Pregnancy Miracle

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"Cottage cheese" discharge, pseudohyphac on KOH preparation,. history of diabetes .meiUuts, an(ibiotic oreatn)em,pregnancy

See bugs swtmining under microscope; pale green, frothy, watery discharge, "strawberry" cervix

Malodorous discharge; llsby smell on KOf I preparation, due cells

Human .papillomavirus Venereal warts, koUocytosis on Pap smear

Herpes Multiple shallow, painful ulcers; recurrence and resolution

Primary syphilis Painless chancre, spirochete on dark-field microscopy

Secondary syphilis Condyloma ]ata, macidopapular rash on palms, serology

CJilciBjydia sp. Most, common sexually transmitted disease; dysuria, positive, culture/

. antibody test

Ndsserifl jjonorrhoctic Mucopurulent cervicitis; gram -.negative bugs on Gram stain

MoJluscinn Characteristic appearance of lesions, intracellular inclusions

Pediculosis "Crabs," itching, J ice on pubic hairs

RDH potassium hydroxide.

TREATMENT Topical anuTungal



Many (acid, cryotherapy,, laser, podopliyllirf)




Dox.yeydine (see. below)

Ceftriaxone (see below)

Many (curette, cryotherapy, coagulation)

Pcrrueihrin cream (or Lindane)

Important points:

1. Chlamydia is treated with erythromycin if the patient is pregnant. If compliance is an issue (alcoholic, drug abusing, homeless, or unreliable patient), you can give azithromycin, 1 gm orally all at once, and watch the patient take it.

2. Any patient with gonorrhea is generally treated lor presumed chlamydial coinfection (give ceftriaxone and doxycycline).

3. With all infections but Candida sp., treat the patient's sexual partners and give counseling (e.g., condoms).

4. Alb of the above information is similar for men (except candidal infection), but any lesions and discharges are on or come from the penis.

Endometriosis: endometrial glands outside the uterus (ectopic). Patients usually are nulli-parous and over 30 with the following symptoms: dysmenorrhea, dyspareunia (painful intercourse), dyschezia (painful defecation), and/or perimenstrual spotting.The most common site is the ovaries (look for tender adnexae in an afebrile patient), followed by the broad or uterosacral ligament (classic signs are nodularities on physical exam and sequela of retroverted uterus), and peritoneal surface. The gold standard of diagnosis is laparoscopy with visualization of endometriosis.

Important points:

1. Endometriosis is the most likely ,cause of infertility in a menstruating woman over age of 30 (in the absence of a PID history).

Z. Treat first with oral contraceptives (danazol and gonadotropin-releasing hormone agonists are second- line agents).

3. Surgery and cautery may be used to destroy endometrioma and improve fertility markedly. In an older patient, consider total abdominal hysterectomy and bilateral salp-ingo-oophorectomy for severe symptoms.

Adenomyosis: endometrial glands within the uterine musculature. Patients usually are over 40 with dysmenorrhea and menorrhagia; physical exam reveals large, boggy uterus. Do dilatation and curettage (D&C) to rule out endometrial cancer, and consider total abdominal hysterectomy to relieve severe symptoms. Gonadotropin-releasing hormone agonists also may relieve symptoms.

Leiomyoma (fibroids): benign tumors; most common indication for hysterectomy (when they grow too large or cause symptoms). Malignant transformation is rare (< 1 %). Look for rapid growth during pregnancy or use of oral contraceptives with regression after menopause (estrogen-dependent). Fibroids may cause infertility; myomectomy may restore fertility. Other symptoms include pain and menorrhagia/metrorrhagia. Anemia due to leiomyoma is an indi cation for hysterectomy. D&C rules out endometrial cancer and malignant transformation in women > 40. Patients may present with polyp protruding through cervix.

Note: Any sexually active woman of reproductive age with abnormal uterine bleeding should have a pregnancy test first.

Dysfunctional uterine bleeding (BUB): defined as abnormal uterine bleeding not associated with tumor, inflammation, or pregnancy. DUB is the most common cause of abnormal uterine bleeding and is a diagnosis of exclusion. Over 70% of cases are associated wi th anovulatory cycles (unopposed estrogen). The age of the patient is important. After rnenarche and just before menopause, DUB is extremely common and, in fact, physiologic. Most other patients have polycystic ovaries. Always do a D&C to rule out endometrial cancer in women over 35. Also get hemoglobin/hematocrit to make sure that the patient is not anemic from excessive blood loss. Uncommon causes of DUB are infections, endocrine disorders (thyroid, adrenal, pituitary/prolactin), coagulation defects, and estrogen-producing neoplasm.

Important points:

1. In the absence of pathology, treat first with NSAIDs (first-line agents for DUB and dysmenorrhea) .

2. Oral contraceptives are also a first-line agent for menorrhagia and DUB if the patient: does not desire pregnancy and cycles are irregular.

3. Use progesterone only for severe bleeding.

Polycystic ovarian syndrome (PCOS): look for heavy woman who has hirsutism, amenorrhea, and/or infertility. PCOS is the. most Likely cause of infertility in a woman, under 30 with abnormal menstruation. Multiple ovarian cysts often are seen, on ultrasound.The primary event is androgen excess. The ratio of luteinizing hormone (LH) to follicle-stimulating hormone(FSH) is greater than 2:1. Unopposed estrogen increases the risk for endometrial cancer. Treat with oral contraceptives or cyclic progesterone. If the patient desires pregnancy, use clomiphene.


1. In two-thirds of couples infertility is a female problem; in one-third, it is a male problem..

2. If nothing is apparent after history and physical exam, the first step is semen analysis (cheap, easy, noninvasive). Normal semen has the following properties:

■ Sperm concentration: > 20 million/ml

■ Initial forward motility: > 50% of sperm a Normal morphology: > 60% of sperm

3. The next step is documentation of ovulation. History may suggest an ovulatory problem (irregular cycle length, duration, or amount of flow, lack of premenstrual symptoms). Basal body temperature, luteal phase progesterone levels, and/or endometrial biopsy can be done to check for ovulation.

4. Tubal/uterine evaluation is done by a hysterosalpingogram. History may suggest" a tubal problem (PID, previous ectopic pregnancy) or a uterine problem (previous D&C may cause intrauterine synechiae, history of fibroids or endometriosis symptoms).

5. Cervical factor may be a cause of infertility and is suggested by a history of cervicitis, birth trauma, or previous cone biopsy. Evaluate cervical mucus, and do a postcoital test.

6. Laparoscopy is a last resort or is done in patients with a history suggestive of endom etriosis. Lysis of adhesions and destruction of endometriosis lesions can restore, fertility.

7. Medical therapy is usually clomiphene citrate to induce ovulation, but this approach re quires that the woman is producing adequate estrogen. If the woman is hypoestrogenic, use human menopausal gonadotropin (hMG), which, is'a combination of FSH and LH. If methods fail, use in vitro fertilization.

Secondary amenorrhea: in a previously menstruating, sexually active woman of reproductive age, the diagnosis is pregnancy until proved otherwise, (with a negative human chorionic gonadotropin assay). Amenorrhea is not uncommon in hard-training athletes (due to exercise induced depression of gonadotropin releasing hormone). Watch for amenorrhea as a presenting symptom for anorexia (amenorrhea required for a diagnosis of anorexia), especially in a ballet dancer or model. Another common cause is PCOS (see above). Secondary amenorrhea also may be due to endocrine disorders (headaches, galactorrhea, and visual field defects may indicate a pituitary tumor), antipsychotics (due to increased prolactin), or previous chemotherapy (which causes premature ovarian failure/menopause).The first step after a negative pregnancy test and no obvious abnormality in the history or physical exam is to administer progesterone, which tells you the patient's estrogen status:

a H the patient lias vaginal bleeding within 2 weeks, she has sufficient estrogen. Next:, check i.l I. If the level is high, think of PCOS. If it is low or normal, check the prolactin level to rule out pituitary adenoma and the thyroid stimulating hormone (TSPI) level to rule out hypothyroidism (higliTSH level causes high prolactin level). If prolactin is high with norma! "I S11, get an MRI of the brain. If prolactin is normal, look for drug-, stress-, or exercise-induced depression of gonadotropin releasing hormone. Any of these patients may try clomiphene to become pregnant.

a If the patient does not have vaginal bleeding, she has insufficient estrogen. Check l;SI I next. If the level is elevated, the patient has premature ovarian failure; check for autoira mime disorder, karyotype abnormalities, and history of chemotherapy. If FSH is low or normal, the patient may have a craniopharyngioma; get an MRI of the brain.

Primary amenorrhea: any female who has not menstruated by age 16 has primary amenor rhea. In the absence of secondary sexual characteristics by age 14 or absence of menstruation within 2 years of developing secondary sex characteristics, patients also should be evaluated.

Important points:

1. The first step is to rule out pregnancy! (Yes, pregnancy can present as primary amenorrhea.)

2. If the patien t is older than 14 and has no secondary sexual characteristics, she most likely lias a congenital problem.

3. In a phenotypically normal female (normal breast development) with an absence of both axillary and pubic hair, think of androgen insensitivity syndrome. The uterus is absent.

4. In the presence of normal breast development and a uterus, the first step is to get a prolactin level to rule out. pituitary adenoma. If prolactin is high, get an MRL If it is normal, administer progesterone and follow the same procedures as for evaluation of .secondary amenorrhea.

When in doubt, follow these steps in order to evaluate any amenorrhea:

1. Do a pregnancy test,

2. Administer progesterone.

3. Further testing depends on results of progesterone challenge (bleeding or no bleeding).

Note: Some clinicians may do a TSPI and/or prolactin level before a progesterone challenge, for board purposes, choose progesterone challenge over TSH/prolactin levels unless obvious clues point to a TSH or prolactin problem (symptoms of hypothyroidism or pituitary tumor).

Any sexually active woman of reproductive cic|t who hits iimenonka .should have a pregnancy test as the first step in evaluation.

Menopause: the average age at menopause is around 50. Patients have irregular cycles or amenorrhea, hot flashes, mood swings, and an elevated FSH level. (See pharmacology chapter.) A bone density test may show osteoporosis and help the patient to make a decision about whether to take hormone replacement therapy. Patients also may complain of dysuria, dyspareuiria, incontinence, and/or vaginal itching, burning, or soreness—symptoms that often are due to atrophic vaginitis in this age group. Look for vaginal mucosa to be thin, dry, and atrophic with increased parabasal cells on cytology. Estrogen, either topical or systemic, improves symptoms.

Breast discharge: first get. the patien t's history of oral contraceptives, hormone therapies, antipsychotic medications, or hypothyroidism symptoms, all of which can cause discharge. When bilateral and nonbloody, the discharge is not due to breast cancer; the cause may be a prolactinoma (check prolactin) or endocrine disorder. A discharge that is unilateral and. bloody and/or associated with a mass should raise concern about possible breast cancer. Nipple discharge secondary to carcinoma should contain hemoglobin. Do a biopsy of any mass.

Breast mass in a woman under 35:

1. Fibrocystic disease: bilateral, multiple, tender (especially premenstrually) cystic lesions. Most common of all breast diseases. Generally, no further work-up is needed—just routine follow-up. Progesterone for 1 week at the end of each month or danazol may help to relieve symptoms.

2. Fibroadenoma: painless, discrete, sharply circumscribed, rubbery, mobile mass. Most common benign tumor of the female breast. Observe the patient for one or more menstrual cycles in the absence of symptoms. Pregnancy or oral contraceptives may stimulate growth; menopause causes regression (estrogen-dependent). Excision is curative but not required.

3. Mastitis/abscess: look for lactating woman with reddish, painful, fluctuant mass. Culture breast milk, discontinue breast-feeding, and start on antistaphylococcal antibiotics (e.g., cloxacillin). Staphylococcal infection is by far the most common cause. If symptoms do not resolve, assume that the patient has an abscess, which requires incision and drainage.

4. Fat necrosis: history of trauma.

Note: Do not do mammography in women under 35 (breast tissue is too dense to give interpretable films). If suspicious of cancer (exceedingly rare in this age group), proceed directly to biopsy.

Breast mass in a woman 35 or over:

1. Fibrocystic disease: as above, but aspiration of cyst fluid and. baseline mammography are recommended. If the cyst fluid is nonbloody and the mass resolves after aspiration, the patient: needs only reassurance, follow-up, and a baseline mammogram. If the fluid is bloody or the cyst recurs quickly, do a biopsy to rule out cancer.

2. Fibroadenoma: get baseline mammogram. Observe briefly if the mass is small and seems benign clinically <md the woman is premenopausal and has no risk factors for breast cancer. Otherwise, do a biopsy. Watch out for cystosarcoma phylloides that masquerades as a fibroadenoma.

1 Fat necrosis: as above.

4. Mastitis/abscess: as above,

5. Breast cancer:, you may not get a classic presentation of nipple retraction and/or peau d'orange in a nulliparous woman with a strong family history. In a woman 35 or older, you will never be faulted for doing a biopsy of any mass. In the absence of a classic benign presentation (such as trauma to the breast with fat necrosis or bilaterality with, premenstrual mastalgia), always consider biopsy. Also get a baseline mammogram. (See oncology chapter.)

Important points:

1. If the patient is postmenopausal (or over age 50) and develops a new lesion, you should proceed directly to biopsy.

2. In patients with a clinically evident breast mass, mammography is a poor test to evaluate the mass, although it should be done in a woman over 3 5 to have a baseline for future comparison. Mammography is used to detect nonpalpable breast masses (as a screening tool), not to evaluate masses that are already present.

3. Any suspicious lesion found on mammogram should be biopsied, even if it seems benign or is inapparent on physical exam.

Pelvic relaxation/vaginal prolapse: due to weakening of pelvic supporting ligaments. Look for history of several vaginal deliveries, feeling of heaviness or fullness in the pelvis, backache, worsening of symptoms with standing, and resolution with lying down:

1. Cystocele: bladder bulges into the upper anterior vaginal wall. Symptoms: urinary urgency, frequency, incontinence.

2. Rectocele: rectum bulges into the lower posterior vaginal wall. Major symptom: difficulty with defecating.

3. Enterocele: loops of bowel bulge into the upper posterior vaginal wall.

4. Urethrocele: urethra bulges into the lower anterior vaginal wall. Symptoms: urinary urgency, frequency, incontinence.

Note: Conservative treatment involves pelvic strengthening exercises and/or a pessary (artificial device to provide support). Surgery is used for refractory or severe cases.

Birth control:

1. The best choice is oral contraceptives if the patient is a candidate and does not desire sterilization. Oral contraceptives do not reduce transmission of sexually transmitted diseases.

2. An intrauterine device should be used only in older women, preferably those who are monogamous, because it increases the risk of ectopic pregnancy and PID (look for Actinomyces sp.).

3. Condoms are good because they prevent transmission of sexually transmitted diseases.

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