CH5: Gynecologic, Reproductive, and Sexual Disorders Flashcards
What is Premenstrual Syndrome (PMS) & its symptoms
The cyclic occurrence, in the luteal phase, of a group of distressing physical and psychological symptoms that begin about 5-7 days before the menstrual period and resolve within about 4 days after onset of menses. Symptoms disrupt normal activities and interpersonal relationships
Symptoms:
- headache
- breast changes
- fluid retention, swelling, bloating
- nausea, vomiting
- changes in appetite, food cravings
- lethargy, fatigue
- exacerbations of chronic conditions, such as asthma
- irritability, depression, anxiety, anger, crying, violent behavior, confusion
- sleep alterations
- difficulty concentrating
- changes in libido
% of folks who experience PMS
50%+, most folks do not require treatment, severe symptoms occur in 3-10%
PMS symptoms recur cyclically in the ______ phase
luteal
Non-pharm therapy options for the treatment of PMS (including herbal/natural supplements)
- reassurance, avoid known physical and emotional triggers, self-management
- 20-30 minutes of aerobic exercise 4 or more times per week
- CBT, relaxation therapies, mindfulness
- biofeedback, acupuncture, massage, light therapy
- supplements, including: vitamin B6 50-150mg/day; calcium carbonate 1200-1600 mg/day; chaste tree berry extract
What medication may be helpful for the treatment of PMS swelling and bloating
spironolactone during the luteal phase
What medication may be helpful for the treatment of PMS fluid retention, breast pain, lower back pain, abdominal and pelvic pain
NSAIDs before and during menstruation
What medication may be helpful in decreasing all of the physical symptoms of PMS
birth control (combined oral contraceptives, progestin-only contraceptives). May be helpful in reducing physical symptoms by suppressing ovulation and/or reducing menstrual bleeding and pain
Medication options for the management of PMS
- birth control
- spironolactone (bloating)
- NSAIDs (pain, bleeding)
- SSRIs
- danazol (androgen receptor agonist, used to suppress ovulation)
- GnRH agonists (inhibits cyclic gonadotropin release, used to suppress ovulation, limit use to 4-6 months unless in combination with hormonal therapy as causes menopause-like side effects)
What is the definition of premenstrual dysphoric disorder (PMDD)
At least 5 PMS-type symptoms severe enough to disrupt normal functioning markedly in most, if not all, menstrual cycles. Occurs in the luteal phase and results within 1 week after menses. Must include at least ONE of these symptoms, specifically: markedly depressed mood, marked anxiety, marked affective lability, persistent and marked anger
Prevalence of PMDD
3-10% reproductive-age females
Medication options for PMDD
- generally, same as for PMS
FDA-APPROVED:
- combination hormonal contraceptives that contain the progestin drospirenone
- fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) [all SSRIs]
OTHER:
- anxiolytic drugs such as alprazolam (Xanax; benzo) or buspirone (Buspar) have mixed results with risk for dependence - use only for short-term
(3) SSRIs FDA-approved for PMDD
fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft)
Define primary dysmenorrhea (age of onset, etiology, characteristic patterns)
Dysmenorrhea is painful menstruation, commonly a sensation of cramping in the lower abdomen during or just before menses, may radiate to the back and thighs. Pain is described as colicky, crampy, or spasmodic.
Primary dysmenorrhea occurs unassociated with an underlying pelvic pathology. It rarely begins after 20yo. It is associated with ovulatory cycles and is stimulated by prostaglandin release
Typically, the pain begins shortly after the onset of menses and usually lasts no longer than 2 days
What is thought to cause primary dysmenorrhea
prostaglandins
Define secondary dysmenorrhea (characteristic onset, pattern, relieving measures, etc.)
Dysmenorrhea is painful menstruation, commonly a sensation of cramping in the lower abdomen during or just before menses, may radiate to the back and thighs.
Secondary dysmenorrhea may onset many years after menarche, most often in folks >20yo, and is related to an organic disease/pelvic pathology
This pain may begin at any time in the cycle, and folks may notice a change in the duration and amount of their menstrual flow. Pain is unlikely to be relieved by OTC measures and symptoms often persist for longer than those with primary dysmenorrhea (>2 days)
General work-up for diagnosis of secondary dysmenorrhea
- vaginal US and hysterosalpingogram to evaluate pelvic structures
- cultures, smears to evaluate for infections
- laparoscopy to evaluate endometrial cavity
- lower GI evaluation
(3) pharm therapies for primary dysmenorrhea, classes
- NSAIDs/prostaglandin synthetase inhibitors (treatment of choice)
- combined hormonal contraceptives
- progestin-only contraceptives (specifically, the arm implant, LNG-IUD, and DMPA)
Describe the use of NSAIDs/prostaglandin synthetase inhibitors for the treatment of primary dysmenorrhea
First line treatment of choice. Best to start 2 days before expected menses and continue for 48-72 hours.
Specific medications shown to be effective include naproxen sodium, ibuprofen, indomethacin, mefenamic acid
Self-help measures for primary dysmenorrhea (non-pharm)
regular exercise, warm heat, relaxation exercises, stress reduction, massage therapy
Define primary amenorrhea
No menstruation by age 14yo (if no secondary sex characteristics have developed) or by 16yo (regardless of the development of secondary sex characteristics)
Define secondary amenorrhea
Absence of menses in a previously menstruating person - no menses for 3-6 months for those with previously regular cycles, or in 3 cycles for those with irregular cycles
Differential diagnosis for/causes of amenorrhea
- disorder of genital outflow tract (vaginal agenesis, imperforate hymen, cervical stenosis)
- endocrine disorders (hyperthyroid, hypothyroid, hyperprolactinemia, hyperandrogenism, ovarian failure, PCOS)
- congenital or chromosomal abnormality (Turner’s syndrome, androgen resistance syndrome, congenital adrenal hyperplasia)
- anorexia nervosa
- excessive exercise or competitive sports
- obesity
- malnutrition
- medications (hormones, contraception, antipsychotics, cancer treatments)
- chronic illnesses (TB, alcohol abuse, T1DM, adrenal gland disorders)
- Asherman’s syndrome (irradiation or surgery resulting in destruction of the endometrium)
- Sheehan syndrome (postpartum hypopituitarism, may occur after massive blood loss)
- excessive or chronic stress
- pregnancy
- menopause
Diagnostic work-up for amenorrhea, initial (3)
- pregnancy test
- serum prolactin
- serum TSH
21yo G0P0 with amenorrhea x7 months with previously regular cycles. Pregnancy test was negative, serum prolactin and TSH WNL. What is the next step in your work-up?
progesterone challenge test to evaluate the availability of estrogen
How do you conduct progesterone challenge test
medroxyprogesterone acetate (Provera) 10 mg PO QD x 10 days.
Bleeding should occur within 7-14 days, which indicates adequate estrogen production and stimulation, as well as no problem with the outflow tract. If no bleeding occurs in 2 weeks, will need further evaluation with FSH/LH tests.
21yo G0P0 with amenorrhea x7 months with previously regular cycles. Pregnancy test was negative, serum prolactin and TSH WNL. You do a 10-day progesterone challenge test and she does not have a withdrawal bleed within 2 weeks. What is your next step in work-up?
FSH and LH
If FSH/LH low … likely hypothalmic or pituitary cause
If FSH/LH high… likely ovarian failure/menopause
21yo G0P0 with amenorrhea x7 months with previously regular cycles. Pregnancy test was negative, serum prolactin and TSH WNL. You do a 10-day progesterone challenge test and she does not have a withdrawal bleed within 2 weeks. You next order serum FSH and LH, which both return abnormally low. You suspect….
hypothalmic or pituitary cause
21yo G0P0 with amenorrhea x7 months with previously regular cycles. Pregnancy test was negative, serum prolactin and TSH WNL. You do a 10-day progesterone challenge test and she does not have a withdrawal bleed within 2 weeks. You next order serum FSH and LH, which both return abnormally high. You suspect….
premature ovarian failure/menopause
21yo G0P0 with amenorrhea x7 months with previously regular cycles. Pregnancy test was negative, serum prolactin and TSH WNL. You do a 10-day progesterone challenge test and she successfully has a withdrawal bleed after 7 days. You suspect….
anovulation
DDx/etiologies of infrequent menstrual bleeding/oligomenorrhea
- perimenopause
- pregnancy
- HPO axis abnormalities
- endocrine disorders (thyroid, adrenal)
- chronic illnesses
- extreme stress or exercise, particularly those causing weight loss
- drug use
Initial laboratory work-up for infrequent menstrual bleeding/oligomenorrhea
pregnancy test, TSH, prolactin, FSH/LH
For those with infrequent menstrual bleeding (oligomenorrhea), treatment with ______ (2) can prevent complications from unopposed estrogen
- medroxyprogesterone acetate (MPA) x10 days of each month
- or combined hormonal contraceptives
Definition of menorrhagia
combination of heavy menstrual bleeding (>80mL blood loss per month) and prolonged menstrual bleeding (bleeding episodes lasting >8 days)
Gynecologic causes of heavy or prolonged menstrual bleeding (5)
leiomyoma (fibroid), adenomyosis, endometrial or endocervical polyp, endometrial hyperplasia, endometrial or cervical cancer
Common bleeding disorders causes of heavy or prolonged menstrual bleeding (5)
von Willebrand disease, ideopathic thrombocytopenia purpura, aplastic anemia, platelet dysfunction, clotting factor deficiencies
Systemic diseases that can cause heavy or prolonged menstrual bleeding (4)
liver disease, kidney failure, adrenal hyperplasia, thyroid dysfunction
Common medications that can cause heavy or prolonged menstrual bleeding (7)
anticoagulants, anticonvulsants, antipsychotics, digitalis, copper IUD, chronic NSAID or aspirin use, tamoxifen,
PALM-COEIN classifications of structural and non-structural causes of AUB
STRUCTURAL: PALM Polyps Adenomyosis Leiomyoma Malignancy/hyperplasia
NON-STRUCTURAL: COEIN
Coagulopathy
Ovulatory dysfunction (PCOS, thyroid, endocrine)
Endometrial (inflammation, infection, vasoconstriction disorder)
Iatrogenic (medications, devices)
Not yet classified (rare disorders, like arteriovenous malformations)
Initial lab tests for work-up of AUB/Heavy or Prolonged menstrual bleeding
- pregnancy test
- pap test as needed
- STI test as needed
- CBC
- TSH
ADDITIONALLY -
- FSH/LH (to evaluate estrogen stimulation, rarely indicted)
- endometrial evaluation if >40yo (biopsy, TVUS, saline infusion sonohysteroscopy)
- coagulation studies as indicated
Non-hormonal medication options for the management of heavy menstrual bleeding (2)
- NSAIDs
- tranexamic acid
Instructions for use of NSAIDs in the treatment of heavy menstrual bleeding
Start at menses onset and continue for 5 days or until cessation of menstruation. Works by increases the ratio of vasoconstrictive prostaglandins to vasodilating prostaglandins
Instructions for the use of tranexamic acid in the treatment of heavy menstrual bleeding
this is an antifibrinolytic agent that blocks the lysis of fibrin clots. Take up to the first 5 days of menses. Works to decrease blood loss in folks who have increased endometrial plasminogen activity. Side effects include nausea, leg cramps. Contraindicated in folks with h/o or at risk for thrombosis/clots
Hormonal medication options for the management of acute heavy menstrual bleeding (2)
- parenteral estrogen or high-dose oral estrogen gradually tapered, then MPA added last 10 days to initiate a withdrawal bleed (UTD: Premarin 2.5mg BID - 4x daily until bleeding is minimal [no more than 21 days] followed by MPA 10mg x 10 days to have a withdrawal bleed)
- high-dose oral progestin therapy, gradually tapered (UTD: norethindrone 5mg QD-BID or MPA 10mg -20mg QD-BID for 5-10 days)
According to UpToDate:
First-line therapy for hemodynamically stable women is high-dose oral estrogen. We give Premarin 2.5 mg four times per day until the bleeding subsides or is minimal. For women with moderate bleeding, we change the regimen to twice daily. We do not continue this regimen for more than 21 to 25 days. After the estrogen is discontinued, a progestin should be given; we use oral medroxyprogesterone acetate (10 mg/day) for 10 days.
Estrogen therapy alone is more effective than combined estrogen-progestin or progestin-alone therapy
Also okay to use the OCPs they are already taking! High doses of oral contraceptives (OCs) (eg, an OC containing 35 mcg ethinyl estradiol taken two to four times daily) will cause bleeding to subside in most women within 48 hours [2,17]. We use a cascading regimen (ie, five pills on day 1, four pills on day 2, three pills on day 3, two pills on day 4, and one pill on day 5). For women with moderate bleeding, we start with three pills daily. An antiemetic medication should be prescribed (eg, promethazine 12.5 to 25 mg per rectum, as needed).
Treatment with one pill daily of OCs should continue for at least one week after the bleeding subsides and then should be stopped for three to five days to allow for a withdrawal bleed. Standard dose OCs may then be restarted either to prevent recurrent menorrhagia or for contraception.
Hormonal medication options for the management of chronic heavy menstrual bleeding (3)
- LNG-IUD (FDA approved indication)
- combined hormonal contraceptives (cyclic, extended, or continuous regimens)
- DMPA
Surgical options for management of acute/chronic heavy menstrual bleeding (3)
- endometrial ablation
- dilation & curettage (D&C - both diagnostic and therapeutic)
- hysterectomy
General definition of PCOS
a symptom complex associated with menstrual irregularity due to oligo-ovulation or anovulation and clinical or biochemical signs of hyperanrogenism
Does multiple ovarian cysts alone on TVUS indicate PCOS?
No - approximately 25% of normal females will demonstrate ultrasonographic evidence typical of polycystic ovaries
Prevalence of PCOS
6-7% of reproductive-age females
Folks with PCOS are at increased risk for these (3) future conditions
endometrial cancer, diabetes mellitus, heart disease
Common presenting signs/symptoms of PCOS
- irregular menses (amenorrhea or infrequent bleeding) (>90%)
- gradual onset hirsutism in puberty or early 20s (50-70%)
- other signs of androgen excess (acne, deep voice, male pattern baldness - 15 to 25%)
- infertility
- abdominal obesity (50-60%)
- acanthosis nigricans, skin tags in neck area
Virilization signs of PCOS
hirsutism, increased muscle mass, frontal balding, clitoral enlargement, deepening voice, decrease in breast size
Diagnostic work-up for PCOS
- pregnancy test
- serum prolactin
- serum TSH
- biochemical hyperandrogenism (serum total testosterone and SHBG OR bioavailable and free testosterone)
- serum 17-hydroxyprogesterone (17-OHP) (PER ANNIE: THIS IS NORMAL IN PCOS, ELEVATED IN NCCAH. IN BOOK: >800 ng/dL suggests PCOS; elevated but <800 think congenital adrenal hyperplasia)
- endometrial biopsy to r/o hyperplasia
- TVUS to assess ovaries
- glucose, lipids
Rotterdam Criteria for diagnosis of PCOS
at least 2 of the 3 following must be present in an adult female:
- oligo-ovulation or anovulation
- clinical or biochemical hyperandrogenism
- polycystic ovaries
First line treatment for PCOS if pregnancy is desired
letrozole. If ineffective, refer to reproductive endocrinologist
Treatment options for PCOS if patient desires contraception
direct therapy towards preventing endometrial hyperplasia and pregnancy
- low dose combined hormonal contraceptives with low-androgenicity progestins (i.e., drospirenone) will inhibit LH secretion and LH-dependent ovarian androgen production, increase SHBG of free testosterone, regulate menstrual cycles, and protect against endometrial cancer
- progestin-only contraceptives will provide contraception and prevent against endometrial cancer
Management of PCOS if not desiring pregnancy and not desiring contraception (i.e., not at risk for pregnancy)
focus on preventing endometrial hyperplasia
- endometrial biopsies as needed
- MPA for 10 days of month to induce a withdrawal bleed, can be used every month or Q2-3 months
- may consider metformin use as insulin-sensitizing agent
- monitor for development of diabetes, hyperlipidemia, obesity
Treatment option for undesired facial hair in pt with PCOS
eflornithine HCl topical cream
General definition of endometriosis
the presence of endometrial stroma and glands outside of the uterus
Prevalence of endometriosis
general estimate: 7-10% of premenopausal folks
- found in 5-15% of surgeries performed on reproductive age females
- found in up to 30% of infertile females during surgery
Typical patient with endometriosis has these (3) characteristics
- 20-30 years of age
- caucasian
- nulliparous
Most common cause of chronic pelvic pain
endometriosis
Symptoms suggestive of endometriosis
MOST COMMON
- dysmenorrhea
- infertility
- premenstrual spotting
- heavy menstrual bleeding
- pelvic pain
- dyspareunia
LESS OFTEN
- low back pain
- diarrhea
- dysuria
- hematuria
- difficult or painful defecation
- rectal bleeding
- symptoms classically occur before or during menses
Physical findings suggestive of endometriosis
- fixed, retroverted uterus
- bilateral fixed, tender adnexal masses
- nodularity or tenderness of uterosacral ligaments and cul de sac
- tenderness, thickening, or nodularity of the rectal-vaginal septum
- cervical motion tenderness associated with menses
- visible lesions on laparoscopy
Role of diagnostic tests/imaging in diagnosis of endometriosis?
Direct visualization with laparoscopic procedure is the only means of confirmation. Otherwise, US cannot demonstrate a specific pattern but could possibly be used to differentiate solid vs. cystic lesions and help distinguish an endometrioma from other adnexal abnormalities. CT and MRI can provide only presumptive evidence and are not diagnostic. CA125 levels may correlate with degree of disease or response to treatment, however, they are not diagnostic because of low sensitivity and specificity
Goals of treatment of endometriosis (3)
There is no universal/sure cure. The goal is to relieve pain, restore fertility (as desired), and prevent progression
Medical management options for endometriosis
- analgesics (NSAIDs are first line)
- continuous use of combined oral contraceptive pills produces atrophy of the implants and an acyclic hormone environment
- GnRH agonists or danazol may induce regression of endometrial implants (more aggressive, menopausal symptoms likely)
- progestins like IM DMPA or SQ 104 DMPA
- laser surgery or hysterectomy with BSO
Describe adenomyosis, generally
Benign condition where ectopic endometrium is found within the myometrium, or muscle layer. This is sometimes considered a subtype of endometriosis
Prevalence of adenomyosis
estimates vary greatly, ranging from 10-90% of hysterectomies. Diagnosis is most common in parous females between 40-50yo
(2) symptoms of adenomyosis
- increasingly severe dysmenorrhea and heavy bleeding during menses
- infertility
(3) physical findings possible with adenomyosis
- boggy, tender uterus
- diffuse, globular enlargement - may be 8-10 weeks gestation size
- may see evidence of anemia
How do you diagnose adenomyosis
US and/or MRI may rule out other pathologies and an endometrial biopsy is important in cases of AUB, however, can only be definitively diagnosed upon hysterectomy
Management options for adenomyosis
Symptomatic treatment options include NSAIDs for pain, hormone suppression to alleviate symptoms, hysterectomy is curative
What is a pituitary adenoma
Benign tumor of the pituitary. Most common type of pituitary adenoma secretes prolactin (>50%)
Population/incidence of pituitary adenomas
Incidence is unknown. Most pituitary adenomas occur in folks younger than 40yo.
% of females with amenorrhea of unknown origin who will have elevated prolactin levels
33%
% of females with secondary amenorrhea who have a pituitary adenoma
33%
% of females with elevated prolactin levels on labs who will also have galactorrhea
33%
S/s of pituitary ademonas or prolactinomas
- spontaneous discharge from unilateral or bilateral nipples that is clear or milky
- irregular menses or secondary amenorrhea
- visual disturbances and/or headaches (if adenoma)
Physical exam findings for pituitary adenomas or prolactinomas
May be no remarkable findings. Possible to have milky nipple discharge or papilledema on fundoscopic exam
30yo pt presents with new onset milky nipple discharge and visual changes. Her periods have always been irregular. No remarkable findings on physical exam. What diagnostic tests will you include in the work-up of suspected pituitary adenoma and/or prolactinoma?
- pregnancy test
- TSH
- serum prolactin
- microscopy of nipple secretions
- CT or MRI brain to r/o adenoma
How to interpret prolactin lab results in work-up of suspected pituitary adenoma or prolactinoma
prolactin elevated if >20ng/mL, refer to reproductive endocrinologist. If 100-300 ng/mL, this is very suspicious for adenoma.
Management for known prolactinoma in patient with prolactin levels <20 and no amenorrhea
follow with yearly prolactin level monitoring
Management for prolactinoma or pituitary adenoma (lifestyle, medical and surgical)
Lifestyle = decrease breast stimulation
Medication = dopamine agonist BROMOCRIPTINE or CABERGOLINE, because dopamine inhibits prolactin. This provides symptomatic relief, decreases or stops galactorrhea, is the treatment of choice with highest cure rate.
Surgery = for failed medical management only, may consider transphenoid neurosurgery with recurrence rate of 10-70%, requires close follow-up
Radiation = reserved only for recurrences or refractory cases, may take several years before results seen with declining prolactin levels
What is a cervical polyp
Pendunculated growth arising from the mucosal surface of the endocervix
Prevalence of cervical polyps
4% of gyn patients; most common of the benign neoplasms of the cervix. Most commonly seen in peri-menopausal, multigravida folks between ages 30-50 years old
Are cervical polyps cancer?
Considered benign. Malignant changes are rare.
Etiology of cervical polyps
inflammation, trauma, pregnancy, abnormal local response to a hypoestrogenic state
Symptoms of cervical polyp
may be asymptomatic or may have abnormal vaginal bleeding including intermestrual and post-coital
Physical exam findings for a cervical polyp
May be single or multiple painless polypod lesions at the cervix that range in size from a few mm up to 2-3 cm. They are usually reddish-purple to cherry red in color, smooth, soft, and bleeds easily. Pelvic exam will otherwise be normal
Differential diagnosis for a cervical polyp
Cancer, prolapsed myoma (fibroid), retained products of conception
Diagnostic tests for cervical polyp
Send removed polyp for histologic evaluation to rule out cancer. A pap test can rule out premalignant cervical lesions or cancer of the cervix.
Management and anticipatory guidance for cervical polyp
May be removed which is usually curative. Do not remove during pregnancy. Cervical polyps recur frequently
What is a uterine fibroid?
Aka leiomyoma, leiomyomata, myoma
A nodular, discrete tumor varying in size rom microscopic to large, multiple nodular masses which are classified according to location: submucosal, subserosal, intraligamentous, intramural (interstitial), pedunculated. Most common benign pelvic neoplasm
What are the (5) types of uterine fibroid
- submucosal: protrude into the uterine cavity
- subserosal: bulge through the outer uterine wall
- intraligamentous: within the broad ligament
- intramural (interstitial): stays within the uterine wall as it grows, most common form
- pedunculated: on a thin pedicle or stalk attached to the uterus
What is the most common type/location of uterine fibroid
intramural (interstitial) - within the uterine wall
Why/how do uterine fibroids develop
The etiology is largely unknown. They may arise from smooth muscle cells of the myometrium.
Prevalence of uterine fibroids
20% of gyn patients in reproductive years. Although, asymptomatic fibroids may be found in as many as 40-50% of females >40yo. More common in African American than Caucasian females. There is also an increased incidence with family history
Symptoms of uterine fibroids
Usually asymptomatic. If symptoms, most commonly see heavy or prolonged menstrual bleeding, pelvic pain/pressure, dyspareunia. May cause acute pain if pedunculated/twisted/infarcted. May cause bowel and bladder problems if large and pressing on surrounding structures
Uterine fibroids usually cause what type of AUB
heavy, prolonged menstrual bleeding
Possible physical exam findings with uterine fibroids
may not be detectable. Or, may have abdominal enlargement, an enlarged irregularly shaped or displaced uterus, a pedunculated tumor may be seen protruding from the cervix. Tumors are usually painless on palpation. There is a wide variance in size from 3-4mm up to 15lbs
Possible complications of uterine fibroids (4)
spontaneous abortion, premature labor, anemia, infertility
Diagnostic evaluation of uterine fibroids, options
- pap test to exclude cervical cancer (if visible protrusion)
- pregnancy test (if AUB or enlarged uterus)
- CBC (if heavy menstrual bleeding or anemia suspected)
- fecal occult blood test (if colon or rectal symptoms present)
- endometrial biopsy or D&C (for AUB)
- US, sonohystogram, CT, or MRI to confirm the diagnosis
- hysteroscopy if need to visual inside of uterine cavity
Management plan for uterine fibroids, overview
May not require any treatment if asymptomatic. May be useful to have periodic bimanual examination to ensure no growth or abnormal changes. Medical and surgical options may be considered if symptomatic.
Medical: aimed at reducing growth and bleeding
Surgical: removal of whole or part of fibroid and/or uterus
Pharmacologic options for management of uterine fibroids
- progestin agents may decrease fibroid size and bleeding (i.e., MPA)
- combined hormonal contraceptives may help with heavy menstrual bleeding but will not decrease fibroid size
- LNG-IUDs (i.e., Mirena) may help with heavy bleeding and decrease dysmenorrhea but will not decrease fibroid size and may be contraindicated if fibroids distort the uterine cavity d/t risk for expulsion
- GnRH agonists can reduce fibroid size 40-60% however regrowth occurs 50% of the time and these medications cause significant symptoms including menopause. Best fit for short-term use to shrink fibroid size pre-operatively, before attempting pregnancy, or in folks attempting to avoid surgery
- remember to treat underlying anemia as needed
When to consider surgery with uterine fibroid diagnosis
abnormal bleeding, rapid growth, desire for definitive diagnosis of the mass if otherwise uncertain, encroachment on organs, symptoms are not well-managed on pharm therapies
Surgical options for the management of uterine fibroids (3) and their impact on fertility and recurrence rate
- myomectomy: via hysteroscopic resection, this method is fertility-preserving with a 30% recurrence rate
- uterine artery embolization: may not preserve fertility, increases risk of IUGR in future pregnancy, up to 40% recurrence rate
- hysterectomy: no fertility, no recurrence
(2) main types of ovarian cysts
functional (s/t hormonal stimulation), dermoid (benign cystic teratoma - the most common ovarian germ cell tumor)
(2) types of functional ovarian cysts
- follicular: occur in the follicular phase of the menstrual cycle when continued hormonal stimulation prevents fluid resorption
- corpus luteum: occurs in the luteal phase, when the corpus luteum fails to degenerate
What are follicular ovarian cysts and their prevalence, characteristics
A type of functional ovarian cyst occurring in the follicular phase of the menstrual cycle that persist when continued hormonal stimulation prevents fluid resorption. They are rare before menarche and after menopause. They are the most common adnexal mass in the reproductive years, accounting for 20-50% of all ovarian cysts. They usually will resolve within 2-3 menstrual cycles which may be unnoticeable or rupture may cause pain or ovarian torsion
What are corpus luteum cysts and their characteristics
A type of functional ovarian cyst occurring when the corpus luteum fails to degenerate after 14 days. May hemorrhage into the cystic cavity.
What are dermoid cysts and their characteristics
Aka benign cystic teratoma. They are one of the most common neoplasms of the ovary, occur during the reproductive years. Composed of well-differentiated tissue from all three germ layers. Usually measure 5-10cm in diameter and 10-15% are bilateral.
Symptoms of ovarian cysts
Usually asymptomatic. They may cause acute pain if twist or rupture. If large, may cause sensation of pelvic pressure or fullness. Rarely cause AUB.
Diagnostic evaluation of ovarian cysts
- pregnancy test (r/o ectopic if palpable/pain)
- TVUS (evaluates mass for cystic vs. solid, complex vs. simple, bilateral vs. unilateral, r/o ectopic pregnancy)
- CA125 may be considered in post-menopausal females though it is NOT diagnostic
- MRI may be considered if dermoid cyst is suspected
What is the role of CA125 in the setting of an ovarian cyst
It is NOT diagnostic and may be considered in post-menopausal patient with ovarian cyst. It is a tumor-associated antigen most commonly used to monitor the clinical status of pts with ovarian cancers. It is not routinely used for evaluation of adnexal masses in PRE menopausal folks because of its low specificity for ovarian cancer, as several other conditions may cause elevated levels. Its specificity and predictive value are consistently higher in postmenopausal folks
Management options for functional ovarian cysts, PRE MENOPAUSAL
If <10cm in diameter and simple features on US, may repeat examination after next menses and/or serial US q4-12 weeks to monitor for resolution. If persists >12 weeks and/or is >10cm or solid/complex features, refer to physician
Management options for functional ovarian cysts, POST-MENOPAUSAL
if <10cm and simple features on US with no concerning symptoms or risk factors for ovarian cancer, and if CA125 <35 U/mL, can perform serial US q4-12 weeks. If persists >12 weeks or if CA125 >35, concerning symptoms or risk factors, or complex/solid features, refer to physician
Management options for dermoid ovarian cysts
if it does not resolve on its own, recommend laparoscopic removal
Peak ages of incidence for cervical cancer
45-55yo
Primary agent in the development of cervical cancer
human papillomavirus (HPV)
Risk factors for OVARIAN cancer
- tobacco smoking
- HPV (most commonly malignant = 16, 18, 31)
- early coitus (<18yo)
- multiple sex partners
- no barrier methods
- immunosuppression
- long-term oral contraceptive use
- infrequent/no pap tests
Symptoms of cervical cancer
May be asymptomatic. If symptoms, may have postcoital or irregular painless bleeding, odorous bloody or purulent discharge. Late symptoms could include pelvic or epigastric pain, urinary or rectal symptoms.
Physical exam findings of cervical cancer
The cervix may range from normal to having ulcerated, necrotic, or large bulky lesion filling the vagina. The cervix may be firm or rocklike to soft and spongy. There may be bloody, purulent, or odorous vaginal discharge. Anemia may be present if bleeding heavily.
Diagnostic evaluation of cervical cancer
- pap test is the gold standard for screening
- biopsy any gross cervical lesions
- If malignancy is suspected but there is no gross lesion visible, suggest colposcopy with biopsy
- colposcopic evaluation of the vulva and vagina to rule out other lesions
- CT, MRI, cystoscopy, sigmoidoscopy, and barium enema may be used as indicated
Management of cervical cancer for WHNP
anticipatory guidance regarding surgery, radiation, chemotherapy, or combination treatments. Refer to gynecologic oncologist
Most common gynecologic cancer
endometrial cancer – 90-95% of malignancies of the uterine corpus are endometrial cancer
Median age of onset for endometrial cancer
63yo, only 5% of cases occur <40yo
Many of the risk factors for endometrial cancer are directly related to length of time exposed to ___________
estrogen, particularly unopposed estrogen (either endogenous or exogenous)
Risk factors for endometrial cancer
- early menarche or late menopause
- unopposed estrogen therapy
- oligo-ovulation or anovulation
- obesity
- estrogen-secreting tumors (granulosa cell tumor)
- family history of endometrial or CRC cancer
- personal history of CRC cancer, diabetes, or HTN
Protective factors against endometrial cancer (3)
depo provera, OCPs, multiparity
Symptoms of endometrial cancer
painless vaginal bleeding is typically the first symptom. May start with serous (watery) odorous discharge, soon replaced by bloody discharge with intermittent spotting to steady, painless bleeding followed by hemorrhage. Lower abdominal pain present in 10% of cases
Physical exam findings of endometrial cancer
May be none in early stage. May see blood present in the vaginal vault. Advanced disease may present with a pelvic mass or ascites. Uterus may be enlarged and soft. Anemia may be present with heavy blood loss
Diagnostic evaluation of concern for endometrial cancer
- pap test may demonstrate glandular abnormalities
- endometrial aspiration biopsy
- TVUS to measure endometrial stripe with risk for endometrial cancer rare if <5mm
- if work-up is non-conclusive and symptoms persist, fractional D&C is the gold standard for diagnosis
- hysteroscopy may be considered for identifying lesions or polyps not otherwise found on biopsy
Management of endometrial cancer for WHNP
Anticipatory guidance for likely surgical treatment, usually hysterectomy recommended. Surgical staging will determine adjuvant treatment which may include radiation, chemotherapy, progesterone/steroids, or combination. Refer to gynecologic oncologist
Most common type of ovarian cancer
epithelial ovarian carcinoma accounts for 80-85% of cases
Which has the highest mortality rate of all the gynecologic cancers
ovarian cancer
Ovarian cancer rates are the highest between these ages
55-64yo
Lifetime risk of ovarian cancer in the general population
1-2%
Lifetime risk of ovarian cancer with one first-degree relative affected
5%, and increases with the number of first or second-degree relatives
% of ovarian cancers believed to be caused by genetic inheritance (BRCA, Lynch, etc.)
20-25%
BRCA 1 and 2 mutation risks for ovarian cancer
BRCA 1: 39-4% lifetime risk
BRCA 2: 12-20% lifetime risk
Risk factors for ovarian cancer
- family history
- gene mutations (BRCA, Lynch, Peutz-Jeghers)
- h/o breast, colon, or endometrial cancer
- early menarche or late menopause (increased estrogen exposure)
- nulliparity or birth of first child >30yo
- inferility
- endometriosis
- obesity
- postmenopausal HRT
Protective factors from ovarian cancer
oral contraceptives, with protection lasting up to 2 decades after use. breast feeding
Symptoms of ovarian cancer
Often asymptomatic or with symptoms that are mild, vague, or inconsistent. May include abdominal discomfort, pressure sensation to bladder or rectum, pelvic fullness or bloating, vague GI symptoms. Late signs include increasing abdominal girth, abdominal pain, abnormal vaginal bleeding, nausea, anorexia, and dyspepsia
Physical findings of ovarian cancer
Fixed, irregular, non-tender adnexal mass, possibly bilateral. Ascites. Pleural effusion and subclavicular lymphadenopathy are late signs
Diagnostic evaluation for suspected ovarian cancer
- pelvic US with CT or MRI as needed
- CA215 levels at baseline are not diagnostic but helpful for following response to treatment
- definitive diagnosis is made with laparotomy (surgery)
Conditions that can cause elevated CA125
ovarian cancer, endometriosis, fibroids, pelvic inflammatory infection, hepatitis, other malignancies
Management of ovarian cancer for the WHNP
Anticipatory guidance regarding surgery typically total hysterectomy with bilateral salpingoophorectomy and omentectomy which establishes histologic staging and grading of the tumor. Will consider chemotherapy and/or radiation with gyn onc. Consider genetic counseling to determine if family members at increased risk and if pt themselves is at increased risk for breast cancer. Refer to gyn onc and high risk genetics.
What is the most rare gynecologic cancer
vaginal carcinoma - 2% of gyn malignancies
Mean age of diagnosis for vaginal carcinoma
mean = 65yo. Range = 30-90yo
Risk factors for vaginal cancer
persistent HPV with high-risk subtypes, other genital cancers, DES exposure, prior radiation to the area
Pre-cursor to vaginal carcinoma
vaginal intraepithelial neoplasm (VIN)
5 year survival rates for vaginal cancer
Stage 1 = 80%
Stage 4 = 17%
Symptoms of vaginal cancer
vaginal bleeding, odorous or blood tinged discharge, pruritis, palpable or visible mass or lesion, urinary problems if bladder involvement
Physical exam findings concerning for vaginal cancer
early lesions appear raised, granular, may be white. Late lesions are friable, granular, and cauliflower-life, may be palpable, may have superficial or deep ulceration. If the lesion is darkly pigmented, suspect melanoma. The most common site of occurrence is the upper 1/3 of the vagina
Diagnostic eval of suspected vaginal cancer
- pap test to evaluate for cervical cancer
- colposcopy and biopsy of the lesion
- staging will involve cystoscopy, proctosigmoidoscopy, IV urography, chest radiography, barium enema with CT/MRI to evaluate for metastases
Management of vaginal cancer for the WHNP
Anticipatory guidance regarding treatment includes laser therapy for pre-cancerous lesions (VAIN I, II, and III). Local excision may be an option for early lesions (partial vaginectomy). Radiation is otherwise the mainstay of treatment. Refer to gynecologic oncologist
Risk factors for vulvar cancer
High risk HPV infection (30-50% of cases), multiple sexual partners, cigarette smoking, chronic irritation, vulvar dermatoses
Types of vulvar cancers
squamous cell carcinoma, melanoma, adenocarcinoma, basal cell carcinoma, sarcoma
Mean age of diagnosis for vulvar cancer
mean age = 65yo. Range 30-90 yos.
Symptoms of vulvar cancer
May be asymptomatic. If symptoms, may notice lesion on the vulvar, pruritis, pain, burning, bleeding, odorous discharge that may be blood-tinged
Physical exam findings concerning for vulvar cancer
White, red, or irregularly pigmented vulvar lesions that is ulcerated, flat, or wart-like, may be single or multiple. Hyperkeratotic patches (leukoplakia). Excoriation or erythema. Most common sites of involvement are the labia majora and minora. May also see bartholin gland enlargement or inguinal lymphadenopathy
Diagnostic evaluation of suspected vulvar cancer
- Pap test, colposcopy can help rule out other sites of disease
- Biopsy and wide excision make the definitive diagnosis
- CT or MRI to rule out metastasis
Management of vulvar cancer for the WHNP
Anticipatory guidance regarding treatment which may include local excision, simple or radical vulvectomy, or topical treatments with immunologic agents or chemotherapy. Recurrence is common. Refer to gynecologic oncologist.
What is choriocarcinoma?
a malignant form of gestational trophoblastic disease or may be primary in the ovary. Gestational trophoblastic disease follows any gestational event (i.e., intrauterine or ectopic pregnancy, abortion, hydatiform mole), whereas nongestational choriocarcinoma is a mixed germ cell tumor of the ovary that may occur in childhood or early adolescence…. would be unusual in 20s or 30s. These cancers are disseminated by the blood to the lungs, vagina, brain, liver, kidneys, and GI tract. However, it is one of the few metastatic cancers that can be curable
Symptoms of choriocarcinoma
Symptoms often masquerade as other diseases as a result of metastases to other organs. Strongly suspect if follows a pregnancy event. May have irregular vaginal bleeding (anywhere from intermittent to hemorrhage, or may occur postpartum with uterine subinvolution), or may see amenorrhea (r/t gonadotropic secretion). Lung metastasis may present as hemoptysis, cough, dyspnea. CNS metastasis may present as headache, dizziness, fainting. GI metastasis may present as rectal bleeding or tarry stools, abdominal pain. GU metastasis may present as hematuria.
Physical findings of choriocarcinoma
May have abdominal mass/ascites, blood in vaginal vault, enlarged soft uterus. May see abnormalities of multiple organs if metastatic, including possible vulvar or vaginal metastatic lesion
Diagnostic evaluation of suspected choriocarcinoma
- quantitative beta HCG. Will see abnormal beta HCG regression titers following a molar pregnancy.
- CT scan of abdomen, pelvis, head. Chest radiograph
- lumbar puncture may be necessary for diagnosis
Management of choriocarcinoma for WHNP
Anticipatory guidance that treatment typically consists of surgery and/or chemotherapy. Non-metastatic disease carries a good prognosis and metastatic disease carries a good to poor prognosis. Refer to gynecologic oncologist
What is bacterial vaginosis? (overview)
An alteration of the normal flora of the vagina (Lactobacillus species) with dominance of anaerobic bacteria. This is the most common vaginal infection in the US for females ages 15-44yo
What is the pathophysiology for bacterial vaginosis
Lactobacilli are the hydrogen-peroxide producing strains of bacterial flora natural to the vagina during reproductive years. They maintain an acidic environment. A loss in lactobacilli dominance leads to elevated pH (more basic/alkaline) and subsequent overgrowth of other strains of bacteria. Bacterial concentrations are increased 100 to 1000-fold. There is not one specific offending organism, but there are some most common anaerobic strains including Gardnerella.
Is bacterial vaginosis an STI?
The textbook says not an STI, but then later goes on to say it can be transferred between female sex partners.
It is more common in folks with new or multiple partners, and risk is increased with shared sex toys or douching. BV may also increase the risk for acquiring an STI such as HIV or HSV2
What are the most common anaerobic bacteria contributing to BV?
- gardnerella vaginalis*
- mycoplasma hominis
- bacteroides species
- haemophilus
- mobiluncus
- corynebacterium
Symptoms of BV
most often asymptomatic. Otherwise, may experience pruritis (occasionally), a grayish/yellowish/whitish malodorous discharge, a rancid or fishy-odor during menses and after sex
Physical findings suggestive of BV
- adherent, homogenous, whitish-gray vaginal discharge
- vulvar and vaginal mucosa should appear normal although discharge may coat the vaginal walls and vulva
- presence of foul odor
Diagnostic evaluation of suspected BV
- wet mount of vaginal secretions
- pH testing
Amsel Criteria is diagnostic (at least 3 out of 4 criteria is diagnostic)
+ vaginal pH >4.5
+ clue cells on saline wet mount >20% of epithelial cells (epithelial cell borders are obscured as a result of stippling with bacteria)
+ homogenous discharge that is white and coating the vaginal wall
+ positive “whiff test” demonstrating fishy amine odor to vaginal discharge before or after addition of 10% potassium hydroxide (KOH)
What is the name and components of the criteria used for clinical diagnosis of BV
Amsel Criteria
Amsel Criteria is diagnostic (at least 3 out of 4 criteria is diagnostic)
+ vaginal pH >4.5
+ clue cells on saline wet mount >20% of epithelial cells (epithelial cell borders are obscured as a result of stippling with bacteria)
+ homogenous discharge that is white and coating the vaginal wall
+ positive “whiff test” demonstrating fishy amine odor to vaginal discharge before or after addition of 10% potassium hydroxide (KOH)
Positive whiff test is suggestive of BV, but may also occur with…. (3)
blood, semen, trichomonas
BV is not an inflammatory infection, therefore you would not expect to see this on wet mount
an increase in the normal number of WBCs on wet mount
Is it necessary or useful to do a culture to diagnose strain of bacteria causing BV?
No, cultures for anaerobes are unnecessary at initial evaluation
Management of BV including patient counseling on meds, side effects, and lifestyle
Treatment is recommended for all pts with symptoms.
ORAL: metronidazole (Flagyl) 500mg PO BID x 7 days
TOPICAL: metronidazole gel (Metrogel) 0.75%, use one full applicator (5g) intravaginally at bedtime x5 days; OR clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime x7 days
For metronidazole use, counsel pt to avoid alcohol until 24 hours after completion of therapy. Side effects may include metallic taste, nausea, headache, dry mouth, dark-colored urine. Clindamycin cream is oil-based and thus may weaken latex condoms or diaphragms if these are being used for contraception.
Lifestyle - avoid douching as may increase risk for recurrence.
Oral first line treatment for BV
metronidazole (Flagyl) 500mg PO BID x7 days
Topical first line treatments for BV (2)
- metronidazole gel (Metrogel) 0.75%, use one full applicator (5g) intravaginally at bedtime x5 days
- clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime x7 days
Alternative regimen options for the treatment of BV (not first line)
- tinidazole 2g PO QD x2 days
- tinidazole 1g PO QD x5 days
- clindamycin 300mg PO BID x7 days
- clindamycin ovules 100mg intravaginally QHS x3 days
Do you need partner treatment for BV?
If female partner is symptomatic, yes. If male partner, no as will not change course of condition or prevent its recurrence
What is trichomoniasis?
A vaginal infection caused by trichomonas, an anaerobic flagellated protozoan parasite
What change to vaginal pH would you expect with BV
increased pH >4.5
What change to vaginal pH would you expect with trichomoniasis
increased pH 5.6-7.5
Risk factors for trichomoniasis
- multiple sex partners
- presence of another STI
- lack of condom use
- sex work
- injectable drug use…………..?
Risk of trichomonas in pregnancy
premature rupture of membranes, preterm labor
Risk of BV in pregnancy
intra-amniotic infection, postpartum infection, endometritis
Symptoms of trichomoniasis
Most males and females are asymptomatic. If symptoms, may describe copious, malodorous, yellow-green discharge with vulvar irritation, pruritis, occasionally dysuria/urgency/frequency. May have intermenstrual bleeding. Symptoms often occur after menses
Physical findings suggestive of trichomoniasis
- erythema, edema, excoriation of the vulva
- red speckles “strawberry spots” on the vagina and cervix (punctate lesions)
- homogenous watery yellow-green or grayish frothy discharge
- vaginal pH >5.0
- friable cervix
Strawberry cervix, think….
trichomoniasis
Diagnostic evaluation of trichomoniasis
- saline wet mount is 60-70% sensitive, demonstrates motile trichomonads and an increased number of WBCs
- rapid tests on vaginal secretions (10-45 min for results) have great >82% sensitivity and >97% specificity
- culture is the only definitive test
- urine microscopy may reveal live trichomonads too
- if detected on pap test, 40% positive predictive value
Treatment/management of trichonomoniasis
- metronidazole (Flagyl) 2g PO 1x
alternatively, tinidazole 2g PO 1x OR metronidazole (Flagyl) 500mg PO BID x7 days
Counsel to avoid alcohol until 24 hours after finish course of metronidazole. All sex partners should be treated. Offer repeat testing in 3 months for detection of reinfection. If treatment failure, use metronidazole or tinidazole 2g PO QD x7 days. Screen for other STIs as indicated.
Oral first line treatment for trich
metronidazole (Flagyl) 2g PO 1x
Can you use metronidazole to treat trich in pregnancy or lactation?
Yes, metronidazole crosses the placenta but there has been no teratogenicity or mutagenic effects found in infants. Similarly, metronidazole is secreted in breastmilk but there is no evidence of adverse effects in infants exposed to metronidazole in breastmilk. Some clinicians will defer breastfeeding for 12-24 hours after maternal treatment (2g PO 1x metronidazole).
What is vulvovaginal candidiasis
yeast infection. inflammatory vulvovaginal process caused by a yeast organism (dimorphic fungus), candida, which superficially invades the epithelial cells
How common are yeast infections
Second most common vulvovaginal infection (second to BV). 75% of females will have at least one episode in reproductive years, 45% will have a second episode, and 5% will have recurrent or intractable episodes
What are the most common species responsible for yeast infection/VVC
85-90% is Candida Albicans (C. albicans)
Remaining infections are usually C. galbrata and C. tropicalis, which are more resistant to therapy
Predisposing factors to yeast overgrowth
- pregnancy
- reproductive years
- uncontrolled diabetes
- immunosuppressive disorders
- frequent intercourse
- antibiotic use
- high dose corticosteroids
Symptoms of VVC/yeast infection
- irritation of vulva, pruritis, soreness, external dysuria
- discharge may be thick, curdy, thin/watery, or with yeast odor
- dyspareunia upon penetration
Physical findings suggestive of yeast infection
- erythema of vulva and vagina
- discharge adherent to vaginal wall
- cervix will appear normal on speculum exam
Diagnostic evaluation of yeast infection/VVC
- wet mount of vaginal secretions with 10% KOH will demonstrate mycelia, spores, and pseudohyphae
- vaginal pH is usually normal (<4.5) and amine whiff test negative
- may see increased number of WBCs on wet mount
- fungal culture is the confirmatory diagnosis - most often used in cases of frequent recurrence or intractable episodes to determine which candida is causative
When should you consider a fungal culture when pt presents with yeast infection?
Frequent recurrence (i.e., 4+ symptomatic episodes in 1 year) or intractable episodes, as may be an atypical causative species
Which is more effective for yeast infection treatment - azole antifungals or nystatin?
azole antifungals are more effective than nystatin
First line ORAL therapy for yeast infection/VVC?
fluconazole (Diflucan) 150mg PO x1
Topical OTC therapy options for the treatment of a yeast infection if pt does not prefer the oral therapy
MANY OPTIONS! All must be placed INTO the vagina (not just vulvar application) to achieve effect. Overview: primary options include clotrimazole or miconazole, 1%- 4%, 5g intravaginally x3-7 days
Creams & Ointments -
- clotrimazole 1% cream, 5g intravaginally x7-14 days
- clotrimazole 2% cream, 5g intravaginally x3 days
- miconazole 2% cream, 5g intravaginally x7 days
- miconazole 4% cream, 5g intravaginally x3 days
- tioconazole 6.5% ointment, 5g intravaginally 1x
Suppositories -
- miconazole 200mg vaginal suppository, QD x3 days
- miconazole 1200mg vaginal suppository, 1x
Treatment considerations for recurrent yeast infections/VVC
if 4 or more symptomatic episodes in 1 year with no predisposing factor, culture to identify if non-albicans candida species is present. Consider longer duration of therapy or a maintenance regimen, as well as intravaginal probiotics.
Counseling points regarding yeast infection and sex
- azole creams and suppositories are oil-based so they can weaken latex condoms or diaphragms
- partner treatment is not routinely recommended (unless male partner has balanitis)
- encourage use of cotton underwear
Treatment considerations for severe yeast infection (extensive erythema, edema, or fissure formation)
Usually requires a longer (7-14 day) course of topical azoles, or a repeat dose of fluconazole 72 hours after the initial dose
Treatment considerations for yeast infections in someone with uncontrolled diabetes or on corticosteroid therapy
May need longer (7-14 day) course of topical azoles
Treatment considerations for yeast infections in pregnancy
VVC occurs frequently in pregnancy. DO NOT USE ORAL AGENT. Recommend topical azole therapies applied x7 days.
Risks of chlamydia exposure for neonate (2)
pneumonia, conjunctivits
prevalence of chlamydia
most common STI in the US. The cause of up to 50% of pelvic infections. >4 million annually
If untreated in pregnancy, what is the risk of transmitting chlamydia to the neonate
70%
Sequelae of chlamydia
- cervicitis
- endometritis
- PID
- ectopic pregnancy
- infertility
- acute urethral syndrome (asymptomatic bacteruria)
- postpartum infections
- premature labor
- premature ROM
- perinatal morbidity
Risk actors for chlamydia
- sexually active
- <25 yo
- multiple partners
- no barrier method
Symptoms of chlamydia infection
May be asymptomatic. If symptoms, may experience:
- postcoital bleeding
- intermenstrual bleeding or spotting
- UTI symptoms (dysuria, frequency)
- vaginal discharge
- abdominal pain
Physical Exam findings suggestive of chlamydia
- mucopurulent endocervical discharge
- edematous, tender cervix that bleeds easily (CMT)
- suprapubic pain or tenderness on palpation
