Gynecology - Archer USMLE Step 3


Published on

Archer USMLE step 3 Gynecology lecture notes. These lecture notes are samples and are intended for use with Archer video lectures. For video lectures, please log in at

  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Gynecology - Archer USMLE Step 3

  1. 1. OBSTETRICS & GYNECOLOGY <ul><li>Archer Online USMLE Reviews </li></ul><ul><li> </li></ul><ul><li>All rights reserved </li></ul><ul><li>Archer Slides are intended for use with Archer USMLE step 3 video lectures. Hence, most slides are very brief summaries of the concepts which will be addressed in a detailed way with focus on High-yield concepts in the Video lectures. </li></ul><ul><li>These slides are only SAMPLES </li></ul>
  2. 2. Menopause Amenorrhea for at least 1 year associated with elevated FSH level
  3. 3. Menopause and After <ul><li>Symptoms : amenorrhea, oligomenorrhea, hot flashes, night sweats, mood changes, vaginal dryness, urinary incontinence, dyspareunia </li></ul><ul><li>Signs  Carefully evaluate patient for height loss and kyphosis ( signs of osteoporosis) </li></ul><ul><li>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 ) </li></ul><ul><li>On pelvic exam, look for signs of estrogen deficiency (e.g., vulvar or vaginal atrophy). </li></ul>
  4. 4. <ul><li>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 </li></ul><ul><li>If amenorrhea is present without other evidence for menopause, rule out other etiologies </li></ul>
  5. 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 Hyperprolactinemia Galactorrhea, drug use, headache, visual disturbance Pregnancy Weight gain, nausea, breast tenderness Late-onset congenital adrenal hyperplasia Elevated 17 OH progesterone May be associated with virilization
  6. 6. Lab Studies - Menopause
  7. 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 stimulating hormone Screen for hypothyroidism or hyperthyroidism 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. 8. D/D – Hot Flashes <ul><li>Recognize that hot flashes may be caused by conditions other than menopause. </li></ul><ul><li>If the patient does not otherwise clinically appear to be menopausal, screen for: </li></ul><ul><ul><li>Symptoms of thyroid disease </li></ul></ul><ul><ul><li>Alcohol intake </li></ul></ul><ul><ul><li>Infection, such as malaria </li></ul></ul><ul><ul><li>Pheochromocytoma </li></ul></ul><ul><ul><li>Carcinoid syndrome </li></ul></ul><ul><ul><li>Panic attacks </li></ul></ul>
  9. 9. <ul><li>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? </li></ul><ul><li>She also asks if HRT will reduce her CAD risk? </li></ul>
  10. 10. Hot Flushes <ul><li>Affect 75% of peri-menopausal women. </li></ul><ul><li>Consider lifestyle modifications, such as: Regular exercise , Avoidance of caffeine and alcohol , Stress reduction </li></ul><ul><li>Oral estrogen  effectively treats hotflashes, night sweats and sleep disturbances that accompany them </li></ul><ul><li>To prevent Ca. Endometrium  progesterone should be given with estrogen unless they had a hysterectomy </li></ul><ul><li>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 </li></ul><ul><li>SERMs ( Selective Estrogen Receptor Modulators) may precipitate hot flushes in some women </li></ul><ul><li>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 ) </li></ul>
  11. 11. Genitourinary Symptoms - Menopause <ul><li>Vaginal dryness, Dypareunia, urinary frequency and incontinence  common in postmenopausal women. </li></ul><ul><li>Rx: Vaginal Lubricants and Kegel Exercises </li></ul><ul><li>Other options  vaginal estrogen cream or a diaphragm like vaginalestrogen/silicone ring. </li></ul><ul><li>Serum estrogen levels are not increased with ring device  hence, a preferred option over vaginal cream in women with ca.breast. </li></ul>
  12. 12. Osteoporosis - Menopause <ul><li>Screening BMD/ Dexa Scan recommended only for women > 65 yrs and for women under 65 yrs if there are additional risk factors </li></ul><ul><li>HRT ( Estrogen) can increase the BMD and reduce risk of vertebral and hip #s by 27%. </li></ul><ul><li>In pts not on HRT, if BMD/DEXA shows T score less than – 2.5  definitely should be on bisphosphonates + calcium supplements. </li></ul><ul><li>Repeat BMD testing in 2 years for women diagnosed with osteopenia or osteoporosis. </li></ul>
  13. 13. Screen for risk factors and/or presence of osteoporosis in Post Menopausal pts <ul><li>Non modifiable risk factors for osteoporotic fracture: </li></ul><ul><ul><li>Personal history of fractures as an adult </li></ul></ul><ul><ul><li>History of fracture in a first-degree relative </li></ul></ul><ul><ul><li>Caucasian or Asian race </li></ul></ul><ul><ul><li>Advancing age (relative risk increases two- to three-fold per decade after age 50) </li></ul></ul><ul><ul><li>Female sex </li></ul></ul><ul><ul><li>Dementia </li></ul></ul><ul><ul><li>Neuromuscular deficits </li></ul></ul><ul><ul><li>Delayed menarche (after age 15) </li></ul></ul><ul><ul><li>Early menopause (under age 45) or bilateral ovariectomy </li></ul></ul><ul><ul><li>Loss of height (>2 cm) </li></ul></ul><ul><ul><li>Frailty or poor health </li></ul></ul><ul><li>Potentially modifiable risk factors for osteoporotic fracture include: </li></ul><ul><ul><li>Current cigarette smoking </li></ul></ul><ul><ul><li>Low body weight (under 127 lbs) </li></ul></ul><ul><ul><li>Recent weight loss of 10 lbs or more </li></ul></ul><ul><ul><li>Estrogen deficiency </li></ul></ul><ul><ul><li>Prolonged premenstrual amenorrhea (more than 1 year) </li></ul></ul><ul><ul><li>Low calcium intake (lifelong) </li></ul></ul><ul><ul><li>High alcohol intake </li></ul></ul><ul><ul><li>Recurrent falls </li></ul></ul><ul><ul><li>Inadequate physical activity </li></ul></ul><ul><ul><li>Glucocorticoid use </li></ul></ul><ul><ul><li>Use of medications that affect balance </li></ul></ul><ul><ul><li>Frailty or poor health </li></ul></ul><ul><ul><li>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). </li></ul></ul>
  14. 14. CAD – Menopause - ? HRT <ul><li>“ 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 </li></ul>
  15. 15. Venos Thromboembolism and Ca. Breast Risks - HRT <ul><li>Venos thromboembolism  </li></ul><ul><li>A known risk of HRT and SERMs. </li></ul><ul><li>The risk of venous thromboembolism in women on HRT is 2 x control population </li></ul><ul><li>All women must be counseled regarding this risk before HRT </li></ul><ul><li>Ca. Breast  There is slightly increased risk for women on HRT. </li></ul><ul><li>Risk does not increase in first 5 yrs of use and risk returns to baseline 5 yrs after cessation of HRT. </li></ul>
  16. 16. Cognitive Function - HRT <ul><li>Women on Estrogen + progestin have an increased risk of dementia or mild cognitive impairment as opposed to those on placebo. </li></ul><ul><li>TO Summarize  remember  </li></ul><ul><li>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. </li></ul><ul><li>Less than 3 years of use for perimenopausal symps ( hotflashes ) does not increase risk of ca.breast </li></ul><ul><li>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 ) </li></ul>
  17. 17. Some points - HRT <ul><li>For HRT  Consider tamoxifen for women at high risk of breast cancer. </li></ul><ul><li>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 . </li></ul><ul><li>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. </li></ul>
  18. 18. HRT - Contraindications <ul><li>Absolute contraindications to HT: </li></ul><ul><ul><li>Pregnancy </li></ul></ul><ul><ul><li>Unexplained vaginal bleeding ( ? Cancer ) </li></ul></ul><ul><ul><li>Active or chronic liver disease </li></ul></ul><ul><ul><li>Acute cardiovascular disease or immobilization </li></ul></ul><ul><ul><li>History of breast or endometrial cancer </li></ul></ul><ul><ul><li>History of cardiovascular disease (CAD or stroke) </li></ul></ul><ul><ul><li>History of thromboembolic disease not related to hormone therapy </li></ul></ul><ul><ul><li>Recent vascular thrombosis </li></ul></ul><ul><ul><li>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.) </li></ul></ul><ul><li>Relative contraindications: </li></ul><ul><ul><li>Increased risk for breast cancer </li></ul></ul><ul><ul><li>Increased risk for cardiovascular disease </li></ul></ul><ul><ul><li>Gallbladder disease </li></ul></ul><ul><ul><li>Migraine headache (however, Some types of menstrual migraine responds to OCPills like seasonale) </li></ul></ul>
  19. 19. Patient education - HRT <ul><li>Inform patients about the benefits of HT. </li></ul><ul><li>Educate all patients that HRT: </li></ul><ul><ul><li>Can help alleviate the vasomotor symptoms of menopause and relieve vaginal dryness </li></ul></ul><ul><ul><li>Has been shown to reduce the risk of osteoporosis and colorectal cancer </li></ul></ul>
  20. 20. Patient Education - HRT <ul><li>Counsel patients regarding the risks associated with HT. </li></ul><ul><li>Associated with an increased risk of: </li></ul><ul><ul><li>CHD, when estrogen is used in combination with progestin </li></ul></ul><ul><ul><li>Endometrial cancer when estrogen is used unopposed in women with an intact uterus </li></ul></ul><ul><ul><li>Stroke </li></ul></ul><ul><ul><li>Breast cancer </li></ul></ul><ul><ul><li>Venous thrombotic events (DVT and PE) </li></ul></ul><ul><ul><li>Gallbladder disease </li></ul></ul><ul><ul><li>Abnormal mammogram </li></ul></ul><ul><ul><li>Urinary incontinence </li></ul></ul><ul><ul><li>Ovarian cancer </li></ul></ul><ul><ul><li>Dementia </li></ul></ul><ul><li>Remember that HRT is contraindicated in women with: </li></ul><ul><ul><li>Known cardiovascular disease </li></ul></ul><ul><ul><li>Breast cancer </li></ul></ul><ul><ul><li>Hormone-sensitive cancers </li></ul></ul>
  21. 21. NOTE: <ul><li>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) </li></ul><ul><li>OCPs role in breast Ca is controversial. HRT increases Breast cancer risk ( esply, hormone +ve breast CA, ER+, PR+, HER2) </li></ul><ul><li>OCPs decrease endometrial ca. HRT increases it. </li></ul>
  22. 22. Post Menopausal Bleeding
  23. 23. For Women on HRT <ul><li>Consider the following for bleeding: </li></ul><ul><li>With cyclic therapy, obtain endometrial biopsy if bleeding occurs irregularly and/or unpredictably, or if bleeding is unusually heavy or prolonged </li></ul><ul><li>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 </li></ul><ul><li>For women using unopposed estrogen, evaluate any vaginal bleeding with an endometrial biopsy </li></ul><ul><li>For women not on HRT, any postmenopausal bleeding requires endometrial biopsy </li></ul>
  24. 24. Contraception
  25. 25. Types <ul><li>Natural Methods : Abstinence, Breast feeding ( Lactation Amenorrhea Method) and Coitus interruptus </li></ul><ul><li>Condom </li></ul><ul><li>Oral Contraceptive pills </li></ul><ul><li>Contraceptive patch </li></ul><ul><li>Hormonal Vaginal Ring </li></ul><ul><li>Diaphragm </li></ul><ul><li>Depo-Provera </li></ul><ul><li>Cervical cap </li></ul><ul><li>IUD </li></ul><ul><li>Which type preferred when – refer to pdf files on this desktop eg: iud, levonorgesterol implant etc – several QS </li></ul>
  26. 26. Breast Feeding <ul><li>Lactation Amenorrhea Method  Suckling causes increased prolactin,which inhibits estrogen production and ovulation </li></ul><ul><li>2% failure rate observed in 1st six mos. </li></ul><ul><li>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 </li></ul><ul><li>Breast feeding should be encouraged as a mode of contraception in </li></ul><ul><ul><ul><li>– Women free of blood-borne infections </li></ul></ul></ul><ul><ul><ul><li>– Women not on drugs that could effect baby </li></ul></ul></ul><ul><li>Adverse effects : increased risk of mastitis. Also, be warned that return of ovulation may precede return of menses </li></ul>
  27. 27. Condom <ul><ul><li>Condom Effective for contraception –95% </li></ul></ul><ul><ul><li>Only contraception that also prevents of STD </li></ul></ul><ul><ul><li>Typical use failure rate 15% </li></ul></ul><ul><ul><li>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 </li></ul></ul>
  28. 28. Female condom <ul><li>Sheaths of Latex, Polyurethane or natural membranes that may or may not have spermicide </li></ul><ul><li>Failure rate : 21% if used alone without spermicide gel </li></ul><ul><li>Female condom can also protect against STDs and it is reusable if the partner has no STD. </li></ul>
  29. 29. Diaphragm <ul><ul><li>Latex dome shaped device that covers the cervix ( may cause reaction in latex allergic people) </li></ul></ul><ul><ul><li>Must be combined with contraceptive gel </li></ul></ul><ul><ul><li>Can be put in several hours before intercourse and must be left in 8 hours after intercourse </li></ul></ul><ul><ul><li>Side effects : Increased risk of UTIs </li></ul></ul><ul><ul><li>Decreases risk of PID </li></ul></ul><ul><ul><li>No protection against HIV </li></ul></ul>
  30. 30. Spermicide <ul><li>Most common spermicide is nonoxynol-9 </li></ul><ul><ul><ul><li>Available in creams, films, foams, gels, suppositories, sponges, and tablets </li></ul></ul></ul><ul><ul><ul><li>It is of best use when combined with barrier methods </li></ul></ul></ul><ul><ul><ul><li>29% failure rate when used alone </li></ul></ul></ul>
  31. 31. Cervical Cap <ul><ul><li>Must be combined with contraceptive gel </li></ul></ul><ul><ul><li>Can be put in several hours before intercourse and must be left in 8 hours after intercourse </li></ul></ul><ul><ul><li>Does not protect against HIV </li></ul></ul><ul><ul><li>May decrease risk of PID, Gonorrhea and Chlamydia </li></ul></ul><ul><ul><li>No side effects </li></ul></ul>
  32. 32. Hormonal Vaginal Ring <ul><li>Nuvaring  estradiol & etonogestrel </li></ul><ul><li>Keep one ring for three weeks and no ring for one week  hormones will be absorbed anywhere in vagina </li></ul><ul><li>Advantage : </li></ul><ul><ul><li>Patient compliance increased  has to remember to insert and remove the ring once a month </li></ul></ul><ul><ul><li>Can be placed anywhere in the vagina </li></ul></ul>
  33. 33. Contraceptive patch <ul><li>Ortho Evra  </li></ul><ul><ul><ul><li>Keep one patch a week for three weeks and fourth week is without a patch. </li></ul></ul></ul><ul><ul><ul><li>Compliance is increased with this as opposed to OCPills </li></ul></ul></ul><ul><li>Disadvantages  patch is less effective in obese women above 198 pounds </li></ul>
  34. 34. Depo-Provera <ul><ul><li>Only injectable contraceptive currently available. </li></ul></ul><ul><ul><li>Given as intramuscular injection every 3 months ( contraceptive level maintained for 14 weeks) </li></ul></ul><ul><ul><li>Mechanism : Thickens cervical mucus, blocks LH surge </li></ul></ul><ul><ul><li>Compliance is easy </li></ul></ul><ul><ul><li>Side effects : </li></ul></ul><ul><ul><ul><li>Can cause irregular bleeding and most are amenorrheic at one year </li></ul></ul></ul><ul><ul><ul><li>If > 2 years of continuous usage, obtain DXA to evaluate bone density </li></ul></ul></ul>
  35. 35. Depo-Provera <ul><li>Indicated in women: </li></ul><ul><ul><li>Who desire long-term continuous contraception. </li></ul></ul><ul><ul><li>Those who have compliance issues and want to avoid a contraceptive method which requires a daily regimen </li></ul></ul><ul><ul><li>Who can not tolerate estrogen preperations. </li></ul></ul><ul><ul><li>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) </li></ul></ul><ul><ul><li>Who are taking anticonvulsants or rifampin or other drugs which decrease the efficacy of estrogen preperations (combined oral contraceptives) </li></ul></ul>
  36. 36. Depo - Provera Advantages Disadvantages <ul><li>Long acting </li></ul><ul><li>Estrogen free </li></ul><ul><li>Safe in breast feeding </li></ul><ul><li>No need to take daily  compliance increased </li></ul><ul><li>Increases milk quality in nursing mothers </li></ul><ul><li>Irregular bleeding  70% cases in first year of use </li></ul><ul><li>Depression ( hx of endogenous depression is an absolute contraindication) </li></ul><ul><li>Breast tenderness </li></ul><ul><li>Weight-gain </li></ul><ul><li>Decreases bone density </li></ul><ul><li>Menses only slowly return even after stopping use. </li></ul><ul><li>Decreases HDL cholesterol </li></ul>
  37. 37. Depo-Provera <ul><li>It is progesterone only. So, sometimes can cause heavy bleeding as it makes endometrium thin and unstable. </li></ul><ul><li>Managing heavy bleeding on Depo-Provera </li></ul><ul><ul><ul><li>Rule out pregnancy first – obtain HCG. </li></ul></ul></ul><ul><ul><ul><li>Add a low dose monophasic combined oral contraceptive for 2-3 cycles, or </li></ul></ul></ul><ul><ul><ul><li>Add premarin ( conjugated estrogens) 1.25 daily for 2 to 3 months. </li></ul></ul></ul>
  38. 38. IUD <ul><li>Copper T  </li></ul><ul><ul><ul><ul><li>copper is a spermicide that inhibits sperm motility and acrosomal enzyme action. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>It lasts 10 to 12 years. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>May cause Dysmenorrhea </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Failure rate is 0.8% </li></ul></ul></ul></ul><ul><li>Mirena (levonorgestrel) </li></ul><ul><ul><ul><ul><li>Increases cervical mucus thickness there by preventing sperm migration. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Can be left in place for 5 years </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Causes amenorrhea in many patients </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Advantages : </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Compliance is easy -Nothing to remember like OC pills </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Improves menorrhagia in 90% pateints </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Suited for longer contraceptive needs </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Failure rate 0.1% </li></ul></ul></ul></ul>
  39. 39. IUD <ul><li>IUD mainly preferred for people in mutually monogamous relationships and those who seek long term contraception </li></ul><ul><li>Adverse effects : </li></ul><ul><ul><ul><li>Not good for those with multiple sex partners because IUDs increase the risk of PID , esply within first 20 days of insertion. </li></ul></ul></ul><ul><ul><ul><li>Uterine perforation </li></ul></ul></ul><ul><ul><ul><li>Expulsion of IUD </li></ul></ul></ul><ul><ul><ul><li>Vasovagal syncope after insertion </li></ul></ul></ul>
  40. 40. Oral Contraceptive Pills <ul><li>- 99.9% efficacy rate if used correctly </li></ul><ul><li>In Adolescents – compliance is low and hence, efficacy rate is only 95% </li></ul><ul><li>Read in and out </li></ul><ul><li>A Very high-yield topic </li></ul>
  41. 41. OC Pills <ul><li>Most commonly used estrogen in the OC pills is ethinyl estradiol. However, multiple forms of progestins are used in combination pills. </li></ul><ul><li>Two types : </li></ul><ul><ul><ul><li>Monophasic: same amount of hormone in each active tablet </li></ul></ul></ul><ul><ul><ul><li>Multiphasic: varying amounts of hormone in each active pill </li></ul></ul></ul><ul><li>Most OCP’s have 21 active pills and 7 placebo pills </li></ul>
  42. 42. Instructions on use of OC Pills <ul><li>Starting OC pill </li></ul><ul><ul><li>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. </li></ul></ul><ul><li>Missed pill </li></ul><ul><ul><li>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. </li></ul></ul><ul><ul><li>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. </li></ul></ul><ul><ul><li>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. </li></ul></ul><ul><li>Using Additional contraceptive method </li></ul><ul><ul><li>Patient should use additional contraception for the first 7 days after first starting oc pills. </li></ul></ul><ul><ul><li>An additional contraceptive is also needed for 7 days if she is more than 12 hours late in taking ocp. </li></ul></ul><ul><ul><li>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 </li></ul></ul>
  43. 43. OCP - Absolute Contraindications <ul><li>Venous thromboembolism </li></ul><ul><li>Cerebrovascular or coronary artery disease </li></ul><ul><li>Diabetes with complications </li></ul><ul><li>Breast Cancer ( If History of breast cancer but no recurrence in past 5 years – just caution, not absolute contraindication) </li></ul><ul><li>Pregnancy </li></ul><ul><li>Lactation (<6 weeks postpartum) – estrogen inhibits milk secretion </li></ul><ul><li>Liver disease </li></ul><ul><li>Headaches with focal neurologic symptoms </li></ul><ul><li>Major surgery with prolonged immobilization </li></ul><ul><li>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) </li></ul><ul><li>Hypertension (blood pressure of >160/100 mm Hg or with concomitant vascular disease) </li></ul>
  44. 44. OCPills – Benefits outweigh Risk <ul><li>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. </li></ul><ul><li>- 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 </li></ul><ul><li>- Age >50 years - Family history of lipid disorders - Family history of premature myocardial infarction </li></ul>
  45. 45. OCPills - Non-contraceptive Benefits <ul><li>Dysmenorrhea </li></ul><ul><li>Mittelschmerz </li></ul><ul><li>Metrorrhagia </li></ul><ul><li>Premenstrual syndrome </li></ul><ul><li>Hirsutism </li></ul><ul><li>Reduces risk of Ovarian and endometrial cancer </li></ul><ul><li>Rx for functional ovarian cysts in young women </li></ul><ul><li>Reduces benign breast cysts </li></ul><ul><li>Useful in Ectopic pregnancy </li></ul><ul><li>May reduce Acne which in androgen dependant </li></ul><ul><li>Useful in endometriosis </li></ul><ul><li>Increases bone mineral density </li></ul>
  46. 46. Side Effects - OCPills <ul><li>Breakthrough bleeding or spotting is a very common side effect - esply in first few months. </li></ul><ul><li>Nausea, breast tenderness and vascular headaches are estrogen mediated </li></ul><ul><li>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) </li></ul>
  47. 47. Side Effects - OCPills <ul><li>Addressing Breakthrough Bleeding: </li></ul><ul><ul><li>A common side effect after starting OC Pills. </li></ul></ul><ul><ul><li>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. </li></ul></ul><ul><ul><li>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. </li></ul></ul><ul><ul><li>Approach to break through bleeding : </li></ul></ul><ul><ul><ul><li>Do not immediately make changes in OC pills </li></ul></ul></ul><ul><ul><ul><li>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. </li></ul></ul></ul><ul><ul><ul><li>If there is bleeding issues do not resolve even after third cycle, one of the following approaches can be used : </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Switch to a combination pill with higher estrogen or </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Prescrible additional estrogen for one to two cycles until bleeding resolves . </li></ul></ul></ul></ul></ul><ul><ul><ul><li>If the bleeding continues despite above measures, structural causes of bleeding such as fibroids and polyps must be ruled out. </li></ul></ul></ul>
  48. 48. Side Effects - OCPills <ul><li>Amenorrhea </li></ul><ul><ul><li>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. </li></ul></ul><ul><ul><li>Women may be concerned that the pregnancy might have occurred </li></ul></ul><ul><ul><li>Approach : </li></ul></ul><ul><ul><ul><ul><li>Get a beta HCG to rule out Pregnancy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>If not pregnant, one of the following approaches can be used to treat post pill amenorhea </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Switch to higher estrogen containing combination or </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Prescribe additional small dose of estrogen to one or two cycles or </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Obtain Urine HCG monthly to r/o pregnancy ( less cost-effective option) </li></ul></ul></ul></ul></ul>
  49. 49. Side Effects - OCPills <ul><li>Post Pill Amenorrhea : </li></ul><ul><ul><ul><ul><li>This is the amenorrhea that occurs after the woman stops taking the OC pills. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>It is possible that this is related to OC pills but one should keep in mind other causes of secondary amenorrhea. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Always get a pregnancy test. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Approach : </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Post pill amenorrhea problem should usually resolve in about 3 months after stopping the OC pills. So, observe the woman for three months. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>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 ) </li></ul></ul></ul></ul></ul>
  50. 50. OC pills and Headaches <ul><li>Headache is a common side effect with OCPs. </li></ul><ul><li>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 </li></ul><ul><li>Note that Migraine with Aura is a risk factor for ischemic stroke. OCPills is also an independent risk factor for ischemic stroke. </li></ul><ul><li>Migraine without aura does not seem to significantly increase the risk of stroke. </li></ul><ul><li>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) </li></ul><ul><li>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 </li></ul><ul><li>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. </li></ul><ul><li>Also, realize that Tension headaches are not a contraindication to OC pill use </li></ul>
  51. 51. Progestin Component <ul><li>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. </li></ul><ul><li>Third-generation progestins ( norgestimate, desogestrol) in oral contraceptive pills have a better side effect profile. </li></ul><ul><li>Minimal androgenic effects </li></ul><ul><li>Does not adversely effect BP or glucose or lipids or weightgain </li></ul><ul><li>In all pts, you can start 1 st generation progestin. Switching to OCPill combination with 3 rd generation progestin is advised in DM, Hyperlipidemia or in pts who cannot tolerate other combination ocpills because of severe acne/ hirsutism </li></ul>
  52. 52. Considering a switch? <ul><li>If considering switching oral contraceptives from one form to another, follow the guidelines: </li></ul><ul><li>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 . </li></ul><ul><li>If switching to reduce nausea, breast tenderness or Migraine :Choose an OC pill with lower dose of estrogen eg: Loestrin </li></ul><ul><li>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) </li></ul><ul><li>If switching to reduce androgenic effects (acne, hirsutism, weightgain, oily skin) : Choose a product containing a Third-generation progestin , low-dose norethindrone or ethynodiol diacetate. Eg: Demulen 1/35 </li></ul><ul><li>If switching to prevent dyslipidemia : use a product containing a third-generation progestin, low-dose norethindrone or ethynodiol </li></ul>
  53. 53. Mini Pill <ul><li>Progestin-only pills, or minipills  contain no estrogen and have a lower dose of progestin thasn traditional oCPs. Eg: Norethindrone (Norlutin) and norgestrel (Ovrette). </li></ul><ul><li>USES : </li></ul><ul><li>- For women with contraindications to the use of combined oral contraceptives </li></ul><ul><li>- Women who are breast-feeding ( does not intefere with quantity or quality of breast milk). </li></ul>
  54. 54. Minipill <ul><li>Irregular bleeding more common  also causes a great “breakthrough” bleeding and hence, these pills are usually reserved for lactating women. </li></ul><ul><li>Daily compliance is crucial </li></ul><ul><ul><li>An active pill every day, no placebos </li></ul></ul><ul><ul><li>Same timeevery day (even 2-3 hr change can cause bleeding) </li></ul></ul>
  55. 55. OCPs and Interactions
  56. 56. OCPs and Interactions <ul><li>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. </li></ul><ul><li>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). </li></ul>
  57. 57. Board Style Scenarios <ul><li>OC pills and Rifampin interaction </li></ul><ul><li>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) </li></ul><ul><li>Preferred hormonal contraception in lactating women. </li></ul><ul><li>Preferred hormonal contraception for those requiring long term contraception ( Depo-provera) </li></ul><ul><li>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) </li></ul>
  58. 58. Q <ul><li>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? </li></ul>
  59. 59. OCPs - Postpartum <ul><ul><li>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 </li></ul></ul><ul><ul><li>If delivery occurred less than of 20 weeks of gestation – patient can begin OCPs immediately. </li></ul></ul><ul><li>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 </li></ul>
  60. 60. Q <ul><li>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? </li></ul>
  61. 61. <ul><li>Ask Lisa which pills were missed: </li></ul><ul><li>If placebo pill - Reassure </li></ul><ul><li>If it is an active pill & is delayed less than 24 hrs , take pill immediately </li></ul><ul><li>If active pill & delayed more than 24 but less than 48 hrs  take both pills immediately </li></ul><ul><li>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. </li></ul><ul><li>If >3 days missed  stop pills, wait for menses and then begin a new pack. Use alternative form of birth control until next menses. I f unprotected intercourse during missed pill days  consider emergency contraception </li></ul><ul><li>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. </li></ul>
  62. 62. Emergency Contraception <ul><li>“ Emergency&quot; contraception is used in the first 72 hours after unprotected sex. </li></ul><ul><li>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. </li></ul><ul><li>Post coital contraception usually causes nausea and vomiting. Premedicate with an anti-emetic (eg: Phenergan). </li></ul><ul><li>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) </li></ul>
  63. 63. Emergency Contraception <ul><li>Mechanism of action - </li></ul><ul><ul><li>inhibits or delays ovulation if taken prior to ovulation </li></ul></ul><ul><ul><li>interferes with egg/sperm transport – egg and sperm will not meet. </li></ul></ul><ul><ul><li>If fertilization has already occurred, alters endometrium and prevents implantation of the fertilized egg </li></ul></ul><ul><ul><li>Does not terminate established pregnancy </li></ul></ul><ul><li>Contraindications : </li></ul><ul><ul><li>only contraindication is pregnancy </li></ul></ul><ul><ul><li>History of ectopic pregnancy is not a contraindication </li></ul></ul><ul><ul><li>Smoking & over age 35 is not a contraindication </li></ul></ul>
  64. 64. Copper IUD <ul><ul><li>Can be used for emergency contraception within 5 days of unprotected intercourse. </li></ul></ul><ul><ul><li>Interferes with implantation after fertilization </li></ul></ul><ul><ul><li>May be more effective than hormonal emergency contraception </li></ul></ul><ul><ul><li>Provides on-going contraception after insertion ( preferable for a woman who also desires long term contraception) </li></ul></ul>
  65. 65. Permanent Contraception <ul><li>Recommended for those who have completed their families </li></ul><ul><li>Tubal ligation </li></ul><ul><ul><li>Effective immediately </li></ul></ul><ul><ul><li>More invasive and requires longer post-op recovery </li></ul></ul><ul><li>Vasectomy </li></ul><ul><ul><li>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) </li></ul></ul><ul><ul><li>Outpatient procedure with local anesthetic </li></ul></ul><ul><ul><li>Does not effect the orgasms </li></ul></ul>
  66. 66. Q1 <ul><li>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? </li></ul><ul><li>A. Reassure her and start OC Pills </li></ul><ul><li>B. Tell her to use condoms alone </li></ul><ul><li>C. Start minipill because OC pills may worsen her headache </li></ul><ul><li>D. Start OC pills but switch topiramate to valproic acid to prevent her migraines better </li></ul>
  67. 67. Ans. A <ul><li>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. </li></ul><ul><li>Studies have shown that headache occurring in association with OC use tended to improve despite continued OC use </li></ul>
  68. 68. Q2 <ul><li>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 ? </li></ul><ul><li>A. Discontinue oral contraceptive pills </li></ul><ul><li>B. Switch to OCPills with low dose estrogen </li></ul><ul><li>C. Switch to OC pills with high dose estrogen </li></ul><ul><li>D. Start Topiramate for prophylaxis of migraine </li></ul><ul><li>E. CT head without contrast </li></ul>
  69. 69. Ans.B <ul><li>Benefits outweigh risks – has endometriosis and desires contraception </li></ul><ul><li>Her migraine is with out aura or focal neuro deficits and she has no additional risk factors for ischemic stroke </li></ul><ul><li>Reducing estrogen component may reduce migraine severity. </li></ul><ul><li>Studies have shown that headache occurring in association with OC use tended to improve despite continued OC use </li></ul>
  70. 70. Q3 <ul><li>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 &quot;bright, zigzag lines&quot; 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? </li></ul><ul><li>A. Reduce the dose of estrogen in the combination pill </li></ul><ul><li>B. Switch to mini pill </li></ul><ul><li>C. Ask her to convince her partner to use condoms </li></ul><ul><li>D. Reassure her and continue OC Pills </li></ul><ul><li>E. Stop OC pills and restart after one month. </li></ul>
  71. 71. Ans. B <ul><li>If migraines worsen or if there is new-onset migraine related to OC use, consider the following stroke risk factors: </li></ul><ul><li>patient's age ( age > 35 increased risk) </li></ul><ul><li>the type of migraine i.e; with aura is increased risk for cva </li></ul><ul><li>The presence of other vascular risk factors i.e; smoking, HTN – in this woman, smoking additional risk alon with migraine with aura </li></ul><ul><li>So, combination pills have to be d/ced. Switch to minipill or other forms of reasonable contraception </li></ul><ul><li>Any unusual headache with sudden onset, focal neuro deficits – immediately stop OC pills and get a Head CT. </li></ul>
  72. 72. Q.4 <ul><li>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 ? </li></ul><ul><li>A. Switch to low dose estrogen pills </li></ul><ul><li>B. Switch to minipill </li></ul><ul><li>C. Discontinue OC pills </li></ul><ul><li>D. Start extended duration OC pills like seasonale </li></ul>
  73. 73. Ans. D <ul><li>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. </li></ul><ul><li>Seasonale: 84 consecutive hormonal pills followed by 7 days of placebo </li></ul><ul><li>Reasons for the use of extended duration OC regimens ( 91 days) </li></ul><ul><ul><ul><li>Convenience </li></ul></ul></ul><ul><ul><ul><li>patient desire for fewer episodes of withdrawal bleeding ( they will have only 4 bleeding episodes per year) </li></ul></ul></ul><ul><ul><ul><li>To reduce the occurrence of headache and other estrogen-withdrawal symptoms ( Premenstrual syndrome). </li></ul></ul></ul>
  74. 74. Choosing The Right OCP <ul><li>Endometriosis: Choose a pill with a strong progestin to create a pseudo-pregnancy state ( you know pregnancy improves endometriosis) </li></ul><ul><li>Functional Ovarian Cysts: High dose monophasic pill may be more effective </li></ul><ul><li>Androgen excess: Choose a pill with high estrogen/progestin ratio to reduce free testosterone and inhibit 5α reductase activity </li></ul><ul><li>Breastfeeding: Progestin -only pill </li></ul>
  75. 75. Vaginitis / Vaginal Disharge Step3 Topics  Diagnosis, Antibiotic choices in pregnancy, Treat sexual partner or not, counseling
  76. 76. Vaginal Discharge - Causes <ul><li>Physiology: Normal vaginal secretions </li></ul><ul><li>Dependent on multiple factors </li></ul><ul><ul><li>Age </li></ul></ul><ul><ul><li>Timing of Menstrual Cycle </li></ul></ul><ul><ul><li>Sexual arousal </li></ul></ul><ul><ul><li>Contraceptive use </li></ul></ul><ul><ul><li>Douching </li></ul></ul><ul><li>Composed of Cervical Mucus , Vaginal wall transudate & Exfoliated vaginal cells </li></ul>Common Causes Normal discharge (30%) Candida Vulvovaginitis (20-25%) Bacterial Vaginosis (23-50%) Trichomonas vaginitis (5-15%) Mixed infection or Sexually Transmitted Disease (20%)
  77. 77. Vaginal discharge <ul><li>Other Causes </li></ul><ul><li>Atrophic Vaginitis (post-menopausal women) </li></ul><ul><li>Infectious Cervicitis : Neisseria gonorrhoeae , Chlamydia trachomatis and Herpes Simplex Virus </li></ul><ul><li>Vaginitis or Vulvitis </li></ul><ul><ul><li>Scabies </li></ul></ul><ul><ul><li>Neurodermatitis </li></ul></ul><ul><ul><li>Vaginal or vulvar trauma </li></ul></ul><ul><ul><li>Irritant or Allergic Contact Dermatitis </li></ul></ul><ul><ul><ul><li>Soaps, Tampons or sanitary napkins , Condoms , Spermicidal gel , Diaphragm </li></ul></ul></ul><ul><ul><li>Herpes Vulvitis </li></ul></ul><ul><ul><li>Malignancy </li></ul></ul><ul><li>Physiologic discharge </li></ul><ul><ul><li>Ovulation , Pregnancy </li></ul></ul>
  78. 78. Women tend to self treat <ul><li>As per studies, </li></ul><ul><li>Women often self-treat chronic vaginal symptoms </li></ul><ul><ul><li>In a study 73% used Over-the-counter yeast vaginitis medication and 42% used Alternative Medicine yeast vaginitis treatment </li></ul></ul><ul><li>Self-diagnosis often incorrect and may be harmful </li></ul><ul><ul><li>Correct diagnosis of yeast vaginitis seen only in 11-28% of self treated cases </li></ul></ul><ul><ul><li>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) </li></ul></ul>
  79. 79. Vaginitis <ul><li>R/O STD in cases of Vaginitis. Most important clues in history : </li></ul><ul><li>Hx of multiple sexual partners </li></ul><ul><li>Not using barrier methods of contraception </li></ul><ul><li>Hx of STDs in the past </li></ul>
  80. 80. Symptoms – Vaginitis <ul><li>Intense Vaginal itching or burning: one of the most important symptom that goes in favor of Candida Vulvovaginitis </li></ul><ul><li>Malodorous or unusual vaginal discharge </li></ul><ul><li>External Dysuria (pain with urine passing over vulva) </li></ul><ul><li>Dyspareunia </li></ul>
  81. 81. Distinguish between vaginitis and cervicitis <ul><li>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. </li></ul><ul><li>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 </li></ul><ul><li>Always remember to Treat patients with gonococcal cervicitis for chlamydial infection as well, even if laboratory confirmation of the latter is not obtained. </li></ul><ul><li>Although signs and symptoms may suggest a cause for vaginitis or cervicitis, perform specific diagnostic testing . </li></ul>
  82. 82. Signs – Vaginitis – Clues to Etiology <ul><li>Character of vaginal secretions </li></ul><ul><li>Normal  clear or white, non-clumping, odorless </li></ul><ul><li>Dry cottage cheese-like discharge  Candida Vulvovaginitis </li></ul><ul><li>Frothy discharge (rarely present)  Trichomonas vaginitis </li></ul><ul><li>Fishy Odor  Bacterial Vaginosis & Trichomonas vaginitis </li></ul><ul><li>Vagina and Cervix appearance </li></ul><ul><li>Vulvar redness, edema and adherent white clumps </li></ul><ul><ul><li>Candida Vulvovaginitis </li></ul></ul><ul><li>Strawberry cervix with punctate hemorrhage </li></ul><ul><ul><li>Trichomonas vaginitis </li></ul></ul><ul><li>Pale, dry, thin vaginal and vulvar skin </li></ul><ul><ul><li>Atrophic Vaginitis </li></ul></ul>
  83. 83. Signs – Vaginitis – Clues to Etiology <ul><li>Vaginal Ph </li></ul><ul><li> Use standard vaginal Ph paper </li></ul><ul><li> 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!!! </li></ul><ul><li> 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 </li></ul>
  84. 84. Diagnosis - Vaginitis <ul><li>Include the following tests in the diagnostic evaluation: </li></ul><ul><li>Vaginal pH </li></ul><ul><li>“ Whiff” test </li></ul><ul><li>Wet mount for vaginitis and potassium hydroxide prep </li></ul><ul><li>Endocervical specimen for gonorrhea and chlamydia verification for cervicitis </li></ul>
  85. 85. Diagnosis – Vaginitis/ Discharge <ul><li>Lab: Microscopy </li></ul><ul><li>Normal </li></ul><ul><ul><li>Few Polymorphonuclear Leukocyte (PMNs) </li></ul></ul><ul><ul><li>Vaginal epithelial cells </li></ul></ul><ul><li>KOH Preparation: Pseudo-hyphae or budding yeast </li></ul><ul><ul><li>Candida Vulvovaginitis </li></ul></ul><ul><li>Saline preparation (Wet Prep) </li></ul><ul><ul><li>Curved motile organisms: Trichomonas vaginitis </li></ul></ul><ul><ul><li>Clue Cells: Bacterial Vaginosis </li></ul></ul><ul><ul><li>Numerous Leukocytes </li></ul></ul><ul><ul><ul><li>Trichomonas vaginitis </li></ul></ul></ul><ul><ul><ul><li>Gonorrhea </li></ul></ul></ul><ul><ul><ul><li>Chlamydia </li></ul></ul></ul><ul><ul><li>Desquamative vaginitis (local irritant induced) </li></ul></ul><ul><ul><ul><li>Many White Blood Cells </li></ul></ul></ul><ul><ul><ul><li>Parabasilar cells </li></ul></ul></ul>
  86. 86. Treatment – Vaginitis/ Discharge <ul><li>Treat the specific cause </li></ul><ul><li>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 </li></ul><ul><li>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 ) </li></ul><ul><li>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 “ </li></ul><ul><li>All cases of gonorhhea/ chlamydia must be reported to state health department!! </li></ul>
  87. 87. Bacterial vaginosis <ul><li>Accounts for 30 – 50% of vaginitis </li></ul><ul><li>Occurs because of Marked reduction in normally predominant lactobacillus and overgrowth of facultative Anaerobic Bacteria </li></ul><ul><li>like Peptostreptococcus , Haemophilus vaginalis, Bacteroides and Mycoplasma hominis </li></ul><ul><li>Symptoms: usually asymptomatic, If present they are mild  Musty/ fishy odor to gentilia & thin greywhite, non clumping vaginal discharge </li></ul><ul><li>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 </li></ul><ul><li>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 </li></ul>
  88. 88. Treatment – Bacterial Vaginosis <ul><li>Non-Pregnant </li></ul><ul><ul><li>First-Line: Oral Metronidazole 500 mg PO bid for 7 days </li></ul></ul><ul><ul><li>Topical options (higher recurrence rate)  MetroGel (0.75%) 5g PV qhs for 5 days / Clindamycin Cream (2%) </li></ul></ul><ul><li>Pregnancy: </li></ul><ul><ul><li>First Trimester </li></ul></ul><ul><ul><ul><li>Avoid treatment if possible in first trimester </li></ul></ul></ul><ul><ul><ul><li>Clindamycin 300 mg PO bid for 7 days </li></ul></ul></ul><ul><ul><ul><li>Clindamycin Cream 5 grams PV qhs for 7 days / Metronidazole Gel PV bid for 5 days </li></ul></ul></ul><ul><ul><li>After First Trimester  Metronidazole 250 mg tid for 7 days or Consider with Erythromycin x14 days or Clindamycin for 7 days </li></ul></ul><ul><li>Resistant/Refractory Cases  Metronidazole 500 mg bid x14 days(preferred) </li></ul><ul><ul><li>Consider treating sexual partner and patient ( remember evidence is lacking in this case about Rxng sexual partners in case of recurrence) </li></ul></ul><ul><ul><li>Other options : Clindamycin at above dose , Povidone-iodine gel OR suppository (Betadine) </li></ul></ul><ul><li>Recurrent Bacterial Vaginosis  Treat as refractory cases above </li></ul><ul><ul><li>Consider maintenance therapy </li></ul></ul><ul><ul><ul><li>Induction: Metronidazole gel qhs x10 days </li></ul></ul></ul><ul><ul><ul><li>Maintenance: When wet prep with no clues, pH lower </li></ul></ul></ul><ul><ul><ul><ul><li>Metronidazole gel twice weekly for 3 months </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Treat concurrent Candida if present  Fluconazole150 mg q Week </li></ul></ul></ul></ul>
  89. 89. Clue Cells <ul><li>Clue Cells present on >20% of cells is significant </li></ul><ul><li>Bacteria adhered to vaginal epithelial cells </li></ul><ul><li>Most reliable single indicator of bacterial vaginosis </li></ul>
  90. 90. Complications – Bacterial Vaginosis <ul><li>Complications </li></ul><ul><li>Associated with preterm delivery (23-26 weeks) </li></ul><ul><li>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 </li></ul><ul><li>(“ 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 ) </li></ul>
  91. 91. Trichomonas Vaginitis <ul><li>Protozoan infection accounting for 10% cases of vaginitis </li></ul><ul><li>Remember this is an STD  sexual partner must be treated. Men are asymptomatic in 90% cases </li></ul><ul><li>Associated Conditions : Preterm Labor, other STDs </li></ul><ul><li>Test for other STDs  Gonorrhea, chlamydia </li></ul><ul><li>Symptoms : Asymptomatic in 25-44% of women </li></ul><ul><li>Copious, grayish-green Vaginal Discharge, may have Fishy odor to discharge , Frothy discharge (Carbon dioxide bubbles , Frothy discharge has  Sensitivity: 10% , Specificity: 70% ) </li></ul><ul><li>Vulvar/vaginal irritation, itching, dysuria </li></ul><ul><li>Signs  Vulvar edema and erythema </li></ul><ul><li>Strawberry Cervix (seen in 3% of cases) (  associated with Punctate hemorrhages or Petechiae, Telangiectasia is pretty specific ) </li></ul>
  92. 92. Trichomonas - Rx <ul><li>General: Treat Sexual Partner also , Avoid treatment in first trimester of pregnancy </li></ul><ul><li>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 </li></ul><ul><li>Pregnant </li></ul><ul><ul><li>First Trimester  Clotrimazole 100 mg PV qhs for 7 days </li></ul></ul><ul><ul><li>After First Trimester </li></ul></ul><ul><ul><ul><li>Metronidazole 2 g PO for 1 dose or 500 mg PO bid for 7 days </li></ul></ul></ul><ul><li>Lactation </li></ul><ul><ul><li>Metronidazole 2 grams PO for 1 dose </li></ul></ul><ul><ul><li>Discontinue Lactation for 24 hours after dose </li></ul></ul><ul><li>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 </li></ul>
  93. 93. Trichomonas - Diagnosis <ul><li>Vaginal Ph > 5.0 </li></ul><ul><li>On Koh preperation, Sniff test +ve in some cases </li></ul><ul><li>On Wet preperation  you will see motile curved rods wich are twice the size of wbcs </li></ul><ul><li>Culture  grown on modified diamond media </li></ul>
  94. 94. Candida Vulvovaginitis <ul><li>Often self diagnosed by women incorrectly </li></ul><ul><li>Accounts for 40% of vaginitis </li></ul><ul><li>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 </li></ul><ul><li>Symptoms  asymptomatic 20-50% cases, Intense vaginal/vulvar pruritis in 50% cases, curdy white discharge, vulvar burning, dysuria, dyspareunia </li></ul><ul><li>Signs  Adherent white cottage-cheese discharge in vagina ( Sensitivity: 50% , Specificity: 90% ) </li></ul><ul><li>Vulvar erythema and edema (24% of cases) </li></ul>
  95. 95. Candida Vulvovaginitis - Diagnosis <ul><li>Lab </li></ul><ul><li>KOH Preparation  shows Pseudohyphae or budding yeast forms </li></ul><ul><li>Fungal Culture rarely performed </li></ul><ul><li>Fungal Culture may be very helpful in certain cases </li></ul><ul><ul><li>Confirm asymptomatic carrier of vaginal Candida </li></ul></ul><ul><ul><li>Identify cause of recurrent vaginitis </li></ul></ul><ul><li>Candida on Pap Smear  Specific but not sensitive </li></ul><ul><li>Vaginal pH <4.5 (Normal acidity) </li></ul><ul><li>Absent Amine odor </li></ul><ul><li>White Blood Cells not increased </li></ul><ul><li>Wet-Prep is not sensitive or specific for yeast </li></ul>
  96. 96. If candida is refractory to Rx <ul><li>Consider for refractory cases: - </li></ul><ul><li>Other Vaginitis cause </li></ul><ul><ul><li>Bacterial Vaginosis </li></ul></ul><ul><ul><li>Trichomonas vaginitis </li></ul></ul><ul><li>Infectious Cervicitis (Sexually Transmitted Disease) </li></ul><ul><li>Allergic Vaginitis or Vulvitis </li></ul><ul><li>Vulvodynia  chronic vulvar itching/ irritation ( rx  reassurance, TCAs, SSRIs) </li></ul>
  97. 97. Candida Vulvovaginitis - Rx <ul><li>First choice is local agents  Miconozole cream/ pessaries/ vag tabs PV, Clotrimazole PV, Nystatin PV  3 to 7 days </li></ul><ul><li>Oral Agents  Fluconozole 150mg Po x 1 dose </li></ul><ul><li>Recurrence/ resistant candida  </li></ul><ul><ul><li>Any of above intravaginal meds for 14 days, After initial daily regimen , start maintainance Rx at least once a week </li></ul></ul><ul><ul><li>Oral agents  2 dose Fluconozole  150 day 1 and another 150 mg 72 hrs after 1 st dose </li></ul></ul><ul><li>Prophylaxis  when will you consider???? </li></ul><ul><li>Indication  Four or more yeast infections per year </li></ul><ul><li>Initial treatment  Fluconazole 150 mg PO q3 days for 3 doses </li></ul><ul><li>Maintenance </li></ul><ul><ul><li>Fluconazole 150 mg PO each week </li></ul></ul><ul><ul><li>Monitor liver enzymes (consider q1-2 months) </li></ul></ul><ul><li>Efficacy </li></ul><ul><ul><li>Suppression while on treatment: 90% </li></ul></ul><ul><ul><li>Following treatment: Infection recurs in 60 </li></ul></ul>
  98. 98. Screen women at risk for sexually transmitted causes of vaginitis and cervicitis <ul><li>Screen sexually active women aged <25 years for chlamydia on an annual basis. </li></ul><ul><li>Screen all women aged 25 years and younger for chlamydia </li></ul><ul><li>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 </li></ul><ul><li>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 ). </li></ul><ul><li>Include a serologic screening test for syphilis in populations at high risk for syphilis. </li></ul>
  99. 99. Screen for STDs during pregnancy <ul><li>Screen for STDs in high-risk groups and in communities with high prevalence rates during the first trimester. </li></ul><ul><li>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. </li></ul><ul><li>Screen for gonorrhea and chlamydia in all patients by the third trimester. </li></ul><ul><li>Screen for syphilis, hepatitis B, and HIV in all pregnant women. </li></ul>
  100. 100. Chlamydia Screening <ul><li>Use cervical DNA Probe </li></ul><ul><li>Screen anually, all sexually active women under the age of 25. </li></ul><ul><li>In women older than 25, screen annually, if they have risk factors for STDs – new sex partner, multiple partners etc </li></ul><ul><li>SCREEN ALL PREGNANT WOMEN </li></ul>
  101. 101. Chlamydia <ul><li>Presents with cervicitis and PID in women ( cervical DNA probe best test/ PCR) </li></ul><ul><li>A common cause of non gonococcal urethritis in men ( Urine for leucoesterase screening test. If +ve, do urine chlamydia antigen in men) </li></ul><ul><li>Can also cause Epidydymitis in men, esply age <35 yrs. </li></ul>
  102. 102. Chlamydia - Therapy <ul><li>1. First Choice - Azithromycin 1 gram PO for 1 dose or Doxycycline 100 mg PO bid for 7 days Alternatives : Ofloxacin, Levofloxacin, Erythromycin </li></ul><ul><li>2. If pts have persistant or recurrent urethritis despite treatment : use Metronidazole 2 grams PO for 1 dose + Erythromycin twice daily x7 days </li></ul><ul><li>3. In Pregnancy use: Azithromycin 1 gram PO as single dose or Amoxicillin 500 PO tid x7 days </li></ul><ul><li>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) </li></ul>
  103. 103. Chlamydia - Therapy <ul><li>Make sure to refer all sexual contacts for treatment </li></ul><ul><li>No sexual intercourse for 7 days </li></ul><ul><li>Indications to retest chlamydia after antibiotic therapy to confirm eradication: </li></ul><ul><ul><li>Having persistent symptoms </li></ul></ul><ul><ul><li>Pregnancy </li></ul></ul>
  104. 104. Dysmenorrhea
  105. 105. Dysmenorrhea <ul><li>Painful Menses </li></ul><ul><li>Risk Factors </li></ul><ul><ul><ul><li>Age under 20 years </li></ul></ul></ul><ul><ul><ul><li>Tobacco Abuse </li></ul></ul></ul><ul><ul><ul><li>Mood Disorder </li></ul></ul></ul><ul><ul><ul><li>Menorrhagia </li></ul></ul></ul><ul><ul><ul><li>Nulliparity </li></ul></ul></ul><ul><li>Types of dysmenorrhea </li></ul><ul><ul><li>Primary Dysmenorrhea – accounts 90% cases </li></ul></ul><ul><ul><ul><li>Occurs within 6 to 12 months of Menarche </li></ul></ul></ul><ul><ul><ul><li>Idiopathic with no clear pelvic explaination of pain </li></ul></ul></ul><ul><ul><li>Secondary Dysmenorrhea: Acquired due to a pelvic disease </li></ul></ul><ul><ul><ul><li>Endometriosis & Pelvic Inflammatory Disease (PID) – MCC of secondary dysmenorrhea </li></ul></ul></ul><ul><ul><ul><li>Other causes :Uterine Fibroids, Endometrial Polyps, Adenomyosis, IUDs </li></ul></ul></ul>
  106. 106. Dysmenorrhea <ul><li>Points in history that suggest Secondary Dysmenorrhea </li></ul><ul><ul><ul><li>Changed dysmenorrhea character, location or intensity </li></ul></ul></ul><ul><ul><ul><li>History of prior STDs </li></ul></ul></ul><ul><ul><ul><li>Pelvic Pain persisting throughout cycle </li></ul></ul></ul><ul><ul><ul><li>Infertility </li></ul></ul></ul><ul><ul><ul><li>Abnormal Menstrual Bleeding </li></ul></ul></ul><ul><ul><ul><li>Dyspareunia </li></ul></ul></ul>
  107. 107. Dysmenorrhea <ul><li>Cramping or colicky lower abdominal or Pelvic Pain beginning within a few hours of menstrual flow </li></ul><ul><li>May be assocaited Nausea, vomiting, bloating or diarrhea </li></ul><ul><li>I mproved by Oral Contraceptive use and after childbirth </li></ul><ul><li>Do a careful physical exam </li></ul><ul><ul><ul><li>Normal Pelvic exam  Suggests Primary Dysmenorrhea </li></ul></ul></ul><ul><ul><ul><li>Uterosacral nodularity  Suggests Endometriosis </li></ul></ul></ul><ul><ul><ul><li>Thickened Adnexal Masses  Suggests PID </li></ul></ul></ul><ul><ul><ul><li>Enlarged, irregular uterus  Suggests Uterine Fibroids </li></ul></ul></ul><ul><ul><ul><li>Enlarged, boggy uterus  Suggests Adenomyosis </li></ul></ul></ul>
  108. 108. Rx - dysmenorrhea <ul><li>Rx </li></ul><ul><li>NSAIDs – very effective in dysmenorrhea </li></ul><ul><ul><li>Ibuprofen, Naproxen or Mefenamic acid </li></ul></ul><ul><li>Hormonal Contraception </li></ul><ul><ul><li>Combined OC pills or Progesterone only Pill </li></ul></ul><ul><li>In refractory cases, obtain OBGYN consult for diagnostic laparoscopy </li></ul><ul><li>Danazol or Leuprolide may be tried in severe cases </li></ul>
  109. 109. Amenorrhea <ul><li>Lack of menses </li></ul><ul><li>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 </li></ul><ul><li>Secondary Amenorrhea  Previously regular cycles but now 3 months of no Menses or Previously irregular cycles with now 6 months of no Menses </li></ul>
  110. 110. Secondary Amenorrhea <ul><li>Do pregnancy test in all cases first </li></ul><ul><li>Then obtain TSH and Prolactin </li></ul><ul><li>Then do Progesterone Challenge Test </li></ul><ul><li>Recognized Female Athlete Triad ( Highyield on Step3) </li></ul><ul><li>Other conditions : PCOS, Premature ovarian failure </li></ul>
  111. 111. Progesterone Challenge Test <ul><li>Procedure: Progesterone Challenge </li></ul><ul><li>Administer Progesterone ( Norethindrone 5 mg PO once daily for 7-10 days or Progesterone 200 mg IM for one dose) </li></ul><ul><li>Determine if there is menstrual bleeding after Progesterone which should occur within 7 days of Progesterone completion </li></ul><ul><li>Here is how you interpret : </li></ul><ul><ul><ul><li>If Withdrawal bleeding within 7 days </li></ul></ul></ul><ul><ul><ul><ul><li>Suggests Anovulation with Progesterone deficiency ( Mullerian duct development anomalies, hyperprolactinemia, gonadal dysgenesis, PCOS) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>These patients have high risk of Endometrial Cancer with unopposed Estrogen  They Require Progesterone replacement </li></ul></ul></ul></ul><ul><ul><ul><li>If No withdrawal bleeding  Do a Estrogen-Progesterone Challenge Test ( OC Pills for 2 cycles) </li></ul></ul></ul><ul><ul><ul><ul><li>No withdrawal bleed suggests uterine outflow obstruction </li></ul></ul></ul></ul><ul><ul><ul><ul><li>If withdrawl bleed, Obtain Serum FSH and Serum LH </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>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) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>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 ) </li></ul></ul></ul></ul></ul>
  112. 112. Female Athlete Triad <ul><li>Disordered Eating (Anorexia Nervosa) </li></ul><ul><li>Secondary Amenorrhea </li></ul><ul><li>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!) </li></ul><ul><li>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) </li></ul><ul><li>Prevention of secondary amenorrhea in female athletes  increase body weight by 2kgs and decrease exercise activity by 10%. </li></ul><ul><li>Management : </li></ul><ul><ul><ul><li>Maintain adequate calorie intake </li></ul></ul></ul><ul><ul><ul><li>Take adequate calcium </li></ul></ul></ul><ul><ul><ul><li>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 ) </li></ul></ul></ul>
  113. 113. Infertility Inability to conceive after 12 months of unprotected intercourse.
  114. 114. Etiologies <ul><li>Male factor alone – 33% </li></ul><ul><ul><li>Idiopathic (40-50%) </li></ul></ul><ul><ul><li>Primary Hypogonadism (Testicular Failure): </li></ul></ul><ul><ul><ul><li>Varicocele </li></ul></ul></ul><ul><ul><ul><li>Medication of drug use ( alcohol, cocaine, marijuana, methotrexate, cimetidine, spironolactone) </li></ul></ul></ul><ul><ul><ul><li>Testicular surgeries or injury </li></ul></ul></ul><ul><ul><ul><li>Cryptorchidism </li></ul></ul></ul><ul><ul><ul><li>Chromosomal abnormality (e.g. Klinefelter Syndrome) </li></ul></ul></ul><ul><ul><ul><li>Genital radiation or Chemotherapy </li></ul></ul></ul><ul><ul><ul><li>Orchitis : Post-pubertal mumps and STDs </li></ul></ul></ul><ul><ul><li>Obstructive azoospermia or altered transport </li></ul></ul><ul><ul><ul><li>Erectile Dysfunction </li></ul></ul></ul><ul><ul><ul><li>Retrograde ejaculation or other dysfunction </li></ul></ul></ul><ul><ul><ul><li>Hypospadias </li></ul></ul></ul><ul><ul><li>Secondary Hypogonadism (Hypothalamic-Pituitary Axis issues) </li></ul></ul><ul><ul><ul><li>Hypogonadotropic Hypogonadism </li></ul></ul></ul><ul><ul><ul><li>Androgen Excess (e.g. Anabolic Steroids) </li></ul></ul></ul><ul><ul><ul><li>Estrogen excess (e.g. tumor) </li></ul></ul></ul><ul><ul><ul><li>Pituitary adenoma </li></ul></ul></ul><ul><ul><ul><li>Infiltrative Disorder </li></ul></ul></ul><ul><ul><ul><ul><li>Sarcoidosis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Tuberculosis </li></ul></ul></ul></ul><ul><li>Both male and female causes – 1/3 cases </li></ul>
  115. 115. Approach in Infertility <ul><li>First obtain Semen analysis after abstinence x 5 days </li></ul><ul><li>If semen analysis normal  evaluate female infertility </li></ul><ul><li>In female infertility  </li></ul><ul><ul><ul><li>Establish if ovulation is occuring : </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Serum progesterone on day 21 of 28 day cycle > 3ng/ml </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Basal Body Temperature charting with increase in themp by 0.5F every 12 – 15 days </li></ul></ul></ul></ul></ul><ul><ul><ul><li>If anovulatory, obtain TSH, Prolactin and FSH. Day 3 of cycle’s FSH > 15 is abnormal ( indicates anovulation) </li></ul></ul></ul><ul><ul><ul><li>Then r/o hyperandrogenism  obtain DHEAS, Testosterone, LH levels </li></ul></ul></ul><ul><ul><ul><li>Later assess tubal patency  Transvaginal ultrasound and HYsterosalpingogram ( to assess uterine abnormalities, synechiae, submucosal fibroids) </li></ul></ul></ul><ul><ul><ul><li>For Unexplained infertility  consider laparoscopy to rule out endometriosis or tubal adhesions </li></ul></ul></ul>
  116. 116. Semen Analysis <ul><li>Normal : </li></ul><ul><ul><ul><li>Semen volume greater than or equal to 2ml </li></ul></ul></ul><ul><ul><ul><li>Sperm concentration greater than or equal to 20 million per ml </li></ul></ul></ul><ul><ul><ul><li>50% or more should have progressive motility </li></ul></ul></ul><ul><ul><ul><li>14% or more should have strictly normal morphology </li></ul></ul></ul><ul><ul><ul><li>WBC should be less than 1 million per ml </li></ul></ul></ul><ul><li>Findings suggestive of Infertility </li></ul><ul><ul><ul><li>Sperm count (concentration): <13.5 million per ml </li></ul></ul></ul><ul><ul><ul><li>Initial sperm motility: <32% ( oligozoospermia) </li></ul></ul></ul><ul><ul><ul><li>Normal sperm morphology: <9% </li></ul></ul></ul><ul><li>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) </li></ul>
  117. 117. Hypertension in pregnancy Essential hypertension Pre-Ecclampsia Ecclampsia
  118. 118. First Trimester Bleeding
  119. 119. Third Trimester Bleeding
  120. 120. Post partum hemorrhage
  121. 121. Post partum blues Post partum depression Psychosis
  122. 122. PELVIC PAIN
  123. 123. Acute Pelvic Pain <ul><li>* Pregnancy Related Causes of Acute Pelvic Pain </li></ul><ul><li>Ectopic Pregnancy </li></ul><ul><li>Miscarriage </li></ul><ul><ul><li>Threatened Abortion </li></ul></ul><ul><ul><li>Incomplete Abortion </li></ul></ul><ul><ul><li>Septic Abortion </li></ul></ul><ul><li>Preterm Labor </li></ul><ul><li>Rupture corpus luteum cyst </li></ul><ul><li>Abruptio Placentae </li></ul><ul><li>Uterine Rupture </li></ul><ul><li>* Miscellaneous Causes of Acute Pelvic Pain </li></ul><ul><li>Acute Appendicitis, Inflammatory Bowel Disease, Diverticulitis, Urinary Tract Infection, Nephrolithiasis, Sexual abuse, Bowel or bladder perforation </li></ul><ul><li>*Gynecologic Causes of Acute Pelvic Pain </li></ul><ul><li>Mittelschmerz </li></ul><ul><li>Ovarian Cyst (hemorrhage or rupture) </li></ul><ul><li>Ovarian Torsion </li></ul><ul><li>Acute Pelvic Inflammatory Disease </li></ul><ul><li>Endometriosis </li></ul><ul><li>Uterine Fibroids </li></ul><ul><li>Primary Dysmenorrhea </li></ul><ul><li>Pelvic Neoplasm </li></ul>
  124. 124. Pelvic Inflammatory Disease
  125. 125. PID <ul><li>Causes :Chlamydia, Gonorrhea, mycoplasma hominis, facultative anerobes </li></ul><ul><li>Risk factors : hx of STDs, previous hx of PID, Onset sexual intercourse at a young age, Multiple sexual partners </li></ul><ul><li>Symptoms : Abdominal pain, high fever, discharge, dyspareunia, prolonged menses </li></ul><ul><li>Signs : Cervical motion tenderness, Adnexal tenderness, Discharge, R/O tuboovarian abcess ( local peritoneal signs – local rigidity ), r/o ruptured TOA ( generalized rigidity, rebound tenderness ) </li></ul><ul><li>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) </li></ul><ul><li>Lab Diagnosis </li></ul><ul><li>Do not delay treatment while waiting for labs </li></ul><ul><li>Inflammatory markers (if all normal, rules-out PID) </li></ul><ul><ul><li>Complete Blood Count (CBC) </li></ul></ul><ul><ul><li>Erythrocyte Sedimentation Rate or C-Reactive Protein </li></ul></ul><ul><ul><li>Vaginal secretion exam (saline wet prep)  Vaginal PMNs (Negative Predictive Value 95%) </li></ul></ul><ul><li>Other initial labs </li></ul><ul><ul><li>DNA probe for Gonorrhea and Chlamydia  Cervical specimen recommended over urine specimen </li></ul></ul><ul><ul><li>Blood Culture </li></ul></ul><ul><ul><li>Urine Pregnancy Test </li></ul></ul><ul><ul><li>Rapid Plasma Reagin(RPR) </li></ul></ul>
  126. 126. PID - Imaging <ul><li>No need of imaging in uncomplicated PID </li></ul><ul><li>If signs of TOA  obtain pelvic ultrasound/ MRI </li></ul>
  127. 127. PID – Indications For Admission <ul><li>Hospitalize patients with: </li></ul><ul><li>Surgical emergencies (eg: suspected leaking abscess) </li></ul><ul><li>Abscess formation ( TOA ) </li></ul><ul><li>Lack of response (i.e., no clinical improvement after 48 to 72 hours) to outpatient therapy </li></ul><ul><li>Inability to tolerate oral antibiotics (severe nausea and vomiting) </li></ul><ul><li>Severe illness with nausea, vomiting, or high fever > 103 F </li></ul><ul><li>Pregnancy </li></ul><ul><li>Noncompliance with outpatient therapy </li></ul><ul><li>IMMUNOCOMPROMISED ( AIDS) </li></ul><ul><li> 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 </li></ul>
  128. 128. PID – Drug treatment <ul><li>Management: </li></ul><ul><li>General </li></ul><ul><li>Remove Intrauterine Device (IUD) </li></ul><ul><li>Treat patient's sexual contacts within last 60 days </li></ul><ul><li>Start empiric therapy even if minimal criteria present </li></ul><ul><li>Do not delay treatment </li></ul><ul><ul><li>Delay >3 days increases ectopic and Infertility risk </li></ul></ul><ul><li>Antibiotic should cover Gonorrhea and Chlamydia </li></ul><ul><li>BE AWARE Fluoroquinole resistant Gonorrhea is increasing </li></ul><ul><ul><li>Do not use Fluoroquinolones in high risk groups </li></ul></ul><ul><ul><li>Cohorts at risk for resistance </li></ul></ul><ul><ul><ul><li>Homosexual men and any female sexual contacts of those men. </li></ul></ul></ul><ul><ul><ul><li>Endemic areas </li></ul></ul></ul><ul><ul><ul><ul><li>Asia: China, Japan, Korea, Philippines, Vietnam </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Other: England, Wales, Australia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>US: California </li></ul></ul></ul></ul>
  129. 129. PID – Drug treatment <ul><li>Management Outpatient </li></ul><ul><li>Step 1: Initial Treatment at Diagnosis (with step 2)  to cover for fluroquinolone resistant gonorrhea </li></ul><ul><ul><li>Cefoxitin 2g IM and Probenecid 1g PO or </li></ul></ul><ul><ul><li>Ceftriaxone 250 mg IM for 1 dose or </li></ul></ul><ul><ul><li>Other third generation Cephalosporin (e.g Cefotaxime) </li></ul></ul><ul><li>Step 2: Outpatient 14 day antibiotic course </li></ul><ul><ul><li>Select general antibiotic coverage </li></ul></ul><ul><ul><ul><li>Ofloxacin 400 mg PO bid for 14 days (95% cure) or </li></ul></ul></ul><ul><ul><ul><li>Levofloxacin 500 mg PO daily for 14 days or </li></ul></ul></ul><ul><ul><ul><li>Doxycycline 100 mg PO bid for 14 days (75% cure) </li></ul></ul></ul><ul><ul><li>Add anaerobic coverage (may or may not use this) </li></ul></ul><ul><ul><ul><li>Clindamycin 450 mg PO qid for 14 days or </li></ul></ul></ul><ul><ul><ul><li>Metronidazole 500 mg PO bid for 14 days </li></ul></ul></ul>
  130. 130. Management Inpatient <ul><li>Inpatient treatment Regimens </li></ul><ul><li>General  Treat for at least 24 - 48 hours IV after clinical improvement or at least 48 hrs IV </li></ul><ul><li>Regimen A (preferred) </li></ul><ul><ul><li>Cefoxitin 2g IV q6h/ Cefotetan 2g IV q12h and Doxycycline 100 mg PO or IV q12h </li></ul></ul><ul><li>Regimen B  Clindamycin 900 mg IV q8h and Gentamicin 2 mg/kg IV load, then 1.5 mg/kg IV q8h </li></ul><ul><li>Regimen C  Ofloxacin 400 mg IV q12h or Levaquin 500 IV qd + Metronidazole 500 IV q8 hours </li></ul><ul><li>Regimen D  Unasyn 3g IV q6 hours and Doxycycline 100 mg PO or IV q12 hours </li></ul><ul><li>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 </li></ul>
  131. 131. PID – IV antibiotics <ul><li>Determine the duration of intravenous therapy based on the clinical response of the patient. </li></ul><ul><li>Discontinue parenteral therapy 24 to 48 hours after clinical improvement: </li></ul><ul><ul><li>Defervescence </li></ul></ul><ul><ul><li>Reduction in direct or rebound tenderness </li></ul></ul><ul><ul><li>Reduction in pelvic tenderness </li></ul></ul><ul><ul><li>Improvement in lab values (e.g., leukocytes, ESR, or CRP) </li></ul></ul><ul><li>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. </li></ul>
  132. 132. Cervical Cancer Pap Smear – ASCUS etc and management LEEP etc – Rx choices CIN I, II and III Cervical Cancer
  133. 133. Normal Pregnancy
  134. 134. Is your computer male or female? <ul><ul><li>Women believe computers are male because: </li></ul></ul><ul><ul><ul><li>In order to get their attention, you have to turn them on. </li></ul></ul></ul><ul><ul><ul><li>They have a lot of data but are still clueless. </li></ul></ul></ul><ul><ul><ul><li>They are supposed to help you solve your problem, but half the time they ARE the problem. </li></ul></ul></ul><ul><ul><ul><li>As soon as you commit to one, you realize that , if you had waited a little longer, you could have had a better model. </li></ul></ul></ul>
  135. 135. Is your computer male or female? <ul><ul><li>Men believe computers are female because </li></ul></ul><ul><ul><ul><li>No one but their creator understands their internal logic. </li></ul></ul></ul><ul><ul><ul><li>The native language they use to communicate with other computers is incomprehensible to everyone else. </li></ul></ul></ul><ul><ul><ul><li>Even your smallest mistakes are stored in long-term memory for later retrieval. </li></ul></ul></ul><ul><ul><ul><li>As soon as you make a commitment to one, you find yourself spending half your paycheck on accessories </li></ul></ul></ul>