3. Menopause and After
Symptoms : amenorrhea, oligomenorrhea, hot
flashes, night sweats, mood changes, vaginal
dryness, urinary incontinence, dyspareunia
Signs Carefully evaluate patient for height
loss and kyphosis ( signs of osteoporosis)
On breast exam evaluate for evidence of
possible breast mass as well as axillary and
supraclavicular lymphadenopathy. ( Age is the
most imp risk factor for ca.breast )
On pelvic exam, look for signs of estrogen
deficiency (e.g., vulvar or vaginal atrophy).
4.
If woman under age 40 shows evidence of
menopause refer to reproductive
endocrinologist because most women
experience menopause in their 40s and 50s.
( this may suggest premature ovarian failure
If amenorrhea is present without other
evidence for menopause, rule out other
etiologies
5. Differential Diagnosis of Menopause
Disease
Characteristics
Notes
Premature
ovarian
failure
Age <40 years
Thyroid
disorders
Weight gain or loss, heat
or cold intolerance,
fatigue, anxiety, change in
bowel habits
More frequently
hypothyroidism, but also
hyperthyroidism may
cause amenorrhea
Autoimmune
disorders
Other systemic symptoms,
such as joint pain
May cause premature
ovarian failure
Hyperprolact Galactorrhea, drug use,
inemia
headache, visual
disturbance
Pregnancy
Weight gain, nausea,
breast tenderness
Late-onset
congenital
adrenal
hyperplasia
Elevated 17 OH
progesterone
May be associated with
virilization
7. Test
Notes
Follicle
stimulatig
hormone
(FSH)
An elevated follicle stimulating hormone level (>30
mIU/mL) is consistent with the diagnosis of
menopause . In women under 40, two to three levels
may be needed to make the diagnosis; best done
around day 3 of the cycle if it can be timed
Thyroid
Screen for hypothyroidism or hyperthyroidism
stimulatin
g
hormone
Prolactin
Hyperprolactinemia may be accompanied by
galactorrhea
Pregnany
test
(BhCG)
Although unlikely in this age group, pregnancy can
occur
Estradiol
May be useful in women using hormonal
contraception; 7 days after discontinuation of oral
contraceptives, a result of <20 pg/mL is consistent
with menopause
8. D/D – Hot Flashes
Recognize that hot flashes may be caused by
conditions other than menopause.
If the patient does not otherwise clinically appear to
be menopausal, screen for:
Symptoms of thyroid disease
Alcohol intake
Infection, such as malaria
Pheochromocytoma
Carcinoid syndrome
Panic attacks
9.
A 50 Y/O Just attained Menopause has this
severe hot flashes. She does not want to use
HRT and asks you about alternative therapies
what will you explain?
She also asks if HRT will reduce her CAD
risk?
10. Hot Flushes
Affect 75% of peri-menopausal women.
Consider lifestyle modifications, such as: Regular exercise ,
Avoidance of caffeine and alcohol , Stress reduction
Oral estrogen effectively treats hotflashes, night sweats and
sleep disturbances that accompany them
To prevent Ca. Endometrium progesterone should be given
with estrogen unless they had a hysterectomy
Combination therapy or Estrogen alone should be given
continuously when combination therapy is given
continuously 70% women may experience some spotting during
first 6-12 mos and then become amenorreoc after 1 yr. Do not
confuse this with postmenopausal bleeding
SERMs ( Selective Estrogen Receptor Modulators) may
precipitate hot flushes in some women
Alternative therapies for Hot Flushes SSRIs, Venlafaxine,
Gabapentin, dietary soy protein > 25g/day ( consider these in pts
with hx of DVT/PE etc where HRT is absolutely
contraindicated )
11. Genitourinary Symptoms Menopause
Vaginal dryness, Dypareunia, urinary
frequency and incontinence common in
postmenopausal women.
Rx: Vaginal Lubricants and Kegel Exercises
Other options vaginal estrogen cream or a
diaphragm like vaginalestrogen/silicone ring.
Serum estrogen levels are not increased with
ring device hence, a preferred option over
vaginal cream in women with ca.breast.
12. Osteoporosis - Menopause
Screening BMD/ Dexa Scan recommended
only for women > 65 yrs and for women under
65 yrs if there are additional risk factors
HRT ( Estrogen) can increase the BMD and
reduce risk of vertebral and hip #s by 27%.
In pts not on HRT, if BMD/DEXA shows T
score less than – 2.5 definitely should be on
bisphosphonates + calcium supplements.
Repeat BMD testing in 2 years for women
diagnosed with osteopenia or osteoporosis.
13. Screen for risk factors and/or presence of osteoporosis in Post
Menopausal pts
Non modifiable risk factors for osteoporotic fracture:
Personal history of fractures as an adult
History of fracture in a first-degree relative
Caucasian or Asian race
Advancing age (relative risk increases two- to three-fold per decade after age 50)
Female sex
Dementia
Neuromuscular deficits
Delayed menarche (after age 15)
Early menopause (under age 45) or bilateral ovariectomy
Loss of height (>2 cm)
Frailty or poor health
Potentially modifiable risk factors for osteoporotic fracture include:
Current cigarette smoking
Low body weight (under 127 lbs)
Recent weight loss of 10 lbs or more
Estrogen deficiency
Prolonged premenstrual amenorrhea (more than 1 year)
Low calcium intake (lifelong)
High alcohol intake
Recurrent falls
Inadequate physical activity
Glucocorticoid use
Use of medications that affect balance
Frailty or poor health
Do a DEXA scan to assess risk for osteoporosis in all women over age 65, and in women under age 65 with risk factors ( begin
at 60 if risk factors).
14. CAD – Menopause - ? HRT
“ HRT is not effective for primary or
secondary prevention of CAD “ even
though HRT has modest beneficial effects on
serum lipids, studies ( HERS trial ) have not
shown any reduction in cardiovascular
mortality. In fact, there is an increased risk of
CAD & Stroke probably related to thrombosis
in the first 6 mos of therapy
15. Venos Thromboembolism and Ca.
Breast Risks - HRT
Venos thromboembolism
A known risk of HRT and
SERMs.
The risk of venous
thromboembolism in
women on HRT is 2 x
control population
All women must be
counseled regarding this
risk before HRT
Ca. Breast There is
slightly increased risk for
women on HRT.
Risk does not increase in
first 5 yrs of use and risk
returns to baseline 5 yrs
after cessation of HRT.
16. Cognitive Function - HRT
•
•
•
Women on Estrogen + progestin have an increased risk of
dementia or mild cognitive impairment as opposed to those on
placebo.
TO Summarize remember
Even though Risk of DVT/PE and Cardiovascular events is
increased in first 6mos of use, HRT remains preferred Rx for
vasomotor symptoms and an effective preventive therapy for
osteoporosis and hip # for women without significant risks for
CAD or thromboembolism.
Less than 3 years of use for perimenopausal symps
( hotflashes ) does not increase risk of ca.breast
Women on HRT for more than 3 yrs should be tapered off
unless osteoporosis prevention is a major concern ( eg: in
women who cannot tolerate bisphosphonates )
17. Some points - HRT
For HRT Consider tamoxifen for women at
high risk of breast cancer.
May consider using of raloxifene (60 mg/d), a
selective estrogen receptor modulator
(SERM), for patients with high risk of breast
cancer and risk for osteoporosis.
Note that Tamoxifen/ raloxifene is not useful
in the treatment of hot flashes or other
menopausal symptoms and may induce or
worsen symptoms in some women.
18. HRT - Contraindications
Absolute contraindications to HT:
Pregnancy
Unexplained vaginal bleeding ( ? Cancer )
Active or chronic liver disease
Acute cardiovascular disease or immobilization
History of breast or endometrial cancer
History of cardiovascular disease (CAD or stroke)
History of thromboembolic disease not related to hormone therapy
Recent vascular thrombosis
Hypertriglyceridemia ( Estrogens increases TG level and also HDL level.
In pts with baseline hypertriglyceridemia, better avoid ERT. If ERT is
started for compelling causes monitor TG level frequently to avoid
Pancreatitis.)
Relative contraindications:
Increased risk for breast cancer
Increased risk for cardiovascular disease
Gallbladder disease
Migraine headache (however, Some types of menstrual migraine
responds to OCPills like seasonale)
19. Patient education - HRT
Inform patients about the benefits of HT.
Educate all patients that HRT:
Can help alleviate the vasomotor symptoms of
menopause and relieve vaginal dryness
Has been shown to reduce the risk of osteoporosis
and colorectal cancer
20. Patient Education - HRT
Counsel patients regarding the risks associated with HT.
Associated with an increased risk of:
CHD, when estrogen is used in combination with progestin
Endometrial cancer when estrogen is used unopposed in women with
an intact uterus
Stroke
Breast cancer
Venous thrombotic events (DVT and PE)
Gallbladder disease
Abnormal mammogram
Urinary incontinence
Ovarian cancer
Dementia
Remember that HRT is contraindicated in women with:
Known cardiovascular disease
Breast cancer
Hormone-sensitive cancers
21. NOTE:
OCPs decrease the risk of ovarian ca where as HRT
increases it. (OCPs reduce risk of ovarian ca by
causing anovulation and there by, reduces the repair
associatyed with it. HRT, given in post menopausal
women obviously loses this advantage of
anovulation. On the contrary, some epithelial ovarian
cancers have estrogen receptors increased risk)
OCPs role in breast Ca is controversial. HRT
increases Breast cancer risk ( esply, hormone +ve
breast CA, ER+, PR+, HER2)
OCPs decrease endometrial ca. HRT increases it.
23. For Women on HRT
Consider the following for bleeding:
With cyclic therapy, obtain endometrial biopsy if
bleeding occurs irregularly and/or unpredictably, or if
bleeding is unusually heavy or prolonged
With continuous therapy, obtain endometrial biopsy
if bleeding is heavy or extended, or if light bleeding
or spotting continues more than 12 months after
starting therapy
For women using unopposed estrogen, evaluate any
vaginal bleeding with an endometrial biopsy
For women not on HRT, any postmenopausal
bleeding requires endometrial biopsy
25. Types
Natural Methods : Abstinence, Breast feeding ( Lactation Amenorrhea
Method) and Coitus interruptus
Condom
Oral Contraceptive pills
Contraceptive patch
Hormonal Vaginal Ring
Diaphragm
Depo-Provera
Cervical cap
IUD
Which type preferred when – refer to pdf files on this desktop eg: iud,
levonorgesterol implant etc – several QS
26. Breast Feeding
Lactation Amenorrhea Method Suckling causes increased
prolactin,which inhibits estrogen production and ovulation
2% failure rate observed in 1st six mos.
Good contraceptive method for :– Amenorrheic women < 6
months post-partum who exclusively breastfeed i.e; if they are
providing 90% of nutrition via. breast milk
Breast feeding should be encouraged as a mode of
contraception in
– Women free of blood-borne infections
– Women not on drugs that could effect baby
Adverse effects : increased risk of mastitis. Also, be warned
that return of ovulation may precede return of menses
27. Condom
Condom Effective for contraception –95%
Only contraception that also prevents of STD
Typical use failure rate 15%
Ideal for couples in which one member has STD or
if couples do not want to use hormonal
contraception or when couples are just beginning
use of another mode of contraception
28. Female condom
Sheaths of Latex, Polyurethane or natural
membranes that may or may not have
spermicide
Failure rate : 21% if used alone without
spermicide gel
Female condom can also protect against STDs
and it is reusable if the partner has no STD.
29. Diaphragm
Latex dome shaped device that covers the cervix
( may cause reaction in latex allergic people)
Must be combined with contraceptive gel
Can be put in several hours before intercourse and
must be left in 8 hours after intercourse
Side effects : Increased risk of UTIs
Decreases risk of PID
No protection against HIV
30. Spermicide
Most common spermicide is nonoxynol-9
Available in creams, films, foams, gels, suppositories,
sponges, and tablets
It is of best use when combined with barrier methods
29% failure rate when used alone
31. Cervical Cap
Must be combined with contraceptive gel
Can be put in several hours before intercourse and
must be left in 8 hours after intercourse
Does not protect against HIV
May decrease risk of PID, Gonorrhea and
Chlamydia
No side effects
32. Hormonal Vaginal Ring
Nuvaring estradiol & etonogestrel
Keep one ring for three weeks and no ring for
one week hormones will be absorbed
anywhere in vagina
Advantage :
Patient compliance increased has to remember
to insert and remove the ring once a month
Can be placed anywhere in the vagina
33. Contraceptive patch
Ortho Evra
Keep one patch a week for three weeks and fourth week
is without a patch.
Compliance is increased with this as opposed to OCPills
Disadvantages patch is less effective in
obese women above 198 pounds
34. Depo-Provera
Only injectable contraceptive currently available.
Given as intramuscular injection every 3 months
( contraceptive level maintained for 14 weeks)
Mechanism : Thickens cervical mucus, blocks LH
surge
Compliance is easy
Side effects :
Can cause irregular bleeding and most are amenorrheic
at one year
If > 2 years of continuous usage, obtain DXA to
evaluate bone density
35. Depo-Provera
Indicated in women:
Who desire long-term continuous contraception.
Those who have compliance issues and want to
avoid a contraceptive method which requires a
daily regimen
Who can not tolerate estrogen preperations.
Who desire a contraceptive that does not increase
the risk of thrombosis or those who have a history
of thrombophilia ( with no active DVT or PE)
Who are taking anticonvulsants or rifampin or
other drugs which decrease the efficacy of
estrogen preperations (combined oral
contraceptives)
36. Depo - Provera
Advantages
1.
2.
3.
4.
5.
Long acting
Estrogen free
Safe in breast feeding
No need to take daily
compliance increased
Increases milk quality in
nursing mothers
Disadvantages
1.
2.
3.
4.
5.
6.
7.
Irregular bleeding 70%
cases in first year of use
Depression ( hx of
endogenous depression is an
absolute contraindication)
Breast tenderness
Weight-gain
Decreases bone density
Menses only slowly return
even after stopping use.
Decreases HDL cholesterol
37. Depo-Provera
It is progesterone only. So, sometimes can
cause heavy bleeding as it makes endometrium
thin and unstable.
Managing heavy bleeding on Depo-Provera
Rule out pregnancy first – obtain HCG.
Add a low dose monophasic combined oral
contraceptive for 2-3 cycles, or
Add premarin ( conjugated estrogens) 1.25 daily for 2 to
3 months.
38.
Copper T
IUD
copper is a spermicide that inhibits sperm motility and acrosomal
enzyme action.
It lasts 10 to 12 years.
May cause Dysmenorrhea
Failure rate is 0.8%
Mirena (levonorgestrel)
Increases cervical mucus thickness there by preventing sperm
migration.
Can be left in place for 5 years
Causes amenorrhea in many patients
Advantages :
Compliance is easy -Nothing to remember like OC pills
Improves menorrhagia in 90% pateints
Suited for longer contraceptive needs
Failure rate 0.1%
39. IUD
IUD mainly preferred for people in mutually
monogamous relationships and those who seek
long term contraception
Adverse effects :
Not good for those with multiple sex partners because
IUDs increase the risk of PID, esply within first 20
days of insertion.
Uterine perforation
Expulsion of IUD
Vasovagal syncope after insertion
40. Oral Contraceptive Pills
- 99.9% efficacy rate if used correctly
-
In Adolescents – compliance is low and hence,
efficacy rate is only 95%
Read in and out
A Very high-yield topic
41. OC Pills
Most commonly used estrogen in the OC pills
is ethinyl estradiol. However, multiple forms
of progestins are used in combination pills.
Two types :
Monophasic: same amount of hormone in each active
tablet
Multiphasic: varying amounts of hormone in each
active pill
Most OCP’s have 21 active pills and 7 placebo
pills
42. Instructions on use of OC Pills
Starting OC pill
Missed pill
The patient begins taking the pills on the first day of menstrual bleeding or on the first Sunday
after menstrual bleeding begins or patient takes the pills immediately if she is definitely not
pregnant and has not had unprotected sex since her last menstrual period.
If it has been less than 24 hours since the last pill was taken, advise patient to take the pill now
and resume normal pill-taking routine.
If it has been 24 hours since the last pill was taken, advise the patient to take both the missed
pill and the next scheduled pill together.
If it has been more than 24 hours since the last pill was taken (i.e., two or more missed pills),
advise her to take the last pill that was missed and throw out the other missed pills and take the
next pill on time. Additional contraception like condoms should be used for the rest of the
cycle.
Using Additional contraceptive method
Patient should use additional contraception for the first 7 days after first starting oc pills.
An additional contraceptive is also needed for 7 days if she is more than 12 hours late in taking
ocp.
An additional contraception should be used if the patient is taking an interacting drug and for
7 days thereafter. Some eg: of the drugs that reduce the efficacy of OC Pills are Rifampin
( well known to cause contraceptive failure) , Tetracycline, metronidazole, phenytoin,
carbamazepine can lead to contraceptive failure Valproic acid and Gabapentin do not
interfere with OCPs
43. OCP - Absolute Contraindications
Venous thromboembolism
Cerebrovascular or coronary artery disease
Diabetes with complications
Breast Cancer ( If History of breast cancer but no recurrence
in past 5 years – just caution, not absolute contraindication)
Pregnancy
Lactation (<6 weeks postpartum) – estrogen inhibits milk
secretion
Liver disease
Headaches with focal neurologic symptoms
Major surgery with prolonged immobilization
Age >35 years and hx of smoking more than 20 cigarettes day
(Age >35 years and if smoked fewer than 20 cigarettes per day
- just caution, not absolute contraindication)
Hypertension (blood pressure of >160/100 mm Hg or with
concomitant vascular disease)
44. OCPills – Benefits outweigh Risk
For these patients, there is a risk with OC Pills. But if benefits
outweigh risk, so OCPs can generally be prescribed without
restriction to patients with these conditions.
- Severe headaches after initiation of oral contraceptive pills
- Diabetes mellitus
- Major surgery without prolonged immobilization
- Sickle-cell disease or sickle-cell- hemoglobin C disease
- Blood pressure of 140/100 to 159/109 mm Hg
- Undiagnosed breast mass
- Cervical cancer
- Age >50 years
- Family history of lipid disorders
- Family history of premature myocardial infarction
45. OCPills - Non-contraceptive Benefits
Dysmenorrhea
Mittelschmerz
Metrorrhagia
Premenstrual syndrome
Hirsutism
Reduces risk of Ovarian and endometrial cancer
Rx for functional ovarian cysts in young women
Reduces benign breast cysts
Useful in Ectopic pregnancy
May reduce Acne which in androgen dependant
Useful in endometriosis
Increases bone mineral density
46. Side Effects - OCPills
Breakthrough bleeding or spotting is a very
common side effect - esply in first few months.
Nausea, breast tenderness and vascular
headaches are estrogen mediated
Acne, oily skin, hirsutism and, possibly, weight
gain are androgen mediated ( Progestins)
( Weight gain with ocpills has not really been
established as a side effect in the studies – this is
mostly patient felt side effect)
47. Side Effects - OCPills
Addressing Breakthrough Bleeding:
A common side effect after starting OC Pills.
Women are often concerned that this might reflect failure of OC Pills. This
does not reflect a failure but it is secondary to tissue breakdown as the
endometrium adapts to the new thin and atrophic state.
Estrogen stabilizes the endometrium. So, breakthough bleeding is usually
rare with preperations containing high estrogen component. However, the
preperations that are commonly used now are low in estrogen.
Approach to break through bleeding :
Do not immediately make changes in OC pills
First step is Reassurance. Encourage the patient to take the OC Pill for at least
three cycles before switching to another combination . Most times bleeding
stops by third cycle.
If there is bleeding issues do not resolve even after third cycle, one of the
following approaches can be used :
Switch to a combination pill with higher estrogen or
Prescrible additional estrogen for one to two cycles until bleeding
resolves.
If the bleeding continues despite above measures, structural causes of bleeding
such as fibroids and polyps must be ruled out.
48. Side Effects - OCPills
Amenorrhea
Amenorrhea can occur in some women after starting OC pills.
This can occur anytime in about 10% of cycles. This is due to a
very atrophic endometrium.
Women may be concerned that the pregnancy might have
occurred
Approach :
Get a beta HCG to rule out Pregnancy
If not pregnant, one of the following approaches can be
used to treat post pill amenorhea
Switch to higher estrogen containing combination or
Prescribe additional small dose of estrogen to one or two cycles
or
Obtain Urine HCG monthly to r/o pregnancy ( less costeffective option)
49. Side Effects - OCPills
Post Pill Amenorrhea :
This is the amenorrhea that occurs after the woman stops
taking the OC pills.
It is possible that this is related to OC pills but one
should keep in mind other causes of secondary
amenorrhea.
Always get a pregnancy test.
Approach :
Post pill amenorrhea problem should usually resolve
in about 3 months after stopping the OC pills. So,
observe the woman for three months.
If the woman, continues to be amenorrheic even after
3 months after discontinuing the OC pill need to
evaluate for endocrine causes of amenorrhea - Work
up for secondary amenorrhea ( check the slide on
work-up for secondary amenorrhea )
50. OC pills and Headaches
Headache is a common side effect with OCPs.
You will be frequently tested on exam to give advice about the use of OCs to
women with headache because OCpill use and headaches are both common
problems in women
Note that Migraine with Aura is a risk factor for ischemic stroke. OCPills is
also an independent risk factor for ischemic stroke.
Migraine without aura does not seem to significantly increase the risk of stroke.
In case of Migraines, it is safe to initiate OC pills if there is no aura and if there
are no additional risk factors for stroke ( eg: HTN, Smoking etc)
If Migraines worsen after starting OC Pills, use combinations with lower
estrogen. If migraines occur with aura after starting OC Pills, discontinue
combination pill. In this case, Progestin-only pill, implantable contraception or
other forms of contraception can be used
Realize that lot of migraines may actually improve with OC pill use. Migraines
with OC Pill use seems to occur during the pill free week and may be explained
by estrogen withdrawal.
Also, realize that Tension headaches are not a contraindication to OC pill use
51. Progestin Component
First ( Norethindrone) and second generation progestins
( levonorgesterol) have high androgenic side effects such as
weight gain, acne, hirsutism, mood changes, adverse effect on
carbohydrate and lipid panel.
Third-generation progestins ( norgestimate, desogestrol) in
oral contraceptive pills have a better side effect profile.
Minimal androgenic effects
Does not adversely effect BP or glucose or lipids or
weightgain
In all pts, you can start 1st generation progestin. Switching to
OCPill combination with 3rd generation progestin is advised in
DM, Hyperlipidemia or in pts who cannot tolerate other
combination ocpills because of severe acne/ hirsutism
52. Considering a switch?
If considering switching oral contraceptives from one form to
another, follow the guidelines:
If switching to reduce high risk of thrombosis : Choose an Oc
pill with lower dose of estrogen eg: Loestrin. In patients who
have previous DVT or high risk thrombophilia like factor V
leiden, switch to progestin only pill.
If switching to reduce nausea, breast tenderness or
Migraine :Choose an OC pill with lower dose of estrogen eg:
Loestrin
If switching to reduce spotting or breakthrough bleeding :
Choose a product with a higher dosage of estrogen or a
progestin with greater potency : eg: Lo/Ovral ( Breakthrough
bleeding is related to the ratio of estrogen to progestin in a pill
formulation)
If switching to reduce androgenic effects (acne, hirsutism,
weightgain, oily skin) : Choose a product containing a Thirdgeneration progestin, low-dose norethindrone or ethynodiol
diacetate. Eg: Demulen 1/35
If switching to prevent dyslipidemia : use a product containing
53. Mini Pill
Progestin-only pills, or minipills contain no
estrogen and have a lower dose of progestin thasn
traditional oCPs. Eg: Norethindrone (Norlutin)
and norgestrel (Ovrette).
USES :
- For women with contraindications to the use of
combined oral contraceptives
- Women who are breast-feeding ( does not
intefere with quantity or quality of breast milk).
54. Minipill
Irregular bleeding more common also
causes a great “breakthrough” bleeding and
hence, these pills are usually reserved for
lactating women.
Daily compliance is crucial
An active pill every day, no placebos
Same timeevery day (even 2-3 hr change can cause
bleeding)
56. OCPs and Interactions
A non hormonal contraception is recommended for
women using Rifampin or anticonvulsants ( WHO
recommends a non hormonal contraception for women
using anti-convulsants). If such a woman desires a
hormonal contraception, Depo-provera is an option in
such women.
An additional non-hormonal contraception is
recommended for those receiving antibiotics that may
reduce OCPill efficacy to some extent tetracyclines,
penicillins, or cephalosporins ( since antibiotic is given
only for short duration, using the non hormonal
additional contraception during and for 7 days after
taking the antibiotic is sufficient).
57. Board Style Scenarios
OC pills and Rifampin interaction
Preferred contraceptive method in women using
anticonvulsants ( best is non-hormonal. However,
hormonal mode such as Depo-Provera can be used as
it has no estrogen)
Preferred hormonal contraception in lactating women.
Preferred hormonal contraception for those requiring
long term contraception ( Depo-provera)
Recommendation for additional non-hormonal
contraception for women using antibiotics such as
tetracycline, cephalosporins etc ( use additional non
hormonal method during and 7 days after the use of
antibiotic)
58. Q
27 year old G1P1 just delivered a baby girl.
She plans to breastfeed and return to work in 6
weeksWhen she can restart her OCPs?
59. OCPs - Postpartum
Patients can begin OCPs after 3 weeks postpartum for a
delivery >20 weeks gestation Starting OC pills less than
3 weeks postpartum associated with increased risk of
DVT/PE
If delivery occurred less than of 20 weeks of gestation –
patient can begin OCPs immediately.
Combination OC pills may be used while
breastfeeding However, if begun immediately
post-partum may decrease milk production so, one
should consider progestin only OCP if concerned
about milk production
60. Q
You saw Lisa 6 months ago and prescribed
her OC pills for contraception. She calls you
now saying she has occasionally forgotten to
take her pills. What information do you ask for
& what instructions do you give her about
forgetting to take her pills?
61. Ask Lisa which pills were missed:
If placebo pill - Reassure
If it is an active pill & is delayed less than 24 hrs , take pill
immediately
If active pill & delayed more than 24 but less than 48 hrs
take both pills immediately
If 2 active pills missed, then double up for 2 days but should
also use alternative birth control E.g. missed Monday &
Tuesday Take 2 pills Wednesday & Thursday.
If >3 days missed stop pills, wait for menses and then
begin a new pack. Use alternative form of birth control until
next menses. If unprotected intercourse during missed pill
days consider emergency contraception
Most dangerous pill to miss is first pill of a new pack. Being
pill free more than 7 days increases risk of ovulation. If this
happened, patient should use alternative form of birth control
until she takes 14 consecutive days of pills.
62. Emergency Contraception
“Emergency" contraception is used in the first 72 hours
after unprotected sex.
Post-coital contraception reduces the pregnancy risk by
75% much lesser than the risk resduced by regular
use of ocpills or other forms of contraception.
Post coital contraception usually causes nausea and
vomiting. Premedicate with an anti-emetic (eg:
Phenergan).
Give the first dose of oral contraceptive pill within 72
hours of unprotected sex, and give the second dose 12
hours after the first dose.. Regular oral contraceptive
pill use can be started after the second dose. Several
regimens are available for emergency contraception eg:
Plan B (brand) one pill per dose – it uses progestin
only (0.75 mg of levonorgestrel per dose)
63. Emergency Contraception
Mechanism of action
inhibits or delays ovulation if taken prior to ovulation
interferes with egg/sperm transport – egg and sperm will
not meet.
If fertilization has already occurred, alters endometrium
and prevents implantation of the fertilized egg
Does not terminate established pregnancy
Contraindications :
only contraindication is pregnancy
History of ectopic pregnancy is not a contraindication
Smoking & over age 35 is not a contraindication
64. Copper IUD
Can be used for emergency contraception within 5
days of unprotected intercourse.
Interferes with implantation after fertilization
May be more effective than hormonal emergency
contraception
Provides on-going contraception after insertion
( preferable for a woman who also desires long
term contraception)
65. Permanent Contraception
Recommended for those who have completed their
families
Tubal ligation
Effective immediately
More invasive and requires longer post-op recovery
Vasectomy
Not effective for about 4 weeks advise to use another
contraception for at least 12 weeks ( takes 12 weeks or 10
to 20 ejaculations to become completely
azoospermic ) !! ( Very IMP Question)
Outpatient procedure with local anesthetic
Does not effect the orgasms
66. Q1
A 26 year old woman has dysmenorrhea that has not responded to
treatment with NSAIDs. Her past medical history is significant for
migraine without aura and takes Topiramate for prevention of migraine.
Her migraines are well prevented now. She is also sexually active and
requests contraception. In view of her dysmenorrhea, OC pills have been
recommended to her as it serves to address both the issues of contraception
as well as her dysmenorrhea. But she tells you that she once read the
package insert in the OC pills and also heard from her friends that she
should not use OCPs because she has migraine. Her exam does not reveal
any neurological deficits. She does not smoke and leads an active lifestyle.
Her B.P is 110/70. What is your best recommendation to her?
A. Reassure her and start OC Pills
B. Tell her to use condoms alone
C. Start minipill because OC pills may worsen her headache
D. Start OC pills but switch topiramate to valproic acid to prevent her
migraines better
67. Ans. A
This pt has migraine without aura, no focal
neurological deficits and no additional risk
factors for stroke. So, it is recommended to
start OC pills as benefits outweigh risks in her
case.
Studies have shown that headache occurring in
association with OC use tended to improve
despite continued OC use
68. Q2
A 25 y/o woman with hx of endometriosis, has had 2 year
history of migraines, however, they bother only once or twice
a month. Only one of these attacks a month makes her really
disabled. She has been started on propranolol 6 months ago
and has been headache free for a bout three months. She says
she recently started oral contraceptive pills 3 months ago and
her headaches have been out of control. She is getting about 3
to 4 episodes of migraines per month now but no aura.
Physical exam is normal. What is your next step in
management ?
A. Discontinue oral contraceptive pills
B. Switch to OCPills with low dose estrogen
C. Switch to OC pills with high dose estrogen
D. Start Topiramate for prophylaxis of migraine
E. CT head without contrast
69. Ans.B
Benefits outweigh risks – has endometriosis and
desires contraception
Her migraine is with out aura or focal neuro deficits
and she has no additional risk factors for ischemic
stroke
Reducing estrogen component may reduce migraine
severity.
Studies have shown that headache occurring in
association with OC use tended to improve despite
continued OC use
70. Q3
A 35-year-old woman with history of smoking 1 ppd x 15 yrs, comes to
you 4 months after beginning OC pills. Shortly after starting OCs, she
started experiencing headaches twice a week lasting 12 hours. The
headaches are bilateral, throbbing, and accompanied by nausea and
sensitivity to light and sound. They are heralded by a 50-minute visual
disturbance consisting of a "bright, zigzag lines" and then fades away as
the headache begins. Upon questioning, she reports occasional similar
headaches prior to OC use but they were not this bad and never had visual
disturbances earlier. Her physical examination is normal. She is sexually
active with one partner and desires effective contraception. Her partner
does not like using condoms. The next step in management?
A. Reduce the dose of estrogen in the combination pill
B. Switch to mini pill
C. Ask her to convince her partner to use condoms
D. Reassure her and continue OC Pills
E. Stop OC pills and restart after one month.
71. Ans. B
If migraines worsen or if there is new-onset migraine related
to OC use, consider the following stroke risk factors:
patient's age ( age > 35 increased risk)
the type of migraine i.e; with aura is increased risk for cva
The presence of other vascular risk factors i.e; smoking, HTN
– in this woman, smoking additional risk alon with migraine
with aura
So, combination pills have to be d/ced. Switch to minipill or
other forms of reasonable contraception
Any unusual headache with sudden onset, focal neuro
deficits – immediately stop OC pills and get a Head CT.
72. Q.4
A 30-year-old woman has been using oral contraceptive pillls,
combination type for past 8 yrs. However, she also has a
history of migraines. Lately, she has been experiencing an
average of 14 episodes of severe migraine without aura yearly.
Careful evaluation of her headache calender reveals that most
of them occur exclusively during the pill-free week of her OC
regimen. She has no history of smoking. She has never had
DVT or family hx of thrombophilia. Her physical exam is
normal without any neurological deficits. Next step in
management ?
A. Switch to low dose estrogen pills
B. Switch to minipill
C. Discontinue OC pills
D. Start extended duration OC pills like seasonale
73. Ans. D
Realize that some migraines improve with OC pills. Some
patients especially gives you a history that they get more
migraines during pill free period – this is related to estrogen
withdrawal. This patients will benefit from extended OC
regimens.
Seasonale: 84 consecutive hormonal pills followed by 7 days
of placebo
Reasons for the use of extended duration OC regimens ( 91
days)
Convenience
patient desire for fewer episodes of withdrawal bleeding ( they will have
only 4 bleeding episodes per year)
To reduce the occurrence of headache and other estrogen-withdrawal
symptoms ( Premenstrual syndrome).
74. Choosing The Right OCP
Endometriosis: Choose a pill with a strong progestin
to create a pseudo-pregnancy state ( you know
pregnancy improves endometriosis)
Functional Ovarian Cysts: High dose monophasic
pill may be more effective
Androgen excess: Choose a pill with high
estrogen/progestin ratio to reduce free testosterone
and inhibit 5α reductase activity
Breastfeeding: Progestin -only pill
76. Vaginal Discharge - Causes
Physiology: Normal vaginal
secretions
Dependent on multiple
factors
Age
Timing of Menstrual
Cycle
Sexual arousal
Contraceptive use
Douching
Composed of Cervical
Mucus , Vaginal wall
transudate &
Common Causes
Normal discharge (30%)
Candida Vulvovaginitis (2025%)
Bacterial Vaginosis (23-50%
Trichomonas vaginitis (515%)
Mixed infection or Sexually
Transmitted Disease (20%)
77. Vaginal discharge
Other Causes
Atrophic Vaginitis (post-menopausal women)
Infectious Cervicitis : Neisseria gonorrhoeae , Chlamydia trachomatis
and Herpes Simplex Virus
Vaginitis or Vulvitis
Scabies
Neurodermatitis
Vaginal or vulvar trauma
Irritant or Allergic Contact Dermatitis
Soaps, Tampons or sanitary napkins , Condoms , Spermicidal gel ,
Diaphragm
Herpes Vulvitis
Malignancy
Physiologic discharge
Ovulation , Pregnancy
78. Women tend to self treat
As per studies,
Women often self-treat chronic vaginal symptoms
In a study 73% used Over-the-counter yeast vaginitis
medication and 42% used Alternative Medicine yeast
vaginitis treatment
Self-diagnosis often incorrect and may be harmful
Correct diagnosis of yeast vaginitis seen only in 11-28% of
self treated cases
Secondary irritant vaginitis may develop in 15% of these
cases ( be aware of this and ask the woman if she had used
an OTC/ Alternative therapies to treat her vaginitis!!
these by themselves may be causing her vaginitis refractory
by secondary irritation)
79. Vaginitis
R/O STD in cases of Vaginitis. Most important
clues in history :
Hx of multiple sexual partners
Not using barrier methods of contraception
Hx of STDs in the past
80. Symptoms – Vaginitis
Intense Vaginal itching or burning: one of the
most important symptom that goes in favor of
Candida Vulvovaginitis
Malodorous or unusual vaginal discharge
External Dysuria (pain with urine passing over
vulva)
Dyspareunia
81. Distinguish between vaginitis and
cervicitis
Vaginitis refers to inflammation of the vagina and is caused by
infections such as candidiasis and trichomoniasis. Bacterial
vaginosis is a syndrome that seems to be noninflammatory, is
characterized by alterations in the microbial composition of
the vaginal flora, and may cause vaginal discharge and odor.
Cervicitis, or cervical inflammation, is caused by different
infectious diseases, including gonorrhea and chlamydia. if
cervicitis is present you need to screen for gonorrhea,
chlamydia as well. Also, if pt cervicitis u can start emperic
Rx to cover gonorrhea and chlamydia
Always remember to Treat patients with gonococcal cervicitis
for chlamydial infection as well, even if laboratory
confirmation of the latter is not obtained.
Although signs and symptoms may suggest a cause for
vaginitis or cervicitis, perform specific diagnostic testing.
82. Signs – Vaginitis – Clues to Etiology
Character of vaginal secretions
Normal clear or white, non-clumping, odorless
Dry cottage cheese-like discharge Candida
Vulvovaginitis
Frothy discharge (rarely present) Trichomonas
vaginitis
Fishy Odor Bacterial Vaginosis & Trichomonas
vaginitis
Vagina and Cervix appearance
Vulvar redness, edema and adherent white clumps
Strawberry cervix with punctate hemorrhage
Candida Vulvovaginitis
Trichomonas vaginitis
Pale, dry, thin vaginal and vulvar skin
Atrophic Vaginitis
83. Signs – Vaginitis – Clues to Etiology
Vaginal Ph
Use standard vaginal Ph paper
N is 3.8 to 4.5 ( acidic). Increased vaginal Ph can
occur in Trichomoniasis, Bacterial Vaginosis and
infections associated with foreign body retention
( tampon etc) Recognize that in candida vaginal Ph
is usually in 3.8-4.2 range and almost always less
than 4.5!!!
Increased vaginal Ph may be seen with non
infectious etiologies like ovulation ( increased
cervical mucus), menses, semen after intercourse,
estrogen deficiency, rupture of membranes in
pregnancy
84. Diagnosis - Vaginitis
Include the following tests in the diagnostic
evaluation:
Vaginal pH
“Whiff” test
Wet mount for vaginitis and potassium
hydroxide prep
Endocervical specimen for gonorrhea and
chlamydia verification for cervicitis
86. Treatment – Vaginitis/ Discharge
Treat the specific cause
Do not recommend non-drug therapy for the treatment of vaginitis or
cervicitis Inform patients that non-drug therapies such as boric
acid, providone-iodine douches, yogurt, and vaginal acidification
(Acigel) are of no benefit. Discuss with all patients the lack of
efficacy of these non-drug therapies in a nonjudgmental way
Emperic Rx is not recommended because our clinical diagnosis
based on symptoms and signs is often incorrect confirm the
etiology with lab studies, KOH or culture (“We conclude that
presenting symptoms and signs in vaginitis evaluation have limited
value, and that half of the women with vaginitis may lack a
microbiologic diagnosis. “ Schaaf (1990) Arch Intern Med
150:1929-33 )
Cosider topical/ oral therapies and treatment of sexual partners
depending on the etiological agent. Rx sexual partner in
trichomonas, gonorrhea, chlamydia “Advise patients of the
importance of partner notification, and encourage the prompt
treatment of partner “
All cases of gonorhhea/ chlamydia must be reported to state health
department!!
87. Bacterial vaginosis
Accounts for 30 – 50% of vaginitis
Occurs because of Marked reduction in normally predominant
lactobacillus and overgrowth of facultative Anaerobic Bacteria
like Peptostreptococcus , Haemophilus vaginalis, Bacteroides
and Mycoplasma hominis
Symptoms: usually asymptomatic, If present they are mild
Musty/ fishy odor to gentilia & thin greywhite, non clumping
vaginal discharge
Amsel Criteria for bacterial vaginosis Must have 3 of the
following 4 signs: vaginal pH >4.5, positive “whiff” test,
presence of clue cells, and homogenous vaginal discharge
Whiff test Add 10% KOH to vaginal secretions; test is
positive if a fishy smell is present (fishy smell is because of
volatilization of amines produced by anaerobes); positive in
BV 90% specific for bacterial vaginosis, also seen
sometimes with Trichomonas
88. Treatment – Bacterial Vaginosis
Non-Pregnant
First-Line: Oral Metronidazole 500 mg PO bid for 7 days
Topical options (higher recurrence rate) MetroGel (0.75%) 5g PV qhs for 5
days / Clindamycin Cream (2%)
Pregnancy:
First Trimester
Avoid treatment if possible in first trimester
Clindamycin 300 mg PO bid for 7 days
Clindamycin Cream 5 grams PV qhs for 7 days / Metronidazole Gel PV bid for 5 days
After First Trimester Metronidazole 250 mg tid for 7 days or Consider with
Erythromycin x14 days or Clindamycin for 7 days
Resistant/Refractory Cases Metronidazole 500 mg bid x14 days(preferred)
Consider treating sexual partner and patient ( remember evidence is lacking in
this case about Rxng sexual partners in case of recurrence)
Other options : Clindamycin at above dose , Povidone-iodine gel OR suppository
(Betadine)
Recurrent Bacterial Vaginosis Treat as refractory cases above
Consider maintenance therapy
Induction: Metronidazole gel qhs x10 days
Maintenance: When wet prep with no clues, pH lower
Metronidazole gel twice weekly for 3 months
Treat concurrent Candida if present Fluconazole150 mg q Week
89. Clue Cells
Clue Cells present on
>20% of cells is
significant
Bacteria adhered to
vaginal epithelial cells
Most reliable single
indicator of bacterial
vaginosis
90. Complications – Bacterial Vaginosis
Complications
Associated with preterm delivery (23-26 weeks)
Screen for bacterial vaginosis during pregnancy if woman has
hx of previous preterm delivery Treating pts with
asymptomatic bacterial vaginosis in early second trimester
was associated with better pregnancy outcomes in studies
Reduces preterm birth and late Miscarriage rate the Study
used Clindamycin
(“ Treatment of asymptomatic abnormal vaginal flora and
bacterial vaginosis with oral clindamycin early in the second
trimester significantly reduces the rate of late miscarriage and
spontaneous preterm birth in a general obstetric population “
ref:Ugwumadu (2003) Lancet 361:983-8 )
91. Trichomonas Vaginitis
Protozoan infection accounting for 10% cases of vaginitis
Remember this is an STD sexual partner must be treated.
Men are asymptomatic in 90% cases
Associated Conditions : Preterm Labor, other STDs
Test for other STDs Gonorrhea, chlamydia
Symptoms : Asymptomatic in 25-44% of women
Copious, grayish-green Vaginal Discharge, may have Fishy
odor to discharge , Frothy discharge (Carbon dioxide bubbles ,
Frothy discharge has Sensitivity: 10% , Specificity: 70% )
Vulvar/vaginal irritation, itching, dysuria
Signs Vulvar edema and erythema
Strawberry Cervix (seen in 3% of cases) ( associated with
Punctate hemorrhages or Petechiae, Telangiectasia is pretty
specific )
92. Trichomonas - Rx
General: Treat Sexual Partner also , Avoid treatment in
first trimester of pregnancy
Non-Pregnant, Non-Lactating Patient Metronidazole
2 g PO for 1 dose or 250 mg PO tid x 7 days or 500
mg PO bid for 7 days
Pregnant
First Trimester Clotrimazole 100 mg PV qhs for 7 days
After First Trimester
Lactation
Metronidazole 2 g PO for 1 dose or 500 mg PO bid for 7 days
Metronidazole 2 grams PO for 1 dose
Discontinue Lactation for 24 hours after dose
Persistent or Recurrent Cases Metronidazole 500
mg PO bid for 14 days or Metronidazole 2g PO qd for
3 days ) or Povidone-Iodine Suppository PV bid for 14
days
93. Trichomonas - Diagnosis
Vaginal Ph > 5.0
On Koh preperation,
Sniff test +ve in some
cases
On Wet preperation
you will see motile
curved rods wich are
twice the size of wbcs
Culture grown on
modified diamond
media
94. Candida Vulvovaginitis
Often self diagnosed by women incorrectly
Accounts for 40% of vaginitis
Predisposing factors DM, corticosteroids,
Immunosuppression, Broad spectrum antibiotics,
OCPills ( OCPs increase the frequency of candida
carrier state but does not increase symptomatic
vulvovaginitis ), pregnancy, Premenstrual phase of
menstrual cycle, obesity
Symptoms asymptomatic 20-50% cases, Intense
vaginal/vulvar pruritis in 50% cases, curdy white
discharge, vulvar burning, dysuria, dyspareunia
Signs Adherent white cottage-cheese discharge in
vagina ( Sensitivity: 50% , Specificity: 90% )
Vulvar erythema and edema (24% of cases)
95. Candida Vulvovaginitis - Diagnosis
Lab
KOH Preparation shows Pseudohyphae or
budding yeast forms
Fungal Culture rarely performed
Fungal Culture may be very helpful in certain cases
Confirm asymptomatic carrier of vaginal Candida
Identify cause of recurrent vaginitis
Candida on Pap Smear Specific but not sensitive
Vaginal pH <4.5 (Normal acidity)
Absent Amine odor
White Blood Cells not increased
Wet-Prep is not sensitive or specific for yeast
96. If candida is refractory to Rx
Consider for refractory cases: Other Vaginitis cause
Bacterial Vaginosis
Trichomonas vaginitis
Infectious Cervicitis (Sexually Transmitted
Disease)
Allergic Vaginitis or Vulvitis
Vulvodynia chronic vulvar itching/
irritation ( rx reassurance, TCAs, SSRIs)
97. Candida Vulvovaginitis - Rx
First choice is local agents Miconozole cream/ pessaries/
vag tabs PV, Clotrimazole PV, Nystatin PV 3 to 7 days
Oral AgentsFluconozole 150mg Po x 1 dose
Recurrence/ resistant candida
•
•
Any of above intravaginal meds for 14 days, After initial daily regimen
, start maintainance Rx at least once a week
Oral agents 2 dose Fluconozole 150 day 1 and another 150 mg
72 hrs after 1st dose
Prophylaxis when will you consider????
Indication Four or more yeast infections per year
Initial treatment Fluconazole 150 mg PO q3 days for 3
doses
Maintenance
Fluconazole 150 mg PO each week
Monitor liver enzymes (consider q1-2 months)
Efficacy
Suppression while on treatment: 90%
Following treatment: Infection recurs in 60
98. Screen women at risk for sexually transmitted
causes of vaginitis and cervicitis
Screen sexually active women aged <25 years for
chlamydia on an annual basis.
Screen all women aged 25 years and younger for
chlamydia
Screen all other women with new or multiple sexual
partners, history or current symptoms of STDs, or
history of unprotected intercourse. – For gonorrhea
and chlamydia
Do not screen asymptomatic women for bacterial
vaginosis, because treatment of asymptomatic
bacterial vaginosis is controversial and not
recommended by the CDC. ( unless they are pregnant
and have a hx of preterm delivery).
Include a serologic screening test for syphilis in
populations at high risk for syphilis.
99. Screen for STDs during pregnancy
Screen for STDs in high-risk groups and in
communities with high prevalence rates during the
first trimester.
Screen for trichomoniasis and bacterial vaginosis in
patients with a history of preterm labor or delivery.
The optimal time to screen for bacterial vaginosis
during pregnancy is not known; however, earlier
screening allows treatment before complications
arise.
Screen for gonorrhea and chlamydia in all patients by
the third trimester.
Screen for syphilis, hepatitis B, and HIV in all
pregnant women.
100. Chlamydia Screening
Use cervical DNA Probe
Screen anually, all sexually active women
under the age of 25.
In women older than 25, screen annually, if
they have risk factors for STDs – new sex
partner, multiple partners etc
SCREEN ALL PREGNANT WOMEN
101. Chlamydia
Presents with cervicitis and PID in women
( cervical DNA probe best test/ PCR)
A common cause of non gonococcal urethritis
in men ( Urine for leucoesterase screening test.
If +ve, do urine chlamydia antigen in men)
Can also cause Epidydymitis in men, esply age
<35 yrs.
102. Chlamydia - Therapy
1. First Choice - Azithromycin 1 gram PO for 1 dose or
Doxycycline 100 mg PO bid for 7 days Alternatives :
Ofloxacin, Levofloxacin, Erythromycin
2. If pts have persistant or recurrent urethritis despite
treatment : use Metronidazole 2 grams PO for 1 dose
+ Erythromycin twice daily x7 days
3. In Pregnancy use: Azithromycin 1 gram PO as single
dose or Amoxicillin 500 PO tid x7 days
4. In Neonates (Conjunctivitis from 5 to 14 days or
Chlamydia Pneumonia) Erythromycin PO
suspension x 2wks ( not eye ointment because there is
a high risk of developing an associated pneumonia)
103. Chlamydia - Therapy
Make sure to refer all sexual contacts for
treatment
No sexual intercourse for 7 days
Indications to retest chlamydia after antibiotic
therapy to confirm eradication:
Having persistent symptoms
Pregnancy
105. Dysmenorrhea
Painful Menses
Risk Factors
Age under 20 years
Tobacco Abuse
Mood Disorder
Menorrhagia
Nulliparity
Types of dysmenorrhea
Primary Dysmenorrhea – accounts 90% cases
Occurs within 6 to 12 months of Menarche
Idiopathic with no clear pelvic explaination of pain
Secondary Dysmenorrhea: Acquired due to a pelvic disease
Endometriosis & Pelvic Inflammatory Disease (PID) – MCC of secondary
dysmenorrhea
Other causes :Uterine Fibroids, Endometrial Polyps, Adenomyosis, IUDs
106. Dysmenorrhea
Points in history that suggest Secondary
Dysmenorrhea
Changed dysmenorrhea character, location or intensity
History of prior STDs
Pelvic Pain persisting throughout cycle
Infertility
Abnormal Menstrual Bleeding
Dyspareunia
107. Dysmenorrhea
Cramping or colicky lower abdominal or Pelvic Pain
beginning within a few hours of menstrual flow
May be assocaited Nausea, vomiting, bloating or diarrhea
I mproved by Oral Contraceptive use and after childbirth
Do a careful physical exam
Normal Pelvic exam Suggests Primary Dysmenorrhea
Uterosacral nodularity Suggests Endometriosis
Thickened Adnexal Masses Suggests PID
Enlarged, irregular uterus Suggests Uterine Fibroids
Enlarged, boggy uterus Suggests Adenomyosis
108. Rx - dysmenorrhea
Rx
NSAIDs – very effective in dysmenorrhea
Hormonal Contraception
Ibuprofen, Naproxen or Mefenamic acid
Combined OC pills or Progesterone only Pill
In refractory cases, obtain OBGYN consult
for diagnostic laparoscopy
Danazol or Leuprolide may be tried in severe
cases
109. Amenorrhea
Lack of menses
Primary Amenorrhea No menses by Sixteen years old or
One year beyond Family History and charecterized by No
secondary sexual characteristics by 14 years age
Secondary Amenorrhea Previously regular cycles but
now 3 months of no Menses or Previously irregular cycles
with now 6 months of no Menses
110. Secondary Amenorrhea
Do pregnancy test in all cases first
Then obtain TSH and Prolactin
Then do Progesterone Challenge Test
Recognized Female Athlete Triad ( Highyield
on Step3)
Other conditions : PCOS, Premature ovarian
failure
111. Progesterone Challenge Test
Procedure: Progesterone Challenge
Administer Progesterone ( Norethindrone 5 mg PO once daily
for 7-10 days or Progesterone 200 mg IM for one dose)
Determine if there is menstrual bleeding after Progesterone
which should occur within 7 days of Progesterone completion
Here is how you interpret :
If Withdrawal bleeding within 7 days
Suggests Anovulation with Progesterone deficiency ( Mullerian duct
development anomalies, hyperprolactinemia, gonadal dysgenesis, PCOS)
These patients have high risk of Endometrial Cancer with unopposed Estrogen
They Require Progesterone replacement
If No withdrawal bleeding Do a Estrogen-Progesterone Challenge Test
( OC Pills for 2 cycles)
No withdrawal bleed suggests uterine outflow obstruction
If withdrawl bleed, Obtain Serum FSH and Serum LH
If FSH>20 and LH>40: Hypergonadotropic Hypogonadism ( Turner’s
syndrome i.e; streak gonads, Premature ovarian faliure, Menopause, 17
alpha hydroxylase deficiency in these states, gonads not producing
enough hormone, so pituitary responds by increasing Gn production)
FSH and LH<5: Hypogonadotropic Hypogonadism ( Isolated GnRh def
i.e; Kallman’s syndrome, Hypopituitarism, Brain tumors, Female
Athlete Triad Lack of leptin reduces GnRh production)
112. Female Athlete Triad
Disordered Eating (Anorexia Nervosa)
Secondary Amenorrhea
Osteoporosis (Stress Fractures) due to anovulation and estrogen
deficiency osteoblasts are estrogen dependant ( stress fractures can occur
in tibia, metatarsals, fibula and calcaneus while running - Imp Question!)
Features of stress # deep ache after rapid training change and followed
pain that increases with activity. No pain in nights ( Rx rest, non weight
bearing and immobilization in a brace. May take 8 - 12 weeks to recover)
Prevention of secondary amenorrhea in female athletes increase body
weight by 2kgs and decrease exercise activity by 10%.
Management :
Maintain adequate calorie intake
Take adequate calcium
Once female athlete triad is recognized Very important to start
OC pills cycling to prevent osteoporosis and to ensure normal
bleeding patterns ( FAT is a Estrogen Deficient state) (Female
athlete at age 20 may have 70 year old bone )
114. Etiologies
Male factor alone – 33%
Idiopathic (40-50%)
Primary Hypogonadism (Testicular Failure):
Obstructive azoospermia or altered transport
Varicocele
Medication of drug use ( alcohol, cocaine, marijuana, methotrexate, cimetidine, spironolactone)
Testicular surgeries or injury
Cryptorchidism
Chromosomal abnormality (e.g. Klinefelter Syndrome)
Genital radiation or Chemotherapy
Orchitis : Post-pubertal mumps and STDs
Erectile Dysfunction
Retrograde ejaculation or other dysfunction
Hypospadias
Secondary Hypogonadism (Hypothalamic-Pituitary Axis issues)
Hypogonadotropic Hypogonadism
Androgen Excess (e.g. Anabolic Steroids)
Estrogen excess (e.g. tumor)
Pituitary adenoma
Infiltrative Disorder
Sarcoidosis
Tuberculosis
Both male and female causes – 1/3 cases
115. Approach in Infertility
First obtain Semen analysis after abstinence x 5 days
If semen analysis normal evaluate female infertility
In female infertility
Establish if ovulation is occuring :
Serum progesterone on day 21 of 28 day cycle > 3ng/ml
Basal Body Temperature charting with increase in themp by 0.5F every
12 – 15 days
If anovulatory, obtain TSH, Prolactin and FSH. Day 3 of cycle’s FSH >
15 is abnormal ( indicates anovulation)
Then r/o hyperandrogenism obtain DHEAS, Testosterone, LH levels
Later assess tubal patency Transvaginal ultrasound and
HYsterosalpingogram ( to assess uterine abnormalities, synechiae,
submucosal fibroids)
For Unexplained infertility consider laparoscopy to rule out
endometriosis or tubal adhesions
116. Semen Analysis
Normal :
Findings suggestive of Infertility
Semen volume greater than or equal to 2ml
Sperm concentration greater than or equal to 20 million per ml
50% or more should have progressive motility
14% or more should have strictly normal morphology
WBC should be less than 1 million per ml
Sperm count (concentration): <13.5 million per ml
Initial sperm motility: <32% ( oligozoospermia)
Normal sperm morphology: <9%
If semen volume less than 1 ml, first obtain post ejaculatory
urinalysis to rule out retrograde ejaculation ( if urine +ve for
sperm retrograde ejaculation. If –ve ejaculatory duct
obstruction)
125. PID
Causes :Chlamydia, Gonorrhea, mycoplasma hominis, facultative anerobes
Risk factors : hx of STDs, previous hx of PID, Onset sexual intercourse at a young age,
Multiple sexual partners
Symptoms : Abdominal pain, high fever, discharge, dyspareunia, prolonged menses
Signs : Cervical motion tenderness, Adnexal tenderness, Discharge, R/O tuboovarian
abcess ( local peritoneal signs – local rigidity ), r/o ruptured TOA ( generalized rigidity,
rebound tenderness )
D/D UTI ( no cervical motion tenderness/ discharge), ruptured ovarian cyst ( sudden
onset midcycle pain, ectopic pregnancy ( pregnancy test +ve, unilateral pain) ,
appendicitis ( RLQ pain, more bowel symps), ovarian torsion ( afebrile, sudden onset, very
localized pain, normal wbcs)
Lab Diagnosis
Do not delay treatment while waiting for labs
Inflammatory markers (if all normal, rules-out PID)
Complete Blood Count (CBC)
Erythrocyte Sedimentation Rate or C-Reactive Protein
Vaginal secretion exam (saline wet prep) Vaginal PMNs (Negative Predictive Value 95%)
Other initial labs
DNA probe for Gonorrhea and Chlamydia Cervical specimen recommended over urine
specimen
Blood Culture
Urine Pregnancy Test
Rapid Plasma Reagin(RPR)
126. PID - Imaging
No need of imaging in uncomplicated PID
If signs of TOA obtain pelvic ultrasound/
MRI
127. PID – Indications For Admission
Hospitalize patients with:
Surgical emergencies (eg: suspected leaking abscess)
Abscess formation ( TOA )
Lack of response (i.e., no clinical improvement after 48 to 72 hours)
to outpatient therapy
Inability to tolerate oral antibiotics (severe nausea and vomiting)
Severe illness with nausea, vomiting, or high fever > 103 F
Pregnancy
Noncompliance with outpatient therapy
IMMUNOCOMPROMISED ( AIDS)
In addition to admitting and starting antibiotics immediately in
patients with suspected severe PID, consider laparotomy or
laparoscopy for: Generalized peritonitis and/or sepsis due to a
suspected, ruptured TOA , Lack of clinical response to therapy
within 48 to 72 hours , Clinical deterioration , Suspected TOA ,
Drainage of abscess, loculations, or pyosalpinx , Ruptured TOA
Consider unilateral/ bilateral salpingo-oophorectomy, or total
abdominal hysterectomy with bilateral salpingo-oophorectomy,
depending on extent of disease and patient's desire for fertility
128. PID – Drug treatment
Management:
General
Remove Intrauterine Device (IUD)
Treat patient's sexual contacts within last 60 days
Start empiric therapy even if minimal criteria present
Do not delay treatment
Delay >3 days increases ectopic and Infertility risk
Antibiotic should cover Gonorrhea and Chlamydia
BE AWARE Fluoroquinole resistant Gonorrhea is
increasing
Do not use Fluoroquinolones in high risk groups
Cohorts at risk for resistance
Homosexual men and any female sexual contacts of those men.
Endemic areas
Asia: China, Japan, Korea, Philippines, Vietnam
Other: England, Wales, Australia
US: California
129. PID – Drug treatment
Management Outpatient
Step 1: Initial Treatment at Diagnosis (with step 2)
to cover for fluroquinolone resistant gonorrhea
Cefoxitin 2g IM and Probenecid 1g PO or
Ceftriaxone 250 mg IM for 1 dose or
Other third generation Cephalosporin (e.g Cefotaxime)
Step 2: Outpatient 14 day antibiotic course
Select general antibiotic coverage
Ofloxacin 400 mg PO bid for 14 days (95% cure) or
Levofloxacin 500 mg PO daily for 14 days or
Doxycycline 100 mg PO bid for 14 days (75% cure)
Add anaerobic coverage (may or may not use this)
Clindamycin 450 mg PO qid for 14 days or
Metronidazole 500 mg PO bid for 14 days
130. Management Inpatient
Inpatient treatment Regimens
General Treat for at least 24 - 48 hours IV after clinical
improvement or at least 48 hrs IV
Regimen A (preferred)
Cefoxitin 2g IV q6h/ Cefotetan 2g IV q12h and Doxycycline 100
mg PO or IV q12h
Regimen B Clindamycin 900 mg IV q8h and Gentamicin
2 mg/kg IV load, then 1.5 mg/kg IV q8h
Regimen C Ofloxacin 400 mg IV q12h or Levaquin 500
IV qd + Metronidazole 500 IV q8 hours
Regimen D Unasyn 3g IV q6 hours and Doxycycline
100 mg PO or IV q12 hours
Continue parenteral therapy for 24 - 48 hours after clinical
improvement, and ensure that the patient completes a total
14-day course of antibiotic therapy. Discharge Regimen
(after IV antibiotics above) See Outpatient Management
Step 2 above
131. PID – IV antibiotics
Determine the duration of intravenous therapy
based on the clinical response of the patient.
Discontinue parenteral therapy 24 to 48 hours after
clinical improvement:
Defervescence
Reduction in direct or rebound tenderness
Reduction in pelvic tenderness
Improvement in lab values (e.g., leukocytes, ESR, or CRP)
Continue oral therapy to complete a 14-day course of
antibiotic therapy. Choose oral doxycycline (100
mg bid) or oral clindamycin (450 mg qid) as
preferred options for oral therapy. Consider
clindamycin as the oral drug of choice for women
with a TOA.
132. Cervical Cancer
Pap Smear – ASCUS etc and
management
LEEP etc – Rx choices
CIN I, II and III
Cervical Cancer
134. Is your computer male or female?
Women believe computers are male because:
In order to get their attention, you have to turn them on.
They have a lot of data but are still clueless.
They are supposed to help you solve your problem, but
half the time they ARE the problem.
As soon as you commit to one, you realize that , if you
had waited a little longer, you could have had a better
model.
135. Is your computer male or female?
Men believe computers are female because
No one but their creator understands their internal logic.
The native language they use to communicate with
other computers is incomprehensible to everyone else.
Even your smallest mistakes are stored in long-term
memory for later retrieval.
As soon as you make a commitment to one, you find
yourself spending half your paycheck on accessories
