Menstruation + Infection Flashcards
Primary amenorrhea is defined as
Primary amenorrhea is the failure of menses to occur by age 15 years (some sources say 16 years), in the presence of normal growth and secondary sexual characteristics (breast development, axillary or pubic hair).
At age 13 years, if no menses have occurredand there is a completeabsence of secondary sexual characteristics, evaluation for primary amenorrhea should begin
MCC of secondary amenorrhea
Intrauterine pregnancy is the most common cause of secondary amenorrhea. The first step in the workup of amenorrhea should almost always be a pregnancy test.
17-year-old female who is concerned that she has not yet had her period. She is sexually active and uses condoms consistently. She does not use other forms of contraception. On physical exam, there is normal breast maturation. The uterus is not palpable, and this is confirmed by pelvic ultrasound. Karyotype testing is performed and returns as 46 XX. Her serum testosterone levels are within normal limits.
Primary amenorrhea
3-year-old female who is concerned that she has not had her menses over a period of four months. She is also very distressed about increased hair growth. She reports having to shave frequently above the lip, chin, chest, and lower back. Prior to this, she had regular menses. The patient’s weight is 168 lbs. (76.2 kg) and height 5 feet and 1 inch (154.9 cm). On physical examination, there is hair above the lip and chin area. She also has acne on her cheeks and forehead. Hyperpigmented plaques of the skin are found on the nape of her neck. Bilateral enlarged ovaries are palpated on pelvic examination. β-hCG is negative and LH: FSH is 3.
Secondary amenorrhea
MCC of primary amenorrhea
- Pregnancy
- Imperforate hymen
- Gonadal dysgenesis - Turner’s syndrome (46 XO) - short web neck
- Müllerian agenesis (absent uterus and vagina)
- HPO axis abnormalities - Anorexia, bulimia, weight loss, excessive exercise
Absence of menses for 3 months in a woman with previously normal menstruation or 6 months in a woman with a history of irregular cycles
Secondary amenorrhea
Labs for primary amenorrhea
- Quantitative βHCG
- FSH, prolactin, TSH, T3, Free T4 estrogen, progesterone
Excessive uterine bleeding and prolonged menses that is NOT caused by pregnancy or miscarriage, diagnosis of exclusion, look for an underlying endocrine disorder
Dysfunctional uterine bleeding
a 35-year-old woman with concerns about heavy menstrual periods for the past year that occur at irregular intervals. She explains that sometimes her menses come twice a month but other times will skip two months in a row. Her menses may last 7 to 10 days and require 10 to 15 thick sanitary napkins on the heaviest days. She admits to some fatigue, but she denies any lightheadedness. She has no pain with menses or intercourse and denies any vaginal discharge. She has had normal Pap smears in the past. She is in a stable monogamous relationship with her husband and denies a history of STIs. On physical examination, her blood pressure is 120/ 80 mm Hg and her body mass index (BMI) is 32. Her pelvic examination is normal.
Dysfunctional uterine bleeding
menses that occur more frequently (menses < 21 days apart)
Polymenorrhea
menses that involve more blood loss (> 7 days or > 80 mL) during menses
Hemorrhagic or hypermenorrhea
prolonged/heavy bleeding (>7 days or >80 mL); regular intervals
Menorrhagia
uterine bleeding that occurs frequently and irregularly between menses
Metorrhagia
more blood loss during menses and frequent and irregular bleeding between menses
Menometrorrhagia
Period = long intervals > 35 days
Oligomenorrhea
AUB in the absence of an anatomic lesion, caused by a problem with the hypothalamic-pituitary-ovarian axis
Dysfunctional uterine bleeding
Dysfunctional uterine bleeding dx
Diagnosis of exclusion, Uterine Dilation and Curettage is the gold standard diagnosis
- Urinary β-hCG levels—r/o pregnancy
- Labs: CBC, iron studies, PT, PTT, TSH, progesterone, prolactin, FSH, LFTs
- Progestin trial—if the bleeding stops, anovulatory cycles confirmed
- Ovulation journal, Pap smear
- Pelvic U/S, endometrial biopsy, HSG, hysteroscopy
- Urinary β-hCG levels—r/o pregnancy
Tx of dysfunctional uterine bleeding
a 19-year-old nulligravid college female who complains of dull, throbbing, cramping lower abdominal pain during menses for the past three years. She reports nausea and vomiting during menses but denies irregular or heavy periods, pain with intercourse, or abdominal pain outside of menses. Pain tends to peak 24 h after the onset of menses and subsides after 2 to 3 days. A pelvic exam is normal.
Dysmenorrhea
Refers to uterine pain around the time of menses, which can either be primary or secondary
Dysmenorrhea
S/S of primary dysmenorrhea
- Painful uterine muscle activity due to an excess of prostaglandins (F2a)
- Teens-early 20s, declines with age, no associated pelvic pathology
- Risk factors include menarche before age 12, nulliparity, smoking, family history, obesity
- Pain with menstruation, lower abdominal, intermittent, “labor-like” on days 1-3
- Nausea, vomiting, diarrhea (smooth muscle contraction), headache
- Normal pelvic exam
Tx of primary dysmenorrhea
Treatment: NSAIDs and oral contraceptive pills
Secondary dysmenorrhea mcc
- Painful menstruation caused by clinically identifiable cause
- Etiology: Endometriosis, adenomyosis, polyps, fibroids, PID, IUD, tumors, adhesions, cervical stenosis/lesions, psych
- Pain with menstruation begins mid-cycle and increases in severity until end
- Common women age (20-40 s)
Tx of secondary dysmenorrhea
Tx underlying cause
12 or more months of amenorrhea occurring at a mean age of 51 years
Menopause
the transition between reproductive capability and menopause hallmark is irregular menstrual function, lasts 3-5 years
Perimenopause
Onset of menopause < 40 years old
premature ovarian failure
FSH and estradiol levels of menopausal women
FSH and estradiol levels (FSH > 30) with ↓ estradiol (although not necessary for diagnosis)
Tx of menopause
-
Estrogens are used to treat hot flashes
- If uterus: HRT (estrogen + progesterone), if no uterus (ERT)
- Woman with an intact uterus should not use estrogen alone because of the increased risk of endometrial cancer
- Progestins: Hot flashes, increased risk of breast cancer
- HRT—severe menopausal symptoms (hot flashes, night sweats, vaginal dryness)
- “Smallest dose for shortest possible time and annual reviews of the decision to take hormones”
- HRT should not be used to prevent cardiovascular disease due to slightly increased risk of breast cancer, MI, CVD, DVT
- Hormone therapy effect on lipid profile: HDL and TG levels ↑, LDL levels ↓
Contraindications for HRT
- ↑ triglycerides
- Undiagnosed vaginal bleeding
- Endometrial cancer
- History of breast CA or estrogen-sensitive cancers
- CVD History
- DVT or PE history
Non hormonal therapies for menopause
Cool temperatures, avoid hot, spicy foods or beverages, avoid ETOH, exercise, soy
- Alternative drugs for vasomotor symptoms
- SSRIs (paroxetine)
- SNRIs
- clonidine
- gabapentin
Follicular (proliferative) phase of menstrual cycle
- The follicular phase is the first part of the menstrual cycle
- It goes from day 0 to day 14
- First, GnRH (from the hypothalamus) stimulates FSH and LH release (from anterior pituitary)
What causes ovulation
- Estrogen secretion is increased even more from the follicle in FOLLICULAR PHASE . It induces an LH spike, which causes ovulation
Which phase is 15-28 of the cycle
Luteal phase
What happens in the luteal phase
- After ovulation, the follicle becomes the corpus luteum, which secretes progesterone and provides negative feedback to FSH and LH
- If pregnancy does not occur, the corpus albicans is formed, which no longer secretes estrogen and progesterone
Which phase does endometrial sloughing or menses occur in?
- This decrease in hormones leads to endometrial sloughing or menses
- To begin a new follicular phase of the menstrual cycle, GnRH is secreted.
DSM-5 criteria for PMDD
In the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week post menses.
One (or more) of the following symptoms must be present:
- Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful, or increased sensitivity to rejection).
- Marked irritability or anger or increased interpersonal conflicts.
- Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts.
- Marked anxiety, tension, and/or feelings of being keyed up or on
a 25-year-old female who complains of abdominal bloating, headache, irritability, depression, poor sleep quality, and breast tenderness. These symptoms occur on a monthly basis 5 days before menses. Her symptoms greatly improve within 4 days of the onset of menses.
Premenstrual syndrome
Premenstrual syndrome caused by
- Caused by an imbalance of estrogen and progesterone along with excess prostaglandin production
- Symptoms during the luteal phase (1-2 weeks before menses) - Bloating, irritability. PMDD- causes marked disruption in functioning.
- Symptoms resolve at the onset of mense
is based on history and physical exam
- ACOG criteria: Need one of the following symptoms is present during the 5 days before menses and abates within 4 days of the onset of menses
- Somatic: Breast tenderness, abdominal bloating, headache, edema
- Affective: Irritability, depression, angry outbursts, anxiety, social withdrawal, confusion
Tx of premenstrual syndrome
Exercise and stress reduction are beneficial in general and should be recommended on this basis
-
SSRIs are first-line options for women with moderate to severe premenstrual symptoms who do not desire contraception
- Can be administered as continuous daily therapy or may be used cyclically 2 weeks prior to the menstrual cycle
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Combined estrogen-progestin oral contraceptive as first-line therapy if contraception is a high priority (stops ovulation and stabilizes hormone levels)
- Start with a 3 mg drospirenone (DRSP)/20 mcg ethinyl estradiol (EE) COC (Yazmin) with a four-day pill-free interval as the first-line pill
- If symptom relief with the COC monotherapy is incomplete, an SSRI can be added
- GnRH agonist therapy: For women who have not responded to or cannot tolerate SSRIs or OCs and continue to experience severe symptoms
- Surgery (bilateral oophorectomy/bilateral salpingoophorectomy [surgical menopause]) is considered only as a last resort
Gonorrhea tx
CDC recommends a single 500 mg intramuscular dose of ceftriaxone for uncomplicated gonorrhea. Treatment for coinfection with chlamydia with oral doxycycline (100 mg twice daily for 7 days) should be administered when a chlamydial infection has not been excluded.
sx of gonorrhea in women vs men
- Women: often asymptomatic, a prolonged infection can result in pelvic inflammatory disease when the bacterium travels into the pelvic peritoneum
- Men: yellow, creamy, profuse, and purulent discharge
- Can infect any mucocutaneous surface (oral, urethral, vaginal, and anal)
Fitz-Hugh-Curtis syndrome
gonococcal (or chlamydial) perihepatitis that occurs predominantly in women and causes right upper quadrant abdominal pain, fever, nausea, and vomiting, often mimicking biliary or hepatic disease
How can you differentiate gonococcal urethritis from chlamydial urethritis on examination?
Gonorrhea presents with a purulent discharge from the urethra, whereas chlamydia is generally associated with a thinner, white mucous discharge.
Dx of gonorrhea
Diagnosis is made with Nucleic acid amplification testing (NAAT)
- For urogenital infections, vaginal swabs in women (clinician-collected and self-collected) and first-catch urine in men are the preferred specimens for NAAT
- For extragenital infections, NAAT, used on pharyngeal and rectal swabs, is also the preferred test
- Patients with confirmed gonococcal infection who have persistent symptoms after appropriate therapy with good adherence and lack of re-exposure should be tested for antibiotic resistant N. gonorrhoeae with culture and susceptibility testing
Tx of gonorrhea if there is a cephalosporin allergy
- When ceftriaxone cannot be used because of cephalosporin allergy, a single 240 mg IM dose of gentamicin plus a single 2 g oral dose of azithromycin is an option
- Cefixime 800 mg orally as a single dose is another alternative
Most common sexually transmitted infection
Chlamydia trachomatis ⇒ Serotypes D-K cause chlamydia
Tx of chlamydia
TX: The CDC recommended treatment for chlamydia is doxycycline 100 mg PO BID × 7 days
a 22-year-old patient presents with a complaint of painful blisters on the vulva and vaginal introitus. She admits to a prodrome of burning, tingling, and pruritus before the appearance of lesions. Upon examination, you note vesicles on an erythematous base.
Herpes simplex
Dx of genital herpes
- hus, it is important to confirm the diagnosis of herpes simplex virus (HSV) infection with either of the following techniques: viral culture (gold standard), polymerase chain reaction (PCR), direct fluorescence antibody, and type-specific serologic tests
- Tzanck prep from skin scrapings ⇒ multinucleated giant cells
Genital warts are caused by
Genital warts caused by HPV type 6 and 11
Gardasil protects against
The HPV 9-valent vaccine (Gardasil-9) protects against nine subtypes, including seven types that cause cancer, and is indicated for females and males ages 9–45 years old.
- >90% of cervical cancer is associated with HPV types
16, 18, 31, 33, and 35
Dx of genital warts
DX: Shave or punch biopsy confirms the diagnosis, only if necessary - uncertain diagnosis, poor response to therapy, atypical appearance, immunocompromised
- Koilocytic squamous epithelial cells in clumps are found on a pap smear and are typical of cervical warts
- HPV DNA can be detected on cervical swabs
Tx of genital warts
TX: Spontaneous remission in months to years is typical of skin warts
- Treat to improve symptoms and remove warts
- The provider may apply podophyllin or trichloroacetic acid (TCA)
- Topical imiquimod (Aldara) cream can be applied by the patient
- Surgery: cryotherapy with liquid nitrogen, surgical excision, electrocautery, laser, intralesional interferon
a 30-year-old woman complains of a painful sore on her vulva that first resembled a pimple. On examination, you find an ulcer with clearly demarcated borders, gray base, and foul-smelling discharge.
Chancroid
Etiology of chancroid
- The causative pathogen is Haemophilus ducreyi, a gram-negative rod that is very contagious but rarely found in the developed world
- Cases of chancroid in the developing world may be underreported due to the difficulty of definitive diagnosis
Sx of chancroid
one or severalpainful genital ulcers on an erythematous base, 1–2cm/0.39–0.79in diameter with sharply demarcated borders; the base of ulcer covered with purulent exudate bleeds easily when scraped
- In about half of patients with chancroid, there will also be marked lymphadenopathy in the inguinal chain.
Dx of chancroid
Serologic testing for syphilis - RPR/VDRL
- Gram stain, culture, and biopsy (used in combination because of the high false-negative rates) show the causative agent Haemophilus ducreyi
Tx of chancroid
The CDC recommends single-dose therapy with ceftriaxone 250 mg IM × 1 dose or azithromycin 1 g PO × one dose
- Fluctuant lymphadenopathy - needle aspiration, drainage to prevent spontaneous rupture
Lymphogranuloma venereum (LGV)
ulcerative disease of the genital area
- It is an uncommon, sexually transmitted infection. It is transmittable by vaginal, oral or anal sex
- Its cause is the gram-negative bacteria chlamydia trachomatis, especially serotypes L1, L2, and L3
lymphogranuloma venereum three stages of infection
- Primary stage is characterized by the development of painless genital ulcers or papules
- Secondary stage with the development of unilateral or bilateral tender inguinal and/or femoral lymphadenopathy (also called buboes)
- Late-stage with strictures, fibrosis, and fistulae of the anogenital area
Dx of Lymphogranuloma venereum (LGV)
Diagnosis is by clinical suspicion. Other causes of genital ulceration and inguinal adenopathy should be excluded ⇒ Serologic testing for syphilis—RPR/VDRL
- The basis for a definitive diagnosis of LGV is on serology tests (complement fixation or micro-immunofluorescence) or identification of Chlamydia trachomatis in genital, rectal, and lymph node specimens
Tx of Lymphogranuloma venereum (LGV)
The CDC recommended treatment regimen is doxycycline 100 mg orally twice a day given for 21 days
PID
Infection that ascends from the cervix or vagina to involve the endometrium and or the fallopian tubes
Etiology of PID
Infection that ascends from the cervix or vagina to involve the endometrium and or the fallopian tubes
- Causative agents include Gonorrhea and chlamydia
Sx of PID
- Common symptoms include pelvic pain and fever. There may be vaginal discharge (cervicitis)
- Complications: infertility, ectopic pregnancy, tubo-ovarian abscess (adnexal mass)
Abdominal tenderness, cervical motion tenderness, and adnexal tenderness plus one or more of the following:
- Temperature > 38°C
- WBC count > 10,000/mm3
- Pelvic abscess found by manual examination or ultrasonography
PID
Tx of PID
- Outpatient: ceftriaxone IM 250 mg once + PO doxycycline 100 mg BID × 14 d ± PO Flagyl 500 mg BID × 14 d
-
Inpatient
- Severely ill or nausea and vomiting precludes outpatient management
- Consider hospitalization if the diagnosis is uncertain, ectopic and appendicitis cannot be ruled out, pregnancy, pelvic abscess suspected, HIV positive, unable to follow or tolerate outpatient regimen, or failed to respond to outpatient therapy
- Doxycycline + IV cefotetan or cefoxitin × 48 h until the condition improves, then PO doxycycline 100 mg BID × 14 d
- Clindamycin + gentamicin daily, if normal renal function, ×48 h until the condition improves, then PO doxycycline 100 mg BID × 14 days
painless ulcer (chancre) in the genital or groin region persisting 3 to 6 weeks
Primary syphillis
erythematous rash involving the palms and soles or a condyloma lata, which is similar to the lesions of primary syphilis in its infectivity but differs in appearance.
Secondary syphillis
systemic involvement and can present with major vessel changes, such as in the aorta, permanent CNS changes (neurosyphilis), or even benign mucosal growths called gummas.
Tertiary syphillis
Dx of Syphilis
RPR/VDRL and confirmed by the treponemal antibody-absorption test (FTA-ABS). Lyme disease can cause a false positive.
Tx of Syphilis
TX: Benzathine PCN G, 2.4 million units IM × one dose for primary and secondary disease
- Additional doses if the infection has been for >1 year or if the patient is pregnant
- If the patient is penicillin-allergic, treat with doxycycline
- IV penicillin G (for Gummas) for congenital and late disease
MCC of vaginitis
Candida
Clumpy or cheesy vaginal discharge, pruritus, dysuria, burning, dyspareunia, vaginal or vulvar edema, and erythema
Candida vaginitis
Dx of candida vaginitis
KOH branching hyphae
- PH < 4.5 (acidic)
Tx of candida vaginitis
ral fluconazole (Diflucan) 150 mg PO x 1 then repeat in 7 days
- Topical clotrimazole (Gyne-Lotrimin)
- Topical tioconazole (Monistat)
- In severe infections (generally hospitalized patients), amphotericin B, caspofungin, or voriconazole may be used)
MCC of bacterial vaginitis
- The causative agent is Gardnerella (anaerobic bacteria)
Sx of bacterial vaginitis
frothy, grayish-white, fishy-smelling vaginal discharge is noted
Dx of bacterial vaginitis
“Clue cells,” which are epithelial cells with bacilli attached to their surfaces. On saline wet mount adding 10% KOH of the discharge produces a fishy odor (+ whiff test)
- PH > 4.5 (BACTERIA = BASIC)
Tx of bacterial vaginitis
First-line treatment is metronidazole (Flagyl) either orally or vaginally
- Metronidazole oral 500 mg PO b.i.d. × 7 days
- Metronidazole gel 0.75%: 5 g intravaginally daily × 5 days
- Clindamycin 2% cream: 5 g intravaginally QHS × 7 days
- Second-Line Treatment
- Clindamycin
- Tablets: 300 mg PO b.i.d. × 7 days
- Vaginal suppositories 100 g intravaginally QHS × 3 days
- Bioadhesive cream 2%: 5 g × 1 dose
- Clindamycin
- During therapy with metronidazole, alcohol should not be consumed
Greenish gray frothy vaginal discharge with mild itching
Trichomonas
Hallmark pelvic exam finding in 20% of trichomonas infections is petechiae on the cervix (also known as a “strawberry cervix”)
Trichomonas
Dx of trichomonas
The presence of mobile and pear-shaped protozoa with flagella on wet mount
Tx of trichomonas
Metronidazole 2 g PO x 1 dose
- Sexually transmitted; therefore, the partner must also be treated
Irritation, dryness, painful intercourse, increased UTIs, urinary incontinence; Recurrent UTI despite treatment
Atrophic vaginitis
Dx of atrophic vaginitis
Can diagnose on vaginal exam – thin, pale appearing mucosa – diagnosis of exclusion in postmenopausal women
Tx of atrophic vaginitis
with topical estrogen creams (View full treatment guidelines)
- Conjugated estrogens vaginal cream (0.625 mg/g) 0.5–2 g vaginally daily for three weeks, then tapered to lowest effective dose twice weekly; administer cyclically (3 weeks on, one week off)
- Can give oral HRT if no contraindication
- Non-hormonal vaginal moisturizers
