pregnancy, ectopic preg, Adnexal mass

Prevention and control of STIs

Education and counseling Identification of infected individuals Effective dx and treatment Evaluation, treatment and counseling of partners Pre-exposure vaccination Post-exposure prophylaxis

MOST DUB is due to

Endocrine origin Most often associated with anovulation 85%*, but occasionally assoc with ovulatory cycles with short or inadequate follicular or luteal phases. **Menometrorrhagia is MC sx *50% perimenopausal, 20% adolescent, 30% other

PID can involve infection of:

Endometritis Parametritis (broad ligament) Salpingitis (oviducts) Oophoritis- ovary Tubo- ovarian abscess Myometritis- uterine wall Peritonitis- pelvic peritoneum

Mollescum Contagiosum

Epidemiology: Mildly contagious Incubation period is several weeks Clinical Presentation: Small (1-5mm) umbilicated papules in cutaneous genital region

Location of abdominal pain

Epigastric- stomach, duodenum, pancreas, liver, GB Periumbilical- sm ingesting, appendix, upper ureters, ovaries Hypogastric or suprapubic pain- colon, bladder, lower ureters, uterus Pelvic pain-cervix, ovaries, Fallopian tubes Shoulder pain- referred from diaphragmatic irritation

Alternative regimen

Erythromycin base 500mg po aid x 21 days * C. Trachomatic resistant to PCN Surgical reconstruction may be required with lots of tissue damage

Which hormones increase at age ll? 13?

Estrogen and progresgteron 11 FSH at 13yo

Other estrogen/progesterone contraceptive options

Estrostep- estrophasic regimen; indicated for treatment of moderate acne Natazia-4 phase OC w/ an estrogen step-down and a progestin strop up Seasonale- extended cycle OC; 91 day regimenl menses only ones every 3months, less dysmenorrhea, PMS, HA, anemia Femcon FE- only chewable OC Lybrel-continuous OC; taken 365 days a yr without placebo

Menorrhagia

Excess or prolonged uterine bleeding at regular intervals.

Menometorrhagia

Excessive uterine blading both during menses and at irregular intervals

Menometorrhagia

Excessive uterine bleeding both during menses and at irregular intervals.

switching from pill to patch or ring

Need 48 hours for patch to be fully effective Start patch the day before they take their last pill for a 2-day overlap Start ring the day after they take the last pill No need to complete an entire pack of pills before switching to patch or ring

Vaginal ring

FDA approved 2001 Soft, flexible, transparent ring, cost same as OCs Contains etonagestrel and ethical estradiol Steady release of hormone over 3 weeks with ring in place when ring removed for one week. New ring placed after one week ring free period. No fitting necessary, inserted by women. Very effective; 1st yr failure rate .7% MOA: Inhibiton of ovulation

Barriers to seeking care

Failure of providers to inquire about sexual orientation Reluctance to disclose sexual orientation Deficiency in health research about the lesbian population No need for BC methods Lack of health benefits for same sex partners

Mittelscherz lasts how long?

Few hours, no longer than 2 days

Mammary Dysplasia tx

Fibrocystic changes: 1. Good breast support 2. Avoidance of methylxanthenes (coffee, tea, chocolate, cola) 3. Occasional use of mild diuretic

AIDS

Final stage in HIV infection *Severe alterations of cell-mediated immunity (decreased T4 cell counts) *Results in lymphadenopathy, Kaposi's sarcoma, opportunistic infections (PCP), malaise, diarrhea, weight loss and death.

Luteal (secretory) phase:

From ovulation until onset of menses Under the influence of progesterone Endometrial glands develop the secretory status necessary for implantation of embryo.

Ovarian remnant syndrome

From residual ovarian tissue after bilateral oophorectomy Sx- pelvic mass, pelvic or flank pain from assoc urethral obstruction

periodic abstinence (NFP)

General: Avoidance of intercourse during presumed fertile times of menstrual cycle. Relatively long periods of abstinence necessary with all methods. Effectiveness: 80% Four Types: 1. Calendar (rhythm) 2. Temperature 3. Cervical Mucus 4. Sympto-thermal (most difficult but most effective). Cervical mucus (ovulation) method supplemented by calendar in pre-ovulatory and basal body temperature in the post-ovulatory phases. Most effective form of NFP.

Genital Tuberculosis:

Genital TB almost always from miliary hematogenous or lymphatic spread. Initial involvement usually tubal --> ovaries --> endometrium. Relatively uncommon in USA, but increasing incidence in some immigrant groups, immunosuppressed, and IVDU groups.

HPV: Condyloma Acuminatum:

Genital warts. Affects both men and women Epidemiology: One of the most common causes of STIs in the world. *Predominant means of transmission is through sexual intercourse. Probably also passed vaginally during birth to neonate. Risk of contracting warts for women whose sexual partners have warts is 60-85% *HPV associated with increased risk of pre-invasive and invasive neoplastic lesions of lower genital tract. Incubation time is between 6 weeks to 18 months.

Secretion of GnRH

GnRH secreted in pulsating manner* Mechanism unknown Amplitude and freq of secretions vary throughout the cycle. 1 pulse every hr is typical of follicular and 1 pulse every 2-3 hrs in luteal phase Amplitude and frequency regulated by feedback of estrogen and progesterone and neurotransmitters in the brain (catecholamines, dopamine, and norepinephrine)

Hormonal involvement- the menstrual cycle involves the interaction of :

GnRh, FSH, LH, and sex steroids (androstenedione, estradiol, estrone, and progesterone)

Neisseria gonorhoeae

Gram neg diplococcus One of the MC reported communicable disease in USA Humans only natural host

Premenstrual syndrome

Group of physical, mood and he gave oral changes that occur in a regular, cyclical relationship to the luteal phase of the menstrual cycle.

Most common sx of PMS

HA, nervous irritability, insomnia, crying spells, depression, back ache, lower abdominal pain, tender and painful breasts. *should have sx free follicular phase*

What labs and imaging do you get in ectopic pregnancy?

HCG, US, culdocentesis, laparoscopy

all women who receive a diagnosis of acute PID should be tested for

HIV gonorrhea chlamydia using NAAT

HPV types and risks

HPV types 6 and 11-low risk oncoviruses HPV types 31, 33, 35, and 42-intermediate risk oncoviruses HPV types 16 and 18-high risk oncoviruses Cancer of the cervix

Ovulation

Happens 10-12hrs after LH peak and 24-36 hours after estradiol peaks. The onset of LH surge is most reliable indicator of timing of ovulation.

MC SE of vaginal ring

Headache

2 day method

Helps determine fertility based on presence or absence of cervical secretions. Presence of secretions of any type indicate fertility and patient should avoid unprotected sex. No cervical secretions for 2 consecutive days makes it unlikely pt will get preg go from sex that day.

hpv and cervical cancer in WSW

Highly contagious HPV can infect another woman during any mucosal contact. HPV can be transmitted among lesbians (oral sex, genital-genital, digital-genital, digital-anal and use of sex toys) CDC recommends HPV vaccination for all females at ages 11-12 y.o. USPSTF recommends age-based screening for cervical cancer for all sexually active women who have a cervix, regardless of sexual orientation.

What is the most common sexually transmitted infection in the US?

Human papillomavirus (HPV)

Ovarian hyperstimulation syndrome

Hx of infertility being tax w. Hormones *Ovaries are enlarged with multiple follicular cysts, a large cystic corpus luteum and stromatolites edema *Associated sx; Weight gain, abdominal dissension, abd pain. If severe- ascites, pleural effusion, hypovolemic, oliguria, electrolyte disturbances, dyspnea Tx: hospitalization, observation, bed rest, fluid, and lyte replacement.

Chronic PID refers to chronic problems associated with PID-

Hydrosalpinx Infertility Adhesions Infection

GnRH

Hypothalamic hormone that controls gonadotropin release. Secreted into the portal circulation, which carries it to the anterior lobe of the pituitary gland.

When is laparoscopy CI?

Hypovolemic shock or GI obstruction

switching to progestin IUD, Implant or Injection

IUD and injection take several weeks to get to peak hormone concentration but reach peak efficacy in 7 days from initiation. Continue using pill, patch or ring for 7 days or use barrier contraception during this interval. Implant effective in 4 days so continue using pill, patch or ring for 4-days after insertion of implant. Return to fertility after IUD removal may be immediate

What method of contraception is linked to increased risk of PID?

IUDs

TSS treatment

IV fluids IV antibiotics- nafcillin, oxacillin, cephalosporins, vanco if PCN allergic Deep surgical cleaning of any infected wounds Tx hypotension Oxygen and or mechanical ventilation as needed Blood products if needed Dialysis as needed Hospitalization (ICU)

Breast feeding and NFP

If supplementing , start mucus and temp observations once menses resumes (2-4 months). If solely breast feeding stat mucus signs at 4 months, 5% pregnancy rate without contraception. Look for more fertile mucus in the first ovulatory cycle.

Implanon

Implantable contraceptive w/ progestin etonogestrel MOA: Decr gonadotropin secretion, inhibits ovulation & suppr sperm penetration by thickening cervical mucus. Alt endometrium Admin: Single rod inserted sub-dermally in inside of upper arm. Must be removed after a period of no more than 3 yrs. SE: Irregular bleeding and amenorrhea common

Reporting and confidentiality

Needed to assist local health authorities in partner notification and treatment. *syphilis, gonorrhea, chlamydia, HIV, and AIDs in every state Reports are confidential

Menstruation

In the absence of a pregnancy, there is a dec in steroid levels, this leads to constriction of spiral arteries of fcnl endometrium. Dec blood flow to fcnl portion of endometrium causes ischemia and degradation of endometrial tissue. Bleeding (menses) is result of degraded endometrial tissue, which is desquamated/shed into uterine cavity. Within 2 days of onset. Of menses, surface epithelium begins to regenerate under influence of estrogen and continues while endometrium is shedding.

at what age is there an increase in growth hormone?

Inc in growth hormone 3-4yrs before menarche. Growth slows due to increased estrogen.

Cervical changes phase 2

Inc mucus production in response to estrogen from follicles. Thin, stretchy, clear and watery, peak vertical mucus occurs at height of estrogen secretion.

Effects of estrogen and menarche

Inc vag secretions Decreased vag pH Vag mucosoa thickens and bc rugated Labia protrudes and thickens uterus increases in size and length ovaries increase in mean weight

Risk factors for STI in adolescence

Incarceration in the juvenile justice system Lack of supervision at home after school Women of all ages have a lrg ectropion/squamocolumnar junction Anovulatory menstrual cycles Low progesterone thins mucus and eases penetration by bacterial organisms.

Treponema tests

Include FTA-ABS and MHA-TP Specific anti-treponema antibody tests. Confirmatory or diagnostic, but not used for routine screening. Used to assess false pos screening tests. Detect antibody against Treponema spirochete. More sensitive and specific than non-treponema tests. *Remain pos despite therapy. Not used to follow serologic response to therapy.

lesbian health childhood and adolescence

Increase in number of "adjustment problems". Role models are scarce. See homophobia from parents, teachers, peers. "Gay-straight alliances" in schools promote friendship and open discussion. Sexual expression is fluid. See sexual experimentation. Encourage self-empowerment; discourage coercive behavior or victimization Screen and counsel about drug use, safe sex, condom use "Coming Out"-process of accepting same-sex attraction as one's self; openness about being gay, lesbian or bisexual. May occur in young adulthood or later in life

preantral follicle

Increase in number of granulosa cells in primordial follicle by FSH Increase in estradiol secretion, which stimu preantral follicle growth, reduces follicle atresia, and increases FSH action. Nearly all prenatal follicles become atretic.

STD 4

Increase the proportion of sexually active females aged 24 and under enrolled in commercial health insurance plans who are screened for genital chlamydia infections during th measurement year.

STD 3

Increase the proportion of sexually active females aged 24 and under enrolled in medicaid plans who are screened for genital chlamydia infections during the measurement year

Other factor assoc w menarche

Increased fat, lean ratio in body composition, good nutrition, abscence of debilitating disease

Aging lesbians

Increased worries about being alone or poor. LGBT seniors' organizations helpful in preventing isolation (e.g. Senior Action in a Gay Environment and Pride Senior Network) Lesbians in a SNF for seniors may experience discrimination Critical Care and partner visitation-work to honor health care proxies, civil union documents, advance directives

OC drug interactions

Induce metabolism, dec effectiveness of estrogen Rifampin and grisepofulvin most important. Induce estrogen metabolism in liver, dec estrogen -antibiotics -st johns wort- CYP 3A4 inc metabolism of OC

PID

Infection of pelvic organs usually by GC, chlamydia, and mycoplasma hominis

A defective luteal phase can contribute to..

Infertility and early pregnancy loss. In early pregnancy, HcG maintains the corpus luteum

Ovarian accidents

Inflammatory cysts, endometriomas, benign or malignant cysts, or solid tumors, or variations in normal ovarian cycle. A. Bleeding- caus pain by irritation of peritoneal cavity by blood or acute dissension of ovary B. rupture of a cyst- releases cyst fluid- very irritating to peritoneum C. Torsion- leads to ischemia and tissue necrosis. Presentation depends on extent or torsion on blood supply.

Constant pain suggests

Inflammatory process, dissension of solid organ, compromise blood supply

Oligomenorrhea

Infrequent menstruation. Menstrual cycles that occurs at long intervals (more than 35 days)

Oligomenorrhea

Infrequent uterine bleeding that occurs at intervals more than 35days

Hormonal injectables

Inject I left medroxyprogesterone (depo-provera) Acts on hypothalamic-pituitatary axis to inhibit ovulation. Usual dose is 150mg IM every 3mo. Black box warning for risk of bone los

switching to injection from a copper IUD

Injection should be administered 7-days before the IUD is removed Use barrier method for first 4-days with implant or first 7-days after injection if you want the IUD removed the same day as the implant or injection

Abd exam

Inspect, auscultation, percuss, palpate

Providing health care that is inclusive of pts in same sex relationships must include:

Intake forms, waiting rooms, medical interview, terminology, life stages-childhood and adolescence, coming out, raising children, midlife concerns, aging Mental health Breast and gynecological cancer Smoking, obesity, coronary risk Critical care and partner visitation STI's/STDs

gap contraception

Interval btw stopping 1 method of BC and starting another.

Sx of PMS/PMDD group 1

Irritability Affective lability Depressed mood or hopelessness Tension or anxiety

Function of corpus luteum

Is responsible for secretion of progesterone, until placental steroidogenesis (production of progesterone) is established (around week 8-12 of pregnancy )

Spermicides

Kills or disable sperm so they cannot cause pregnancy

Estrogen production

LH acts on theca cells to produce androgens Androgens transported from theca cells to granulosa cells . Androgen are aromatized to estrogens by action of FSH on enzyme aromatase in granulosa cells

Therapy of ovarian accidents

Laparotomy

Follicular phase

Lasts from 1st day of menses until ovulation. Endometrial gland proliferate under the influence of estrogens (mostly estradiol)

Lesbian health in primary care

Lesbian and bisexual women and all women who have sexual relations with women have distinct health concerns

provider education on lesbians

Lesbians are more likely to make poor lifestyle choices, making them more susceptible to cancer risks. Lesbians have higher incidence of obesity, smoking, alcohol, and less physical activity. Provider education is very important. Use available resources.

Mollescum contagiosum dx

Lesion is pathognomonic of MC but diagnosis can be confirmed histologically (molluscum bodies)

Gonorrhea transmission man to women

Likely to result in infection after a single exposure

Cervical changes phase 1

Little mucus produced, if found its thick, tacky, opaque

Sit of entry of syphilis

MC for female: vulva, vagina, cervix Other sites Anus, rectum, phaynx, tongue, lips, fingers

LGV epidemiology

MC in tropical countries, rare in US, most new cases in men. Dx progresses from primary, secondary and tertiary stages. Incubation is 4-21 days.

Urethritis

MC male STI presentation Sx: urinary sx like dysuria, frequency, urgency, penile discharge Dx: mucopurulent urethral discharge, WBCs on urethral gram stain, pos leukocyte esterase test, pyuria Gonococcal vs. nongonococcal Gram-neg intracellular diplococci NGU is more common sign are more subtle 40-60% with NGU have no detectable pathogen- treat presumptively Causes- Chlamydia*, ureoplasma, mycoplasma genitalium, trichomonas, HSV Tax: Azithro 1gm single dose Doxy 100mg bid x7 days Alt NGU tx: Erythromycin base 500mg BID 7 days Levofloxacin 500mg 7 days

Phase 3 cervical changes

Marked decrease in quantity of mucus Thick, sticky, opaque.

Physiology of primary dysmenorrhea

Menstrual cramps are the result of uterine contractions Phospholipids -> precursors for arachidonic acid—> precursor of PGE —> potent vasoconstrictor —> ischemia, bleeding endometrial desquamation and hypercontractility of uterus.

Polymenorrhea

Menstrual cycles that occur at short intervals (less than 21 days)

Main reason for d/c injectable hormone is:

Menstruated irregularities/ bleeding (frequent, irregular, heavy menses or even amenorrhea)

Chronic pelvic pain

Mittelschmerz Dysmenorrhea Ovarian cysts Ovarian cancer Ovarian remnant syndrome Urinary tract pathology- cystitis, urethral colic Intestinal tract pathology- diverticulitis, colitis Orthopedic conditions- spina bifida, scoliosis, osteoarthritis, fibromyositis, herniated intervertebral disc Psychogenic causes

Lubricants

Moistening substances to make sex more comfortable and pleasure able Oil based can cause condoms to tear- avoid petroleum jelly, baby oil, mineral pol.

PMS sx diaries

Moos- * 8 categories from Moos menstrual distress questionnaire: Autonomic control, Arousal Behavioral change Concentration, control neg affect pain water retention Calendar of premenstrual experiences (COPE) Penn daily sx report Premenstrual sx screening tool

PMS sx diaries

Moos- * 8 categories from Moos menstrual distress questionnaire: pain, concentration, behavioral change, autonomic rxn, water retention, neg affect, arousal, control Calendar of premenstrual experiences (COPE) Penn daily sx report Premenstrual sx screening tool

trichomonas vaginalis

Motile flagellated protozoan. *Most common sexually transmitted protozoal infection *Causes acute vulvovaginitis. transmitted by sexual intercourse

Depo- SUb Q provers 104

New formulation of Depo Provera. Still given every three months. Given SQ instead of IM SQ version provides 30% less hormone- 104 mg vs 150 mg per injection Lower dose hoped to reduce long-term effects. Approved for both contraception and endometriosis pain management. Monitor bone density like with Depo-Provera if using more than 2 years; prescribe Ca++ and Vit D

adolescents versus older women criteria for hospitalization, does it differ?

No

PMS tx

No quick fix Both physiologic and psychosocial aspects o fPMS must be considered when setting up a treatment program. More than 70% of women w PMS will respond to therapy. 2 tax types: symptomatic and syndrome Reassurance-consider involving fam members

mid life lesbian concerns

No studies to show increased rates of breast, gyn or lung cancer, or CAD or stroke Increased rates of smoking. Higher body mass index. Fewer pregnancies. Address mental health issues-depression

Neoplasia and hormonal contraception

No valid data to support that OC use causes cancer of breast, cervix, endometrium or ovary in this women who do NOT have cancer. DO NOT use OCs in wome w hx or strong fam hx of: 1. Breast 2. Cervix 3. Endometrium 4. Ovary

chronic pelvic pain syndrome

Non-cyclic pelvic pain over 6 months duration, not relieved with meds. 3 groups of ppl: 1. Pathology at time of lap (endometriosis, infections) 2. Occult pathology (irritable bowel) 3. Non-somatic disorder-psychogenic disorder

Active agents in spermicides

Nonoxynol-9, octoxynal-9, gossypol Work by killing the spores, decreasing sperm motility or inactivating the enzymes needed for the sperm to penetrate the ova.

Menorrhea

Normal discharge

Dental Dams

Not a method of birth control. Can be used to protect from STIs and HIV during oral vaginal or oral-anal sex.

Etiology of PMS

Not really known but associated with excess or deficiencies of progesterone, estrogen, prolactin, aldosterone, pyridoxine 10-90% Severe is 2-10% MC in 30-40yo

Who might use sponges today?

Nursing mothers, smokers Over 35 Have pill side effects Prefer non-hormonal methods Need a backup to the pill Prefer a method affording sexual spontaneity No need to consult a physician

Age and hormonal contraception*

OCs can be used safely by women age 35-45yrs old if they are in good health and do NOT smoke Use low dose formulations. Obesity, hyperlipidemia, diabetes and cardiovascular disease are additional risk factors that CI OC use by women over 35.

Elective surgery and hormonal contraception*

OCs should be d/c when elective surgery is scheduled, stop estrogen containing pills 1mo prior to surgery to lessen the incidence of postoperative thrombophlebitis.

menstrual cycle onset, duration, frequency

Onset: 9-14 yrs old, avg 12.8yo Decreased from 15 probably due to improved nutrition. Lasts till menopause, typically occurs at tanner stage IV breast dev Freq: 28 days Irregular first 2 yrs and 3 yrs before menopause, anovulation(absent ovulation) is most common. Duration 3-5 days

ParaGard IUD

Option 1: Emr contraception: Get a ParaGard IUD within 120 hours (5 days) after having unprotected sex. This is the most effective type of emergency contraception. Requires insertion by a qualified clinician

The most common form of reversible contraception in the US

Oral contraceptives

Most effective reversible method of birth control?

Oral contraceptives 97-99% when used properly.

contraceptive patch

Ortho Evra Apply one patch a week for 3 weeks/skip a week *less effective with weight >198lbs May cause skin irritation Patch may fall off- replace patchy use backup contraception if off>24hrs

Dysmenorrhea usually begins with

Ovulatory menstrual periods (during first 3-6 ovulatory mentrual cycles)

5 Ps of sexual health

PArtners- number and gender; partner risk factors Prevention of pregnancy- desire for pregnancy and info on BC Protection from STIs Practices- focuses on high risk behaviors Past hx of STIS

Mastodynia

Pain usually swelling of the breasts causes by edema and engorgement of the vascular and ductal systems *common in PMS *NO palpable abnormality on breast exam Good breast exam needed to R./o malignancies Tx: Danazol (gonadotropin-release inhibitor) Bromocriptine (dopamine agonist) Vit E, primrose oil

Sx of chancroid

Painful soft chancres Adenopathy

*CDC Diagnostic Criteria for PID: PID should be suspected and treatment initiated if:

Patient is at risk of STIs/PID AND Patient is experiencing pelvic or lower abdominal pain, if no cause for the illness other than PID can be identified, and if one or more of the following minimum clinical criteria are present on pelvic examination (without other obvious cause): • Cervical motion tenderness (CMT); or • Uterine tenderness; or • Adnexal tenderness

Follow-up for PID

Patients should demonstrate substantial clinical improvement w/in 3 days (defervescence, reduction in direct or rebound abdominal tenderness, reduction in adnexal tenderness and CMT). Patients who do not improve w/in 3 days usually req hospitalization, additional diagnostic tests and surgical intervention. Follow up exam within 72 hours in those on outpatient treatment. Consider re-culture 4-6 weeks after therapy in those with N. gonorrhoeae and C. trachomatis

Ectoparasites

Pediculosis pubis (Phthirus pubis): *Crab louse Confined to hair-bearing regions of vulva *highly contagious STI of young active adults

Most common complaint in GYN?

Pelvic pain

Postcoital douche

Plain water, vinegar and other "feminine hygiene". Douche does NOT prevent pregnancy or STIs.

Calymmatobacterium granulomatis

Pleomorphic gram neg rods Forms granulomatous and ulcerative lesions of lower genital tract. Epidemiology: Rare in US, 1 mo incubation Sx: raised red lesions

clinical presentation and dx of scabies

Predominant symptom (sin qua non) is ITCH *Hands, wrists, breasts and buttocks most commonly affected sites. Diagnosis: 1. See burrows with hand lens. 2. Skin scrapings in mineral oil-adult mites, eggs and fecal pellets

Abnormal uterine bleeding ddx

Pregnancy Endometriosis, endometrial polyps, uterine leiomyoma, endometrial hyperplasia, *endometrial carcinoma, cervical neoplasia Meds: Estrogen admin, combo OCs, aspirin Trauma Foreign body, IUD Ovulatory Anovulation, luteal phase deficiency Endocrine gland dysfunction Hypothyroidism, hyperthyroidism, pituitary adenomyosis Systemic dx Hematologic dx, cirrhosis

Treatment of HPV

Prevention-Vaccination: •Gardasil-quadrivalent HPV (types 6, 11, 16, 18) oElected date, 2 months, 6 months •Gardasil-9 oProtects against HPV (6, 11, 16*, 18*, 31, 33, 45, 52, & 58) •Cervarix-bivalent HPV (types 16, 18)-not indicated for prevention of genital warts oElected date, 1 month, 6 months

treatment of HSV

Primary Episode: Acyclovir 400 mg po tid for 7-10 days OR Acyclovir 200 mg po five times a day for 7-10 days OR Valacyclovir 1 g po bid for 7-10 days OR Famciclovir 250 mg po tid for 7-10 days More expensive. Easier dosing * Treatment can be extended if healing is incomplete after 10 days of therapy. Continuous use of acyclovir on a prophylactic basis may reduce frequency of eruptions in some patients with recurrent episodes. Sitz baths-palliative *Until all vesicles crusted over, lesions are highly contagious and intercourse should be avoided. *Active genital herpes in pregnant female at time of delivery--> C-section.

Period pattern

Regular from 15 to 45yo. Ovulate approx 13-14 times./yr Irregular cycles mostly in first 2 yrs after menarche and 3-5 yrs before menopause. Anovulation common at this time.

Clinical presentation of syphilis

Primary- Initial lesion is painless, ulcerated, hard chancre usually external genitalia. Non-tender nodes* *firm, punched out appearance with rolled adages. Usually asx Resolve in 3 to 9 weeks Secondary- In untreated pts, chancre followed in 6 weeks to 6 mo by secondary or bacteremic stage (skin and mucus membranes affected) * low grade fever , HA, malaise, sore throat, anorexia, general lymphadenopathy and rash. Rash is asx maculopapular rash of palms and soles and mucous membranes (* money spots) *condyloma lava-flat topped papules that coalesce. Seen in moose areas. Broader base, and flatter than genital warts. Resolve in 2-6 weeks.

Causes of dysmenorrhea

Primary- *fcnl; due to PGE excess- pain Sec- 1) organic disorders - endometriosis*MCC, adenomyosis, IUDs, pelvic congestion syndrome, fibroids and masses 2) infection- PID 3) Malformation- cervical stenosis

Clinical LGV presentation

Primary- lesion consist of papules or ulcers *women-vulva lesion, painless vesicular or popular lesion. Resolves in 1 weeek. Secondary- regional lymphadenopathy (bubonic stage) Inguinal adenopathy (groove sign) Fever, myalgia, arthralgias Tertiary- suppurative buboes-> draining fistulas and lymphatic obstruction *can see elephantitis in untreated patients. Dx: complement fixation is test of choice. Tx: Doxycycline 100mg po bid x 21 days

clinical presentation of HSV

Prodromal Phase: Mild paresthesia and burning 2-5 days after infection, prior to vesicles breaking out. primary lesions recurrent lesions

Nexplanon

Progestin implant. Modified version (bioequivalent) of Implanon. Etonogestrel (68 mg) Single rod sub-dermal contraceptive. Implanted into inside of upper arm. Reversible and effective up to 3 years. Rod is radiopaque and can be seen with CT scan making it easier to remove than Implanon. Will eventually replace Implanon. Wholesale cost of device is $659.42

Progestin only emergency contraception

Progestin only pill. Levonorgestral 1.5 mg Only use for back up when primary method fails Start within 72 hours for 89% effectiveness Work best when taken within 72 hours (3 days) of unprotected sex. May still work in some for up to 5 days post sex SEs-nausea, vomiting, H/A, abdominal pain, breast tenderness Common OTC Brands: Plan B One Step, Next Choice One Dose, My Way, Take Action, After Pill, EContra Ez, Aftera (OTC for women over 17-years old and by RX to younger patients) Cost: $40.62 (Plan B One Step by Rx)

Menorrhagia

Prolonged (exceeding 7 days ) and excessive (greater than 80ml) uterine bleeding that occurs at regular intervals.

What a potent stimulator of of uterine contractions?

Prostaglandins

FSH and LH

Protein hormones secreted by anterior pituitary FSH receptors on granulosa cell membrane* FSH acts primarily on granulosa cells to stimu follicular growth. Stimu formation of LH receptors Stimu follicular growth by inc both LH and FSH receptors in granulosa cells Estradiol enhances action

Mandatory reporting by phone

Provider must make a report by phone. Ex. Rubella (measles) and pertussis (whooping cough).

Mittelschemerz

Psychosomatic and physical disorder of the menstrual cycle. Intermenstrual pain at the time of ovulation, usually lower abdominal pain that is unilateral. Pain NOT usually severe and last less than 12 hrs. Indicates ovulation has occurred, but there is NO intra-abdominal pathology. If recurrent or severe—> OCs

Non-treponema tests

RPR and VDRL- nonspecific Reagan-type antibody tests. Measure regain if antibody. Detected by cardiolipin-lecithin antigen. Rapid, easy, inexpensive Used primarily for screening, but do get false pos VDRL bc pos in 3-6weeks after infection. Watch VDRL titers to monitor response to tx.

Spermicide mode of action

Rapid in releasing active ingredient Able to spread over the cervix and vag Able to act as physical barriers at the cervix to prevent sperm penetration *effectiveness depends on the couples motivation to use this form of contraception correctly for every act of coitus. No serious SE have been reported with the currently available spermicides.

Treatment of chlamydia

Recommended Regimen Azithromycin 1 g po single dose OR: Doxycycline 100 mg po bid x 7 days Alternative Regimens Erythromycin base 500 mg po qid x 7 days Erythromycin ethylsuccinate 800 mg po qid x 7 days Levofloxacin 500 mg po x 7 days Ofloxacin 300 mg po bid x 7 days *Azithromycin is also recommended during pregnancy *Follow up cultures and evaluation should be done due to high re-infection rate. *Treat partners. *Acute PID should probably be hospitalized.

treatment of trichomonas

Recommended Regimen: Metronidazole 2 g po single dose (including pregnant women) OR Tinidazole 2 g orally in a single dose Alternative Regimen: Metronidazole 500 mg orally twice a day for 7 days

chronic PID

Recurrent lower abdominal pain. Chronic infection vs complications of acute infection Do lap to get diagnosis

STD 9

Reduce females with HPV (vaccination)

STD 1 & 2

Reduce the proportion of adolescents and young adults with Chlamydia trachomatic infections

STD 5

Reduce the proportion of females 15-44 who have ever req tx for PID

Cervical cap with spermicide

Rubber device smaller than a diaphragm that fits over cervix like a large thimble. Can be left in place up to 48hrs. Remains effective for more than one episode of intercourse without adding more spermicide. Mechanical barrier and inactivation of sperm 80-82% effective

STIs in lesbians

STIs in WSW varies with age, economic status, number and health status of current and past male and female sexual partners 1. *Bacterial vaginosis most common among WSW 2. Trichomonas less common than BV but also transmitted from woman to woman 3. Genital herpes 4. Human papillomavirus 5. Other-syphilis, hepatitis A and HIV uncommon in private practice in WSW but all have been reported. Hepatitis B and HIV much higher incidence in WSW who are also IVDU 6. Sexual transmission of Chlamydia, gonorrhea, hepatitis B and hepatitis C from woman to woman not yet documented

cancer in WSW

See an increased risk of: •ovarian cancer (do not use hormonal contraceptives) •endometrial cancer (nulliparity is a risk) •breast cancer (risks include nulliparity, not breast feeding, birth to only one child)

Risk factors for Contracting STIs

Sexual activity beginning at an early age Unprotected sex with an infected partner Intercourse with a new partner Multiple sexual partners Prior hx of STI Inconsistent or incorrect use of condoms Use of illegal drugs Intercourse between men Intercourse with sex workers Sexual assault or abuse

Sharp vs dull pain etioo

Sharp- obstruction or an acute peritoneal event Dull- suggests an inflammatory process

Safety of Vaginal sponges Toxic shock syndrome

Some ceases of TSS have been reported in women using this. Rare but serious, may abuse death- fever, N/V/D, muscle pain, dizziness, faintness, or a sunburn-like rash

Primary dysmenorrhea

Spasmodic due to sx, usually starts 2-3 yrs after menarche Max btw 15 to 25yo Decreases with age and ceases after child birth usually Pain lasts 24-36hrs Involves progesterone-PGEs-myometrial contractions

Switching from progestin implant to copper IUD

Start the new method 4-days before removing the copper IUD.

Action of GnRH

Stimulates synthesis and release of both FSH and LH from the same cel. GnRH stimulation produces a rapid (30min) increase in serum FSH and LH then a slower 90min release of LH High, prolonged GnRH exposure saturated the GnRH receptors and inhibits FSH and LH secretion.

Lactational Amernorrhea

Suckline-> dec GnRH, LH, FSH and dopamine-> suppresses prolactin —> amenorrhea and anovulation Good for first 6mop if breast feeding exclusively If using lam, must only breastfeed., no supp feedings. Must stay amenorrheic

Onset differential

Sudden- perforation, hemorrhage, rupture or torsion Gradual- inflammation, obstruction, or slowly evolving problem.

switching from patch or ring to a pill

Switching from patch or ring: Patch provides 9 days of pregnancy prevention Ring provide 35 days of pregnancy prevention When switching from patch or ring to a pill take first pill the day before they are scheduled to remove the patch or ring for a one-day overlap. Don't need to complete full schedule of patch or ring before switching to pill. When switching from a patch to a ring, insert the ring and remove the patch on the same day. When switching from a ring to a patch apply the patch 2-days before removing the ring.

Most effective of all periodic abstinence approaches?

Symptothermal method

Management of Chronic DUB

Tailor to patient's ovulatory status, age, health risks and contraception preferences. *Cyclic progestins are the mainstay of therapy. *Commonly used in perimenopausal age group. May also use combo OCs but must evaluate for risks associated with estrogen. Treatment: •Medroxyprogesterone (MPA) 10 mg po QD for 10-12 days a month •Norethindrone acetate 5 mg po bid for 10-12 days a month •Micronized progesterone 300 mg po qd for 10-12 days a month •IUD with progesterone (LNG-IUS, Mirena) releases 20 mcg of levonergesterol per day

Emergency contraceptive pills (option 2)

Take an emergency contraceptive pill within 120 hours (5 days) after having unprotected sex. There are 2 types of morning after pills(Ella and Progestin only OC) and the Yuzpe regimen

Postcoital contraception/Emergency contraception

The "morning after pill" can be used after unprotected coitus around the time of ovulation. Combination estrogen-progesterone or progesterone only *Must be taken within 72 hrs of coitus; use within 24 hrs preferable.

Prostaglandins and proteolytic enzymes are responsible for

The digestion and rupture of the follicle wall. Mid- cycle rise in FSH (progesterone dept) free oocyte from follicle and ensures sufficient LH receptors for adequate luteal phase.

Basal body temperature changes

The temp of the body at complete rest after a period of sleep and before normal activity, including eating. 1. The basal body temp in .4-1.0F during the post-ovulatory phase of the cycle because of progesterone effect. 2. An indicator of fertility, basal body temp can detect only the end of fertile phase, since the temperature remains elevated for 3 days after the shift. 3. Avoid pregnancy using this method alone. Must restrict intercourse to period from 3rd day of temp elevation until end of cycle.

Phase 2- the fertile phase

The women observes the amount and quality for her cerivical mucus every day. Extends from beginning of follicular development until 48hrs after ovulation. Lasts approx 8-10days per cycle and begins when the woman first notices mucus production. Typically 5 days of clear, stretchy mucus, corresponds to her most fertile time. Last day of this clear, stretchy mucus is considered the most fertile day. Sperm have the capacity to fertilize the ovum up to 5 days in the cervical mucus. Couple must abstain from intercourse to prevent conception. Conception most successful with intercourse up to 6 days before ovulation

Genital Tuberculosis tx

Treatment: Single or multi drug therapy with INH, Rifampin, Streptomycin, Ethambutol, Pyrazinamide. Surgical treatment for persistent disease, abscess formation and persistent pelvic pain. Surgical treatment is TAH/BSO

Treatment in 2ndary dysmenorrhea

Tx underlying disorder Initiate NSAIDs 24-48hrs prior Can also use OCs

switching from copper IUD to progestin IUD

Use barrier contraception during the first week.

Bartholinitis:

Usually due to E. coli or staphylococci or after a GC infection. Duct and gland involved. Can form abscess if not treated promptly. May become chronically enlarged after inflammatory process --> Bartholin cyst

PID epidemiology

Usually from STI 10% of American women dev during productive years 25% w. PID develop serious sequellae Significant cause of infertility in US 1/ 2of all ectopic are from PID

Signs and sx of PMS

Usually seen 7-10 days prior to menses. Gradually increase in intensity Disappear when menstrual flow established Weight gain 2 to 6 pounds common; generalized edema and decreased urine output Weight loss and diuretics with onset of menses

polymenorrhea

Uterine bleeding (menstruation) that occurs at regular intervals less than 21 days apart

metrorrhagia

Uterine bleeding at time other than expected menses; irregular bleeding

metrorrhagia

Uterine bleeding that occurs at irregular but frequent intervals; the amount of uterine bleeding is variable, and the duration of flow is often prolonged

Female condom

Vag pouch. 79% effective, good protect against STIs and pregnancy. Completely covers vagina and cervix.

Source of pelvic pain

Visceral (doesn't respond to thermal, chemical or tactile sensations). Visceral pain is A) referred B) splanchnic - tension -peritoneal irritation or inflammation

Laparoscopy

Visualization of pelvic structures Opportunity to dx and to problem w/ o extensive surgery *30% of ppl w. Pelvic pain have normal pelvis

Psychogenic causes

When organic dx is eliminated look for psych reasons*. Borderline personality, hypochondriasis, depression, hysteria. Look for hx of sexual abuse as a child, emotional instability Management- team approach w social worker and psychiatrist

Coitus Interruptus

Withdrawal of penis before ejaculation Semen deposited outside female genital tract Requires significant self-control by male Reliable failure rate statistics not known

Do NOT use sponge with

Within first 6 weeks after giving birth If you the patient has had Toxic shock syndrome During the menstrual period

Types of infections

Women- *cervicitis, urethritis, PID, acute pharyngitis Men- urethritis, prostatitis, epididymitis

Acute heavy bleeding

a. High dose conjugated equine estrogens with antiemetic: 25 mg conjugated estrogen IV Q 4-6 hours or, 2.5 mg conjugated estrogen po Q 6 hours b. Monophasic preps: 30ug ethinyl estradiol (Lo/Ovral) - 1 pill 4x/d for 4d, then 3x/d for 3d, then 2x/d for 2 weeks. *Once acute bleed stopped, start progestins for several days to stabilize endometrium followed by combo OCs for 3-6 cycles.

prostaglandins have important action on endometrial vasculature and on endometrial hemostasis

a. Thromboxane-platelet pro-aggregating vasoconstrictor b. Prostacyclin is anti-aggregating vasodilator The concentration of prostaglandins increases progressively during the menstrual cycle. NSAIDS decrease menstrual blood loss *NSAIDS are primarily effective in reducing menstrual blood loss in women who ovulate. Mild cases of DUB amenable to NSAIDS and watchful waiting

heavy bleeding from IUD use due to

a. Vascular erosions-may occur in areas of the endometrium in direct contact with IUD b. Excessive bleeding-in first few months after insertion treated with reassurance and supplemental oral iron. Usually stops as uterus adjusts to IUD. MUST REMOVE if bleeding continues.

Causes of AUB/DUB by age in adolecence

adolescence **MCC of DUB in anovulation

Integrase inhibitors

block the HIV enzyme integrase, which the virus uses to integrate its genetic material into the DNA of the cell it has infected (i.e., raltegravir, dolutegravir).

what tx is used when tubo-ovarian abcess is present?

clindamycin (450 mg orally four times daily) or metronidazole (500 mg twice daily) should be used to complete at least 14 days of therapy with doxycycline to provide more effective anaerobic coverage than doxycycline alone.

multi class combination products

combine HIV drugs from two or more classes, or types, into a single product (e.g. efavirenz, emtricitabine and tenofovir).

most women with PID have

either mucopurulent cervical discharge or evidence of WBCs on a microscopic evaluation of a saline preparation of vaginal fluid

expedited partner treatment

good alternative to treating male partners

what are the MC reasons for D/c IUD use?

heavy/prolonged menses and intermenstrual bleeding are the major reasons

protease inhibitors

interfere with the HIV enzyme called protease, which normally cuts long chains of HIV proteins into smaller individual proteins. When protease does not work properly, new virus particles cannot be assembled (i.e., indinavir, saquinavir, ritonavir, nelfinavir).

entry inhibitors

interfere with the virus' ability to bind to receptors on the outer surface of the cell it tries to enter. When receptor binding fails, HIV cannot infect the cell (i.e., maraviroc).

fusion inhibitors

interfere with the virus's ability to fuse with a cellular membrane, preventing HIV from entering a cell (i.e., enfuvirtide, T-20).

PID: Management of Sex Partners:

men who had sex w/ woman w/in 60 days of onset of sx should be eval, tested, and treated for chlamydia and gonorrhea regardless of etio of PID or pathogens isolated from the woman. if last sexual intercourse >60 days treat her last partner

PID IM/Oral Treatment is used for

mild to mod cases of acute PID because outcomes are similar to those treated w IV therapy

pathophysiology of PID

multifactorial etiology. Includes menses, sexual intercourse and genital procedures.

STIS

total 2,295,739 Chlamydia 1,708,569 Gonorrhea 555,608 Syphilis 30,644

Pubarche

onset of development of pubic and axillary hair

reverse transcriptase inhibitors

prevent the HIV enzyme reverse transcriptase (RT) from converting single-stranded HIV RNA into double-stranded HIV DNA―a process called reverse transcription. There are two types of RT inhibitors: • Nucleoside/nucleotide RT inhibitors (NRTIs) are faulty DNA building blocks. When one of these faulty building blocks is added to a growing HIV DNA chain, no further correct DNA building blocks can be added on, halting HIV DNA synthesis (e.g., lamivudine, zidovudine, emtricitabine, abacavir, zalcitabine). • Non-nucleoside RT inhibitors (NNRTIs) bind to RT, interfering with its ability to convert HIV RNA into HIV DNA (e.g., rilpivirine, delavirdine, etravirine, nevirapine)

determining the best emergency contraception (EC)

o When did the patient have unprotected sex? o Which kind of EC is easiest for the patient to get? o The patient's height and weight (BMI) o Whether patient is breastfeeding. o If the patient has used the pill, patch, or ring in the last 5 days

Menorrhalgia-

painful menstruation

Menoschesis

retention of the menses

Women who do not respond to IM/oral therapy within 72 hours should do what?

should be reevaluated to confirm the diagnosis and should be administered intravenous therapy.

Use conservative therapy with antibiotics first. If no response to antibiotic therapy in 48-72 hrs, must consider what?

surgery! a. Colpotomy drainage of pelvic abscess b. Laparotomy-hysterectomy, bilateral salpingo-oophorectomy, and drainage of the pelvic cavity in severe cases unresponsive to above.

Iron

those with menorrhagia should be treated with iron. Elemental iron (60-180 mg daily) and folate.

other management considerations with PID

to min dz transmission, women should not have sex till therapy over and sx gone and sexual partner treated. *all women who receive dx of acute PID should also be tested for HIV and GC and chlamydia, using NAAT

when selecting a treatment regimen, health care providers should consider

• Availability • Cost, and • Patient acceptance In women with PID of mild or moderate clinical severity, parenteral and oral regimens appear to have similar efficacy.

CDC-Most specific criteria for the diagnosis:

• Endometrial biopsy with histopathologic evidence of endometritis; • Transvaginal sonography or magnetic resonance imaging techniques showing thickened, fluid-filled tubes with or without free pelvic fluid or tubo-ovairan complex, or Doppler studies suggesting pelvic infection (e.g., tubal hyperemia); or • Laparoscopic findings consistent with PID

CDC-Findings that support the diagnosis: One or more of the following additional criteria can be used to enhance specificity of the minimal clinical criteria and support a diagnosis of PID:

• Oral temperature of 1010F (38.30C) or greater • Abnormal cervical or vaginal mucopurulent (green or yellow) discharge or cervical friability • Presence of abundant numbers of WBCs on saline microscopy of vaginal fluid; • Elevated erythrocyte sedimentation rate; • Elevated C-reactive protein; and Laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis

CDC five P's

• Partners, • Practices • Prevention of STIs • Past history of STIs • Prevention of pregnancy

communication techniques

• Providers need to identify their own cultural competence. • Good communication style important • Establish rapport based on confidentiality, openness and sensitivity • Establish a safe, comfortable environment for disclosure and discussion. • Post a statement about the facility's policy against discrimination. • Display patient education materials designed for lesbians. • Intake forms inclusive in terminology and "lesbian friendly"; use more neutral terms • Use open-ended questions and using inclusive language and being confident • Make the medical interview inclusive of all sexual relationships and open for further discussion of sexual concerns • Elicit a detailed sexual history to identify health risks and necessary screening tests.

sexual hx questions for lesbian patients

•Are you sexually active with women, men or both? •How many sexual partners have you had in the past 5 years? •Does your current partner have sex with women, men or both? •Describe your sexual contact-oral, vaginal, anal? •Is your sexual contact with someone who shared needles for injection drug use? •During sexual contact do you use barrier methods? •If active with men, what is your method of birth control? •Do you or your partners have any history of STIs? •Do you have any further concerns about sex or STIs?

labs that could be ordered for PID

•CBC-look for leukocytosis; not reliable •Increased sed rate/CRP-nonspecific •LFT's-look for elevation (peri-hepatitis) •Rapid enzyme tests for GC and Chlamydia •Nucleic acid amplification tests-chlamydia, GC DNA, PCR •Non-amplification nucleic acid tests-chlamydia or GC DNA probe •Non-nucleic acid tests-chlamydia, GC

emergency contraception patient screening

•Confirm unprotected sexual intercourse within previous 72 hours •Focus on hours since intercourse and date of LMP •Counsel use of contraception and safe sex precautions for future •Pelvic exam and pregnancy test not required •Parental permission not required for dispensing EC to an adolescent

Goals of treatment

•Control bleeding •Prevent further episodes •Restore synchrony to endometrium •Replenish iron stores •Prevent serious long-term consequences of anovulation •Preserve desired fertility

Indications for IUD use

•Desire for long-term contraception •Monogamous relationship •No history of present or recent STI •Approved for parous as well as nulliparous women •No intrauterine abnormalities

MOA of emergency contraception

•Inhibit or delay ovulation •Disrupting follicular development •Interfering with maturation of corpus luteum

CI to IUD use

•Severe uterine distortion •Active, recent o recurrent pelvic infection •Known or suspected pregnancy •Wilson's disease or copper allergy Undiagnosed uterine bleeding

hospitalization for PID

•Surgical emergencies (e.g., appendicitis) cannot be excluded; •Tubo-ovarian abscess; •Pregnancy; •Severe illness, nausea and vomiting, or high fever; •Unable to follow or tolerate an outpatient oral regimen; Or •No clinical response to oral antimicrobial therapy.