Unit 8, STIs, Contraception

Question 1

Amenorrhea
Common Causes
Primary vs. Secondary

Answer 1

Absence of menstrual flow
Not a disease, but often a sign of one
Most common reason: Pregnancy
Other causes:
- Endocrine disorders, such as thyroid issues, pituitary disorders
- Excessive exercise, extreme weight loss
- Anatomical abnormalities with uterus or cervix
- Medications such as hormonal contraceptives
Primary
- When a girl has reached the age of 16 and has still not started her period
Secondary
- When a woman experiences an absence of her cycles after previous normal cycles
Woman needs a full workup

Question 2

Dysmenorrhea
Primary vs. Secondary
Treatment

Answer 2

Pain during or shortly before menstruation most common in young adult women ages 17-24
Primary
- What affects younger women (late teens-20s), basic menstrual cramps
- Caused by the release of prostaglandins by the endometrium (inflammatory mediators)
- First line treatment: NSAIDS (block prostaglandins), such as Ibuprofen
- OCPs
- Heat pad
- Regular exercise
Secondary
- Acquired form of dysmenorrhea, related to underlying pathology in the pelvis; develops later in life
- Common problem: Endometriosis
- Treatment: discovering the cause and treating it

Question 3

Premenstrual syndrome (PMS)
Symptoms
Management

Answer 3

Physical and/or psychological symptoms beginning in the luteal phase
Progesterone is the dominant hormone in the luteal phase, causes most of the symptoms
Symptoms are cyclic: appear in luteal phase, then go away
- Fluid retention
- Bloating
- Breast tenderness
- Emotional lability (mood swings)
- HA
- Fatigue
Management
- Regular exercise
- Stress reduction
- Diet changes
- Smoking cessation
- SSRIs

Question 4

Endometriosis
Symptoms
Diagnosis

Answer 4

Presence and growth of endometrial tissue outside of the uterus - on the tubes, ovaries, out in the abdomen, on the bladder, on the colon
Possible cause: retrograde menstruation (period going back into the tubes)
These “endometrial implants” grow and bleed when a woman has her period no matter where they are -> inflammation, adhesion, scarring (painful)
Major Symptoms
- Pelvic pain: chronic, pain with sex (endometrial implants can cause the uterus to be in a retrograde position)
- Dysmenorrhea
- Dyspareunia: pain with sex
- Infertility
Diagnosis:
- Only way to diagnose with certainty is surgery (laparoscopic)

Question 5

Management of Endometriosis

Answer 5

Drug therapy
- Depends on severity, how quality of life is affected, childbearing goals
- Degree of endometriosis does not match the amount of pain
- NSAIDS, OCPs (continuous, where periods happen 4x a year)
Surgical intervention
- Laser/ablation procedures remove endometrial tissue
- Performed before a woman tries to get pregnant
- Commonly endometriosis will come back
- Only 100% “cure” is a hysterectomy: removal of uterus AND ovaries (have to remove ovaries)
- Hysterectomy with VSO
- Have to take ovaries because the hormones are what keeps the endometrial tissue growing
- Done for someone that is done having children; conservative measures are not working
- Endometriosis WILL go away with menopause

Question 6

Menopause
Onset
Physiologic characteristics

Answer 6

Onset
- Onset: late 40’s to early 50’s (average is 51-52)
- Genetic, depends on family hx (when mom had it)
- Anomaly: 30s
Physiologic characteristics
- Changes in menstrual bleeding with eventual cessation of menses
- Gradual process (process usually begins in mid-40s)
- Start to have unpredictable and erratic bleeding
- Anovulatory cycles (cycle with no ovulation)
- One full year with no periods = postmenopausal

Question 7

Menopause Symptoms

Answer 7

Bleeding
- Unpredictable and erratic
Genital changes
- Estrogen plays crucial role in urogenital tissues, keeps them thick and moist
- When estrogen drops and goes away = vaginal dryness and thinning
- Common complaints: Pain with sex, bleeding after sex
- Women will try hormones to help with painful sex
- Urogenital changes can lead to uterine or bladder prolapse (urination changes)
Vasomotor instability
- Hot flashes: sudden warming sensation of head, neck, and chest; breaks out in a sweat
- Management: Avoid crowded or warm rooms, spicy foods, hot beverages
Night sweats
- Another reason women go on hormones
Mood and behavioral responses
- Women can experience insomnia (esp if experiencing night sweats)
- “Brain fog”
Different behavioral responses
- Some view this as a loss (loss of youth and attractiveness, loss of childbearing role)
- Some view it as a positive thing (no longer worry about pregnancy or periods)

Question 8

Infertility
Factors Associated with Infertility (Female, Male)

Answer 8

One year of unprotected sex and no pregnancy = seek evaluation
Exception: woman has known risk factors, such as endometriosis, advanced maternal age = seek evaluation after 6 months
Female Infertility
*Hormonal and ovulatory factors:
- Endocrine disorders (pituitary or thyroid disorder)
- Age-related
*Tubal factors:
- Anything causing a blockage of tubes
- Endometriosis
- Scarring from STIs, PID
- Missing tubes: Salpingectomy for ectopic pregnancy
*Uterine factors
- Bicornuate uterus (irregular shape)
- Septum in uterus
- Fibroids
*Other factors
- Obesity
- Medical conditions
- Anxiety
Male infertility
*Structural and hormonal disorders
- Low testosterone
- Hypospadias, undescended testicle (usually treated in childhood)
- Varicocele: collection of varicose veins in the scrotum
- Vasectomy
*Obesity
- Decreases semen quality
*Endocrine disorders
- Diabetes -> erectile dysfunction
*STIs
- Affects number and quality of sperm

Question 9

Assessment of Female Infertility

Answer 9

Detection of ovulation
- Is the woman ovulating?
- Having a period regularly does not always mean a woman is ovulating
- Home Ovulation Kits: Test for LH Surge
Hormone analysis
- Blood work: Progesterone, estrogen, prolactin, thyroid, FSH/LH
Ultrasonography: Transvaginal
- Assess pelvic structures
- Look for fibroids, uterine abnormalities
- Assess ovarian follicles
- Assess thickness of endometrium or lining
Hysterosalpingography (HSG)
- Live X-ray is performed with dye
- Shoot dye through cervix
- Look to see if dye comes out of both tubes
- Shows tubal patency
- Can also be curative: can unblock the tube
Hysteroscopy
- Scope through the cervix, looks at uterine cavity
- Also can look at the tubes
Laparoscopy
- Most invasive*
- Pt under general anesthesia
- Scope in pelvic cavity
- Look for abnormalities
- Look for endometriosis

Question 10

Assessment of Male Infertility

Answer 10

Semen analysis
- Most basic test of male fertility
- Look at: sperm count, sperm motility, sperm morphology (shape)
Ultrasonography
- Look for structural abnormalities
- Look for varicocele
Other blood tests
- Testosterone levels, endocrine function

Question 11

Infertility Interventions
Non-medical

Answer 11

Water soluble lubricants
- Oil-based can damage sperm
Avoid hot tub/sauna use (males)
- Heat is damaging to sperm (testicles outside of body because the body is too warm, shrinkage when cold)
Diet
Avoid alcohol, smoking, drugs
Reduce stress
Moderate weight loss (exercise)
- Particularly for females with PCOS
Proper timing of intercourse (fertile window of 3-4 days)

Question 12

Infertility Interventions
Medical
(surgical, medications, side effects, consequences, etc)

Answer 12

Correct preexisting factors
Surgery
- Remove varicocele for male
- Laparoscopy for female (endometriosis)
Drug therapy for preexisting medical problems
Ovarian stimulation (females)
- Clomiphene citrate (Clomid)
- Helps to induce ovulation by binding to estrogen receptors and blocks them from detecting estrogen
- Makes the body think estrogen levels are low, causing FSH levels to increase -> stimulates ovaries to release follicles
- Can cause ovarian hyperstimulation
- Bothersome side effects: N/V, hot flashes, breast tenderness
- Monitor pt closely through ultrasound, monitor follicles -> ovaries can get enlarged -> ovarian torsion (weight of ovary causes it to twist)
FSH/LH injections
- Daily injections
Human Chorionic Gonadotropin
- Injection
- Triggers ovulation -> when a woman has been treated with Clomid and FSH/LH makes the ovary “ready”
- Consequences: multiple gestation is common in women that use these treatments to get pregnant

Question 13

Assisted Reproductive Technology (ART)
- Intrauterine Insemination (IUI)
- In vitro fertilization (IVF)
- Oocyte donation
- Embryo donation
- Surrogate mothers/embryo hosts
Risks with ART

Answer 13

Intrauterine Insemination (IUI)
- Less invasive than IVF
- Drugs are used to stimulate ovulation, given a trigger shot; partner brings in semen sample -> sperm is transferred to reproductive tract
In vitro fertilization (IVF)
- Pt still undergoes stimulation of ovaries
- The eggs are aspirated or retrieved through laparoscopy; the sperm sample is take; fertilized in a tube -> put in woman
- Preimplantation genetic diagnosis (PGD): Testing each of the embryos created through IVF (a couple can get 20 embryos from IVF)
- Cryopreservation of human embryos: Can freeze the embryos that are not used
Oocyte donation
- Using a donor egg (can still use partner’s sperm)
- Used if female partner has poor egg quality
Embryo donation
- The whole embryo is donated
- Surrogate mothers/embryo hosts
- Another woman carries the baby -> can use surrogate egg or your egg
- Used if the potential mother’s body can not go through pregnancy
Adoption
Risks with ART
- Ectopic pregnancy
- Congenital malformations
- Multiple gestation

Question 14

Benign Conditions of the Breast
Fibrocystic changes
Treatment

Answer 14

Fibrocystic changes
- Most common benign breast problem
- Affects glandular tissue of breast (tissue that makes milk)
- Cyclic symptoms (comes before or around time of period)
- Breasts become “lumpy” and may have some tenderness
- Nodular on physical exam
- Bilateral change*** symptoms are in BOTH breasts
- Most common in women 2nd/3rd decades of life
Treatment
*Lifestyle changes
- Diet changes: avoiding caffeine and chocolate; limiting sodium; avoiding alcohol, smoking
*If discomfort
- Apply heat to the breast
- Wearing a supportive bra
- NSAIDs

Question 15

Benign breast conditions
Nipple Discharge
Physiologic vs. Pathologic

Answer 15

• Most nipple discharge is physiologic
• Can be related to malignancy or endocrine disorders (elevated prolactin levels, as in hypothyroidism or pituitary adenoma)
• “Normal” discharge: bilateral, expressed with stimulation, coming out of multiple ducts, serous “clear” discharge
• Malignancy-related discharge: unilateral, expressed spontaneously, bloody, coming out of one or two ducts.
• Galactorrhea: bilateral, milky, sticky discharge; normal in pregnancy; seen when prolactin levels are elevated

Question 16

Malignant Conditions of the Breast
Breast Cancer
Male Breast Cancer
Incidence

Answer 16

• 2nd leading cause of cancer death in women ages 45-55
• Incidence is higher in white women, but deaths are higher in black women
• 1 in 8 women at risk for breast cancer
• 79% found in women over age 50
  *Areas of detection
• 50% (majority): Outer upper quadrant
• 18%: nipple
• 12%: inner upper quadrant
  Male breast cancer
• <1% of all breast cancers
• Not a good prognosis (caught at a later stage)

Question 17

Risk Factors for Breast Cancer
Modifiable and Non-Modifiable

Answer 17

Non-modifiable Risk Factors
- Gender (female)
- Age (Biggest risk factor)
- Early menarche or late menopause
- Age at first live birth
- Nulliparity
- Family history
- Personal history of breast cancer
- Dense breast tissue
- Genetics: BRCA-1, BRCA-2
Risk Factors (Modifiable)
- Obesity
- Lack of exercise
- Diet high in saturated fat
- Moderate to high alcohol consumption
- Use of exogenous hormones for more than 10 years
- Not breastfeeding

Question 18

Pathophysiology and Clinical Manifestations of Breast Cancer

Answer 18

• Begins in the epithelial cells lining the mammary ducts and lobules
• Invasive (infiltrating) - grow into the wall of mammary ducts and into surrounding tissues
• Noninvasive (in situ) - stays in the epithelial cells
• Generally either ductal or lobular
• Most common: ductal carcinoma
• Metastasis: usually spreads to liver, lung, brain, bone (PET scan will show)
  Clinical Manifestations/RED FLAGS:
• Usually painless
• Immobile, palpable lump
• Nipple retraction (esp if on one side, or it is new)
• Nipple discharge
• Dimpling of breast tissue
• Skin changes
• Peau d’orange (orange peel appearance)
• Change in breast size or shape

Question 19

Prognosis and Screening/Diagnosis of Breast Cancer

Answer 19

Prognosis
- 1. Nodal involvement
- 2. Tumor size
- Various molecular and biologic markers
- Estrogen/progesterone receptor status
Screening and Diagnosis
- Mammography: Gold standard for screening and early detection
- Younger women who are not as likely to develop breast cancer
- 20-39 years: clinical breast exam every 3 years
- 40 years old: yearly clinical breast exam and yearly mammogram
Ultrasound
- Used in women with significant breast density
- Distinguishes between fluid filled (cysts) and solid masses (benign and malignant) -> mammogram can not do
MRI
- High sensitivity for breast cancer, expensive
PET scan
- Detect metastasis
Biopsy
- Mass: detects receptors, biomarkers

Question 20

Care Management for Women with Breast Cancer
Treatment Options (surgery, side effects, education)

Answer 20

*Breast conserving surgeries
- Lumpectomy : Most minimal, just the tumor and a small rim of healthy tissue is removed
- Partial mastectomy: Remove a quadrant of the breast
*Mastectomy
- Total simple mastectomy: breast is removed
- Radical mastectomy: remove the breast, axillary lymph nodes, and pectoralis muscle
*Chemotherapy
- Kills rapidly dividing cells
- Affects hair follicles, GI mucosa, etc
- Used to eradicate metastatic disease
- Alopecia, bone marrow suppression, oral sores, risk for bleeding
*Hormone Therapy
*Radiation
- Usually after surgery
- Side effects: heaviness or swelling of the breast, sunburn like rash, skin irritation
- Clean area with mild soap and water; avoid lotions and powders
- Do not remove marking radiologist makes on breast
- Wear soft, non-irritating, loose clothing over area

Question 21

Post-Mastectomy Care
Discharge Teaching

Answer 21

*Routine post-op care, PLUS
- Recognize infection or complications
- Get patient up and moving; cough and deep breathing; incentive spirometer
- Goal: minimize lymphedema from impaired lymphatic drainage
*Minimize lymphedema of the affected arm:
- Elevate arm with pillows
- No blood draws, IVs, injections, or BPs in affected arm
- If both arms affected: pt will usually have a port for blood draws/fluids; take BP on leg
- Encourage early arm exercises to promote lymphatic drainage
- Encourage self-care (brushing teeth, putting on clothes, etc)
- Report increase in arm circumference
*Discharge teaching
- Follow up in about 6 weeks
- No heavy lifting (nothing over 10 lbs) -> stress of suture lines
- Do not lift arms over head
- How to empty drains
- What to report: S/S of infection
- Do not wear tight clothing or tight jewelry on affected arm

Question 22

Uterine prolapse:
Signs and symptoms
Management and Treatment

Answer 22

Cervix and body of uterus protrude “falls” into the vagina
- Ranges from mild to complete prolapse
- Prostaventia: external
Signs and symptoms
- Pelvic pressure, protrusions, “something falling out”, low backache, pelvic fullness
- Can get worse when standing for a while
Management and Treatment
- Depends on degree of prolapse
- Kegel Exercises
- Pessaries: supportive device that is inserted vaginally; “holds up” the uterus
- Estrogen therapy
- Severe: complete hysterectomy (uterus is taken out)

Question 23

Cystocele
Signs and symptoms
Treatment

Answer 23

Protrusion of bladder downward into the vagina
- “Pouch” is lower than”neck”
Signs/symptoms:
- “Something is in my vagina”
- Urinary frequency
- Urine retention
- Lots of UTIs
Treatment
- Kegel exercises
- Pessary
- Estrogen therapy
- Surgery (not the same as for uterine prolapse): “anterior repair”

Question 24

Urinary Incontinence
Risk Factors
Urge incontinence versus stress incontinence
Signs/symptoms
Management

Answer 24

• Prevalence increases as woman ages
• The more babies a woman has had, the more prevalence
• Losing protective estrogen
• Caucasion, smokers, overweight
  *Urge incontinence versus stress incontinence
• Stress: increase in abdominal pressure from laugh, cough, or sneeze causes involuntary urination
• Urge: when the urge hits, the woman immediately has to pee
  *Signs/symptoms: involuntary leaking of urine
  *Management
• Kegel exercises
• Estrogen therapy
• Surgery
• Lifestyle: losing weight, smoking cessation

Question 25

Benign Neoplasms
Fibroids
More common in…
Clinical manifestations
Medical management

Answer 25

• Most common benign tumors of the reproductive system
• Growth influenced by estrogen
• Spontaneously shrink after menopause (no estrogen)
• More common in African American women
  *Clinical manifestations
• Heavy uterine bleeding
• Dysmenorrhea
• Low abdominal pressure; can feel pelvic pressure
• Some women may look pregnant
• Treatment depends on amount of bleeding
  *Medical management
• Expectant management
• NSAIDS and oral contraceptive pills (OCPs): Tristeta
  Iron: stimulate production of blood
  Blood transfusions are sometimes required

Question 26

Fibroids
Surgical management (types, risks, results)

Answer 26

*Myomectomy
- Removal of the fibroids
- Leaves uterine muscle walls relatively intact
- Fibroids may come back
- Future pregnancy: risk of uterine rupture; have to deliver by C/S
*Hysterectomy (last option)
Total abdominal hysterectomy (TAH)
- Bilateral salpingo-oophorectomy (BSO)
- Cut open like a C/S
- Takes out uterus, both ovaries, both tubes
- Puts woman into an abrupt menopause
LAVH-Laparoscopic assisted vaginal hysterectomy
- Less invasive, few puncture marks
TVH-Total Vaginal Hysterectomy
- Minimal incisions

Question 27

Hysterectomy
Postoperative care
Discharge planning and teaching

Answer 27

Postoperative Care
- Monitor VS every 15 minutes until stable, then every 4 hours for 48 hours
- Remind client to turn, cough, deep breathe every 2 hours for 24 hours
- Incentive spirometry if ordered
- Leg exercises every 2-4 hours until ambulatory
- Assess bleeding
- Abdominal: assess dressing or incision
- Vaginal: perineal pad count (one saturated pad in less than 1 hour is excessive; vaginal bleeding is usually minimal)
- Check lab values
- Assess lung sounds
- Assess bowel sounds, function
- Perineal pain -> ice pack
- Monitor I&O
- Swelling to tissues around urethra -> watch for urinary retention
- Assess abdominal incision or vagina for signs of infection
- Pain relief
Discharge planning and teaching
- No heavy lifting
- No tub baths or sex (about 6 weeks, till follow up)
- Cessation of menses
- Surgical menopause if ovaries removed
- PAP testing no longer necessary if hysterectomy was done for benign reasons
- Avoid constipation

Question 28

Endometrial cancer
Risk Factors
Symptoms

Answer 28

• Most common malignancy of the reproductive system
• Slow-growing
• Most commonly seen in women ages 50-65
  *Risk Factors
• Excess exposure to estrogen is the greatest risk factor
• Starting period at early age
• Late menopause
• Nulliparity
• Obesity
• Fam hx of breast or ovarian cancer
  *Oral contraceptives decrease the risk** keeps endometrial lining thin
  *Symptoms:
• Vaginal bleeding is the hallmark symptom (esp if postmenopausal) -> early sign
• Pain associated with bleeding (low back pain, pelvic pain) -> late sign

Question 29

Endometrial cancer
Diagnosis
Treatment

Answer 29

Diagnosis
- Good prognosis if diagnosed early
- Endometrial biopsy
- Some can be picked on a PAP smear
Treatment
Depends on stage
- Total abdominal hysterectomy -> curative for early stage cancer
- Later stage -> may also need chemo
- Pre andPost Op care: Same for hysterectomy care for fibroids

Question 30

Ovarian cancer
Risk Factors
S/S

Answer 30

Risk factors
- Age
- Nulliparity
- Infertility treatments
- Personal hx of breast cancer
- Family hx of breast or ovarian cancer
- BRCA-1, BRCA-2
Vague symptoms
- Abdominal bloating
- Pelvic/abdominal pain
- Noticeable increase in abdominal girth
- Feeling full quickly
- Urinary urgency or frequency
High rate of recurrence

Question 31

Ovarian cancer
Screening/Dx
Treatment

Answer 31

Definitive screening tests do not exist
- Often caught in later stages; most deadly reproductive disease
- Best: regular GYN visits, regular pelvic exams
- Palpable ovary = concerning
Treatment dictated by stage of disease at time of initial diagnosis
- Surgical removal
- Chemotherapy
- Radiation

Question 32

Cervical Cancer
Risk Factors
S/S

Answer 32

• Usually originates in the transformation zone
• Preinvase
• 70-80% caused by HPV
• HPV 16 and 18 = strongest correlation
  *Risk factors
• Becoming sexually active at a young age
• Multiple sex partner or partner with multiple sex partners
• Lower socioeconomic status
• Smoking
  *Symptoms
• Usually asymptomatic for a long time
• Vaginal bleeding (esp post-coital)

Question 33

Cervical Cancer
Screening/Dx
Treatment

Answer 33

*Pap smear: the most reliable method to detect preinvasive cancer
- Ages 21-65: every 3 years OR (start at 21, every 3 years) Ages 30-65: every 5 years if PAP testing plus HPV testing done
- After age 65 and 3 consecutive negative results: discontinue screening
- After total hysterectomy FOR BENIGN REASONS: discontinue screening
*Follow-up of abnormal PAP test: within a year or 6 months
- Colposcopy: acetic acid makes area appear white (needs to be biopsied)
- Biopsy
*Conization
- Remove some of tissue, more invasive
*Cryosurgery
- Retain cervix integrity, get rid of rapidly dividing cells
- A technique to freeze abnormal cells is used
*Laser ablation
- Retain cervix integrity, get rid of rapidly dividing cells
- A laser mounted on a colposcope that allows precise direction of a beam of light (heat) is used to remove diseased tissue.
*Electrosurgical excision (LEEP): most common
- Retain cervix integrity, get rid of rapidly dividing cells
- Uses a wire loop electrode that can excise and cauterize with minimal tissue damage
*Surgery, radiation, and chemotherapy for invasive cancer
- Can do internal radiation; radioactive implant is inserted into cervix -> radioactive (limit exposure to staff and visitors)
- Chemo if needed

Question 34

Chlamydia
Symptoms
Complications

Answer 34

*Symptoms
Although chlamydial infections are usually asymptomatic, some women may experience:
- Spotting or postcoital bleeding
- Mucoid or purulent cervical discharge
- Dysuria
- Bleeding results from inflammation and erosion of the cervical columnar epithelium
*Complications
- Untreated infection often leads to acute salpingitis or PID
- Past infections: increased risk of ectopic pregnancy and tubal factor infertility.
- Inflammation results in microscopic cervical ulcerations and thus may increase the risk of acquiring HIV infection.
- Infants: neonatal conjunctivitis or pneumonia

Question 35

Chlamydia
Screening and Diagnosis

Answer 35

Screening
* Yearly screening of all sexually active women under age 25 years and women older than 25 years who are at high risk (new or multiple partners)
* All women with two or more of the risk factors for chlamydia should be screened.
* All pregnant women should be screened for chlamydia at the first prenatal visit
* Screening late in the 3rd trimester may be repeated if the woman was positive previously or if she is younger than 25 years, has a new sex partner, or has multiple sex partners.
Diagnosis
* Culture (expensive and labor-intensive)
* DNA probe (relatively less expensive but less sensitive)
* Enzyme immunoassay (also relatively less expensive but less sensitive)
* NAAT—expensive but with relatively higher sensitivity of urinary, vaginal, or endocervical specimens

Question 36

Chlamydia
Management

Answer 36

Azithromycin, 1 g PO once
OR
Doxycycline, 100 mg PO bid (tid for pregnant/lactating) for 7 days
*If the woman is pregnant, azithromycin or amoxicillin is used
*Pregnant women should be retested in 3 to 4 weeks to determine if treatment was effective (test of cure).
*All pregnant women who have a chlamydial infection should be retested 3 months after treatment
*All exposed sexual partners should also be treated.
*Nonpregnant women treated with doxycycline or azithromycin do not have to be retested unless symptoms continue, adherence was in question, or reinfection is suspected

Question 37

Gonorrhea
Symptoms
Complications

Answer 37

• Genital-genital contact; however, it is also spread by oral-genital and anal-genital contact.
  *Symptoms
• Often asymptomatic
• May have a purulent endocervical discharge
• Menstrual irregularities
• Chronic or acute severe pelvic or lower abdominal pain or longer, more painful menses
• Vague abdominal pain
• Low backache
• Dysuria
• Anal: profuse purulent anal discharge, rectal pain, blood in the stool, rectal itching, fullness, pressure, pain, diarrhea.
  *Complications
• Salpingitis may develop in the first trimester.
• Prelabor rupture of membranes
• Preterm birth
• Chorioamnionitis
• Neonatal sepsis
• Intrauterine growth restriction
• Maternal postpartum sepsis
• Newborn Ophthalmia neonatorum

Question 38

Gonorrhea
Screening & Diagnosis

Answer 38

Screening
* All sexually active women < 25 years of age who are at risk due to multiple sex partners or a new sex partner
* Pregnant women screened at the 1st prenatal visit, and infected women and those not infected but identified with risky behaviors should be rescreened at 3rd trimester
Diagnosis
* Culture and nonculture tests (nucleic acid hybridization tests and NAATs)
* Cultures should be obtained from the endocervix, rectum, and, when indicated, the pharynx
* Thayer-Martin cultures
* Should have a chlamydial culture and a serologic test for syphilis if one has not been done in the previous 2 months.

Question 39

Gonorrhea
Management

Answer 39

Recommended: ceftriaxone, 250 mg IM once plus treatment for chlamydia (125 mg for adolescents)
* Pregnant women should be retested after 3 to 4 weeks to determine if treatment was effective (test of cure).
* All pregnant women who have chlamydial infection diagnosed should be retested 3 months after treatment
* All women with both gonorrhea and syphilis should be treated for syphilis
* Recent (past 30 days) sexual partners should be examined, cultured, and treated with appropriate regimens.
* Educate use of condoms.
* Confidential counseling and testing for HIV infection

Question 40

Syphilis
Symptoms
Complications

Answer 40

• Transmitted through microscopic abrasions that can occur during sexual intercourse.
  Symptoms
• Primary syphilis:
• Primary lesion, the chancre that appears 5 to 90 days after infection
• Begins as a painless papule at the site of inoculation
• Erodes to form a nontender, shallow, indurated, clean ulcer
• Secondary syphilis:
• 6 weeks to 6 months after chancre
• Widespread symmetric maculopapular rash on the palms and soles
• Generalized lymphadenopathy
• Condylomata lata (broad, painless, pink-gray wart like infectious lesions) may develop on the vulva, perineum, or anus
• If the woman is untreated, she enters a latent phase that is usually asymptomatic.
• Tertiary syphilis
• Neurologic, cardiovascular, musculoskeletal, or multiorgan-system complications
  Complications
• Serious systemic disease and even death when untreated

Question 41

Syphilis
Screening & Diagnosis

Answer 41

Screening
* All women who are diagnosed with another STI or with HIV should be screened
* All pregnant women should be screened at the 1st prenatal visit and again early in the 3rd trimester and at the time of giving birth if they are at high risk.
Diagnosis
* Microscopic examination of primary and secondary lesion tissue and serology during latency and late infection
* Dark-field examinations and tests to detect T. pallidum directly from lesion exudate or tissue
* A test for antibodies may not be reactive in the presence of active infection because it takes time for the body’s immune system to develop antibodies to any antigen.
* Two types of serologic tests are used: nontreponemal and treponemal.
* Nontreponemal antibody tests: VDRL and RPR
* Treponemal antibody tests: FTA-ABS and TP-PA are used to confirm positive results.
* Seroconversion usually takes place 6 to 8 weeks after exposure, so testing should be repeated in 1 to 2 months when a suggestive genital lesion exists.

Question 42

Syphilis
Management

Answer 42

Primary, secondary, early latent disease:
* benzathine penicillin G, 2.4 million units IM once
Late-latent or unknown-duration disease:
* benzathine penicillin G, 7.2 million units total, administered as three doses, 2.4 million units each, at 1-wk intervals
* Penicillin allergy: doxycycline, 100 mg PO qid for 14 days OR tetracycline, 500 mg PO qid for 14 days
* Pregnant women who have a history of allergy to penicillin should be desensitized and treated with penicillin

Question 43

Pelvic Inflammatory Disease
Symptoms
Complications

Answer 43

• Can be caused by chlamydia or gonorrhea
• Infection is acute, subacute, or chronic
• Most PID results from ascending spread of microorganisms from the vagina and endocervix to the upper genital tract.
  Symptoms
• Pain is common to all types of infections
• Dull, cramping, and intermittent (subacute)
• Severe, persistent, and incapacitating (acute)
• Fever, chills, nausea and vomiting
• Increased vaginal discharge, symptoms of a urinary tract infection, and irregular bleeding.
• Abdominal pain
  Complications
• Increased risk for ectopic pregnancy, infertility, and chronic pelvic pain
• Dyspareunia (painful intercourse)
• Pyosalpinx (pus in the uterine tubes)
• Tubo-ovarian abscess
• Pelvic adhesions.

Question 44

Pelvic Inflammatory Disease
Screening & Diagnosis

Answer 44

The CDC recommends screening/treatment for PID in all sexually active young women and others at risk for STIs if the following criteria are present and no other cause or causes of the illness are found:
* Lower abdominal tenderness
* Bilateral adnexal tenderness
* Cervical motion tenderness
Diagnosis
* Oral temperature of 100.9°F or above
* Abnormal cervical or vaginal discharge
* Elevated erythrocyte sedimentation rate
* Elevated C-reactive protein
* Laboratory documentation of cervical infection with gonorrhea or chlamydia

Question 45

Pelvic Inflammatory Disease
Management

Answer 45

Parenteral Treatment
* Cefotetan 2 q IV q 12 hours
PLUS
* doxycycline, 100 mg PO or IV q 12 hours for 14 days OR Cefoxitin, 2 g IV q 6 hours
PLUS
* doxycycline, 100 mg PO or IV q 12 hours for 14 days OR Clindamycin, 900 mg IV q 8 hours
PLUS
* Gentamicin, loading dose IV or IM (2 mg/kg) followed by maintenance dose (1.5 mg/kg) q 8 hours
* Parenteral therapy can be discontinued 24 hours after clinical improvement. Ongoing oral therapy consisting of doxycycline 100 mg PO or clindamycine 450 mg PO qid for 14 days
Intramuscular/Oral Treatment
* Ceftriaxone 250 mg IM single dose
PLUS
* Doxycycline 100 mg PO bid for 14 days WITH OR WITHOUT Metronidazole 500 mg PO bid for 14 days OR Cefoxitin 2 g IM single dose and probenecid 1 g PO concurrently in single dose
PLUS
* Doxycycline 100 mg PO bid for 14 days WITH OR WITHOUT Metronidazole 500 mg bid for 14 days OR Other parenteral third-generation cephalosporin (ceftizoxime or cefotaxime)
PLUS
* Doxycycline 100 mg PO bid for 14 days WITH OR WITHOUT Metronidazole 500 mg PO bid for 14 days
Educate
- Self-protective behaviors such as practicing risk-reduction measures and using barrier methods
- Analgesics for pain
- As few pelvic examinations as possible during the acute phase of the disease.
- During the recovery phase the woman should restrict her activity and make every effort to get adequate rest and eat a nutritionally sound diet.
- Counsel women to refrain from sexual intercourse until treatment is complete

Question 46

HPV
Symptoms
Complications

Answer 46

• Viral infection; genital warts
• HPV 16 and 18 cause cancer in cervix, vagina, vulva, penis, oropharyngeal areas (complications)
  Symptoms
• HPV lesions commonly seen in the posterior part of the introitus; also found on the buttocks, vulva, vagina, anus, and cervix
• Soft, papillary swellings occurring singly or in clusters in the genital and anorectal regions
• Lesions resulting from infections of long duration may appear as a cauliflower-like mass.
• Chronic vaginal discharge
• Pruritus
• Dyspareunia
• Postcoital bleeding

Question 47

HPV
Screening and Diagnosis

Answer 47

• Physical inspection of the vulva, perineum, anus, vagina, and cervix
• Because speculum examination of the vagina may block some lesions, it is important to rotate the speculum blades until all areas have been visualized.
• When lesions are visible, the characteristic appearance previously described is considered diagnostic.
• Viral screening and typing for HPV is available but not standard practice
• History, evaluation of signs and symptoms, the Pap test, and physical examination are used in making a diagnosis.
• HPV-DNA: used in combination with the Pap test to screen for types of HPV that are likely to cause cancer in women older than age 30
• The only definitive diagnostic test for the presence of HPV is histologic evaluation of a biopsy specimen.

Question 48

HPV
Management

Answer 48

• The goal of treatment for genital warts is removal of the warts and relief of signs and symptoms
• Imiquimod, podophyllin, podofilox, and sinecatechins should not be used during pregnancy
• Genital warts: area clean and dry, oatmeal baths, cool air
• Cotton underwear and loose-fitting clothes
• The majority of partners of women with HPV will be infected even if they are asymptomatic
• Encouraged use of latex condoms consistently and correctly for intercourse
• Annual health exams, PAP test
• Prevention: Gardasil 9 vaccine for girls and boys age 9-45
  Medical Treatment
• Client-applied:
• podofilox, 0.5% solution, OR gel to wart bid for 3 days followed by 4-day rest for ≤ 4 cycles OR imiquimod, 5% cream, at bedtime 3 times a week for ≤16 weeks OR sinecatechins 15% ointment tid for ≤16 wk
• Provider- applied:
• Cryotherapy with liquid nitrogen or cryoprobe OR podophyllin resin, 10%-25% in tincture of benzoin compound weekly (wash off in 1-4 h). - Repeat weekly as necessary OR TCA or BCA 80%-90% weekly

Question 49

Genital Herpes Simplex Virus
Symptoms
Complications

Answer 49

• HSV-1 transmitted non-sexually, HSV-2 transmitted sexually
• HSV-2 usually associated with genital lesion
  Symptoms
• Genital infection is characterized by multiple painful lesions, fever, chills, malaise, and severe dysuria and may last 2 to 3 weeks
• Primary genital herpes lesions progress from macules to papules and then form vesicles, pustules, and ulcers that crust and heal without scarring
• Itching, inguinal tenderness, and lymphadenopathy.
• Severe vulvar edema may develop, and women may have difficulty sitting.
• Heavy watery-to-purulent vaginal discharge
• Urinary retention and dysuria may occur
• Recurrent lesions are unilateral, less severe, and usually last 5 to 7 days.
  Complications
• HSV cervicitis: friable, reddened, ulcerated, or necrotic
• Viremia occurs during the primary infection, and congenital infection is possible though rare.
• Miscarriage
• Neonatal herpes

Question 50

Genital Herpes Simplex Virus
Screening/Dx

Answer 50

• History of having viral symptoms such as malaise, headache, fever, or myalgia is suggestive
• Local symptoms such as vulvar pain, dysuria, itching, or burning at the site of infection and painful genital lesions that heal spontaneously are also highly suggestive
• Physical exam: assesses for lymphadenopathy and elevated temperature
• Vulvar, perineal, vaginal, and cervical areas: inspected for vesicles or ulcerated or crusted areas
• Speculum examination may be very difficult due to tenderness
• Any suggestive or recurrent lesions found during pregnancy should be cultured to verify HSV.
• Viral culture obtained by swabbing exudate during the vesicular stage of the disease.
• Type-specific serologic tests for HSV-2 antibodies

Question 51

Genital HSV
Management
(Medical treatment, care of lesion, education)

Answer 51

Medical Treatment: acyclovir is okay for pregnancy
* Primary infection
- For 7-10 days: acyclovir, famciclovir, valacyclovir
* Recurrent infection
- For 1-5 days: acyclovir, famciclovir, valacyclovir
* Suppression therapy:
- Take daily for 1 year or more: acyclovir, famciclovir, valacyclovir
Lesions
* Cleansing 2x a day with saline
* Warm sitz baths with baking soda
* Blowing the area dry with a hair dryer set on cool or patting dry with a soft towel
* Cotton underwear, loose clothing
* Drying aids: hydrogen peroxide, Burow solution, or oatmeal baths
* Applying cool, wet black teabags to lesions
Pain relief
* Aspirin, acetaminophen, or ibuprofen
* Thin layer of lidocaine ointment or an antiseptic spray
Education:
* When viral shedding and transmission to a partner are most likely
* Refrain from sexual contact from the onset of the prodrome until the lesions have completely healed
* Suppressive therapy decreases the risk of transmission to partners
* Condoms
* How to look for herpetic lesions using a mirror and a good light source and a covered finger to rub lightly over the labia.
* When lesions are active, avoid sharing intimate articles that come into contact with the lesions
* Plain soap and water or hand sanitizer are needed to clean hands that have come into contact with herpetic lesions
* Stress, menstruation, trauma, febrile illnesses, chronic illnesses, and ultraviolet light have all been found to trigger genital herpes.

Question 52

Trichomoniasis
Symptoms/Complications

Answer 52

• Protozoal Infection
  Symptoms
• Yellowish to greenish discharge that is frothy, mucopurulent, copious, and malodorous
• Discharge worsens during and after menstruation.
• Inflammation of the vulva, vagina, or both
• Irritation and pruritus
• Dysuria and dyspareunia
• “Strawberry spots” or tiny petechiae on vaginal or cervical walls
• Severe infections: the vaginal walls, cervix, and occasionally the vulva may be acutely inflamed

Question 53

Trichomoniasis
Screening/Diagnosis

Answer 53

• Complete record of the woman’s symptoms, their onset, and course
• Sexual history
• NAAT is highly sensitive
• Among women, vaginal swab and urine have up to 100% concordance.
• Clinicians using wet mounts should attempt to evaluate slides immediately
• Commonly HCPs will obtain saline and KOH wet smears and check vaginal pH; if the pH is greater than 4.5, trichomoniasis should be suspected.

Question 54

Trichomoniasis
Management

Answer 54

• Metronidazole or Tinidazole PO once
• Metronidazole not recommended during lactation; stop breastfeeding treat, resume breastfeeding in 12-24 h after drug completed
• Tinidazoles: Stop breastfeeding and resume 3 days after treatment
• No alcoholic beverages on metronidazole
• Discuss the significance of partner treatment, because if they are not treated it is likely that the infection will recur.
• Abstain from sex until they and their partners have been treated

Question 55

Fertility-Awareness-Based Methods (Natural Family Planning)
- Calendar Rhythm Method
- Standard Days Method
- TwoDay Method
- Cervical Mucus Ovulation Detection Method
- Basal Body Temp
- Symptothermal

Answer 55

• Identifying beginning and end of the fertile period.
• Relies on avoidance of intercourse during fertile periods
  1. Infertile phase: before ovulation
  2. Fertile phase: approx 5-7 days around the middle of the cycle, including several days before and during ovulation and the day afterward
  3. Infertile phase: after ovulation
• The exact time of ovulation cannot be predicted accurately, couples may find it difficult to exercise restraint for several days before and after ovulation
• Women with irregular menstrual periods have the greatest risk of failure
• Signs used to determine the time of fertility include menstrual bleeding, cervical mucus, and basal body temperature (BBT)
• Calendar Rhythm Method: Fertile period is determined by recording the lengths of menstrual cycles for at least 6 months. Beginning of fertile period: Subtract 18 days from length of shortest cycle. Subtract 11 days from length of longest cycle.
• Standard Days Method: Modified form of the calendar rhythm method that has a “fixed” number of days of fertility for each cycle, CycleBeads (26-32 day cycles)
• TwoDay Method: (1) “Did I note secretions today?” and (2) “Did I note secretions yesterday? if both is yes, no sex
• Cervical Mucus Ovulation Detection Method: Evaluate the mucus for cloudiness, tackiness, and slipperiness. Intercourse is considered safe without restriction beginning the fourth day after the last day of wet, clear, slippery mucus,
• Basal Body Temp: The fertile period is the day of first temperature drop through 3 consecutive days of elevated temperature. Abstinence begins the first day of menstrual bleeding and lasts through 3 consecutive days of sustained temperature rise
• Symptothermal: combines the BBT and cervical mucus methods; palpate cervix to assess for change indicating ovulation

Question 56

Spermicides
Method of Action, side effects, effectiveness

Answer 56

• nonoxynol-9 (N-9)
• Work by reducing the sperm’s mobility. The chemicals attack the sperm flagella and body, thereby preventing the sperm from reaching the cervical os.
• N-9 is a surfactant destroys the sperm cell membrane but may increase STI risk
• Women with high-risk behaviors are advised to avoid the use of spermicidal products containing N-9
• Intravaginal spermicides are marketed and sold without prescriptions as aerosol foams, tablets, suppositories, creams, films, and gels
• Effectiveness of spermicides depends on consistent and accurate use.
• The spermicide should be inserted high into the vagina so that it makes contact with the cervix.
• Some spermicide should be inserted at least 15 minutes before, and no longer than 1 hour before, sexual intercourse.
• Spermicide must be reapplied for each additional act of intercourse
• Some female barrier methods (e.g., diaphragm, cervical caps) offer more effective protection against pregnancy with the addition of spermicides

Question 57

Barrier Methods of Contraception
Condoms
Diaphragms
Cervical Caps
Contraceptive Sponge

Answer 57

Condoms
* Covers the penis, made out of latex, polyurethane, or natural membranes
* Nonspermicidal latex condoms protect against STIs
* Condoms lubricated with N-9 are not recommended for preventing STIs or HIV and do not increase protection against pregnancy.
* Latex condoms break down with oil-based lubricants and should be used only with water-based or silicone lubricants
* Polyurethane condoms are used for those with latex allergies, but slip or lose contour
* Natural membrane condoms do not protect against STIs
* Must be discarded after single use
* Female condoms: vaginal sheath made of nitrile with flexible rings at both ends. Offer protection against STIs
* The closed end of the pouch is inserted into the vagina and anchored around the cervix; the open ring covers the labia
* Female condoms should not be used with male condoms
Diaphragms
* Shallow dome-shaped latex or silicone device with a flexible rim that covers the cervix: coil spring, arcing spring, flat spring, and wide seal rim
* Effectiveness of the diaphragm is less when used without spermicide.
* Needs an annual gynecologic examination to assess the fit of the diaphragm
* Should be inspected before every use, should be replaced every 2 years, may have to be refitted for a 20% weight fluctuation
* Side effects may include irritation of tissues related to contact with spermicides. TSS may occur
Cervical Cap
* FemCap: silicone cervical cap that fits around the base of the cervix
* Recommended that the cap remain in place no less than 6 hours and not more than 48 hours at a time.
* It is left in place at least 6 hours after the last act of intercourse.
* The seal provides a physical barrier to sperm; spermicide inside the cap adds a chemical barrier.
* TSS may occur, another form of birth control is recommended for use during menstrual bleeding and up to at least 6 weeks postpartum
* Refitted for weight changes, checked once a year
Contaceptive Sponge
* Small, round polyurethane sponge that contains N-9, designed to fit over the cervix, opposite side has a woven polyester loop to be used for removal of the sponge.
* Must be moistened with water before it is inserted
* Provides protection for up to 24 hours and for repeated instances of sexual intercourse
* Should be left in place for at least 6 hours after the last act of intercourse.
* Wearing it longer than 24 to 30 hours may put the woman at risk for TSS

Question 58

Oral Contraceptive Pills
Combined Estrogen-Progestin Contraceptives
(COCs)
Minipill
Method of Action, effectiveness, side effects

Answer 58

• COCs suppresses the action of the hypothalamus and AP, leading to insufficient secretion of FSH and LH; follicles do not mature, and ovulation is inhibited.
• Maturation of the endometrium is altered, making it a less favorable site for implantation
• 1 to 4 days after the last COC is taken, the endometrial tissue sloughs and bleeding occurs as a result of hormone withdrawal
• Monophasic pills provide fixed dosages of estrogen and progestin
• Multiphasic pills (biphasic and triphasic) alter the amount of progestin and sometimes the amount of estrogen within each cycle.
• Should be taken at same time everyday
• Overall effectiveness is almost 100%
• Side effects of high doses of estrogen and progesterone include stroke, MI, thromboembolism, HTN, gallbladder disease, and liver tumors
• Estrogen excess: nausea, breast tenderness, fluid retention, and chloasma
• Estrogen deficiency: early spotting (days 1 to 14), hypomenorrhea, nervousness, and atrophic vaginitis leading to painful intercourse.
• Progestin excess: increased appetite, tiredness, depression, breast tenderness, vaginal yeast infection, oily skin and scalp, hirsutism, and postpill amenorrhea.
• Progestin deficiency: late spotting and breakthrough bleeding (days 15 to 21), heavy flow with clots, and decreased breast size.
• Common side effect: bleeding irregularities
• Some women prefer to take COCs in 3-month cycles and have fewer menstrual periods.
• Minipill: Contain only progesterone. Because the dose of progesterone is low, it must be taken at the same time every day

Question 59

Injectable Progestin
Method of Action, effectiveness, side effects

Answer 59

• Two formulations: DMPA or Depo-Provera
• There is a 150 mg IM injections given in the deltoid or gluteus maximus muscle, and a 104 mg SQ injection.
• Considered Long-acting reversible contraceptives
• DMPA should be initiated during the first 5 days of the menstrual cycle and administered every 11 to 13 weeks
• Contraceptive effectiveness comparable to that of perfect use of COCs
• Injections only four times a year
• Side effects at the end of a year include possible decreased bone mineral density, weight gain, and irregular vaginal spotting
• Return to fertility may be delayed as long as up to 10 months after discontinuing DMPA.

Question 60

Implantable Progestin
Method of Action, effectiveness, side effects

Answer 60

• Nonbiodegradable flexible tubes or rods that are inserted under the skin of a woman’s arm
• Effective for contraception for at least 3 years
• Single-rod etonogestrel implant (Nexplanon): only one approved for use in U.S.
• Insertion and removal of the single-rod etonogestrel capsule are minor, in-office surgical procedures
• Implants will prevent some, but not all, ovulatory cycles and will thicken cervical mucus.
• Irregular menstrual bleeding is the most common side effect. Less common side effects: headaches, nervousness, nausea, skin changes, and vertigo.
• Implants are understood to be as effective or even more so than sterilization and IUDs, so they are considered to be the most effective contraceptive methods available

Question 61

Intrauterine Devices
Method of Action, effectiveness, side effects

Answer 61

• A small T-shaped device with bendable arms for insertion through the cervix
• HCP inserts the IUD against the uterine fundus, the arms open near the fallopian tubes to maintain position of the device and to adversely affect the sperm motility and irritate the lining of the uterus.
• 2 strings hang from the base of the stem through the cervix and protrude into the vagina for the woman to feel for assurance that the device has not been dislodged
• 5 IUDs: the ParaGard Copper T 380A and the levonorgestrel hormonal intrauterine systems Mirena, Liletta, Kyleena, and Skyla
• ParaGard Copper T 380A: effective for 10 years of use, copper primarily serves to cause an immune response creating an unreceptive setting for sperm and interferes with oocyte division and development of fertilizable ova
• Mirena, Liletta, and Skyla release LNG from their vertical reservoirs. Effective for up to 5 years (Mirena) and 3 years (Skyla, Liletta) they impair sperm motility, thicken cervical mucus, decrease the lining of the uterus, and have some anovulatory effects.
• Uterine cramping and bleeding are usually decreased with these devices, although irregular spotting is common in the first few months following insertion.