PCOS and menopause

Question 1

Defense mechanisms in the female

Answer 1

Epithelial cells- mechanical barrier, Produce/secrete antimicrobial molecules, transport IgA, process and present Ag, communicate with underlying immune cells

Normal microbial flora- produce lactic acid, hydrogen peroxide to protect against foreign organisms,

Lactobacillus lowers vaginal pH to 4.2 -5

Question 2

Defense mechanisms- male

Answer 2

Epithelial cells, normal flora, Urethral length, and urine flow
Circumcision- may decrease rates of HIV transmission in heterosexual contact, Observational studies suggest decrease in other STIs (HPV and HSV),

Health benefits> risk

Question 3

The 5 ps

Answer 3

Partners, prevention of pregnancy, protection from STIs, practices, past history of STIs
Gonorrhea (the clap, lots of thich discharge), chlamidya (thin less discharge)

Question 4

Chlamydia, goonorrhea, trichomas, ureaplasma

Answer 4

Test for Chlamydia and gonorrhea simultaneously, voided urine PCR probe, First urine after no urination for 1 hr, in women cervical or vaginal swab preferred

Trichomonas- culture or NAAT testing higher sensitivity not always available, elevated vaginal pH, visualization of motile trichomonads on saline microscopy (sensitivity 55-60)

Ureaplasma PCR or culture

Question 5

Neisseria gonorrhea

Answer 5

Gram negative oxidase and catalse- positive diplococci,
Unlike N meningitidis there is no capsule, virulence factors include pili, porins and opa (opaque) proteins
Bacteria switches (mutates) surface antigens to prevent lasting immunity- reinfection is possible effective vaccine does not exist
Culture was routine for diagnosis (choc agar, non selective, Thayer martin- selective), now nucleic acid-based diagnostic approaches are routinely used
Bacteria is extracellular, but can be taken up by cells and released into subepithelial space- promotes invasion
Carriage can be asymptomatic particularly in women
historically treated with penicillin, now many strains are highly resistant, ceftriaxone is the treatment of choice

Question 6

Chlamydia trachomatis

Answer 6

Most common STD (bacterial) in the US
Can also cause pneumonia and conjunctivitis, gram negative bacteria, very hard to see on gram stain, bugs dont have peptidoglycan layer and muramic acid, the cell wall contains LPS with weak endotoxin activity, antibiotics that target peptidoglycan cell wall (penicillins) are not effect

Question 7

Chlamydia trachomatis infection

Answer 7

2 forms
Elementary body- metabolically inactive, cant replicate but infectious and stable in the environment
Initial body- also known as reticulate bodies, forms intracellular inclusions, metabolically active, intra cellular non infectious form, can divide and more of itself

Infects non ciliated epithelial cells of the mucosa, requires cell culture to grow- diagnosis primarily based on Nucleic acid approaches, azithromycin and doxycycline are antibiotics of choice

Question 8

Trichomonas vaginalis

Answer 8

Urogenital Protozoa, its a parasite, Highly motile, four flagella and undulating membrane, trophozoite (replicates by binary fission), colonizes genital mucosa, mostly asymptomatic, diagnosed by direct microscopic examination of discharge, sometimes the organism is found in urine

NAAT testing- higher sensitivity and specificity
Metronidazole is the treatment of choice (pts with severe allergy to flagyl need to be desensitized)

Question 9

Urea plasma urealyticum

Answer 9

bacteria, belongs to mycoplasma family, smallest free living bacteria, has no cell walls ( gram stain and B- lactam antibiotics are useless), very slow rate of growth (takes a long time to detect, can grow on cell free media (unlike chlamydia) nucleic acid- based diagnostic approaches are preffered

Produces urease to break down urine into ammonia- diagnositic smell, treatment of choice is erythromycin, tetracycline

Question 10

Treatment pearls

Answer 10

For Chlamydia/gonorrhea- Azithromycin 1 gm orally, single dose, or doxycycline 100 mg orally 2xday/7days AND Ceftriaxone 250 mg IM single dose

Trichomonas- Metronidazole 2 gms orally single dose

Ureaplasma- erythromycin, doxycycline

Question 11

Pelvic inflammatory disease

Answer 11

infection of the upper female genital tract
Ascending infection of the upper genital tract from the lower genital tract<50% women diagnosed w/PID have cultures positive for GC/chlamydia

Symptoms- pelvic or lower abdominal pain, abnormal cervical/vaginal discharge can be asymptomatic (silent)
Diagnosis- Pelvic/abdominal pain and one of the following: cervical motion tenderness, uterine tenderness, adnexal tenderness with no other cause identified

Specificity of diagnosis increased with T>101, abundant WBC on saline microscopy of vaginal fluid, elevated ESR/CRP, lab diagnosis of chlamydia and gonnorrhea

Endometrial biiopsy

Question 12

PID treatment

Answer 12

Initiate as soon as presumptive diagnosis is made to prevent long term sequalae
Outpatient treatment- give IM ceftriaxone PLUS doxycycline BID with or without metronidazole
Inpatient treatment- surgery, Tuboovarian abcess, pregnancy severe illness with nausea/vomiting, unable to tolerate outpatient regimen no clinical response to outpt treatment
Cefotetan IV doxycycline orally or clindamycin plus gentamicin, IR drainage,

Question 13

Long term complications of PID

Answer 13

Tubal factor infertility, increased tisk of ectopic pregnancy, chronic pelvic pain

Question 14

Painful vs non painful genital sores

Answer 14

Painful lesions- herpes, chancroid, lymphogranuloma venereum

Non painful lesions- Syphillis, Molluscum, Genital wart

Question 15

HSV 1 and 2

Answer 15

double stranded DNA Virus- alpha herpes virus family, DNA is encased into a capsid, which is further wrapped in a lipid bilayer, envelope, and capsid is packed with tegument proteins

Herpesvirus have 2 life cycles:

1) quiescent latent infection- limited to neurons (Sacral ganglion) not associated with clinical symptoms
2) lytic replication- active, many infectious viruses are produced, happens at the mucosa/skin at the site of initial inoculation

Reactivation- latency to lytic cycle, recurrent infection is caused by the exact virus that initiated primary infection, reactivation does not always lead to clinical symptoms, transmission can occur even if no lesions are present, infection is life long- no vaccine, majority

Neonatal herpes- can be fatal, anitviaral (acyclovir are Nucleotide analogs that specifically target viral DNA polymerase and inhibit replicaiton, there are no treatments for latent infection

Question 16

Haemophilus ducreyi

Answer 16

disease= chancroid, pleomorphic gram negative rods (coccobacilli), erythematous papule that becomes pustular then painful ulcer with 48 hrs, lymphadenopathy in approx 50%, disease is uncommon, diagnosis- culture or nucleic acid- based detection, treated with azithromycin , ceftriaxone, ciprofloxacin

Question 17

treponema pallidum

Answer 17

Gram negative spirochete, extra outer membrane, periplasmic flagella, very slow growth compared to other bacteria, causative agent of syphilis, primary stage: painless chncre at the inoculation site, highly infectious

Secondary - 6 weeks to 6 months after primary systemic spread to multiple organs and CNS, both systemic (fever rash - esp palms and soles) and local (conyloma latum- pink tan papules) symptoms

Latent - asymptomatic and noninfectious (except during pregnancy can relapse to secondary stage or remain asymptomatic for decades

Tertiary- may appear up to 20 yrs after 2’ syphillis, due to immune system- driven damage to multiple organs- heart, skin, bones, vessels, nerves
Congenital infection is associated high mortality rate
Diagnosis- cannot be cultured on conventional medium, not seen on light microscopy, Darkfield microscopy, serology, nucleic acid based approaches
Treated with benthazine penicillin, a modified penicillin that is slowly absorbed and has a long half life, antibiotics are not effective against tertiary stage, Jarisch herxheimer reaction- acute, self limited febrile response within 1st 24 h after treatment

Question 18

Molluscum contagiosum

Answer 18

Very large double stranded DNA virus- pox virus family
Virion is ovoid to brick shaped complex structure with several membranes, replicates exclusively in the cytoplasm of infected cell, a unique feature for a DNA virus,
A single life cycle- lytic replication, histology of lesions includes molluscum bodies- large eosinophiilic inclusions in the cytoplasm- viral factories
Some of the nucleotide analogs used to control herpes virus replication have antiviral activity against molloscum- use is frequently limited to the immunocompromised patients

Question 19

HPV

Answer 19

Small, double strandes DNA virus
Papovavirus
Icosahedral capsid, not enveloped, initial requires epithelial damage to access to basal epitheial layer

REplicates in the upper levels of epithelium virus DNA has to be mainted as an episome (covalently linked circle) for productive replication

Viral replication stimulates cellular division- etiology of HPV-induced genital warts

Accidental integration of broken viral DNA terminates virus replication, 2 outcomes - abortive infection or cancer, viral DNA integration that disrupts the expression of viral E2 gene increases risk of cancer along with expression of high risk viral E6 and E7 genes
No treatment specifically targeting the virus
Vaccine against high risk strain sis available

Question 20

bacterial vaginosis

Answer 20

garderella vaginalis, part of normal vaginal flora in manyasymptomatic women, more common if sexually active but nOT an STD, disturbance of normal flora leads to overgrowth causing disease, vaginal lactobacillus keeps G vaginalis in check, can

Metronidazole, Tinidazole, Clindamycin

Question 21

candida yeast infection

Answer 21

expands,

fluconazole