Gyne Key Points 3rd Le

Chapter 37 – Abnormal Uterine Bleeding : Ovulatory and Anovulatory Dysfunctional Uterine Bleeding, Management of Acute and Chronic Excessive Bleeding KEY TERMS AND DEFINITIONS Dysfunctional Uterine Bleeding Excessive uterine bleeding with no demonstrable organic cause (genital or extragenital). It is (DUB) most frequently due to abnormalities of endocrine origin, particularly anovulation. Endometrial Ablation

Destruction of the endometrium by laser or electrocoagulation with instruments placed through a hysteroscope.

Intermenstrual Bleeding

Bleeding of variable amounts occurring between regular menstrual periods.

Menometrorrhagia

Prolonged uterine bleeding occurring at irregular intervals.

Menorrhagia

Prolonged (more than 7 days) or excessive (greater than 80 mL) uterine bleeding occurring at regular intervals. The term hypermenorrhea is synonymous.

Metrorrhagia

Uterine bleeding occurring at irregular but frequent intervals, the amount being variable.

Nonsteroidal Antiinflammatory Drugs (NSAIDs)

Drugs that inhibit the synthesis of prostaglandins.

Polymenorrhea

Uterine bleeding occurring at regular intervals of less than 21 days.

Sonohysterography

Sonographic imaging of the endometrial cavity after installation of 10 to 15 mL of saline to improve contrast and facilitate diagnosis of endometrial lesions.

KEY POINTS •

The percentage of blood to total fluid volume of menstrual discharge averages 36%.

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The most precise method to measure menstrual blood loss (MBL) is the alkaline hematin method.

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Average loss of iron in each menses is 13 mg.

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The mean amount of MBL in one cycle in normal women was previously reported to be about 35 mL but may be as much as 60 mL.

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About 70% of total MBL occurs in the first 2 days of menses.

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Menorrhagia occurs in 9% to 14% of healthy women, and most have normal duration of menses.

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The predominant cause of dysfunctional uterine bleeding (DUB) in the postmenstrual and premenopausal years is anovulation. During the rest of the reproductive years, most DUB is associated with ovulation.

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Hemostatic plugs in the endometrium are smaller, have different morphology, and persist for a shorter time than when vessel damage occurs in other tissue.

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Following the treatment of menorrhagia in women with a normal uterus by endometrial ablation with laser or electrocoagulation, amenorrhea occurs in about half the women. About 40% have decreased bleeding, and 10% have no improvement.

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Within 4 years after endometrial ablation about 25% of women so treated will have a hysterectomy.

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There is an increase in the amount of both PGE2 and PGF2α in the endometrium in the late secretory phase and during menses, with the PGF2α/PGE2 ratio steadily increasing from midcycle to menses.

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There is an inverse correlation between endometrial PGF2α/PGE2 ratio and MBL.

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Anovulatory cycles are usually not associated with dysmenorrhea because of reduced levels of PGF 2α in the endometrium.

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Alterations in prostaglandin synthesis and release occur in women with both ovulatory and anovulatory DUB.

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Endometrial ablation by the thermal balloon technique yields similar results as electrocoagulation without the need to perform hysteroscopy.

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Diagnostic tests in women with menorrhagia include measurement of hemoglobin, serum iron, serum ferritin, HCG, TSH, endometrial biopsy, and hysteroscopy or hysterosalpingography.

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High doses of oral or intravenous estrogen will usually stop acute bleeding episodes caused by anovulatory DUB. Oral estrogen is less expensive and easier to administer than the intravenous form.

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Ergot derivatives do not reduce MBL and should not be used as therapy.

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Anovulatory DUB can be treated by cyclic use of progestins, oral contraceptives, or intermittent clomiphene citrate.

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Patients with ovulatory DUB are best treated with oral contraceptives, NSAIDs (antiprostaglandins), danazol, or progestins during the luteal phase or progesterone or progestins released locally from an IUD.

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NSAIDs administered during menses reduce MBL by 20% to 50% in women with ovulatory DUB.

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The blind technique of dilation and curettage (D&C) misses the diagnosis of uterine lesions in 10% to 25% of women.

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A D&C should be used to stop the acute bleeding episode in patients with hypovolemia or those older than 35. A D&C only treats the acute episode of excess uterine bleeding, not subsequent episodes.

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Endometrial ablation with laser or electrocautery is a useful technique to control ovulatory DUB in women who do not respond to medical management, have excessive side effects with medical therapy, or have no other indications for hysterectomy.

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Hysterectomy should be used to treat women with ovulatory DUB only after medical therapy has failed and excessive MBL has been documented by objective measurement.

Chapter 38 – Primary and Secondary Amenorrhea and Precocious Puberty : Etiology, Diagnostic Evaluation, Management KEY TERMS AND DEFINITIONS Absence of menses during the reproductive years. It can be either physiologic (pregnancy) or Amenorrhea pathologic. A genetically transmitted androgen receptor defect in a 46,XY individual with testes and normal Androgen Resistance Syndrome male testosterone levels. These individuals have normal female phenotype, absent uterus, and scant (Testicular Feminization) body hair. Anorexia Nervosa

A psychiatric disease associated with a fear of weight gain or obesity, food aversion, and a distorted body image in which the individual limits caloric intake to starvation levels. In addition to severe weight loss, there is a decreased metabolic rate and amenorrhea.

Chromophobe Adenoma

A nonhormone-secreting pituitary tumor that can disrupt normal pituitary function and thus produce low gonadotropin levels.

Congenital Absence of Uterus and Vagina

A malformation in a 46,XX individual with normal ovarian function, resulting in failure of the uterus and vagina to form. It is also called uterovaginal agenesis and Rokitansky–Küster–Hauser syndrome.

Cryptomenorrhea

Menstruation without egress of menses through the introitus.

Delayed Menarche

Onset of menses in women older than 16.5 years who have no reproductive abnormalities.

Functional Hypothalamic Amenorrhea.

Amenorrhea caused by nonorganic impairment of normal hypothalamic function with slowing of normal gonadotropin-releasing hormone (GnRH) pulsatility.

Gonadal Failure

Failure of the gonads to develop. It is also called gonadal dysgenesis if the karyotype is abnormal and gonadal agenesis if the karyotype is normal.

Gonadal Streaks

Streaks of fibrous tissue in the normal position of the ovaries.

Gonadotropin-Resistant Ovary Premature ovarian failure in which the ovary contains normal-appearing primordial follicles but no Syndrome follicular development. It is also called ovarian hypofolliculogenesis. Hypogonadotropic Hypogonadism.

Failure of the ovaries to develop as a result of low amounts of circulatory gonadotropins. When anosmia is present, the term Kallmann's syndrome is used.

Hypothalamic Dysfunction

Secondary amenorrhea caused by an abnormal pattern of GnRH pulsatility and normal circulatory estradiol.

Hypothalamic Failure

Secondary amenorrhea caused by an abnormal pattern of GnRH pulsatility and estradiol levels below the normal premenopausal range.

Insulin Tolerance Test

A test of adrenocorticotropic hormone function in which hypoglycemia is produced and cortisol is measured.

Intrauterine Adhesions or Synechiae.

A condition in which fibrous tissue partially or completely obliterates the uterine cavity. It is also called Asherman's syndrome.

Isolated Gonadotropin Deficiency

The presence of hypogonadotropic hypogonadism in individuals who do not produce gonadotropins after prolonged administration of GnRH.

Leptin

A hormone secreted by fat cells that helps regulate the reproductive and GH axis. Low levels with undernutrition explains, in part, the amenorrhea.

Pituitary Destruction

Damage or necrosis of the pituitary gland caused by anoxia, thrombosis, or hemorrhage. It is called Sheehan's syndrome when related to pregnancy and Simmonds' disease when unrelated to pregnancy.

Polycystic Ovary Syndrome

An extremely common disorder in women most frequently diagnosed by anovulation, hyperandrogenism, and polycystic ovaries on ultrasound; it may also occur in women who have regular cycles and ovulation.

Precocious Puberty

Arbitrarily defined as any signs of sexual maturation at an early age (now thought to be younger than age 6 or 7). Types are divided into heterosexual or isosexual, or due to isolated conditions such as premature thelarche.

Premature Ovarian Failure

Cessation of menstruation caused by depletion of ovarian follicles or failure of primordial follicles to respond to gonadotropin before the age of 40. It is also called hypergonadotropic hypogonadism.

Primary Amenorrhea

Absence of any spontaneous menses in an individual older than 16.5 years of age.

Pure Gonadal Dysgenesis

Absence of the gonads in an individual with a normal 46,XX or 46,XY karyotype. It is also called gonadal agenesis.

Secondary Amenorrhea

Absence of menses for a variable period of time (for at least 3 to 12 months, usually 6 months or longer) in an individual who has previously had spontaneous menstrual periods.

KEY POINTS •

The incidence of secondary amenorrhea of more than 6 months' duration in the general population is 0.7%.

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The incidence of amenorrhea lasting more than 6 months after discontinuation of oral contraceptives is 0.8%.

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The most important and probably most common cause of amenorrhea in adolescent girls is anorexia nervosa.

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A woman 13 years of age or older without any breast development has estrogen deficiency due to a severe abnormality and needs a diagnostic evaluation.

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Menarche is delayed about 0.4 year for each year of premenarcheal athletic training.

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Gonadal failure is the most common cause of primary amenorrhea, accounting for nearly half the patients with this syndrome.

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Individuals with gonadal failure and an X chromosome abnormality are shorter than 63 inches in height.

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The testes of individuals with androgen resistance have about a 20% chance of becoming malignant after age 20 years.

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Uterovaginal agenesis is the second most common cause of primary amenorrhea, with an incidence of about 15% of individuals with this symptom.

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About one third of individuals with gonadal failure have major cardiovascular or renal abnormalities.

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Congenital renal abnormalities occur in about one third of women with uterovaginal agenesis.

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The differential diagnosis between estrogen deficiency caused by gonadal failure and hypogonadotropic hypogonadism is best established with measurement of serum follicle-stimulating hormone (FSH).

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The diagnosis of gonadal failure, or hypergonadotropic hypogonadism, can be established if the FSH levels exceed 30 mIU/mL.

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Individuals with gonadal failure should have a peripheral karyotype performed to determine if a Y chromosome is present. If it is present, or signs of hyperandrogenism are present, the gonads should be excised to prevent development of malignancy, mainly a gonadoblastoma.

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Individuals with primary amenorrhea and hypogonadotropic hypogonadism do not need karyotyping but need a cranial CT scan to rule out a CNS tumor.

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The most frequent cause of intrauterine adhesions (IUAs) is curettage performed during pregnancy or shortly thereafter.

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The amenorrhea associated with strenuous exercise is related to stress, not weight loss, and is most probably caused by an increase in CNS opioids (β-endorphin) and catechol estrogens, both of which interfere with gonadotropin-releasing hormone (GnRH) release.

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When women lose 15% below ideal body weight, amenorrhea can occur due to CNS-hypothalamic dysfunction. When weight loss decreases below 25% of ideal body weight, pituitary gonadotropin function can also become abnormal.

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Anorexia nervosa occurs in about 1 in 1000 white women. It is uncommon in men and women older than 25 and rare in blacks and Asians.

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Individuals with anorexia nervosa have impaired peripheral conversion of thyroxine (T4) to triiodothyronine (T3), resulting in normal T4 levels, decreased T3 levels, and increased reverse T3 levels.

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The normal cyclic pattern of LH pulsatility is not present in individuals with functional hypothalamic amenorrhea. Either no pulse or pulses of slow frequency, similar to those in the normal luteal phase, are usually observed.

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The GnRH alterations as reflected in LH pulsatility in persons with severe weight loss and anorexia nervosa are similar to those seen in normal prepubertal girls. When such individuals gain weight, GnRH changes similar to those occurring during puberty take place.

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When uterine bleeding fails to occur after progestin is administered, E2 levels are usually lower than 40 pg/mL.

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In contrast to hypothalamic disorders, pituitary causes of amenorrhea can be associated with ACTH and TSH deficiency.

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Individuals with premature ovarian failure have two dif-ferent histologic findings: generalized sclerosis or primordial follicles scattered through the stroma.

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Individuals with premature ovarian failure frequently have antibodies to gonadotropins and other endocrine organs, indicating an autoimmune origin.

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A karyotype should be obtained in women with premature ovarian failure younger than 25 but not in those who are older.

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Amenorrhea with low estrogen levels is associated with decreased density of trabecular bone.

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The most frequent cause of secondary amenorrhea is hypothalamic dysfunction.

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Physiologic development in females with precocious puberty usually follows the normal sequence of changes of secondary sexual characteristics.

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The two primary concerns of parents of children with precocious puberty are the social stigma associated with the child being physically different from her peers and the diminished ultimate height caused by the premature closure of epiphyseal growth centers.

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The exact cause of the majority of cases of GnRH-dependent (true or complete) precocious puberty is unknown; how-ever, approximately 30% of cases are secondary to CNS disease.

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A definitive diagnosis is established more often for GnRH-independent (pseudoprecocious or incomplete) puberty, and it is usually related to an ovarian or adrenal disorder.

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Breast hyperplasia is a normal phenomenon in neonates and may persist up to 6 months of age.

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The most common cause of GnRH-independent precocious puberty is a functioning ovarian tumor. Granulosa cell tumors are the most common type, accounting for approximately 60%.

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The primary emphasis of the diagnostic workup on a child with precocious puberty should be to rule out life-threatening neoplasms of the ovary, adrenal glands, or CNS. The secondary emphasis is to delineate the speed of the maturation process, for this fact is crucial in decisions concerning therapy.

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The goals of therapy of precocious puberty are to reduce gonadotropin secretions and reduce or counteract the peripheral actions of sex steroids, decreasing growth rate to normal and slowing skeletal maturation. This is best accomplished by GnRH agonists.

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The effect on adult height depends on the chronologic age at which the GnRH therapy is initiated. The therapy is most effective in 4- to 6-year-olds.

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Both the child with precocious puberty and her family need intensive counseling.

Chapter 22 – Infections of the Lower Genital Tract : Vulva, Vagina, Cervix, Toxic Shock Syndrome, HIV Infections KEY TERMS AND DEFINITIONS An enlarged and inflamed lymph node, particularly in the axilla or groin, caused by infections such as Bubo plague, syphilis, gonorrhea, lymphogranuloma venereum, or tuberculosis. Calymmatobacterium granulomatis.

The gram-negative, nonmotile rod that causes granuloma inguinale.

Clue Cells

Epithelial cells with clusters of bacteria adherent to their external surfaces, obscuring their normal, fine border. They have a granular or stippled appearance and are associated with bacterial vaginosis.

Condyloma Acuminatum

A sexually transmitted viral disease of the vulva, vagina, cervix, and rectum caused by the human papillomavirus.

Condyloma Latum

The nonpainful large, raised, flattened, grayish white lesions of secondary syphilis, most often found on the vulva.

Dark-Field Microscopy

A technique used to identify the spirochetes of syphilis, Treponema pallidum.

Donovan Bodies

The pathognomonic clusters of dark-staining bacteria (bipolar in appearance) found in the cytoplasm of large mononuclear cells in patients with granuloma inguinale.

Groove Sign

A depression between groups of inflamed nodes producing a double genitocrural fold in patients with lymphogranuloma venereum.

Gumma

An infectious granuloma characteristic of late or tertiary syphilis.

Mucopurulent Cervicitis

This inflammatory condition is diagnosed by gross visualization of yellow mucopurulent material or the presence of 10 or more polymorphonucleocytes per high-powered field on Gram stain of the endocervix.

Nit

The egg of the crab louse.

Podophyllin

A topical resin mixed with benzoin and alcohol used to treat the lesions of condyloma acuminatum.

Prozone Phenomenon

A false-negative VDRL or RPR caused by an excess of anticardiolipin antibody in the serum.

Sexually Transmitted Disease (STD)

A term used to describe an infection acquired primarily through sexual contact; venereal disease.

Toxin 1

The toxin involved in producing the signs and symptoms of toxic shock syndrome. It is a small protein with a molecular weight of 22,000. Its primary effects are the production of increased vascular permeability and profuse leaking of fluid from the intravascular space to the extravascular space.

Whiff Test

A test used clinically. The smell of vaginal discharge after the addition of 10% potassium hydroxide. A positive sample associated with either bacterial vaginosis or Trichomonas infections will give off a fishy or aminelike smell.

Word Catheter

A short catheter with an inflatable Foley balloon used to help develop a fistulous tract from a Bartholin duct to the vestibule. KEY POINTS

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The three most prevalent primary viral infections of the skin of the vulva are genital herpes, condyloma acuminatum, and molluscum contagiosum.

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Acute bacterial cystitis is characterized by abrupt onset and multiple symptoms, including dysuria, urgency, and frequent voiding. Suprapubic tenderness is a specific sign for acute bacterial cystitis; however, it is not present in the majority of patients.

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The differential diagnosis of dysuria in adult women includes acute cystitis, acute urethritis, or vulvovaginitis.

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The most frequent pathogens involved in uncomplicated lower UTI are Escherichia coli (approximately 80%) and Staphylococcus saprophyticus (approximately 5% to 15%).

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For the first episode of acute, uncomplicated cystitis the current treatment of choice is 3 days of oral therapy with TMPSMZ, trimethoprim alone, or one of the quinolones such as ciprofloxacin or norfloxacin.

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More than 90% of recurrences in young women are exogenous reinfection with new isolates arising from local flora.

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A normal Bartholin's gland cannot be palpated. Approximately 2% of adult women develop enlargement of both Bartholin's glands.

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The treatment of choice for a symptomatic Bartholin's cyst or abscess is the development of a fistulous tract from the dilated Bartholin's duct to the vestibule.

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Excision of Bartholin's duct and gland is indicated for persistent deep infection, multiple recurrences of abscesses, or enlargement of the gland in a woman older than 40. Removal of a Bartholin's gland for recurrent infection should be performed when the infection is quiescent.

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Pediculosis pubis, an infestation by the crab louse Phthirus pubis, is characterized by constant itching, predominantly vulvar involvement, and the finding of eggs and lice by visual inspection. It may be treated by topical application of 1% permethrin cream rinse (Nix) or 1% lindane shampoo (Kwell).

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Scabies, an infection by the itch mite Sarcoptes scabiei, is characterized by intermittent pruritus, most commonly in the hands, wrists, breasts, vulva, and buttocks. It is diagnosed by a scraping of the papules, vesicles, or burrows in which the mites live and inspection under the microscope. It may be treated by topical application of 5% permethrin cream (Nix) or 1% lindane lotion or 30 g of cream.

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Permethrin is more expensive than lindane, and permethrin has less potential for toxicity in the event of inappropriate use. Seizures have been reported when lindane was applied immediately after a bath or in women with extensive dermatitis. Lindane is not recommended during pregnancy or for lactating women or children younger than 2.

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Molluscum contagiosum in adults is an asymptomatic viral disease primarily of the vulvar skin. It is a common generalized skin disease in adults with immunodeficiency, especially HIV infection.

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Condyloma acuminatum presents as a clinically recog-nizable macroscopic lesion in 30% of infected women and as a subclinical infection in 70% of women.

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Condyloma acuminatum is an STD spread by skin-to-skin contact. It is caused by the human papillomavirus (HPV). Autoinoculation also occurs. It is a highly contagious disease.

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Vaginal condylomata are identified in approximately one of three women with vulvar disease.

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No present therapy of HPV eliminates subclinical infection from the surrounding epithelium.

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HPV vaccine against types 6 and 11 can prevent 90% of condylomata when administered to HPV-naïve females

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Genital herpes is a recurrent, incurable STD. Approximately 80% of the individuals are unaware they are infected.

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Genital herpes is most frequently transmitted by individuals who are asymptomatic and unaware that they have the infection at the time of transmission.

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From a clinical standpoint the important difference be-tween HSV-1 and HSV-2 is that the frequency of recurrence is four times greater following a primary infection with HSV-2 than with HSV-1.

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The primary infection by herpes is both a local and a systemic disease. The majority of symptomatic women have severe vulvar pain, tenderness, and inguinal adenopathy. However, subclinical primary herpes infection is common.

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Oral medication effective against HSV has been shown to be beneficial in reducing the duration of herpetic ulcerative lesions and in reducing the time that the virus can be isolated from these lesions.

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Patients with frequent episodes of recurrent genital herpes may be successfully treated with prophylactic oral medication. The primary goals of continuous suppressive therapy are to limit the severity and number of occurrences as well as to give the woman a sense of control over her disease. In discordant couples suppressive therapy also decreases acquisition of HSV in the seronegative partner.

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Granuloma inguinale, also known as donovanosis, is a chronic, ulcerative, bacterial infection of the skin and subcutaneous tissue of the vulva.

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Granuloma inguinale may be managed by a wide range of oral broad-spectrum antibiotics.

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Lymphogranuloma venereum (LGV) is an STD produced by serotypes L1, L2, and L3 of C. trachomatis.

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The treatment for LGV is oral doxycycline, 100 mg twice a day for 3 weeks. An alternative regimen is erythromycin base 500 mg every 6 hours for 3 weeks.

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Chancroid is a sexually transmitted, acute, ulcerative dis-ease of the vulva. The soft chancre of chancroid is always painful and tender. In comparison, the hard chancre of syphilis is usually asymptomatic.

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Syphilis is a chronic complex systemic disease produced by the spirochete Treponema pallidum.

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Early syphilis is a cofactor in the transmission and acquisition of HIV.

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Dark-field microscopy rather than normal light microscopy is used for detection of syphilis because of the extreme thinness of the spirochete Treponema pallidum.

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Quantitative nontreponemal antibody titers usually correlate with the activity of syphilis.

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Nonspecific tests for syphilis, the VDRL and RPR, have a 1% false-positive rate. Many conditions produce biologic falsepositive results, including a recent febrile illness, pregnancy, immunization, chronic active hepatitis, malaria, sarcoidosis, intravenous drug use, and autoimmune diseases such as lupus erythematosus or rheumatoid arthritis. Therefore, specific tests such as the TPI, FTA-ABS, and MHA-TP must be employed when a positive nonspecific test result is encountered.

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A woman with a positive reactive treponemal test usually will have this positive reaction for her lifetime regardless of treatment or the activity of the disease.

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The characteristic chancre of primary syphilis is a red, round ulcer with firm, well-formed, raised edges, with a nonpurulent clean base and yellow-gray exudate. During the first week of clinical disease, the woman develops regional adenopathy that is nontender and firm.

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A woman with syphilis is most infectious during the first 1 to 2 years of her disease with decreasing infectivity thereafter.

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Tertiary syphilis develops in approximately 33% of patients who are not appropriately treated during the primary, secondary, or latent phases of the disease.

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Concurrent HIV infection should be considered in patients with syphilis. It is optimal for all women with syphilis to be tested for HIV infection.

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Sexual partners of women with syphilis in any stage should be evaluated both clinically and serologically.

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In women in the reproductive age range, bacterial vaginosis represents approximately 50% of vaginitis, and candidiasis and Trichomonas infection represent approximately 25% each.

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The normal vaginal environment is a dynamic and delicate ecosystem, with a pH of approximately 4.0 in premenopausal women.

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A vaginal pH of greater than 5.0 indicates atrophic vaginitis, bacterial vaginosis, or Trichomonas infection, whereas a vaginal pH of less than 4.5 in a symptomatic woman is characteristic of either a physiologic discharge or fungal infection.

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Bacterial vaginosis results when high concentrations of anaerobic bacteria replace the normal H 2O2-producing Lactobacillus species in the vagina. Histologically, there is an absence of inflammation in biopsies of the vagina.

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The classic criteria for the diagnosis of bacterial vaginosis are (1) a homogeneous vaginal discharge is present; (2) the vaginal discharge has a pH equal to or greater than 4.5; (3) the vaginal discharge has an aminelike odor when mixed with potassium hydroxide; and (4) a wet smear of the vaginal discharge demonstrates clue cells greater in number than 20% of the number of the vaginal epithelial cells.

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Ironically, 50% of women who have three of the four clinical criteria for bacterial vaginosis are asymptomatic.

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HIV acquisition is increased in women with bacterial vaginosis and Trachomatis vaginalis infection.

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Trichomonas vaginal infection is the most prevalent non-viral, nonchlamydial STD of women. Trichomonas is the causal factor for approximately one in four episodes of infectious vaginitis.

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T. vaginalis infection is a highly contagious STD. Following a single sexual contact, at least two thirds of both male and female sexual partners become infected.

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Dysuria is a symptom in approximately one of five women with symptomatic Trichomonas infection.

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The asymptomatic female who has Trichomonas identified in the lower female genital urinary tract definitely should be treated. Extended follow-up studies have shown that one in three asymptomatic females will become symptomatic within 3 months.

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Candida vaginitis is produced by a ubiquitous, airborne, gram-positive fungus. The vast majority of cases are caused by Candida albicans, with 5% to 20% of vaginal fungal infections produced by C. glabrata or C. tropicalis.

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Candida species are part of the normal flora of approxi-mately 25% of women, being a commensal saprophytic organism on the mucosal surface of the vagina. When the ecosystem of the vagina is disturbed, Candida becomes an opportunistic pathogen.

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Recurrent vulvovaginal candidiasis is defined as four or more episodes of symptomatic lower tract infection within 12 months.

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Toxic shock syndrome (TSS) is an acute, febrile illness, produced by a bacterial exotoxin with a fulminating downhill course involving dysfunction of multiple organ systems.

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Menstrual associated TSS is decreasing. Severe postopera-tive infections by Streptococcus pyogenes may produce a similar TSS.

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Because of the severity of the disease, gynecologists should have a high index of suspicion for TSS in a woman who has an unexplained fever and a rash during or immediately following her menstrual period.

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The initial rash of TSS over the first 48 hours is similar in appearance to an intense sunburn. Over the next several days it evolves into a macular rash with fine, flaky desquamation over the face and trunk, and sloughing of the entire skin thickness over the palms and soles.

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The differential diagnosis of TSS includes Rocky Mountain spotted fever, streptococcal scarlet fever, and leptospirosis.

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Bacterial infection of the endocervix becomes a major reservoir for sexual and perinatal transmission of pathogenic microorganisms.

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The most common site of Chlamydia infection in the female reproductive tract is the columnar cells of the endocervix.

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Symptoms that suggest cervical infection include vaginal discharge, deep dyspareunia, and postcoital bleeding. Chlamydia trachomatis is the major infective agent in women with mucopurulent cervicitis.

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The majority of women who have lower reproductive tract infections by C. trachomatis or N. gonorrhoeae do not have mucopurulent cervicitis. The corollary is the majority of women who have mucopurulent cervicitis are not infected by C. trachomatis or N. gonorrhoeae.

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Routine dual therapy for gonococcal and chlamydial infections is indicated if the woman has chlamydia and comes from a population in which the prevalence of gonococcal infections is greater than 5%.

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Many women harboring sexually transmitted pathogens in the cervix are asymptomatic.

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Nucleic acid amplification testing is the standard detection method for C. trachomatis and N. gonorrhoeae. Urine testing

requires a first void specimen. •

N. gonorrhoeae Gram stain smears are positive for only 50% of women with positive cultures. Culture of a second consecutive endocervical cotton swab will increase detection of N. gonorrhoeae by approximately 7% to 10%.

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If the woman is asymptomatic, follow-up cultures are no longer recommended by the CDC as a test of cure for lower tract infections (uncomplicated gonorrhea).

Chapter 23 – Infections of the Upper Genital Tract : Endometritis, Acute and Chronic Salpingitis KEY TERMS AND DEFINITIONS Atypical, or Silent, Pelvic Relatively asymptomatic inflammation of the upper genital tract. Inflammatory Disease Canaliculus

A small, canallike opening forming a channel for ascension of bacteria from the lower to the upper genital tract.

Commensal Bacteria

An organism that may exist in the genital tract without causing disease.

Fitz-Hugh–Curtis Syndrome

A syndrome of perihepatic inflammation that develops in 5% to 10% of women with acute pelvic inflammatory disease, originating from transperitoneal or vascular dissemination of eitherNeisseria gonorrhoeae or Chlamydia trachomatis.

Hydrosalpinx

A collection of watery, sterile fluid in the fallopian tube, secondary to tubal obstruction, an end stage of a pyosalpinx.

Multidrug-Resistant Tuberculosis.

Infection from Mycobacterium tuberculosis that is resistant to two or more antituberculin drugs, including isoniazid.

Nonoxynol 9

A chemical detergent used in spermicidal preparations that is also bactericidal and viricidal.

Penicillinase-Producing Gonorrhea.

Strains of N. gonorrhoeae that become resistant to penicillin by acquiring a resistance factor plasmid that enables the gonococcus to produce an enzyme that destroys penicillin.

Pelvic Inflammatory Disease

A nonspecific term that most commonly refers to inflammation caused by infection in the upper genital tract; often used synonymously with the term acute salpingitis.

Tuboovarian Complex

A collection of pus within an anatomic space created by adherence of adjacent organs, involving the oviducts, ovaries, and sometimes the intestines. KEY POINTS

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The Centers for Disease Control (CDC) regularly revises its treatment protocols for STDs. This information may be accessed online at www.cdc.gov/publications.htm

.

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Studies have emphasized that organisms that produce bacterial vaginosis may also produce histologic endometritis even in women without symptoms of upper tract disease.

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The diagnosis of chronic endometritis is established by the finding of plasma cells and neutrophils on endometrial biopsy.

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During days 1 and 2 of the menstrual cycle, it is normal to see scattered polymorphonuclear leukocytes in an endometrial biopsy.

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PID may include infection of any or all of the following anatomic locations: the endometrium (endometritis), the oviducts (salpingitis), the ovary (oophoritis), the uterine wall (myometritis), the uterine serosa and broad ligaments (parametritis), and the pelvic peritoneum.

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Approximately one in four women with acute PID experiences further medical sequelae, including recurrent acute PID, ectopic pregnancy, and chronic pelvic pain.

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The CDC has emphasized that physicians should aggressively treat women if there is any suspicion of the disease, since sequelae are so devastating and the clinical diagnosis made from symptoms, signs, and laboratory data is often incorrect.

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Acute PID is usually caused by a polymicrobial infection of organisms ascending from the vagina and cervix, traveling along the mucosa of the endometrium to infect the mucosa of the oviduct. The primary bacterial organisms cultured from tubal fluid and mucosa include Neisseria gonorrhoeae, Chlamydia trachomatis, and endogenous aerobic and anaerobic bacteria.

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Approximately 20% of women with cervical infection by gonorrhea subsequently develop PID. The virulence of the strain of N. gonorrhoeae helps to predict the incidence of upper genital tract infection.

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C. trachomatis is the most prevalent organism causing PID. The salpingitis it produces is usually insidious in onset.

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Approximately 30% of women with documented acute cervicitis secondary to chlamydia subsequently develop acute PID.

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Studies of women with tubal infertility have noted that many women, though not diagnosed as having had overt PID, have had symptoms of pelvic pain. Some investigators believe that atypical or silent PID may be the more com-mon form of upper tract infection, and symptomatic PID may be but the “tip of the iceberg.”

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Anaerobic organisms are almost ubiquitous in pelvic abscesses associated with acute pelvic inflammatory disease. Tuboovarian complexes and abscesses are more common in women with concurrent bacterial vaginosis or HIV infection.

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There is a strong correlation between the incidence of STD within a population and the incidence of acute PID.

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In epidemiologic studies, age at first intercourse, marital status, and number of sexual partners are all gross indicators of the frequency of exposure to STDs. Having multiple sexual partners increases the chance of acquiring acute PID approximately fivefold.

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Acute PID is a condition of young menstruating women, with 75% of cases occurring in women younger than 25 years of age. The risk for a sexually active adolescent female is 1 in 8. This decreases to 1 in 80 for women older than age 25.

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When PID is found in the postmenopausal woman, genital malignancies, diabetes, or concurrent intestinal disease is usually found.

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The increase in risk for PID occurs primarily at the time of insertion of the IUD and in the first 3 weeks after placement.

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Acute salpingitis occurring in a woman with a previous tubal ligation is rare, and, when it does occur, it presents with less severe symptoms.

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Approximately 20% to 25% of women have no identifiable intraabdominal or pelvic disease by laparoscopy when diagnosed as having acute PID on the basis of history, physical, and laboratory examination.

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Pain in the lower abdomen and pelvis is the most frequent symptom of acute PID, and in all large series more than 90% of women with the diagnosis have some type of abdominal pain.

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Seventy-five percent of patients with acute PID have an associated endocervical infection or a coexistent purulent vaginal discharge.

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Nausea and vomiting are comparatively late symptoms in the course of acute PID.

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From 5% to 10% of women with acute PID develop perihepatic inflammation, Fitz-Hugh–Curtis syndrome.

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Approximately one third of women with acute PID present with a temperature greater than 38° C.

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The incidence of adnexal abscess is approximately 10% in women with acute PID.

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Acute PID should be diagnosed with a minimum of suspicion with the knowledge that overtreatment is preferable to missed diagnosis.

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Acute PID should be included in the differential diagnosis of any sexually active young woman with pelvic pain.

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Because acute PID has a wide range of nonspecific clinical symptoms, there is both a high false-positive rate and a high false-negative rate when the diagnosis is based on clinical findings and laboratory results.

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Less than 50% of women with acute PID have a white blood cell count of greater than 10,000 cells per milliliter.

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Most studies demonstrate that women with acute PID and HIV infection have a higher incidence of adnexal masses. However, the acute pelvic infection responds to antibiotic therapy in a similar fashion as in women who are not infected with HIV.

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Though ultrasonography is neither specific nor sensitive in distinguishing the cause of a pelvic mass, findings of dilated and fluid-filled tubes, free peritoneal fluid, and adnexal masses may be confirmatory of symptoms and physical signs. Vaginal ultrasound does have a high positive predictive value when used in a high-risk population.

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Laparoscopy is the optimum method for accurately diagnosing acute PID.

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Women who are being treated as outpatients for acute PID should be reexamined within 48 to 72 hours of initiation of therapy to evaluate the response of the disease to oral antibiotics.

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Indications for hospitalization for treatment of PID include presence of tuboovarian complex or abscess, pregnancy, concurrent HIV infection, uncertain diagnosis, gastrointestinal symptoms, peritonitis in upper quadrants, history of operative or diagnostic procedures, and inadequate response to outpatient therapy.

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There is no clinically significant difference in bioavailability of doxycycline whether it is given by the oral or IV route. Thus doxycycline should be administered orally whenever possible because of the marked superficial phlebitis produced by IV infusion.

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Antibiotics against C. trachomatis must be present in effective dosages for at least 7 days for both clinical and microbiologic cures. C. trachomatis has a 48- to 72-hour life cycle inside of the mucosal cell. Thus prolonged therapeutic

levels of the antichlamydial antibiotic are imperative. •

The advantages of a once daily aminoglycoside program are decreased toxicity, increased efficacy, and a decreased cost.

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Surgical treatment for acute PID is restricted to life-threatening infections, ruptured tuboovarian abscesses, laparoscopic drainage of a pelvic abscess, persistent masses in some older women for whom future childbearing is not a consideration, and removal of a persistent symptomatic mass. Unilateral removal of a tuboovarian complex or abscess is a frequent conservative operation for acute PID for women desiring future childbearing.

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Recurrent acute PID is experienced by approximately 25% of women. The chance that a woman will develop chronic pelvic pain following acute PID is four times greater than is the risk for control subjects.

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Because sequelae of acute PID are related to the number of infections, prevention cannot be overemphasized.

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Actinomyces is a rare cause of upper genital tract infection. Actinomyces israelii is the most common species found and is a gram-positive anaerobe, which is difficult to culture.

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Pelvic tuberculosis may be produced by either Mycobacterium tuberculosis or M. bovis. The primary sites of infection are the lung and the gastrointestinal tract.

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The predominant presentations of tuberculous salpingitis are infertility and abnormal uterine bleeding.

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Because of the emergence of multidrug-resistant strains, the CDC has recommended starting a patient on multidrug regimens until the patient's culture results yield specific sensitivity.