Gynecology - workbook
A 22-year-old woman is seen for evaluation of fever and pelvic pain. She admits to having multiple sexual partners. Cervical exam is significant for bilateral adnexal tenderness, and purulent discharges. Cervical sampling and culturing on Thayer-Martin agar isolates gram-negative diplococci bacteria. What is the best antibacterial treatment for the patient?
Administering ceftriaxone and doxycycline. Patients with gonorrhea should be treated for gonorrhea and presumptive chlamydia. Mnemonic:To get to the letter "G" (Gonorrhea), you must have first passed the letter "C" (Chlamydia). In female patients with nesseria - you have to treat for presumptive occurrence of chlamydia
You are evaluating a married couple for the complaint of infertility. History and physical examination of the couple do not provide any evidence of any overt abnormalities. What should be your first and foremost procedure?
Analyzing the semen of the husband. The general rule is to evaluate the husband first even though in the majority of cases (75%) the issue may stem from malfunction of the female reproductive system. The major reason for this is that diagnosis of male-related issues is by far less costly and less intrusive
A 43-year-old woman is seen for the complaint that her menses is prolonged, heavy, and longer and more painful than usual. She claims that she used to have normal and regular menses in the past. Further examination rules out pregnancy, malignancies, vaginal infections, and endometriosis. What is the most likely pathophysiology of her findings?
High estrogen to low progesterone titers. This patient has dysfunctional uterine bleeding (DUB), which is the most common cause of abnormal uterine bleeding. DUB is described as irregular uterine bleeding that occurs in the absence of recognizable pelvic pathology, general medical disease, or pregnancy. Up to 75% of cases are due to anovulatory cycles and unopposed rise in estrogen titers
You are evaluating a 27-year-old for the complaint of infertility. History is significant for an ectopic pregnancy that happened about a year ago. What test would you order to evaluate the fallopian tubes and the uterus?
Hysterosalpingography (HSG) is a diagnostic study of the uterus and fallopian tubes most commonly used in the evaluation of infertility. Uterine abnormalities are contributing factors in approximately 10% of infertile women and 50% of women with recurrent early pregnancy loss, while the prevalence of tubal abnormalities in infertility is approximately 20%. Thus, assessment of the uterine cavity and fallopian tubes is a standard practice in the baseline infertility workup. Note:An intravenous pyelogram or IVP is used to visualize abnormalities of the urinary system, including the kidneys, ureters, and bladder
PID is often treated with multiple antibiotics because endocervical culture often reveals a polymicrobial infection. What is the most common antibiotic mixture used to treat inpatients?
IV Clindamycin and gentamicin ("Regimen B"). Clindamycin, in particular, is used for patients suspected of having tubo-ovarian abscesses. Another regimen, known as Regimen A, consists of IV Cefoxitin and Doxycycline. Note: The major therapeutic difference between inpatient and outpatient therapy, other than close surveillance, is the mode of drug application: oral for outpatients, IV for inpatients.
5. Measurement of Plasma Testosterone and DHEA
If levels of plasma testosterone and/or DHEA are elevated, then there are ovarian and/or adrenal anomalies
4. Measurement of Prolactin
If prolactin levels are normal (i.e. less than 20 ng/ml) and if progesterone withdrawal causes menorrhea and there is no indication of galactorrhea, then there is no functional pituitary tumor. If there is hyperprolactinemia (prolactin more than 20 ng/ml): - Check pituitary via X-ray, and CT scan for the presence of tumors - Check TSH for thyroid malfunction - Check for hypothyroidism(it is a cause of hyperprolactinemia)
What are the major causes of increased vaginal pH?
Intercourse: Semen has a pH of 7 to 8 Menstruation: Blood pH is 7.4 Hygienic Products: Most soaps have a pH over 8
How do you manage the sexual partner of the above patient?
It is not necessary to evaluate or treat sexual partners of patients who have candidiasis and Gardnerella infections. For the rest of the cited conditions sexual partners should be screened, advised to use condoms, or treated if necessary. Other noteworthy sexually transmitted diseases that require evaluation and treatment of sexual partners are: Human papilloma virus, syphilis (primary and secondary), and herpes infection
A 32-year-old woman is seen for the symptom of itching in her pubic hair. Examination of pubic hair with a magnifying glass shows the presence of many small yellow-gray organisms. The diagnosis is made that she has contracted pediculosis. Proper management of the patient includes all of the following EXCEPT
Lindane cream is the least advisable choice. This patient has pediculosis(lice) due to Phthirus pubis. Diagnosis is made by observing the lice on the pubic hair. Phthirus pubis is often sexually transmitted, and it is recommended that she and her sexual partner(s) also be evaluated for other sexually transmitted diseases. Treatment in pregnant women includes use of permethrin cream. Lindane is another medication for treating lice, but it is neurotoxic and it is often used as the second-line medication. Note:Lice often affect the heads of school-aged children (Pediculus capitis)
A 27-year-old woman is seen for the complaint of vaginal discharges. On examination the discharges are thin, purulent, and mildly odorous. There is cervical friability evidenced by bleeding after manipulation. She is diagnosed with endocervicitis and treated with ceftriaxone and doxycycline. Which of the following is the most likely offending bug?
Neisseria gonorrhea. Gonorrhea causes endocervicitis and presents with thin mucopurulent discharges. Patients have friable cervix, but in contrast to trichomonas infections, lack a "strawberry cervix". In contrast to chlamydial infections, patients with gonorrhea should be treated for presumed chlamydial infections. Culture and staining is the most common diagnostic test for gonorrhea. Nucleic Acid Amplification Testing is more costly and less reliable than testing for chlamydia due to false-positive results that stem from the frequent horizontal genetic exchange occurring within the Neisseria genus, leading to commensal Neisseria species acquiring N. gonorrhoeae genes. Additionally, NAAT only detects the genetic material, it cannot determine whether the bacteria causing infection are living or resistant to antibiotics
What is the NAAT test for detection of Neisseria and Chlamydia?
Nucleic Acid Amplification Testing is currently the preferred method to detect chlamydia (preferably) and Neisseria in men and women. The test is extremely sensitive and detects even small amounts of the bacterial genetic materials via amplification techniques prior to antibody formation by the body. It is also favorable because samples are easy to obtain. Males can submit a first morning urine sample and females can submit a vaginal swab collected themselves or by a healthcare practitioner
What is the best treatment for PID due to Actinomyces israeli?
Penicillin G is by far the most effective treatment; however, high doses must be given long-term (8 weeks to 1 year). Other drugs used include clindamycin, erythromycin, and doxycycline.
What is Reed's syndrome?
Reed's syndrome is also known as familial leiomyomata, or hereditary leiomyomatosis. It is an autosomal dominant condition that causes uterine leiomyomata along with cutaneous leiomyomata and renal cell cancer
What is the most probable cause of endometriosis?
Retrograde menstruation (backward movement of menstrual fluids through the fallopian tubes and into the peritoneal cavity)
Endometriosis may form nodules on the broad ligament that are palpable on physical exam. What is a common consequence of these nodules?
Retroverted uterus
About retroverted uterus
Retroverted uterus (tilted uterus, tipped uterus) is a uterus that is tilted posteriorly and it is seen in 1 in 4 women. This is in contrast to the most common position of the uterus that is slightly anteverted and tipped toward the bladder A retroverted uterus is usually diagnosed during a routine pelvic examination It usually does not pose any medical problems. The only relevant issues are pain in the lower back, dyspareunia, and dysmenorrhea
Regarding the patient in the previous question, proper diagnosis was made after performing a transvaginal ultrasound. Which of the following options is the most desirable next-step management for the patient if she wishes to become pregnant?
The patient has PCOS; if she wishes to become pregnant, clomiphene is the preferred choice. For women who do not wish to become pregnant, contraceptives are a better choice. Clomiphene is helpful in inducing ovulation and promoting pregnancy in PCOS. Clomiphene alone at times may not be an effective treatment for most women with PCOS who wish to become pregnant due to severe insulin resistance and obesity. Women with PCOS who are overweight often begin ovulating when they reduce their body mass index (BMI) with diet and exercise
A 45-year-old multiparous woman has a large boggy uterus on physical exam. Transvaginal ultrasound confirms a large uterus. What is the next step procedure to properly diagnose and manage the patient?
The patient most likely has adenomyosis. Dilation and curettage should be used to rule out endometrial malignancy
You are examining a 25-year-old woman for the complaint of dysmenorrhea and heavy menstrual bleeding. She claims that she has normal cycles. Physical examination reveals an enlarged uterus with a few hard and oval structures of a few centimeters' diameter within its wall. Results of pelvic ultrasound confirm the presence of nodular growths within the myometrium. Which of the following options would be most helpful in managing this patient?
The patient most likely has leiomyoma (fibroids), which are very sensitive to estrogen and oral contraceptives and grow during menstrual cycles or other high-estrogen conditions.
What are sx of PID in males?
The term "PID" is only used for female patients. In males, "STD" is the only applicable term, and covers only a small spectrum of symptoms manifested by females
What is the most likely cause of acidic vaginal secretions?
The vagina is the second source of bacterial flora after the bowels. The balance of the flora determines the health and pH of secretions. The major determinant of the acidity is Lactobacillus acidophilus.
A 19-year-old college student is seen for the complaint of uterine cramping during her mid-cycle. Examination of vaginal secretions indicates a pH of 4.0. What is the significance of this finding?
This is a normal finding. The normal pH of vaginal secretions is acidic (range: 3.5 -4.5)
A 29-year-old woman is being examined for several painless pubic lesions. On examination the lesions appear as pearl-like, flesh-colored, and raised nodules. Which of the following pieces of information will show your mastery of the presumptive disease in this patient?
This patient has Molluscum contagiosum (a pox infection), which is more commonly seen in children. In adults, it is always sexually transmitted
Why are women with leiomyomas who are older than 35 required to undergo dilation and curettage?
This procedure is required in order to rule out malignancies
What are the 3 clinical criteria used for the diagnosis of PID?
Three clinical criteria for the diagnosis of PID: 1) Abdominal pain 2) Adnexal pain (pain of the structures that are most closely related structurally and functionally to the uterus, such as fallopian tubes and ovaries) 3) Chandelier sign (a.k.a. cervical motion tenderness or cervical excitation) Others: Leukocytosis, elevated erythrocytic sedimentation rate, increased c-reactive protein, and presence of purulent cervical discharges
ENDOMETRIOSIS/ADENOMYOSIS
Tissue lining the uterus grows outside the uterus/Tissue lining the uterus grows inside the myometrium Patients are usually nulliparous, over 30 and has predisposing conditions (anatomical or immunologic)///patients are usually multiparous and over 40, Pregnancy and C-section predisposing factor May cause infertility in younger women///Often happens after childbirth and subsides after menopause. Unlike endometriosis, it does not affect fertility requires a more detailed management///Less detailed measurement May persist with hysterectomy///Almost always resolved with hysterectomy because it is an intrauterine issue
A 25-year-old woman is suspected of having PID. Endocervical screening rules out Neisserial and Chlamydial infections. Should the antibacterial regimen of the patient still include coverage for these two bugs?
Yes. All regimens that are used to treat PID should also be effective against N. gonorrhoeae and C. trachomatis because negative endo-cervical screening does not rule out an upper reproductive tract infection
Evaluation of Amenorrhea History
•Age, secondary sex characteristics, abnormal bleeding, use of contraceptives, time of onset of amenorrhea, etc. •Presence or absence of emotional stress, eating habit changes, weight fluctuations, presence of facial and bodily hair growth, and pattern of sexual activities.
Amenorrhea
•Assume pregnancy in woman of childbearing age with amenorrhea, unless proven otherwise. •Primary Amenorrhea:Failure of menarche by age 16 regardless of secondary sex characteristics. •Secondary Amenorrhea:Failure of menstruation over 6 months in a woman with previous periodic menses
2. Progesterone Challenge Test
•Determines estrogen effects as part of the hypothalamic-pituitary-ovarian axis evaluation. •Administer medroxyprogesterone, 10 mg per day for 5 days, then stop (withdraw progesterone) if bleeding does not happen within 7 days, 10 mg of IM progesterone should be provided. If there is still no bleeding within 7 days, then the IM dosage should be raised to 200 mg. If Amenorrhea: Absence of endometrial priming by estrogen; or presence of non-functional endometrium If Menorrhea: Anovulation despite estrogen secretion. An example of this would be polycystic ovary syndrome.
3. Sequential use of estrogen and progesterone
•For evaluation of endometrium: give 2.5 mg of estrogen for 21 days and 20 mg of medroxyprogesterone for the last 5 days (i.e. days 16-21); upon withdrawal: If Menorrhea: Then the patient has hypo-or hypergonadotropin-related amenorrhea (Only if FSH and LH are produced does the ovary produce estrogen and progesterone!). If Amenorrhea: Then there is abnormal outflow of the genital tract(e.g. Asherman's Syndrome) or a non-functional endometrium
What are treatment options for uterine leiomyoma?
•Gonadotropin-releasing hormone (GnRH) agonists (e.g. Lupron, Synarel) treat fibroids by blocking the production of estrogen and progesterone, putting the patients into a temporary postmenopausal state. •Progestin-releasing intrauterine device (e.g. levonorgestrel-releasing intrauterine device) is a progestin-releasing IUD that can relieve heavy bleeding caused by fibroids. •Uterine artery embolization utilizes small particles (embolic agents) that are injected into the arteries supplying the uterus, cutting off blood flow to fibroids. •Myolysis is a laparoscopic procedure whereby an electric current or laser destroys the fibroids and shrinks the blood vessels that feed them. Cryomyolysis, a similar procedure, freezes the fibroids. •Laparoscopic myomectomy is performed if the fibroids are small and few in number. •Hysterectomy is performed if the fibroids are contained inside the uterus (submucosal).
Must-know facts about Actinomyces Israeli
•Gram-positive facultative anaerobe. Micro-scopically, it appears as distinctive "sulfur"granules, usually yellowish and less than 1 mm in diameter, or as tangled masses of branched or unbranched filaments. •Causes chronic localized or hematogenous anaerobic infections that typically involve the neck and face, lungs, or abdominal and pelvic organs. •Key Issue: Actinomycosis does not occur in isolation from other bacteria. This infection depends on other bacteria to aid in invasion of tissue.
Evaluation in Women with Positive Menstrual History 1. measure hCG
•If hCG is high, suspect pregnancy. •The level of hCG increases after implantation of the fertilized egg to the uterus or any other structures. The level continues to increase through the first trimester and peaks at about 2 to 2.5 months. •Note: hCG converts corpus luteum into the corpus luteum of pregnancy and its titer would be high even in ectopic pregnancies
Laparoscopy
•In patients with a history of endometriosis, this is the last resort test to evaluate and remove adhesions or endometriosis tissues
LEIOMYOMAS (FIBROIDS)
•Leiomyoma (a.k.a. Uterine fibroid, uterine leiomyoma, myoma, fibromyoma, fibroleiomyoma) is the most common benign tumor of the female genital tract. •Multiple macroscopic rubbery pale white lesions, 1 to 20 cm in diameter. •Histopathology shows smooth muscles and collagen
More on Endometriosis
•Pathogenesis may involve "retrograde menstruation" or metastatic spread •Ectopic endometrium (glands and tissues) responds to cyclical hormonal stimulation Increased estrogen leads to proliferation Decreased estrogen leads to breakdown and bleeding followed by fibrous adhesions and accumulation of hemosiderin in macrophages. Lesions appear dark brown. This in turn leads to an ectopic endometrium in the fallopian tubes, ovaries (causing cysts leading to infertility and dysmenorrhea), and peritoneal cavity (leading to pelvic pain)
Most patients with PID are managed as outpatients. However, certain patients must be hospitalized. What groups of patients are often treated as inpatients?
•Patients with an uncertain diagnosis •Patients with pelvic abscesses on ultrasonography •Pregnant patients •Patients who are unable to tolerate oral antibiotic regimens •Patients with severe illnesses •Immuno-deficient patients, patients with HIV infection and a low CD4 count, and patients who are using immunosuppressive medications •Patients who fail to improve clinically after 72 hours of outpatient therapy
ADENOMYOSIS
•The endometrium burrows into the myometrium. •Islands of endometrium are surrounded by hypertrophic myometrial muscle (they are continuous with surface endometrium). •It causes uterine enlargement and dysmenorrhea
PCOS: STEIN-LEVENTHAL SYNDROME MORPHOLOGIC ABNORMALITIES
•Thickening of the capsule •Multiple follicular cysts (explains low to normal levels of circulating estrogen) •Stromal hyperplasia (explains high levels of circulating androgens and ketosteroids)
"Abnormal uterine bleeding"is any bleeding which is abnormal in its degree and timing. "Dysfunctional uterine bleeding" is abnormal bleeding that has no obvious pathology. Many conditions may cause abnormal bleeding. What are the important causes of vaginal bleeding?
•Thrombocytopenia, von Willebrand's disease, and myeloproliferative disorders •Liver disease and endocrine disorders such as hypo/hyperthyroidism, Cushing's disease, and diabetes •Pregnancy and pregnancy-related conditions •Trauma to the cervix, vulva, or vagina •Carcinomas of the vagina, cervix, and uterus •Endometrial cancer •Functional ovarian cysts, cervicitis, endometritis, salpingitis, leiomyomas, and adenomyosis •Polycystic ovary disease results in excess estrogen production and commonly presents as abnormal uterine bleeding
Normal Semen 1. Ejaculation volume 2. Sperm concentration 3. Morphology (normal shape) 4. pH 5. Forward motility 6. Vitality
1. More than 1.5 mL 2. Over 20 million/mL 3. Minimum of 60% 4. 7.2 - 8 5. 50% with forward progression 6. More than 75% alive
Clinical Manifestations of leiomyomas
1.Dysmenorrhea 2.Infertility 3.Compression of urinary bladder 4.Spontaneous abortion 5.Premature labor
DUB is for the most part described as a physiologic condition. What is by far the most common cause of non-physiologic DUB?
PCOS
What is the most common cause of infertility in women under the age of 30 with a normal history of menstruation?
PID
ENDOMETRIOSIS AND ADENOMYSOSIS SIMILARITIES
•Both conditions present with dysmenorrhea, dyspareunia, dyschezia, and uterine bleeding •Symptoms of both conditions are augmented during the menstrual period •Both conditions are alleviated by oral contraceptives
A 28-year-old woman hasvaginalitching and a white, lumpy discharge that looks like cottage cheese. What bug causes this?
Candida albicans. Vaginal candidiasis or yeast infection is most often due to Candida albicans
What is the most common site for ectopic endometrial tissues and glands
Ovaries
Strawberry cervix?
Trichomonas Vaginalis Vaginal discharges are pale yellow-green, frothy, and malodorous. The cervix is red in color("strawberry cervix") due to erythematous macular lesions on the surface of the cervix. Treatment:Metronidazole
Pathophysiologic abnormalities
•High levels of LH and androgens •Low to normal levels of FSH •Normal prolactin •Patients seem to be "stuck" in an anovulatory state with infertility and amenorrhea or oligomenorrhea
What is the suggested treatment for chocolate cysts that become too large?
Cystectomy or oophorectomy
What is the preferred treatment for uncomplicated chlamydial infection in pregnancy?
Erythromycin
What does "functional cyst" mean?
A functional cyst is a cyst that responds to the monthly rises and falls in female hormone levels (e.g. estrogen)
A 27-year-old woman who uses an intrauterine devise (IUD) for contraception presents with pelvic inflammatory disease. What is the most likely cause of her PID?
Actinomyces Israeli
What is the common physical exam finding for ovarian endometriosis?
Adnexal tenderness
What are the treatment options for adenomyosis?
Anti-inflammatory medications (ibuprofen), oral contraceptives, progesterone-releasing intra-uterine devices, danazol, or a gonadotropin-releasing hormone agonist. These medications simulate menopause, a period in which adenomyosis often resolves naturally
A 25-year-old woman is seen for the complaint of dysuria, postcoital bleeding, and unusual vaginal discharges. On examination she has painful cervix and discharges that are mucoid and slightly yellow. Based on the culture of the discharges, the patient is treated with azithromycin. What was the presumptive diagnosis?
Chlamydia trachomatis. The most common manifestation of chlamydia in women is cervicitis. Discharges are mucoid and yellow. Proper diagnosis is made by NAAT, culture, and C. trachomatis IgG antibody testing. Treatment:Doxycycline or azithromycin
What does it mean that "DUB is a diagnosis of exclusion"?
DUB is abnormal bleeding with no obvious pathology. It is diagnosed after ruling out signs and symptoms of other causes of anovulatory bleeding
Carcinoma of the cervix in middle-aged premenopausal women, and endometrial carcinoma in postmenopausal women, are two important differentials to rule out before a diagnosis of DUB. What procedure is commonly ordered to rule out these two malignancies?
Dilation and Curettage
What is the term that best describes ascending sexually transmitted diseases that cause any or all of the following conditions: Endometritis, salpingitis, oophoritis and peritonitis
PID
What is the most common cause of DUB?
Failure of ovulation
True/False: Women with endometriosis often present with fever.
False
True/False: Fibroids have a high predisposition for becoming malignant.
False. The chances of malignant transformation are less than 1%. Malignant leiomyomas are known as leiomyosarcoma
What is the last resort management for a 45-year-old woman with DUB who has not responded to medical therapy?
Hysterectomy without cervical preservation. This is the preferred approach for woman who no longer bear children or for whom childbearing is complete. DUB in years immediately prior to menopause is due to loss of fine-tuning of the hypothalamic-pituitary-ovarian-endometrial axis
Your patient is a 28-year old woman who was seen in your office for the complaint of recurring pelvic pain that intensifies at the time of her menstrual period. She also complains of dyspareunia, dysuria, and dyschezia. Pelvic exam is significant for slight adnexal tenderness. Culture and gram-stain are negative for chlamydia and gonococcus. Serum beta-hCG is within normal range. How would you confirm your clinical suspicion?
Laparoscopy. This patient has endometriosis. The best diagnostic measure is laparoscopy and visualization of the ectopic endometrial tissues. It also aids with the removal of mild to moderate endometriosis
What is the key physical and ultrasound finding in adenomyosis?
Large uterus (boggy on physical exam
What is by far the most common indication for hysterectomy in women?
Leiomyoma
Which of the following gynecological conditions is worsened with the use of oral contraceptives?
Leiomyoma. Uterine leiomyomas are estrogen-dependent and grow steadily during pregnancy as estrogen levels rise. Although controversial, some epidemiological studies suggest that oral contraceptives (with estrogen) stimulate the growth of leiomyomas. This is more likely due to induction of genes that cause growth of leiomyomas. Note:In contrast, menopause (and a drop in estrogen levels) causes regression of leiomyomas
What past finding is often a clue to vaginal candidiasis?
Long-term abx therapy
Why does menorrhea after progesterone challenge indicate anovulation in amenorrheic women?
Menorrhea after progesterone challenge (i.e. administration and then withdrawal) indicates priming of the endometrium by estrogen. Only a small dose of progesterone is needed to cause menses in a primed endometrium. Note:Endogenous progesterone is only made by the corpus luteum, which is absent in anovulatory situations
What other medications are used to manage endometriosis?
NSAIDs (ibuprofen) are used for pain, and terbutaline (beta 2 agonist) is used for uterine muscle relaxation
Given the pathophysiology of anovulatory conditions as the most common cause of DUB, what is the best management for a patient with DUB?
The best management for a patient with DUB is administration of progestogen. It stops bleeding temporarily, and allows for normal periods. Note:NSAIDs and oral contraceptives are the other two classes of medications that are used for the management of DUB
A vaginal wet mount of the discharges is significant for epithelial cells that are studded with many particles "B" (compare with normal epithelial cells "A"). What is the term that best describes this finding and what is the most common cause of it?
The cells are "clue cells" and the patient has bacterial vaginosis, which is due to overgrowth of normal vaginal flora. Gardnerella vaginalis is the most common cause. Note: Clue cells are vaginal epithelial cells that are "studded" with bacteria that adhere to them.
What are the top three dreaded complications of PID?
Top three dreaded complications of PID: 1) Tubal strictures lead to infertility or ectopic pregnancy 2) Adhesions between small bowel and pelvic structures can lead to small bowel obstruction 3) Abscesses around tubes and ovaries can cause tubo-ovarian abscesses that may rupture (a medical emergency) Note: Treatment of PID cannot eliminate these complications, but it can potentially reduce their frequency
What is the most common age for the diagnosis of DUB?
The most common age for diagnosis of DUB is at the extremes of reproductive life: In young girls during their first few cycles and before acquisition of a normal menstrual pattern, and in older women as they approach menopause but before they enter into the complete amenorrheic state
You are examining a 22-year-old woman for the complaint of infertility. She has normal height and weight, claims that she has normal menstrual cycles, and denies that she has ever had pelvic inflammatory disease. What is your immediate clinical suspicion
The most common cause of the stated findings is endometriosis. Note: Patients with PCOS are often obese and may have diabetes. They also do not present with menstruation
A 23-year-old woman presents with increased vaginal discharge. Whiff test performed on samples of secretions produces a malodorous fishy smell. What is the most likely cause of this finding?
The patient has vaginosis. Whiff test involves addition of KOH to the samples of discharges. Production of a malodorous fishy smell is indicative of vaginosis. Vaginosis is due to a change in the balance of bacteria that are normally present in the vagina and women are for the most part asymptomatic
Endometriosis is painful. Would this pelvic pain be constant or cyclical?
The pelvic pain would be cyclical, since the endometrium responds to increased estrogen
A 42-year-old woman presents with dysmenorrhea and menorrhagia. She has three children and her last two children were delivered via cesarean section. On physical examination she has an enlarged boggy uterus. Which of the following options is your first-line diagnostic procedure for this patient?
Transvaginal ultrasound. The patient most likely has adenomyosis, which affects older women and quite often happens in women who have already been pregnant. To diagnose or rule out endometriosis, ultrasound is the first diagnostic step. Note:It is important for medical students to compare and contrast endometriosis and adenomyosis, due to their similarities.
How is vaginal candidiasis treated?
Vaginal candidiasis is treated via clotrimazole, miconazole, or terconazole ointments, creams, or suppositories. It is also treated with oral fluconazole
Common findings with actinomyces
•Local abscesses with multiple draining sinuses •TB-like pneumonitis •Low-grade septicemia
Physical exam
•Look for palpable masses and identify the presence of a functional vagina. •Look for evidence of defeminization, masculinization, and thyroid or adrenal dysfunction.
Common Clinical Scenarios
•Lumpy jaw: Often related to extension of decayed teeth •Thoracic (Pulmonary): Results from aspiration of oral secretions •Abdominal: Due to a break in the mucosa of a diverticulum or the appendix, or from trauma •Uterine: Complication of intrauterine devices
Hysterosalpingogram
•Evaluates fallopian tubes and uterus based on a history of tubal issues (PID and ectopic pregnancy), or uterine issues (dilation and curettage, fibroids, endometriosis, etc.).
What percent of women may have fibroids by age 40?
40% of women may have fibroids by age 40. Black women have a much higher risk of developing fibroids.
Which of the following tests should be performed on all women with DUB?
A complete blood cell count. Bleeding is by far one of the most common manifestations of DUB. CBC testing will help to evaluate presence, lack of presence, or extent of anemia. Note:HCG testing is only indicated for younger women
Maintenance of the size of leiomyomas is dependent on adequate supply of estrogen. What drug will induce hypoestrogenism and be helpful in this situation?
A constant administration of GnRh agonists will be helpful in this situation
Your patient is a 28-year old woman who was seen in your office for the complaint of recurring pelvic pain that intensifies at the time of her menstrual period. She also complains of dyspareunia, dysuria, and dyschezia. Pelvic exam is significant for slight adnexal tenderness. Culture and gram-stain are negative for chlamydia and gonococcus. Serum beta-hCG is within normal range. Which of the following options is your preferred first-line treatment for this patient
For endometriosis the first-line treatment is birth control pills, as they contain progesterone. Progestins are commonly used to treat women with endometriosis. Second-Line Medications: Danazol and gonadotropin-releasing hormone agonists Last Resort:Surgery and cautery in younger women to preserve potential for pregnancy, and bilateral salpingo-oophorectomy for older women with serious symptoms.
A 25-year-old woman presents with malodorous white vaginal discharges. Potassium hydroxide test produces a fishy odor. Wet mount of the secretions shows squamous cells with stipples and granules on them. The patient is treated with metronidazole
Gardnerella vaginalis. Gardnerella is a gram-variable facultative anaerobe, and is a major cause of vaginosis. Wet mount shows coccobacillary bacteria adhering to the squamous epithelial cells (Clue cells). Discharges are thin, white, and at times yellow in color.
What medications are helpful in managing cysts of the endometrium
GnRh analogues (constant), oral contraceptives, and high-dose progesterone are all helpful in managing cysts of the endometrium
Your patient is a 28-year-old woman who is admitted with the complaint of fever and abdominal pain. On examination she has cervical motion tenderness (positive chandelier sign). Serology is positive for leukocytosis and elevated erythrocytic sedimentation rate. Which of the following options would you employ to manage the patient?
Ceftriaxone and doxycycline treat both gonorrhea and chlamydia. Doxycycline treats chlamydia and cephalosporin treats Neisseria
What is the medical term used to describe the cysts of ectopic endometrium on the ovary or fallopian tube?
Chocolate Cysts (endometriotic cysts)
Exclusion of organic disease to arrive at the diagnosis of DUB requires thorough examination of the abdomen and the pelvis, hysteroscopy, endometrial biopsy, and uterine curettage. Why is curettage not performed on teenage girls?
Curettage is not performed on teenage girls because organic disease is rare in teenagers. Their DUB is due to immaturity of the hypothalamus, pituitary, ovarian, and endometrial axis, and as a result their menstrual cycles may be anovulatory. Their DUB usually resolves spontaneously. In contrast, benign organic disease is common in women between 20 and 40, and curettage is often performed to exclude other diseases
What is the common pathophysiological consequence of lack of ovulation in DUB?
Due to lack of ovulation the corpus luteum does not develop. Hence, progesterone is not produced. This causes abnormal growth and thickness of endometrium due to unopposed estrogen production, and leads to uneven shedding of the endometrium.
Why does treatment for Actinomyces israeli require extended months of antibiotic therapy?
Extended months of antibiotic therapy is required because there is extensive tissue induration, and because of the relatively avascular nature of the lesions
What is the best next step for management of ruptured tubo-ovarian abscesses?
Emergent laparotomy and excision of the affected tube Note: bilateral cases are managed by total abd hysterectomy or bilateral salpingo-oophorectomy
What is the most dreaded consequence of improperly managed anovulatory bleeding?
Endometrial cancer is the most dreaded consequence. 1 to 2% of women with improperly managed anovulatory bleeding may eventually present with endometrial cancer
What are the top considerations (differentials) in women with heavy uterine bleeding?
Endometrial polyps and fibroids, and endometrial carcinoma
Your patient is a 28-year-old Caucasian woman who is seen for the complaint of infertility and a history of lack of menstruation for 4 months. On examination she has symptoms that resemble Cushing's syndrome. She is overweight with abdominal obesity and blood pressure of 130/90. She has dark hair growing on her upper lip. Urinalysis of the patient shows high titer of ketosteroids and 17-hydroxycorticosteroids. Her fasting blood glucose level is 135 mg/dL.Which of the following transvaginal ultrasound findings would you expect in this patient?
Enlarged ovaries with peripherally-located enlarged follicular cysts. The patient has PCOS. Enlarged ovaries with peripherally-located enlarged follicular cysts are characteristic findings in this condition Androgens are metabolized to ketoacids.
