GU/GYNE Flashcards
The inability to retract the foreskin over the glans penis is known as ___
Phimosis
What are the three etiologies of phimosis?
Congenital, balanitis, poor hygiene
What is the time course of congenital phimosis?
90% experience natural separation by age 3. It is considered normal for the foreskin to adhere to the glans until around age 6
Ok so phimosis is considered normal until age 6! Unless …
Unless urination results in ballooning of the foreskin at any age – this is abnormal
How does phimosis typically present?
Limitation and pain when attempting to retract the foreskin
What investigations are needed to diagnose phimosis?
None! Diagnosed based on history and physical
How do we manage phimosis?
Proper hygiene
Topical corticosteroids
Dorsal slit
Circumcision
10% of males that are not circumcised as newborns require circumcision as adults due to complications of phimosis and balanitis. What is a key risk factor for this?
Uncircumcised males with diabetes
If phimosis is the inability to retract the foreskin, then what is paraphimosis?
Paraphimosis is when the retracted foreskin cannot be returned to its normal position
True or false, routine circumcision is recommended in male infants.
False
What are some benefits of circumcision?
Decreased rates of UTIs and penile cancer. Decreased incidence of cervical cancer in female partners. Decreased HIV incidence of HIV infection in heterosexual men
What are risks of circumcision?
Procedural complications – bleeding, infection, phimosis, urinary retention, etc.
What are the top three causes of inguinal masses in children?
1 enlarged lymph node, followed by hernias and hydroceles
The prevalence of inguinal hernias in newborns is 1-4 in 100.
True or false, surgical correction is recommended.
True! The risk of incarceration is 60% in the first 6 months of life if hernia is left untreated
What is the most significant risk factor for hernias in babies?
Preterm birth (reported in 30% of babies weighing less than 1000 g at birth)
Inguinal masses can occur anywhere along the inguinal canal to the scrotum or labia. What are some differentials for an inguinal canal mass?
Enlarged lymph node, retractile testis, an ovary or a synovial cyst
Inguinal masses can occur anywhere along the inguinal canal to the scrotum or labia. What are some differentials for an inguinal ring mass?
Testis or ovary, or an inguinal hernia
Inguinal masses can occur anywhere along the inguinal canal to the scrotum or labia. What are some differentials for a scrotal mass?
Hernia, hydrocele, varicocele, trauma, testicular pathology
Inguinal masses can occur anywhere along the inguinal canal to the scrotum or labia. What are some differentials for a labial mass?
Trauma, ectopic ovary, mixed gonadal tissue, Bartholin cyst
Non-acute inguinal masses have a slow onset and are not painful – what are some differentials to consider for non-acute masses?
Lymphadenopathy, a retractile testis, hydrocele, hernia, varicocele, tumor, ectopic ovary
Acute inguinal masses have a sudden onset and are associated with pain – what are some differentials?
Epididymitis, orchitis, testicular torsion, traumatic hematoma, lymphadenitis, incarcerated hernia
Diagnostics to consider with an inguinal mass?
CBC (if suspecting infection)
Urine C&S/culture (if suspecting epididymitis, orchitis, STI)
US
Describe what is happening in testicular torsion
Twisting of the testicle causes venous occlusion and engorgement as well as arterial ischemia and infarction
How does testicular torsion present?
Sudden onset severe unilateral scrotal pain, swelling of scrotal sac, high position of the testicle, abnormal cremasteric reflex, negative Phren’s sign.
Pain may radiate to the lower abdomen/groin, may have N/V, scrotum may be indurated and erythematous, reactive hydrocele may occur
May report intermittent periods of testicular pain before torsion
What the heck is a negative cremasteric reflex?
The cremasteric reflex is a superficial reflex, when the inner thigh is stroked – yes stroked – the cremaster muscle should contract and pull the ipsilateral testicle toward the inguinal cancel (basically the scrotum contracts).
This won’t be present in testicular torsion
What the heck is a negative Phren’s sign?
Positive Phren’s sign is a relief of testicular pain with elevation of the scrotum – present with epididymitis
Phren’s sign is negative in testicular torsion
Your patient booked a same day appointment in your primary care clinic this morning, he has acute onset testicular pain with a negative cremasteric reflex and negative Phren’s - What do you do?
Transfer to ED – this is a surgical emergency
True of False – surgical intervention recommended within 4 hours
False – 2 hours. Surgical delay can lead to ischemia and a non-viable testis
The TWIST score can be used to help rule out the diagnosis of testicular torsion, what clinical findings do you think it considers?
TWIST score for testicular torsion (Up To Date)
*Nausea or vomiting: 1 point
- Testicular swelling: 2 points
- Hard testis on palpation: 2 points
- High-riding testis: 1 point
- Absent cremasteric reflex: 1 point
Score <2 excludes torsion with sensitivity 100%, specificity 82 %, negative PPV 100%
When would an orchiectomy be part of the surgical intervention? How about an orchiopexy?
Orchiectomy is done when the testicle is non-viable and needs to be removed
Orchioplexy is done bilaterally when TT occurs to prevent recurrence by anchoring the testes
At which ages does TT most commonly occur?
Small peak in neonatal period, large peak in adolescence. Can occur at any age.
How might TT present in infants?
Hardened, fixed, nontender scrotal mass with a discolored scrotum
What are some differentials for TT?
Epididymitis
Orchitis
Hydrocele
Testicular tumor (hard, enlarged, painless testicle)
Acute appendicitis
Varicocele
Scrotal/testicular trauma
Diagnostics for testicular torsion?
US – definitive diagnosis not required to go to OR if causing too much of a delay
T/F Only 10% of cases of acute scrotal pain are due to TT.
False – 40% of acute scrotal pain is diagnosed as TT
What is the most common STI? What about numero 2?
HPV is most common (30-60% of sexually active adolescents)
CT is the second most common
What are some possible complications of unmanaged CT?
10-15% rate of PID, ectopic pregnancy and chronic pelvic pain and infertility
Epididymitis occurs in 1-3% of urethral infection
What are some risk factors for STIs/complications in adolescents?
Increased risk-taking behaviors without considering long-term consequences
Inconsistent/incorrect use of condoms, unprotected sex
Multiple partners
Experimentation with drugs/alcohol
Mental health issues
Having an STI is a risk factor for future STIs
Poor adherence to antibiotics
Lack of access to education and STI services in certain places/ confidentiality concerns
Being female or MSM
T/F: Pubertal females are at higher risk of contracting G/CT than adult females
True - Pubertal females higher risk for G/CT due to immature histologic state of squamocolumnar junction
These cells are more vulnerable to infection and neoplastic changes, especially with exposure to tobacco or multiple episodes of new HPV infection
Use of oral contraceptives prolongs this immature state
What are common S/S of males with STIs?
Dysuria
Urethral pain or discharge
Testicular pain
Genital lesions – ulcers, vesicles, warts
Non-specific rash
Sexual partner with STI
What are common S/S for females with STIs?
Dysuria
Abnormal vaginal discharge
Intermenstrual or irregular menstrual bleeding
Dysmenorrhea
Dyspareunia
Post-coital bleeding
Lower abdo pain
Nonspecific rash, systemic symptoms (fever, N/V, malaise)
Genital lesions
Sexual partner with STI
T/F - STI testing is only done when symptoms are present
False, asymptomatic screening should be done at least annually – common to have asymptomatic infections
Which infections are reportable? What needs to be done with a reportable infection?
CT, G, syphilis, HIV
requires notification of all sexual partners within 60 days, of last sexual partner if > 60 days
Would you do a test of cure/re-test adolescents who you have treated for STIs?
Our book recommends yes – STIs are a risk factor for STIs, and reinfection for an untreated partner is common.
BC guidelines say to do a TOC when compliance in uncertain, patient not treated with recommended regimen or patient is pregnant. And to rescreen at 6 months, as reinfection rates are high
T/F: If a patient has CT, assume they also have G and treat for both infections.
False – it’s the other way – if a patient has G, then you treat empirically for CT as well. People test positive for G 7 days after contact, but do not test positive for CT until 2-6 weeks after contact, so if the G tests negative, then it probably is.
What is the recommended treatment for CT?
Doxycycline 100 mg po BID for 7 days
OR
Single dose azithromycin 1 G po
What is the recommended treatment for G?
Single dose cefixime 800 mg po
OR
Single dose ceftriaxone 250 mg IM
AND
CT treatment (Doxycycline 100mg po BID or azithromycin 1G po)
What are other important considerations in the management of CT/G?
Test and empirically treat all partners in past 60 days (or last partner if >60days)
Abstain from sex for 7 days after initiation of treatment
Test for other STIs
Rescreen in 6 months
What is enuresis?
Involuntary of intentional urination in children who’s age and development suggest achievement of bladder control
At what age can enuresis be diagnosed?
F 5 or older
M 6 or older
Up to date says any child over 5
How common is enuresis?
One of most common conditions of childhood, 10-20% of first graders
Is day time or night time enuresis more common?
Night (74%)
Both (16%)
Day only (10%)
Define primary enuresis
Discrete episodes of urinary incontinence in a child has never sustained dryness
Define secondary enuresis
Urinary incontinence that occurs after 3-6 mo of dryness.
Causes of primary enuresis?
- Faulty toilet training
- Maturational delay
- Small bladder capacity
- Sleep disorder/impaired arousal
- Allergens – no evidence to support but anecdotal from parents
- Nocturnal polyuria/relative vasopressin deficiency
- Dysfunctional bladder contraction
Causes of secondary enuresis
- UTI
- Diabetes mellitus
- Diabetes insipidus
- Nocturnal seizures
- GU anomalies
- Sickle cell anemia
- Medication use
- Emotional stress
What kind of history would you want to collect for a child with enuresis?
- diary is helpful for a few weeks to a month
- Primary vs secondary
- Night time vs daytime vs both
- Frequency of urination/ defecation
- Associated symptoms
- Do they delay using toiley?
- Any treatments tried?
- Fhx?
- Assoc sx? Polyuria, polyphagia, encopresis, ADHD, OSA
What physical assessments would you want to conduct for a child with enuresis?
-Plot growth, check VS/ BP
-GI (organomegaly, bladder size, fecal impaction)
-Anal exam to evaluate rectal tone
-Gyne to assess appearance of genitals (labial fusion?) (meatal stenosis, epispadias, hypospadias, cryptorchidism?)
-MSK of LE (assess for sacral dimple, tuft of hair, spina bidida?)
-Note PE is usually N
How do you diagnose enuresis?
History
What investigations might you order for enuresis
Generally dx through hx
However, can do a few minimal investigations- UA, CBC, lytes, BUN
If secondary- urine culture and blood glucose
If you are suspicious that there is a condition underlying enuresis, what other diagnostics/ investigations might you order?
- Renal US
- Voiding cystourethrography
- Vertebral XR
- MRI
- EEG
- Urodynamic studies
What are the key ddx to rule out when investigating enuresis
-Bladder/ bowel dysfunction
-Constipation, encopresis
-DM
-UTI,
-OSA
-ADHD
What is the initial management of primary enuresis?
- Family counselling, address psychosocial stressors
- Advise that wetting is not intentional, punishment is inappropriate
- Limit fluids and caffeinated beverages in evening
- Reward chart for dry nights
- Conditioning therapy – use of an alarm that goes off when the child wets – assoc. With 70% success rate when used for 4-6 months
- Bladder retention training for those with small capacity bladders
- Address assoc. s/s such as encopresis or constipation.
How long do we try these initial measures
3-6 mo
What happens if initial measures are not working?
Consider medications
What medications might we try for enuresis?
Desmopressin (antidiuretic) (seems first line per UTD)
TCA (imipramine)
Oxybutnin (antispasmodic or anticholinergic)
Hyoscyamine
What do we do for secondary enuresis?
tx the cause!
When would you refer a child with enuresis?
Refer if
* Suspicion of structural or anatomic abnormalities
* LUTS plus enuresis
* Developmental, attentional, learning difficulties
* Behavioural or emotional problems
* Known or suspected physical/ neurological problems
* Caregivers with difficulty coping with bedwetting who may need additional support
* Refractory enuresis
What is a UTI
Bacteria in any part of urinary tract- can be upper or lower
Urethritis
Cystitis
Pyelonephritis
What is the most common causative bacteria in UTI
E.coli (80-90% of first infections in peds)
In early infancy (<60 months), are M or F more susceptible to UTI?
Males! up until 6 months, when F> M
Is circumcision a risk factor for UTI in infants?
No- it is protective up until 6 mo
i.e., rates of UTI in uncircumcised M are 10x higher than circumcised up to 6 mo
Then rates are equal regardless of circumscion status
What are other common pathogens for UTI in peds (aside from e.coli)?
-Gram negative enteric bacilli (proteus, klebsiella), gram positive cocci (enterococci, s. saprophyticus)
What are common presenting symptoms of UTI in young infants or toddlers?
Non specific s&S -fever, irritability, poor feeding, diarrhea, vomiting, jaundice
What are common symptoms of UTI in children?
- Dysuria
- Frequency
- Urgency
- Enuresis
- Foul smelling urine
-Possible low grade fever or abomdinal pain
What features differentiate UTI from pyelo in children?
Flank or back pain
Fever (esp. if 39+)
CVA tenderness
Be suspicious if child is immunocompromised
What is PE for UTI?
-Weight and height
-Vs to determine severity of infection
-Abdo- masses, tenderness
-CVA tenderness (pyelo)
-Genitalia- local lesions
-Lumbosacral area for anomalies
How to dx UTI in peds?
Positive leuks or nitrites on UA
Positive UC
Always collect culture before Abx
How to collect urine spec in infant?
The notes say in infants specimen should always be obtained by bladder puncture or cath
? Would we have to send them to hosp for this? I am not super comfortable cathing a kid in office….
My preceptor applies a u bag
Any labs needed?
Not if simply cystitis
If appear unwell/ toxic would be sending to ED for parenteral therapy anyways
Would expect WBC and CRP elevated in pyelo
Any imaging required for UTI in kids?
Mixed messaging
If you are going to image- US KUB
The point is to look for abnormalities in the UT
The general concensus is to image
* Child <2 with first febrile UTI
* Child of any age with recurrent febrile UTI
* Child of any age with UTI and fhx of kidney or urologic disease, poor growth, HTN
* Child who does not response as expected to appropriate antimicrobial therapy
This is not a urgent thing (i.e., dont need to do it when they have the UTI)
What is the Tanner Score?
Way of scoring a sexual maturity rating
Because puberty begins and develops along different timelines for different people, a Sexual Maturity Rating (SMR) is used to described breast and pubic hair development in females and genital development and pubic hair growth in males.
What are UTI red flags that indicate need for ED/ parenteral antibiotics?
-age <2 months
-clinical urosepsis (toxic, hypotn, poor cap refill)
-immunocompromised and febrile
-vomiting or unable to tolerate PO meds, lack of adequate OP FU
-failure to respond to OP therapy.
The average age of menarche in US is
12.5 yrs - usually at seuxally maturity rating of 3 or 4 at this time
SexAndU says average age of menarche is 10-14yrs
You dx 1.5 year old charlie with a uti and send them home with outpatient oral antibiotics. Do you need to schedule a reassessment visit, and if so, when?
24-48 hours
Average age of spermarche?
Spermarche usually occurs at age 13, with little to know pubic hair development, in SMR 2-3.
Full fertility in both sexes is usually achieved by age ___
15
What is the first line antibiotic for UTI
-TMP/SMX (Mums)
-Cephlosporins (UTD)
In which age groups is epididymitis most common
M 14- 35
T/F: When completing a physical exam on a teen, a chaperone should be present during breast and genital exams, even if patient and NP are same sex
True
What is a recurrent UTI
Reinfection with new organism (same or different species; common, esp in the first year after initial UTI.
Indications for a speculum exam in an adolescent?
Pregnancy (I wouldn’t…)
Request by adolescent
Unexplained low abdo pain
Persistant abnormal vaginal discharge
Unexplained vaginal bleeding
Dysmenorrhea that is unresponsive to NSAIDs
Suspected or reported sexual assault
Pap test
What does PMS stand for?
Premenstrual syndrome
What is a persistent UTI
Intermittent sx of UTI persist during admin of abx and repeat UC is positive after 14 days
What is PMS? When does it occur in the menstrual cycle?
common cyclic disorder that is characterized by emotional or physical symptoms that consistently occur during the luteal phase of menstrual cycle (1-2 weeks before menses) and resolve shortly after the onset of menses (the follicular phase)
symptoms are typically most severe (and accompanied by functional impairment) in the 4 days before through the first 2-3 days of menses
What is a relapsing UTI
Symptom recurrence within 2 months (even after negative culture obtained at 14 days after completion of abx treatment). May be indicative of underlying structural or functional problems or urinary tract, kidney stones, or inappropriate antibiotic therapy.
S&S of PMS?
Wide variety of ~150 symptoms
Most common affective/behaviour symptom = mood swings
Most common physical manifestations = abdominal bloating & extreme fatigue
Other frequent nonphysical behavioral symptoms include irritability, anxiety/tension, sad or depressed mood, increased appetite/food cravings, sensitivity to rejection, and diminished interest in activities
Other common physical symptoms include breast tenderness, headaches, hot flashes, and dizziness, fluid retention/weight gain, muscle or joint pain…
For most people, symptoms are fairly consistent across cycles and last for an average of six days per month
Outline some risk factors for epididymitis
UTI
unprotected sexual contact
instrumentation/ catheterization
increased pressure in prostatic urethra (straining, voiding, heavy lifting)
immunocompromised
Diagnostic criteria for PMS
- at least one afective and one somatic symptom during the 5 d before menses in each of the three prior
menstrual cycles - symptoms relieved within 4 d of onset of menses and do not recur until at least day 13 of cycle
- symptoms present in the absence of any pharmacologic therapy, hormone ingestion, drug or alcohol
use - symptoms occur reproducibly during 2 cycles of prospective recording
- patient suffers from identifable dysfunction in social or occupational performance
Treatment of PMS?
First line: CBT, exercise, Vit B6, Continuous or luteal phase (day 15-28) low dose SSRIs (e.g. citalopram/escitalopram 10 mg)
2nd line: Estradiol patches (100 µg) + micronised progesterone (100 mg or 200 mg [day 17-28], orally or
vaginally) or levonorgestrel-releasing intrauterine system (LNG-IUS) 52 mg
Higher dose selective serotonin reuptake inhibitors (SSRIs) continuously or in luteal phase
(e.g. citalopram/escitalopram 20-40 mg
What is premenstrual dysphoric disorder?
a severe form of PMS in which symptoms of anger, irritability, and internal tension are prominent
Causes more severe impairment of functioning than PMS
Risk factors for PMDD
fhx, MDD, SUD, trauma
What can you ask your patient to do to help identify if symptoms d/t PMDD?
-Keep a premenstrual daily symptom diary for 2 months (to confirm luteal phase symptoms)
DSM 5 criteria for PMDD
-DSM-5 criteria
-At least 5/11 symptoms during most menstrual cycles of the last year (with at least 1 of the first 4)
1) Depressed mood or hopelessness
2) Anxiety or tension
3) Affective instability
4) Anger or irritability
5) Decrease interest in activities
6) Difficulty concentrating
7) Lethargy
8) Change in appetite
9) Hypersomnia or insomnia
10) Feeling overwhelmed
11) Physical symptoms (breast swelling/ tenderness, headaches, joint/ muscle pain, bloating, or weight gain)
**Symptoms cause significant distress and/or interfere with functioning. Symptoms must be present during the week prior to menses and resolve within a few days after onset of menses. May be superimposed on other psych disorders.
Tx of PMDD
(same as PMS)
-Regular exercise, sleep, healthy diet
-Complex carbs in luteal phase, along with vit D, vit B6 and calcium 1000mg daily
-CBT
Pharm
-SSRIs (can do luteal phase only or continuous administration) (fluoxetine, sertraline, paroxetine)
-Hormonal manipulation of menstruation (COCs >progesterone)
-Ovulatory suppression tx (GnRH agonists; many side effects including vaginitis, vasomotor sx, decreased BMD)
Surgical
-Last line is hysterectomy with bilateral salpingo- oophorectomy (trial of GnRH agonist needed first)
Causes of abnormal uterine bleeding (think PALM COEIN!)
PALM = structural changes
P - Polyps (endometrial, cervical)
A - Adenomyosis
L - leiomyomas (fibroids)
M - malignancy (or precancer/hyperplasia)
COEIN = the nonstructural changes
C - coagulopathies
O - ovulatory dysfx (PCOS, hyperthyroid, mentral stress, obesity, weight loss, etc)
E - Endometrial (endometritis)
I - Iatrogenic (medications such as anticoagulation, contraceptives)
N - not yet classified
What causes epididymitis
Most commonly infection
STI- chlamydia, gonorrhea
Enteric pathogens if >35, penetrative anal intercourse
When you ask about length of a person’s menstrual cycle, how is that measured?
From the first day of one period to the first day of the next
S&S of epididymitis?
-Sudden onset scrotal pain and swelling, +/- radiation along cord to flank.
-Scrotal erythema, tenderness
-Prehn’s sign (relief of pain with lifting testicle)
-Normal cremasteric reflex
-Fever
-Storage symptoms, LUTs symptoms, purulent urethral d/c
-Reactive hydrocele
Define abnormal uterine bleeding? (be specific about length of menstrual cycles)
Vaginal bleeding that occurs outside the normal range, including absence of menses or amenorrhea, menses at irregular intervals, menstrual periods occurring more frequently than every 24 days or less frequently than 38 days, excessive menstrual flow, or intermenstrual bleeding.
What is the most important ddx to rule out when diagnosing epididymitis?
Testicular torsion
What investigations will you conduct if you suspect a dx of epididymitis?
UA, C&S
Urethral discharge culture/ gram stain/ NAAT for G&C
US doppler to r/o torsion if uncertain re dx
What non-pharmacological treatment measures will you recommend to your patient with a dx of epididymitis?
Scrotal support, elevation
Best rest in acute phase
If STI related- treatment of partners, abstain from intercourse until 7d after tx initiation, avoid contact with untreated partners
Seek RA in 3 days or if not improving
Really good education re red flags (testicular torsion- worsening pain, nausea/ vomiting, testicle lies horizontally, pain worsens with testicle elevation)
Education re complications- testicular atrophy, infertility (30%), chronicity
What pharmacological treatment measures will you prescribe for you patient with a dx of epididymitis?
-Antibiotics
* Chlamydia- doxy or azithro
* Gonorrhea- cefixime or ceftriaxone PLUS doxy or azithro
* Negative STI, likely enteric cause- ofloxacin, levolfloxacin
-Analgesics
What kind of fluctuations in bleeding do you expect in perimenopause?
Variable!
may experience intermittent anovulatory cycles (so missed periods)
heavy or prolonged periods are also typical of menopause transition
name some important screening questions for someone with AUB
- age of menarche
- S&S of anemia, syncope
- Hx of blood loss in urine or stool
- easy bruising or signs of bleeding disorder
- Any symptoms of pregnancy (morning sickness, fatigue, breast tenderness)
- Significant weight or diet changes
- Using any medications such as contraceptives, aspirin, anticoags, psychotropic agents
- Systemic illness such as SLE, DM, renal disease
- hx of trauma
- Is bleeding cyclic?
- break through bleeding
- fam hx of DM, bleeding disorders, PCOS, thyroid disease
- exposure to STIs
What labs will you potentially order for someone with AUB?
- CBC (r/o anemia)
- plt (r/o thrombocytopenia)
- iron studies
- STI screening (r/o cervicitis) for G&C, trich
- PAP (if not up to date)
- b-hcg
- TSH
- prolactin
- androgens (DHEA-S, cortisol, testosterone) (only if virilization present in hx/ on exam)
- coag studies (PTT, PT, fVIII, von Willebrand factor antigen and activity) (if fhx or sx coagulopathy).
Why will you order a transvaginal/transabdominal U/S for AUB?
to confirm pelvic exam or look for structural abnormalities (cyst, fibroid
When is an endometrial biopsy necessary for AUB?
*after pregnancy ruled out
recommended if >45 years old to r/o endometrial ca or premalignant lesion. Consider if <45 if AUB persistent and other risk factors present (unopposed estrogen as in obesity and chronic anovulation), failed medical management of bleeding, tamoxifen use)
** may also need Sono hysterogram, hysteroscopy, D&C for diagnostic evaluation
DDx for AUB
- Pregnancy or pregnancy related complications (abortion, ectopic preg, molar pregnancy)
- Cervicitis, endometriosis, STI, PID
- HPV infection (friable cervix)
- Endometrial Ca or endometrial hyperplasia
- Thyroid disease
- Retained tampon or condom
- PALMCOIEN (see etiology above)
Overall goals of tx for AUB
(1) control the bleeding
(2) correct any anemia
(3) replenish iron stores
(4) prevent further episodes of bleeding.
Pharm tx of AUB
**Refer to Gyne!
- Contraceptive to control irregular bleeding and decrease menstrual blood flow
- Iron supplementation
-Conjugated equine estrogen (IV)- for severe acute heavy menstrual bleeding
-TXA (antifibrinolytic) for women with HMB who do not want to use hormones
-NSAIDs- reduce synthesis of PG and thus reduce menstrual blood loss (use at onset of menses)
-Danazol- androgenic hormone that blocks gonadotropins and suppresses ovarian estrogen production (endometrium things, amenorrhea occurs)- reduces HMB
How would you educate a teenage who has recently started periods and wants to know what’s
“normal” for bleeding
(according to SexAndU)
- Long and unpredictable periods are normal for teenagers
- Periods occur every 24-38 days…everyone is different
- Each period usually lasts about 3-8 days
- You usually only lose a small amount of blood – from a few spoonfuls to a half a cup.
- Birth control can affect periods
- Keep track of periods on app/calendar
- Educate on cramping, breast tenderness, bloating, mood changes, etc
What is endometriosis?
the presence of endometrial tissue (glands and stroma) outside of the uterine cavity
usually located in the pelvis but can occur nearly anywhere in the body.
Typical age of onset of endometriosis?
2/3 of adult women with endometriosis report that their symptoms started before age 20
symptomatic endometriosis commonly occurs in adolescents, in rare cases before menarche.
T/F endometriosis is genetically linked
True
What is the cause of endometriosis?
We don’t know!
Many theories outlined in Up to Date…
- Retrograde menstruation: endometrial tissue from the uterus is shed during menstruation and transported through the fallopian tubes, thereby gaining access to, and implanting on, pelvic structures
- dissemination of endometrial cells or tissue through lymphatics and blood vessel
What are some potential long term adverse effects of endometriosis?
chronic pain, endometriomas, infertility
** early recognition and diagnosis in adolescents can help prevent this!
S&S of endometriosis in adolescents?
- usually have both acyclic and cyclic pain/cramps (severe, progressive dysmenorrhea)
- Bowel symptoms (eg, rectal pain, constipation, painful defecation that may be cyclic, rectal bleeding)
- bladder symptoms (eg, dysuria, urgency, hematuria) are also common
- By contrast, adults with endometriosis commonly have cyclic pain (not acyclic), and present with dysmenorrhea, dyspareunia, a pelvic mass, infertility, or chronic pelvic pain
**Can have excessive/irregular bleeding
What are the 4 Dys’s of endometriosis (describes symptoms…more focussed on adulthood)
4 “Dys” of Endometriosis
* Dysmenorrhea
* Dyspareunia (cul-de-sac, uterosacral
ligament)
* Dyschezia (uterosacral ligament, culde-sac, rectosigmoid attachment)
* Dysuria (bladder involvement)
Ddx for pelvic pain in adolescents?
- pregnancy (intrauterine or ectopic)
- appendicitis
- PID
- müllerian abnormalities with outflow obstruction - hernia
- bowel disease
- urinary tract disease
- musculoskeletal issues.
What key imaging should you consider if you’re worried about endometriosis in a teen?
Pelvic U/S
(transabdo is fine unless they’re comfortable with transvaginal)
Time course of endometriosis?
chronic condition
T/F Endometriosis typically regresses with menopause
True
What are the most common sites of endometriosis (where does it deposit)?
- ovaries: 60% of patients have ovarian involvement
- broad ligament, vesicoperitoneal fold
- peritoneal surface of the cul-de-sac, uterosacral ligaments
- rectosigmoid colon, appendix
rarely may occur in sites outside abdomen/pelvis, including lungs and diaphragm
T/F 30-40% of patients with endometriosis will be infertile
True :(
Is it necessary to conduct a pelvic exam on all teens that you suspect endometriosis (or other causes of pelvic pain)?
**We do not typically perform speculum and bimanual exams on adolescents. These exams will likely be low yield and uncomfortable and generally do not add information that cannot be obtained from imaging studies.
Although important, it may not be possible to perform a complete pelvic examination in all adolescents, particularly those who have not been sexually active or are unable to use tampons. A pelvic exam should not be a barrier to further evaluation, diagnosis, and treatment of endometriosis.
T/F Pelvic pain that is not primary
dysmenorrhea should be considered
endometriosis until proven otherwise
True! Endometriosis is considered the most likely cause of secondary dysmenorrhea
Do there need to be abnormal physical findings to diagnose endometriosis?
No, Suggestive history even with a
negative exam should be considered
adequate for a presumptive diagnosis
Definitive diagnosis of endometrosis can be made using laparoscopy. Is this necessary for diagnosis? What is the general approach to diagnosis/treatment in both teens and adults?
No, only move to laparoscopy if first line treatments for dysmennorhea not effective.
1) First step is trial 3 month period of NSAIDs and hormonal contraceptive to see if can control symptoms this way
- cyclic/continuous estrogen-progestin (OCP), depo, or LNG-IUS
2) Patients who do not respond to medical therapy within three months should undergo laparoscopy to make a definitive diagnosis and undergo ablation/resection of lesions and/or adhesions. Fifty to 70 percent of adolescents with chronic pelvic pain have endometriosis diagnosed at the time of laparoscopy.
How do estrogen and progestin work in contraception?
- estrogen: suppresses FSH and follicular development
- progestin: prevents LH surge, suppresses ovulation, thickens cervical mucus, decreases tubal motility,
decidualizes endometrium
How is the contraceptive ring used (Nuva ring)? How effective is it? Is it progestin only?
- thin flexible plastic ring that is inserted into the vagina
- left there for 3 wk then removed for a week to allow for menstruation
- as effective as OCP in preventing pregnancy (98%)
Possible side effects specific to the Nuva Ring? What is a “pro” of this method?
- side efects: vaginal infections/irritation, vaginal discharge
- associated with less breakthrough bleeding than other methods
When starting a hormonal contraceptive, should you tell your patient to start it on a particular day of their cycle?
can start at any time during cycle but ideally within 5 d of LMP
Tell me about Bartholin cysts. And Bartholin glands.
A Bartholin cyst is a small sac of fluid that forms when the opening of a Bartholin gland is blocked.
Bartholin glands make small amounts of mucous to to keep the vulva moist. Is something blocks the opening, fluid can build up and form a cyst. This usually happens in just 1 gland at a time.
There are 2 Bartholin glands, one on each side just below the opening of the vagina.
What assessment do you need to do before starting a person on hormonal contraceptives?
thorough history and BP measurement
(do NOT need a pelvic exam)
What are the advantages of CHCs?
Highly efective
Reversible
Cycle regulation
Decreased dysmenorrhea and heavy menstrual
bleeding (less anemia)
Decreased benign breast disease and ovarian
cyst development
Decreased risk of ovarian and endometrial
cancer
Increased cervical mucus which may lower
risk of STIs
Decreased PMS symptoms
Less acne
Osteoporosis protection (possibly)
Patient controlled
Side effects of CHCs (broken down by estrogen and progestin-based SE’s if you’re feeling keen…)
Estrogen-related:
Nausea
Breast changes (tenderness, enlargement)
Fluid retention/bloating/edema
Weight gain (rare)
Migraine, headaches
Thromboembolic events
Liver adenoma (rare)
Breakthrough bleeding (low estradiol levels)
Progestin-related:
Amenorrhea/breakthrough bleeding
Headaches
Breast tenderness
Increased appetite
Decreased libido
Mood changes
HTN
Acne/oily skin*
Hirsutism*
Contraindications for CHC use?
Age ≥35 years and smoking ≥15 cigarettes per day
●Two or more risk factors for arterial cardiovascular disease (such as older age, smoking, diabetes, and hypertension)
●Hypertension (systolic ≥140 mmHg or diastolic ≥90 mmHg for the CDC and systolic ≥160 mmHg or diastolic ≥100 mmHg for the WHO)
●Venous thromboembolism – Women with a history of thromboembolism not receiving anticoagulation or women with an acute embolic event
●Known thrombogenic mutations
●Known ischemic heart disease
●History of stroke
●Complicated valvular heart disease (pulmonary hypertension, risk for atrial fibrillation, history of subacute bacterial endocarditis)
●Breast cancer
●Cirrhosis
●Migraine with aura
●Hepatocellular adenoma or malignant hepatoma
____ is the most common early side effect after CHC initiation
Unscheduled bleeding
*affects 1/2 of women during the first cycle of use and quickly improves over subsequent months
What are the s/s of a Bartholin cyst?
Sometimes the only s/s is pain and/or discomfort while walking, sitting or having intercourse.
There may be swelling, redness, with a presenting complaint of a lump to the vulva.
If bacteria invade the cyst, an abscess may form.
A 13 year old patient wants to start on birth control but heard from a friend that it made her fat. Is this a known side effect?
As per Up to Date: the use of CHCs does not appear to result in significant weight change, either gain or loss.
I have heard anecdotally of people who feel they gained weight but I think the research generally shows this isn’t linked
T/F the progrestin-only pill is taken for 21 days, followed by 7 days of sugar pills
False - there is no pill free interval for progestin only. All 28 pills in pack contain medication.
What are the treatment options for a Bartholin cyst?
If s/s are nonexistent or mild, no treatment is needed.
I&D, a balloon with catheter (Word catheter) may be placed in the cyst for about a month to facilitate ongoing draining.
If severe, a new opening can be made surgically, or the gland can be removed altogether.
Abx depend on the situation.
If your patient is having breakthrough bleeding on a CHC, you can change to a pill with higher _____ to combat this issue
Estrogen
What kind of birth control is a good option for people who are breast feeding?
How early to start this?
Progestin only methods (estrogen may interfere with milk supply)
Advantages and disadvantages of progestin IUS?
- advantages: convenient, low hormone dose, minimal side efects, no efect on breast milk, quick
return to fertility once removed - disadvantages: uncomfortable to put in, must be inserted and removed by a doctor, rarely can have
uterine perforation or IUS expulsion
Depot provera is given every _______ weeks?
12 weeks (can give between 11 weeks up to 14 weeks)
Your patient presents 16 weeks after their last depo shot. What do you do?
From Up to Date: In women more than two weeks late for their injection (>15 weeks from the last injection), we suggest a pregnancy test before administering DMPA and back-up contraception (or abstinence) for seven days
**Options for Sexual Health also uses the 15 weeks cutoff for assuming protection from pregnancy
You start your patient on depo provera. They are protected from pregnancy right away, right?
No (it depends). need to use a backup method of birth control such as condoms, or not have sex for 7 days.
BUT if you happen to get your shot within the first 5 days of your period you are protected right away.
How long does it take to regain fertility after using the depo shot?
Up to 1-2 years!
Average is 9 months
Some people get pregnant right away but not good option for those wanting to get preggers anytime soon.
Emergency contraception can be taken for up to ___ days after unprotected sex
5 days
Copper IUD can be inserted up to 7 days (and hormonal IUD has proven to have similar efficacy but isn’t official yet)
Progestin only pills must be taken at the same time every day. If you are ___ hours late, you will need backup contraception for ____ days.
3 hours
2 days (48 hours)
What is a unique potential adverse effect of the depo shot?
Decreased bone density (may be reversible)
*encourage vit D/calcium supplementation
Here’s a fun little script for speaking to adolescents and their parents about confidentiality! (thanks Up to Date!)
“I would like to make this visit a positive experience for your child. It is important to respect an adolescent’s privacy as a normal part of growing up. I would first like to have the opportunity to review health information with you, and then I would like to review health information with your child alone. Usually, whatever is discussed between my teenage patients and me is confidential, except in certain situations, such as if they have thoughts of suicide, thoughts of physically harming someone, or reports that they have been or are being physically or sexually abused. If you feel you need to know more about what they and I have discussed, I strongly encourage you and your child to talk to each other directly.”
If your patient is over 40 and presents with a Bartholin cyst, what is something you should consider?
Biopsy for cancer. Rare, but has occurred in those over 40.
What is another name for Bartholin glands?
Greater vestibular glands.
For they reside just outside the great vestibule. Couldn’t resist.
If your patient hasn’t been using their contraceptive pill as prescribed or has missed the window for their depo provera shot, what do you need to rule out?
Pregnancy!
If they have had unprotected intercourse in the past 5 days, consider ECP!
What are two comorbidities that may impact the severity and healing of a Bartholin cyst?
Diabetes and immunosuppression.
How long are copper and hormonal IUDs good for?
Copper - 10 years
Hormonal (Mirena, Kyleena) for 5 years….however the Mirena website now says up to 8 years (and this is starting to be more widely accepted in practice)
Is it recommended to swab fluid from a draining Bartholin cyst?
Yes due to increasing rates of MRSA.
In people born with ovaries who have not reached menopause, the most common causes of ovarian cysts are:
-Ovulation
-Dermoid cysts - made up of germ cells, may contain hair and teeth (NOPE) and rarely are cancerous
-PCOS
-Endometriosis
-Pregnancy - an ovarian cyst normally develops during pregnancy until placenta forms but sometimes remains until later in the pregnancy
In people born with ovaries who are postmenopausal, what are the common causes of ovarian cysts?
-noncancerous growths
-fluid collection in the ovary
-cancer
An ovarian cyst is not always symptomatic. What might some patient complaints be when an ovarian cyst is present?
Pain or pressure in low abdo on side of cyst,
Pain may be intermittent, dull or sharp.
Sudden sharp and severe pain may indicate ruptured cyst.
Severe pain with n/v may indicate torsion.
What is the recommended imaging to order if you suspect ovarian cyst?
Transvaginal U/S.
You complete a Mirena IUD insertion with your patient 3 days after the onset of their period. Do they need to use backup contraceptives? If so, for how long?
No -
If it is fewer than 7 days since the start of your menstrual period, you do not need to use a backup method.
If you have a hormonal IUD inserted more than 7 days after the start of your period, you should avoid vaginal sex or use a backup birth control method, such as a condom, for the next 7 days.
You suspect your patient has a large ovarian cyst and has a family history of ovarian cancer. You order a blood test to test for the cancer antigen 125 (CA 125). You are mindful that this test is not diagnostic of ovarian CA as these other conditions can cause an elevated result:
(This test is not recommended in postmenopausal patients)
Endometriosis
Uterine fibroids
Pelvic infections
Heart failure
Liver disease
Kidney disease
The general term for disorders of the vagina caused by infection, inflammation, or changes in the normal vaginal flora is ____________.
Vaginitis.
Common causes of vaginitis are:
STIs, BV, candida
Changes in estrogen levels - ie. vulvovaginal atrophy with low estrogen
Changes to microbiota
Abx use
Hygiene products ie douches
Pregnancy
Sexy times
Contraceptives
Dermatoses
Systemic disorders ie RA, lupus
Postpartum, lactating
NAAT tests have high specificity and sensitivity (>90%) to diagnose which possible causes of vaginitis?
BV
Candida
Trich
Cervicitis caused by GC and CT
___________ is a clinical condition characterized by a shift in vaginal microbiota away from Lactobacillus species towards more diverse bacterial species.
Bacterial vaginosis.
Which form of vaginitis is the most common cause of abnormal vaginal discharge in people with vaginas, of child-bearing age?
BV accounts for 40-50% of vaginitis cases.
People with female reproductive organs, who have only same-sex relations, have minimal risk of developing BV.
True or false?
False. Rates also increase with more partners.
If your patient has never had sex, including oral sex, their risk of BV is low.
True or false?
True. Even though BV isn’t 100% an STI, sexual activity increases risk and incidence.
What is the 1st line pharmacological treatment recommended for BV?
Which abx can be considered if an alternative is needed?
Metronidazole (po or pv)
PO: 500mg BID x 7/7
PV: 0.75% gel 5 gram pv QD x 5/7
Clindamycin po or pv supps may be used if C/I to above.
If you prescribe oral flagyll, what important teaching do you provide?
Abstain from ETOH during tx and for 24 hours after tx. -UTD doesn’t support this fyi.
What are some risk factors for developing vulvovaginal candidiasis?
Increased estrogen levels (OCP, pregnancy)
Abx
Glucocorticoids
Diabetes Mellitus
IUD use
What is the recommended fluconazole dosing for candidiasis tx?
Flucanozole 150 mg 1 tab is usually effective for mild cases.
A 2nd dose may be needed 72 hours after the 1st dose in moderate cases.
Topical creams and vaginal supps have been proven more effective to clear up a yeast infection, versus fluconazole p.o.
True or false.
False!
Similar efficacy has been shown.
How does pregnancy change your tx options for yeast infection?
Oral meds are contraindicated and so topical clotrimazole or miconazole, or nystatin supps are recommended for initial tx.
Note: fluconazole is ok in breastfeeding
First line treatment for UTIs in kids?
TMP/SMX
(as per MUMs)
Peds cases says course would be 3-5 days if afebrile and immunocompent, and 7-10 days otherwise.
