305 female

• Menstrual Cycle


  • Pituitary gland makes follicle-stimulating hormone (FSH) and LH
  • The ovaries make progesterone and estrogen
• Menstrual Disorders


  • Premenstrual Syndrome
  • Menopause
• Menopause


  • Cessation of menstrual cycles for a year or persistently elevated FSH (>20mIU/mL)
  • Result of diminished estrogen
  • Occurs between 48 and 55 years of age
  • Perimenopause occurs ~ 4 years before menopause
  • Genitourinary: tissues shrink, become dry, lose elasticity, and friable
  • Body hair decreases and subcutaneous fat decreases (breasts shrink); ovaries & uterus decrease in size
• Menopause symptoms


  • Significant vasomotor instability secondary to the decrease in estrogens and relative increase in other hormones
  • "Hot flashes," palpitations, dizziness, and headaches as the blood vessels dilate
  • Estrogen loss increases risk of osteoporosis, cardiovascular disease, vision loss, and cognitive impairment
• Cardiovascular disease is the leading cause of death after menopause
• Vaginal Ecology


  • Balance of hormones & bacterial flora (lactobacillus)
  • pH 4-4.5
  • Imbalances increase the risk of infection
• Vaginitis


  • Inflammation of the vagina
  • Clinical manifestations include discharge, burning, itching, redness, and swelling of vaginal tissues
  • Pain with urination & intercourse
  • Causes-chemical, infection, foreign bodies
• Causes of vaginitis (post-menarche)

  • Candida albicans
  • Trichomonas vaginalis
  • Bacterial vaginosis
• Vaginal Cancer


  • Lifetime risk=1%
  • Most common symptom-abnormal bleeding
  • Other symptoms: vaginal discharge, palpable mass, dyspareunia
  • Often found during routine pelvic exam
  • Most are >60yrs (except for those caused by DES in utero)
  • Treatment-depends on type of cancer, location, size, spread, age
  • 80% of vaginal cancer is due to metastasis
• Acute Cervicitis


  • Infection of the cervix or extension of infection from the vagina or uterus
  • C. trachomatis is most commonly associated with mucopurulent cervicitis
  • Irritated, red, inflamed, edematous cervix
  • Mucopurulent drainage/leukorrhea
  • Treat the cause (antibiotics for bacterial causes)
  • Untreated cervicitis may extend to include the development of pelvic cellulitis, dyspareunia, cervical stenosis, and ascending infection of the uterus or fallopian tubes
• Cervical Cancer


  • Clinical Manifestations: Abnormal vaginal bleeding (freq. after intercourse), spotting, and discharge
  • More advanced disease may present with pelvic or back pain that may radiate down the leg, hematuria, fistulas (rectovaginal or vesicovaginal), or evidence of metastatic disease to supraclavicular or inguinal lymph node areas
  • Diagnosis: Abnormal Pap Smear-atypical squamous cells of undetermined origin (ASC-US) w/ +HPV, LGSIL, HGSIL
  • Treatment: Conservative management in young women; early-removal of lesions; invasive-surgery, radiation therapy
• The squamocolumnar junction (transformation zone) changes location in menarchial, menstruating, menopausal, and postmenopausal women
• The Bethesda system is used for designation of premalignant cervical disease as squamous intraepithelial lesions (SILs)
• Endometritis


  • The endocervix is exposed during childbirth, abortion
  • Clinical manifestations: Mild to severe uterine tenderness, fever, malaise, and foul-smelling discharge
  • Increased Risk: Chorioamnionitis during labor, a cesarean section, or needed manual or instrumented removal of the placenta, pelvic inflammatory disease, retained tissue
  • Diagnosis: Presence of plasma cells
  • Prophylactic antibiotics are given to prevent endometritis
  • This condition can lead to a life-threatening sepsis
• Endometriosis

  • Etiology-unclear, may be immune or inflammatory
  • Functional endometrial tissue is found in ectopic sites outside the uterus
  • Endometrial tissue growth is stimulated by estrogen; this tissue undergoes the changes of the menstrual cycle
  • Clinical manifestations: Pelvic pain, strongest before menses, back pain, dyspareunia, and pain upon defection
  • Can lead to scarring, adhesions, and ovarian cysts (endometriomas)
  • Associated with infertility because of adhesions
  • Treatment: Pain relief, suppress endometrial growth (hormones), and surgery
  • Sites may include ovaries, posterior broad ligaments, uterosacral ligaments, pouch of Douglas, pelvis, vagina, vulva, perineum, or intestines
• Endometrial Cancer


  • Occurs at twice the rate of cervical cancer; average age >60yr
  • Most are adenocarcinomas
  • Two types (1 and 2)
  • Clinical Manifestation: abnormal, painless bleeding
  • Risk factors: anovulatory cycles, disorders of estrogen metabolism (Type 2 DM, HTN, PCOS), unopposed estrogen therapy, estrogen-secreting granulosa cell tumor, and obesity
  • Diagnosis: Biopsy and dilation and curettage (D&C)
  • Treatment: Depends on type; surgery, radiation therapy, other modalities
• Leiomyomas


  • Uterine Leiomyomas (fibroids) are benign neoplasms of muscle origin
  • Submucosal, subserosal, or intramural (in the uterine corpus)
  • Occur in 1:4-5 females >35 yrs
  • Clinical Manifestations: asymptomatic half the time, depends on type-uterine enlargement, impingement on the bladder, ureters, to bleeding, necrosis, and infection
  • May cause menorrhagia, anemia, urinary frequency, rectal pressure/constipation, abdominal distension, and infrequently pain
• Pelvic Inflammatory Disease (PID)

  • Polymicrobial infection of the upper reproductive tract (uterus, fallopian tubes, ovaries)
  • Often Associated with STIs (N. gonorrhoeae or C. trachomatis) but can be found without STIs present
  • Organisms ascend through the endocervical canal to the endometrial cavity, and then to the tubes and ovaries
  • Predisposing factors: Age (16-24), nulliparity, multiple sexual partners, history of PID, IUD use the first month after insertion (3-5-fold increase concurrent w/other factors)
  • Clinical manifestations: Lower abdominal & back pain, Dyspareunia, adnexal tenderness, painful cervix on bimanual pelvic examination, Purulent cervical discharge, fever (>101°F)
  • Diagnosis: Labs-presence microbes, cells of inflammation, WBCs, CRITERIA for diagnosis: Uterine tenderness +/- adnexal tenderness
  • Treatment: Antibiotic therapy
  • Complications: Include pelvic adhesions, infertility, ectopic pregnancy, chronic abdominal pain, and tubo-ovarian abscesses
  • Patients may require hospitalization w/IV antibiotic therapy
• Ovarian Cancer


  • Clinical manifestations: Often attributed to more common maladies
  • Abdominal or pelvic pain, increased abdominal size or bloating, and difficulty eating or feeling full quickly after ingesting food
  • Ascites, assoc. w/worse prognosis
  • Diagnostics: Transvaginal sonography/CT, Lab-biomarker-CA-125
  • Treatment: Surgery, chemotherapy, radiation, hormone therapy, the new frontier-immunotherapy
• Breast Cancer


  • Diagnosis and Classification: Physical examination, mammography, ultrasonography
  • May manifest as a mass, a puckering, nipple retraction, or unusual discharge
  • Changes in tissue texture & appearance
  • Mass on SBE or mammogram
  • Further evaluation-biopsy
  • Management/Treatment: Depends upon stage, Oncologic tissue analysis-identifies tumor type, helps determine most effective treatment
• Sexually Transmitted Infections


  • Viral STIs: Human Papilloma Virus (HPV), Herpesvirus (HSV II), Molluscum Contagiosum, Mpox (monkeypox virus)
  • Bacterial STIs: Bacterial Vaginosis (BV), Gonorrhea, Syphilis
  • Fungal STI: Candidiasis
  • Parasitic STI: Trichomoniasis, Chlamydia
• Human Papilloma Virus (HPV)


  • Causes warts, lesions, and cancers
  • Now the most common STI
  • Risk factors <25 yrs old, early age of first intercourse (<16 years), increased number of sex partners, and having a male partner with multiple sex partners
  • HPV infection can occur with any type of vaginal or anal penetration, or, more rarely, oral sex
  • Most HPV infections are asymptomatic and transient and resolve spontaneously within 2 years without treatment if the person has an intact immunologic system
• Herpesviruses


  • Women-at higher risk, more mucosal surface area: involvement of cervix, vagina, urethra, and inguinal lymph nodes
  • Men: urethritis and lesions of the penis and scrotum
  • Rectal and perianal infections are possible with anal contact
  • Systemic symptoms include fever, headache, malaise, muscle ache, and lymphadenopathy
  • Diagnostics: Labs-swab-polymerase chain reaction test (PCR)
• Candidiasis


  Caused by candida albicans and other types of candida, thick and white discharge
• Trichomoniasis


  Caused by Trichomonas vaginalis, an anaerobic protozoan, causes vaginitis with copious, frothy, malodorous, green or yellow discharge, erythema and edema of the affected mucosa
• Chlamydia


  Caused by C. trachomatis, an obligate intracellular bacterial pathogen, subtypes A-C cause trachoma and chronic keratoconjunctivitis, subtypes D-K cause genital infections like nongonococcal urethritis in men and PID in women
• Human Papilloma Virus (HPV)

  Causes Condylomata Acuminata (Genital Warts), now the most common STI, risk factors include age <25, early age of first intercourse (<16 years), increased number of sex partners, and having a male partner with multiple sex partners, can occur with any type of vaginal or anal penetration, or, more rarely, oral sex, most HPV infections are asymptomatic and transient and resolve spontaneously within 2 years without treatment if the person has an intact immunologic system
• Herpesviruses


  Women are at higher risk due to more mucosal surface area, can involve the cervix, vagina, urethra, and inguinal lymph nodes, in men can cause urethritis and lesions of the penis and scrotum, rectal and perianal infections are possible with anal contact, systemic symptoms include fever, headache, malaise, muscle ache, and lymphadenopathy
• Trichomoniasis


  Caused by Trichomonas vaginalis, an anaerobic protozoan, causes vaginitis with copious, frothy, malodorous, green or yellow discharge, erythema and edema of the affected mucosa, with occasional itching and irritation, small hemorrhagic areas on the cervix called strawberry spots, risk factor for HIV in men and women, complications include tubal infertility, PID, premature birth (in pregnancy), nongonococcal urethritis (in men)
• Chlamydia


  In women can cause salpingitis, mucopurulent cervical discharge, cervix hypertrophies becomes erythematous and friable, in men if symptomatic can cause urethritis including meatal erythema and tenderness, a purulent penile discharge, and urethral itching, complications include fallopian tube damage, prostatitis & epididymitis (may lead to infertility), and Reiter Syndrome
• Chlamydia Diagnostics

  Swab-NAAT (nucleic acid amplification tests)
• Chlamydia Treatment

  Antibiotics (azithromycin or doxycycline, penicillin is ineffective), doxycycline is currently first line in females
• Chlamydia Prevention


  USPSTF recommends annual screening of sexually active adolescents and young adult females
• Gonorrhea


  Bacterial infection due to N. gonorrhoeae, a pyogenic (i.e., pus-forming), gram-negative diplococcus, 2013-2017 saw a 67% increase, at risk are young males (20-24 yrs old), transmitted through sexual intercourse except for perinatal transmission, portal of entry can be the genitourinary tract, eyes, oropharynx, anorectum, or skin
• Gonorrhea Clinical Manifestations


  Usually manifests in 2-7 days, moves exterior to interior, in men it spreads to prostate and epididymis, may be asymptomatic, in men causes urethral pain and a creamy yellow, sometimes bloody, discharge, in women often causes endometritis, salpingitis, and PID, symptoms may be exacerbated during or after menses, can also cause unusual genital or urinary discharge, dysuria, dyspareunia, pelvic pain or tenderness, unusual vaginal bleeding, fever, and proctitis, rectal infections are common in homosexual men
• Gonorrhea Complications


  In males chronic infection can affect the prostate, epididymis, and periurethral glands, in females chronic infection affects the uterus and fallopian tubes leading to scarring and infertility, can also cause gonorrheal conjunctivitis risking blindness in neonates born to infected mothers, can lead to amniotic infection syndrome with premature rupture of the membranes, premature delivery, and increased risk of infant morbidity and mortality, may invade the bloodstream causing disseminated gonococcal infection affecting joint spaces, heart valves, meninges, and other body organs and tissues
• Gonorrhea Diagnostics

  Gram stain/culture; NAAT
• Gonorrhea Treatment

  Antibiotic therapy (IM Ceftriaxone is first line)
• Gonorrhea Prevention


  USPSTF guidelines - screen sexually active females < 25 yrs, new or multiple sexual partners, inconsistent condom use, sex work, or drug use, and screen for other STIs (syphilis and chlamydia), all pregnant women are screened at first prenatal visit (repeat in 3rd trimester if high risk), neonates are routinely treated with antibacterial agents applied to the conjunctiva within 1 hour of birth (against various STIs)
• Syphilis


  Caused by the spirochete Treponema pallidum, 2013-2017 saw a 72.7% increase, highest rates in men aged 25-29, transmitted through direct contact with an infectious moist lesion, usually through sexual intercourse, other portals of entry include contact with secretions, skin abrasions, and transplacental to fetus (after 16 wks gestation)