Gynecology

1 What is the most common cause of preventable infertility in the United States?

2 What is the most likely cause of infertility in a normally menstruating woman younger than age 30 years?

3 What is PID? How do you recognize it?

PID is typically caused by an ascending sexually transmitted infection of the upper female genital tract that may involve the endometrial cavity (endometritis), fallopian tubes (salpingitis), ovaries (oophoritis), parametrial tissues/ligaments (parametritis), and/or peritoneal cavity (peritonitis). Look for a female aged 13 to 35 years with the following symptoms: (1) abdominal pain, (2) adnexal tenderness, and (3) cervical motion tenderness. All three criteria must be present. In addition, one or more of the following should be present: elevated erythrocyte sedimentation rate/C-reactive protein (CRP) level, leukocytosis, fever, or purulent cervical discharge.

4 How is PID treated? What are the common sequelae?

Treat PID with more than one antibiotic to cover multiple organisms, especially Neisseria gonorrhoeae and Chlamydia trachomatis (the most common organisms). There are several different regimens recommended by the Centers for Disease Control and Prevention, but the following are good choices: ceftriaxone plus doxycycline for outpatients; cefoxitin or cefotetan plus doxycycline for inpatients to cover multiple organisms. Also consider Escherichia coli, anaerobes, and, with a history of intrauterine device use, Actinomyces israelii.

Common sequelae include infertility caused by scarring of the fallopian tubes and progression to tuboovarian abscess (palpable on examination, may respond to antibiotics alone) that may rupture. Treat rupture with emergent laparotomy and excision of the affected tube (unilateral disease) or total abdominal hysterectomy and bilateral salpingo-oophorectomy for bilateral disease.

5 Define endometriosis. What are the symptoms and signs?

Endometriosis is defined as endometrial glands outside the uterus (ectopic). Patients are usually nulliparous and older than 30 years with the following symptoms: dysmenorrhea (painful menstruation), dyspareunia (painful intercourse), dyschezia (painful defecation), and/or perimenstrual spotting. The most common site for the ectopic endometrial glands is the ovaries; look for tender adnexa in an afebrile patient. Other sites include the broad (uterosacral) ligament and peritoneal surface. Nodularities on the broad ligament are classic findings on physical examination; the classic sequela is a retroverted uterus.

6 How is endometriosis diagnosed and treated?

The gold standard of diagnosis is laparoscopy with visualization of the endometriosis. Treat first with birth control pills (if acceptable to the patient); danazol and gonadotropin-releasing hormone agonists (e.g., leuprolide) are second-line agents. Surgery and cautery can be used to destroy the endometriomas, a procedure that often improves fertility. In an older patient, consider hysterectomy and bilateral salpingo-oophorectomy for severe symptoms.

7 What is the most likely cause of infertility in a menstruating woman older than age 30 without a history of PID?

Endometriosis.

8 Cover the right-hand columns and specify the findings and treatment for the following vaginal infections:

INFECTIOUS AGENT	FINDINGS	TREATMENT
Candida sp.	“Cottage cheese” appearance; pseudohyphae seen on KOH preparation; history of diabetes, antibiotic treatment, or pregnancy	Topical or oral antifungal
Trichomonas vaginalis	Trichomonads can be seen swimming under microscope; pale green, frothy, watery discharge; “strawberry” cervix	Metronidazole
Gardnerella vaginalis	Malodorous discharge; fishy smell on KOH preparation; clue cells	Metronidazole
HPV	Venereal warts, koilocytosis on Pap smear	Many (acid, cryo therapy, laser, podophyllin)
Herpes virus	Multiple shallow, painful ulcers; recurrence and resolution	Acyclovir, valacyclovir
Syphilis (stage I)	Painless chancre, spirochete on dark-field microscopy	Penicillin
Syphilis (stage II)	Condyloma lata, maculopapular rash on palms, serology	Penicillin
Chlamydia trachomatis	Most common STD; dysuria, positive culture and antibody tests	Doxycycline or azithromycin^∗
Neisseria gonorrhoeae	Mucopurulent cervicitis; gram-negative bacteria on Gram stain	Ceftriaxone
Molluscum	Characteristic appearance of lesions, intracellular inclusions	Curette, cryotherapy, or electrocauterization/coagulation
Pediculosis	“Crabs”; look for itching; lice can be seen on pubic hairs	Permethrin cream (or malathion)

KOH, Potassium hydroxide; STD, sexually transmitted disease; HPV, Human papillomavirus.

^∗Chlamydia can be treated with erythromycin if the patient is pregnant. If compliance is an issue (alcoholic, drug abuse, homeless, or unreliable patient), give azithromycin 1 g orally in a single dose so that you can watch the patient take it. Patients with gonorrhea should be treated for presumed chlamydial co-infection (but the opposite is not true).

9 True or false: With all of the infections listed in the previous table, you should seek out and treat the patient’s sexual partners.

False. Candida and Gardnerella species are not typically STDs; they are usually caused by disturbances in the normal vaginal flora. You should treat the patient’s sexual partners and give counseling (e.g., condoms) for the other infections, which are sexually transmitted.

10 True or false: Patients with gonorrhea usually are treated for presumed chlamydial infection.

True. A common current treatment strategy is to give both ceftriaxone (for gonorrhea) and doxycycline (for chlamydia) together to patients with gonorrhea. The reverse is not true; do not automatically give gonorrhea treatment to patients with chlamydial infection.

11 Define adenomyosis. How does it classically present? What is the treatment?

Adenomyosis is defined as endometrial glands within the uterine musculature. Patients are usually older than 40 with dysmenorrhea and menorrhagia and have a large, boggy uterus on physical examination. Do dilation and curettage first to rule out endometrial cancer. Consider hysterectomy to relieve severe symptoms; gonadotropin-releasing–hormone agonists may also relieve symptoms.

12 What are fibroids? How common are they? How often do they become malignant?

Fibroids (i.e., leiomyomas) are benign uterine tumors (Fig. 16-1). They are the most common tumors in women and the most common indication for hysterectomy (when they grow too large or cause symptoms). Up to 40% of women have fibroids by age 40 years. Malignant transformation is rare (<1%).