NPLEX Study Guide: Reproductive Conditions PDF

NATUROPATHIC NOTES NPLEX STUDY GUIDE: REPRODUCTIVE CONDITIONS Study package includes: Medical history, physical exams and diagnostic procedures Pathology including etiology, pathophysiology, clinical features, diagnostics, treatment, and complications Interventions including pharmacology, botanic...

NATUROPATHIC NOTES NPLEX STUDY GUIDE: REPRODUCTIVE CONDITIONS Study package includes: Medical history, physical exams and diagnostic procedures Pathology including etiology, pathophysiology, clinical features, diagnostics, treatment, and complications Interventions including pharmacology, botanicals, nutrition, and homeopathics NPLEX II – REPRODUCTIVE SYSTEM Reproductive System Disorders 1 | Medical History for Reproductive Conditions Female Reproductive Concerns Presenting Complaint Vaginal bleeding should be evaluated based on the following: • Amount (e.g., spotting, heavy flow) • Relation to menstrual cycle/menopause/sexual contact (e.g, intermenstrual, postmenopausal, postcoital) • Vaginal discharge should be evaluated based on the following: • Color (e.g., bloody, brown, yellow, green, or gray) • Consistency (e.g., frothy, curd-like) • Amount • Smell (e.g., fishy) • Pruritic and/or erythematous vagina Abdominal or pelvic pain should be evaluated based on the following: • Site • Onset • Character • Radiation • Associations • Time course • Exacerbating and relieving factors • Severity Menstrual History • Age at menarche • Date of last menstrual period (LMP) • Duration, regularity, flow and associated symptoms (e.g., dysmenorrhea, mittelschmerz) • History of intermenstrual vaginal bleeding • Menopausal history (if applicable) • Age at onset • History of postmenopausal vaginal bleeding • Associated symptoms (e.g., vasomotor symptoms) • History of hormone replacement therapy • Past gynecologic history 1 NPLEX II – REPRODUCTIVE SYSTEM • Previous gynecologic problems (including diseases of the breast) • Previous gynecologic/pelvic surgeries (e.g., cervical conization, hysterectomy) • History of sexually transmitted infections and/or pelvic inflammatory disorder • Time and results of previous screening/diagnostic tests (e.g., Pap smear, mammography) • Past obstetric history Sexual History • Current/past sexual partners • Current/past sex practices • Current/past contraception methods use • History of STIs • History of postcoital vaginal bleeding • History of sexual dysfunction (e.g., dyspareunia, low libido) • History of sexual abuse Medication History • Medications and allergies • Prescribed drugs • Over-the-counter drugs • Herbal remedies • Allergies to drugs or environmental factors and reaction to each allergen Family History • Cancers of the reproductive system in the family (e.g., breast cancer and ovarian cancer with BRCA1/2 gene mutations) • Endocrine disorders (e.g., diabetes mellitus, hypertension) Social History • Relationship status • Socioeconomic status • Occupation • Drug and alcohol use 2 NPLEX II – REPRODUCTIVE SYSTEM Review of Systems In the OB/GYN examination, a particular emphasis should be placed on the: • Urogenital system (e.g., dysuria, hesitancy, urgency, incontinence, change in bowel habits, rectal bleeding) • Abdomen (e.g., abdominal/pelvic pain) • Breasts • For post/perimenopausal woman, it is important to ask about menopausal symptoms (e.g., hot flashes/night sweats, vaginal dryness, abnormal bleeding, irritability, depression, mood changes). • Past obstetric history o Gravida: number of times the patient has conceived o Term pregnancies (≥ 37 weeks of gestation) o Mode of delivery (e.g., normal spontaneous vaginal delivery/NSVD) o Birth weight/gender of the baby o Maternal/fetal perinatal complications o Use of assisted reproductive therapies o Preterm pregnancies (< 37 weeks of gestation) o Abortions (elective or spontaneous before 20 weeks gestation) o Living children or live births Male Reproductive Concerns Presenting Complaint & History of Presenting Illness Male reproductive symptoms should be evaluated based on the following: • Site • Onset • Character • Radiation • Associations • Time course • Exacerbating and relieving factors • Severity Sexual History • Current/past sexual partners & sex practices • Current/past contraception methods use • History of STIs • History of sexual dysfunction (e.g., dyspareunia, low libido) • History of sexual abuse 3 NPLEX II – REPRODUCTIVE SYSTEM Past Medical History • Urinary symptoms: dysuria, increased frequency, nocturia, dribbling, hesitancy, incontinence? • Urethral discharge: dysuria, sexual contacts, joint pain, eye inflammation, eye pain, gastrointestinal symptoms? • Testicular pain: any trauma? Speed of onset, association with other conditions (e.g., mumps) • Genital ulcers • Impotence: evaluate for emotional and psychological factors, drug and alcohol use, history of diabetes mellitus, neurological disease, cardiovascular disease, loss of libido, erectile failure • Subfertility: conception history, length of subfertility, sexual history (timing, frequency, impotence, ejaculation), medication history, medical conditions that could affect erectile function, history of sexual development • History of sexual abuse • Neurological diseases, hypertension, gout, diabetes, BPH, abdominal operations • Medication history Family History • Cancers of the reproductive system in the family (e.g., breast cancer and ovarian cancer with BRCA1/2 gene mutations) • Endocrine disorders (e.g., diabetes mellitus, hypertension) • History of male sexual function disorders • Family history of kidney failure or polycystic kidney disease Social History • Relationship status • Socioeconomic status • Occupation and occupational exposures • Drug and alcohol use • Travel history 4 NPLEX II – REPRODUCTIVE SYSTEM 2 | Physical Examination for Reproductive Conditions Female Genitourinary Exam External genital exam: check for any abnormalities of the vulva, labia (e.g., swelling, irritation, ulcers) • Check the vulva for any abnormalities (e.g., swelling, irritation, ulcers, warts). • Examine the skin for the presence of scars, discoloration, and hair distribution. • Inspect the vaginal introitus for discharge or swelling. • Ask the patient to perform the Valsalva maneuver and examine the vaginal introitus for organ prolapse or urinary incontinence. • Palpate the labia majora for any masses or tenderness. Internal genital exam: includes the sterile speculum exam, cervicovaginal swab • Insertion of a speculum device facilitates the inspection of the vaginal wall and ectocervix • Evaluate the quality of vaginal discharge to determine whether a smear should be acquired • The amount of vaginal discharge varies by individual and by the stage of the menstrual cycle • Signs that vaginal discharge may be pathologic: malodorous (e.g., fishy), abnormal consistency (e.g., frothy, curd-like), bloody, brown, yellow, green, or gray color • Symptoms indicating pathologic discharge: pruritic and/or erythematous vagina, cervical tenderness • Inspect the cervix and the cervical os for the following: o Position (e.g., anteriorly displaced cervix in a patient with a retroverted uterus) o Color (e.g., ectocervical reddening due to the development of cervical ectropion ) o Abnormal discharge (e.g., mucopurulent discharge in gonococcal cervicitis) o Erosions and ulcerations (e.g., HSV infection) o Hemorrhages (e.g., strawberry cervix in trichomoniasis) o Cervical masses (e.g., polyps, cervical cancer) Bimanual pelvic exam • Conducted by introducing two fingers of one hand in the patient's vagina while pressing on the abdomen with the other hand the physician to examine patient's uterus and adnexa (e.g., their localization, size, tenderness during manipulation, presence of masses) • Lubricate the index and middle fingers of one hand and slowly insert them into the vaginal canal, use the other hand to simultaneously palpate the abdomen. • Allows for palpation of both the uterus and adnexa (e.g., their localization, size, tenderness during manipulation, presence of masses). • Rectovaginal pelvic exam: allows for the palpation of the rectovaginal septum palpation in patients with suspected pelvic masses (e.g., colorectal cancer) 5 NPLEX II – REPRODUCTIVE SYSTEM Male Genitourinary Physical Examination • Inspection o Hair pattern or any signs of lice or nits o Presence of circumcision (uncircumcised patients should be examined with the foreskin retracted) o Lesions, rashes, or edema of the penis, scrotum, or perineum • Palpation of penis and foreskin: ulcers and rashes, phimosis, signs of hypospadias, urethral discharge • Palpation of the scrotum and testes: inspect scrotal skin, testes should be equal in size, smooth, and firm, identify any scrotal swellings and conduct transillumination tests if indicated • Palpate the inguinal lymph nodes for signs of inflammation • Hernia examination • Digital rectal examination: to assess for rectal bleeding, fecal impaction, colorectal cancer, and/or to evaluate the prostate o Procedure: With a lubricated, gloved finger, palpate the anal canal and rectum. Assess anal sphincter tone and the size and consistency of the prostate. o Normal findings: should be no palpable masses, should be rubbery and non-tender. Estimate the size, consistency, presence of medial sulcus, and for any tenderness Differential Diagnoses Dyspareunia • Introital pain: inadequate lubrication, rigid or intact hymen, Bartholin’s or Skene’s gland infection, abscess, lichen sclerosis, vulvovaginitis (atrophic, chemical, infectious), herpes simplex • Mid-vaginal pain: urethritis, short vaginal canal, vaginal atrophy, congenital abnormality of the vagina • Deep pain: endometriosis, endometritis, cervicitis, adenomyosis, leiomyoma (fibroids), pelvic inflammatory disease, hydrosalpinx, tubo-ovarian abscess, uterine retroversion, ovarian cyst Vaginal discharge or pruritus • Infectious causes: candidiasis, trichomoniasis, bacterial vaginosis, chlamydia, gonorrhea, herpes simplex • Neoplastic causes: vulvar cancer, vaginal cancer, cervical cancer, endometrial cancer • Local inflammation: irritant exposure, douches, atrophic vaginitis, desquamative inflammatory vaginitis, progesterone use (IUD, OCP) • Systemic causes: toxic shock syndrome, Crohn’s disease, collagen disease, dermatologic disease (lichen sclerosis) Dysmenorrhea • Endometriosis • Adenomyosis • Uterine polyps • Uterine abnormalities • Leiomyoma (fibroids) • Ovarian cysts • Cervical stenosis • Imperforate hymen • Pelvic inflammatory disease • Copper IUD Female infertility • Ovulatory dysfunction: hypothalamic dysfunction, hypopituitarism, prolactinoma, premature ovarian failure, polycystic ovarian syndrome, systemic disease (thyroid disease, Cushing’s syndrome, renal or hepatic failure), congenital, lifestyle factors • Outflow tract abnormalities: pelvic inflammatory disease, adhesions, tubal ligation, congenital abnormalities, endometriosis, leiomyoma (fibroids), acidic cervical mucus, anti-sperm antibodies, structural defects 6 NPLEX II – REPRODUCTIVE SYSTEM Secondary amenorrhea • Functional causes: pregnancy, prolonged, intense exercise • Excessive dieting • Endocrine causes: hypo- or hyperthyroidism, hypothalamic dysfunction, prolactinoma • Ovarian causes: menopause, premature ovarian failure, polycystic ovarian syndrome • Gonadal dysgenesis • Structural causes: atrophy, imperforate hymen, mullerian agenesis Acute & Chronic Pelvic Pain Chronic pelvic pain differential diagnoses • Gynecological causes: chronic pelvic inflammatory disease, endometriosis, adenomyosis, dysmenorrhea, ovarian cysts, leiomyoma (fibroids), uterine prolapse • Gastrointestinal causes: irritable bowel syndrome, inflammatory bowel disease, constipation, partial bowel obstruction, diverticulitis, hernia formation • Genitourinary causes: urinary retention, urethral syndrome, interstitial cystitis • Miscellaneous causes: nerve entrapment, somatization Abnormal uterine bleeding • Gynecology causes: cervical cancer, endometrial hyperplasia or carcinoma, leiomyoma (fibroids), adenomyosis, pelvic inflammatory disease, copper IUD, infection (endometritis, cervicitis, vaginitis, STI) • Obstetric causes: miscarriage, ectopic pregnancy, placental abruption, placenta previa • Endocrine causes: polycystic ovarian syndrome, hyper or hypothyroidism, adrenal insufficiency, insulin resistance, prolactinoma, estrogen producing tumor, weight loss • Hematological causes: coagulopathy (von Willebrand’s disease), platelet abnormalities (immune thrombocytopenic purpura), hematologic malignancy (leukemia, lymphoma) • Renal causes: impaired estrogen excretion • Hepatic causes: decrease coagulation factors, impaired estrogen metabolism • Drug causes: anticoagulants, danazol, OCP, HRT, spironolactone, steroids, neuroleptics Acute pelvic pain differential diagnoses • Gynecological causes: ruptured ovarian cyst, hemorrhage into cyst, ovarian or tubal torsion, fibroid degeneration, torsion of pedunculated fibroid • Infectious causes: acute pelvic inflammatory disease, endometritis • Gastrointestinal causes: appendicitis, mesenteric adenitis, diverticulitis, inflammatory bowel disease • Genitourinary causes: urinary tract infection, cystitis, pyelonephritis, renal colic • Pregnancy related causes: labor, ectopic pregnancy, spontaneous abortion, placental abruption O Red Flags • • • • • • • • • • • Vaginal bleeding in post-menopausal women (endometrial cancer) Palpable ovary in post-menopausal women (ovarian cancer) Acute, febrile illness with shock symptoms (toxic shock syndrome) Acute, single episode of menorrhagia Ovarian cancer must be ruled out first before diagnosis of PCOS PSA doubles in less than 1-2 years (prostate cancer) Foreskin unable to be retracted and signs of inflammation (phimosis) Retracted foreskin that cannot be replaced over glans penis (paraphimosis) Chronic balanitis (cancer) Severe unilateral testicular pain and edema (testicular torsion) Female abdominal pain in reproductive years (need to rule out ectopic pregnancy) 7 NPLEX II – REPRODUCTIVE SYSTEM 3 | Diagnostics in Reproductive Conditions Vaginal Swab • • • Types o High vaginal swab: taken from the posterior vaginal fornix, where cervical and vaginal secretions pool in the supine position o Low vaginal swab: taken from the mid to distal end of the vagina (obtained by patients themselves or by a health care provider when per speculum examination is not required) Tests o Vaginal pH: normal vaginal pH: 4–4.5 § pH > 4.5 → suspect bacterial vaginosis and trichomoniasis (other causes of increased vaginal pH include menstruation, amniotic fluid, and sexual intercourse) o Vaginal wet mount preparation: sample of vaginal discharge is transferred to a slide and mixed with normal saline or potassium hydroxide (KOH) before examining under a microscope. § Normal findings: cylindrical Lactobacilli (Doderlein's bacilli) Pathological findings: o Motile flagellated protozoa: trichomoniasis o Pseudomycelia and/or yeast cells on a KOH preparation: vaginal candidiasis o Clue cells and a positive whiff test (adding KOH to vaginal smear elicits a fishy odor): bacterial vaginosis o Gram staining can reveal gram-negative, intracellular diplococci in patients with gonorrhea. o Perform a nucleic acid amplification test if chlamydia, gonorrhea, trichomoniasis, or genital herpes is suspected. Endocervical swab • A swab of mucus and cells from the endocervix taken by a health care provider during per speculum examination • Obtained in order to perform a nucleic acid amplification test if cervicitis or pelvic inflammatory disease is suspected Colposcopy Colposcope: a type of microscope used to acquire a magnified view of the ectocervix or vaginal wall • Allows for assessment of the ectocervix under magnification (6–40 x) • Application of acetic acid or iodine facilitates the colposcopic detection of precancerous and cancerous lesions • Colposcopy-directed cervical smears and biopsies • Findings o Cervical ectopy: a state in which the squamous cell epithelium of the ectocervix is replaced by columnar cell epithelium of the endocervix under the physiological influence of estrogen (e.g., pregnancy, certain oral contraceptives). Cervical ectopy is seen on colposcopy as a sharply demarcated bright red area with papillary structures. § Clinical features: mostly asymptomatic; occasional postcoital bleeding and vaginal discharge § Predisposition to chlamydial infection o Malignant transformation may occur in cases of HPV-16 and/or HPV-18 infections. § Transformation zone: the area between the non-keratinized squamous epithelium of the ectocervix and the columnar epithelium of the endocervix. The transformation zone is a common site for infections and dysplastic changes. o Nabothian cysts: retention cysts that arise in the transformation zone o Cervical polyps: hyperplastic cervical epithelium • Abnormal findings require further evaluation o White lesions under acetic acid application: condylomata acuminata o White membrane that cannot be scraped off: cervical leukoplakia o Punctate lesions or coarse mosaic pattern: cervical intraepithelial neoplasia o Atypical vessels: cervical cancer 8 NPLEX II – REPRODUCTIVE SYSTEM Ultrasounds Transabdominal ultrasound • An abdominal ultrasound is the easiest method of assessing the uterus, ovaries, and adnexal structures. • Assessment of: urogenital tract, fetal development, pelvic organs Transvaginal ultrasound • Allows visualization of: o Ovaries (diagnosis of ovarian cysts, tumors, and follicular maturation) o Uterus o Myometrium (e.g., to diagnose leiomyomas) o Endometrium • Endometrial thickness varies with the menstrual cycle o Postmenopausal women with an endometrial thickness greater than 8 mm should undergo a follow-up ultrasound after 1–3 months o Postmenopausal women with an endometrial thickness greater than 10 mm should undergo hysteroscopy and endometrial curettage to rule out endometrial carcinoma. o Measurement of cervical length in cases of cervical incompetence Differential diagnosis for pelvic masses • Uterine causes: pregnancy, adenomyosis, hematometra, endometrial cancer, imperforate hymen, leiomyoma (fibroids), leiomyosarcoma • Gynecological causes: ectopic pregnancy, pelvic adhesions, paratubal cysts • Primary fallopian tube neoplasm • Gastrointestinal causes: appendiceal abscess, diverticular abscess, diverticulosis/ diverticulitis, rectal carcinoma • Genitourinary causes: distended bladder, pelvic kidney, carcinoma of the bladder Hysteroscopy • • • • A fiberoptic scope is introduced transcervically into the uterus to diagnose and/or treat uterine pathologies. Commonly done as part of the work-up for abnormal uterine bleeding. Hysteroscopy can be combined with diagnostic/therapeutic uterine curettage Uterine curettage: scraping away endometrial tissue by introducing a curette into the uterine cavity Reproductive System Laboratory Tests Prostate-Specific Antigen: glycoprotein found mainly in the seminal plasma but also in the circulation and is not specific to cancer • Indications (not routinely required): consider if prostate cancer is suspected in patients with a life expectancy of > 10 years who are eligible for prostate cancer treatment, if detected, to aid the selection of pharmacotherapy for BPH. Free PSA is a more specific marker of prostate cancer risk than in total PSA, which can be elevated due to a number of factors. • Findings o Total PSA > 1.5 ng/mL: suggests an enlarged prostate (> 40 mL) o Total PSA > 4 ng/mL: increased likelihood of prostate cancer • Free PSA levels and free PSA/total PSA ratio o ↑ Free PSA levels and ↑ free PSA/total PSA ratio: usually seen in BPH o ↓ Free PSA levels and ↓ free PSA/total PSA ratio: suggestive of prostate cancer 9 NPLEX II – REPRODUCTIVE SYSTEM • A decreased free PSA to total PSA ratio is prognostic of increased prostate cancer risk. In a patient with prostate enlargement, the lower percentage of free PSA, the greater the likelihood that the cause is prostate cancer rather than benign prostatic hyperplasia. Luteinizing Hormone (LH): hormone that stimulates the menstrual cycle • Male individuals: stimulates testosterone synthesis in Leydig cells o In men, high LH levels may indicate a condition affecting the testicles themselves: viral infection (mumps), trauma, injury, exposure to radiation, chemotherapy, autoimmune disease, germ cell tumor, gonadal agenesis or gonadal dysgenesis, Klinefelter’s syndrome o Low levels of LH and FSH may indicate a problem with the pituitary or hypothalamus. • Female individuals: triggers ovulation o Increased levels of LH are seen in ovarian agenesis, Turner’s syndrome, 17 alpha hydroxylase deficiency, damage or injury to the ovaries due to exposure to radiation, chemotherapy, autoimmune disease, or underlying conditions that affect ovary function, such as PCOS, adrenal disease, thyroid disease o In women who are trying to become pregnant, multiple LH tests can be used to detect the surge that precedes ovulation. An LH surge indicates that ovulation has occurred. o Low levels of LH and FSH may be seen in problems with the pituitary or hypothalamus. Estrogens: Hormones involved in regulating the menstrual cycle, development of the breasts and uterus, and many other functions in the body. Estrogen tests measure one of three components: estrone (E1), estradiol (E2), or estriol (E3) in the blood or urine. • E1: directly converted from androstenedione (from the adrenal gland) or indirectly from other androgens. This can also be produced by the ovaries and placenta, testicles, and adipose (fat) tissues. E2 and E1 can be converted into each other as needed, primary estrogen in men and post-menopausal women. • E2: primarily produced in the ovaries under stimulation of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) in pre-menopausal women and men’s testicles. Converted from E1 in post-menopausal women, E2 is the most potent estrogen, the one present in the highest concentration in non-pregnant, pre-menopausal women. E2 levels vary depending on a woman’s age and reproductive status. They are a good marker of ovarian function. • E3: produced by the placenta, with concentrations rising throughout a woman’s pregnancy. Increasing levels indicate the health of the pregnancy and developing baby. It is part of the second-trimester maternal serum screen performed to evaluate fetal risk due to certain chromosomal abnormalities. Very low levels of E3 are present in non-pregnant women or men. • Indications o E2 and/or E1 testing in females may be ordered when sex organs develop earlier or later than normally expected, symptoms such as abnormal vaginal bleeding after menopause or abnormal or lack of menstrual cycles, infertility (E2 measurements throughout a woman’s menstrual cycle may be done to monitor follicle development before in vitro fertilization techniques timed with a surge in E2), symptoms of menopause, including hot flashes, night sweats, insomnia, and/or irregular or lack of menstrual periods, menopausal woman is taking hormone replacement therapy; her health practitioner may periodically order E1 levels to monitor treatment o E3 testing in women may be ordered during pregnancy, when a health care practitioner may order serial E3 samples to look for a trend, whether there is a rise or fall in the E3 level over time, unconjugated E3 is often measured in the 15th to 20th week of gestation as part of the triple/quad screen o E2 and/or E1 testing in males may be ordered when there is delayed puberty, characterized by delayed development of muscle mass, lack of deepening of the voice or growth of body hair, slow or delayed growth of testicles and penis, signs of feminization, such as enlarged breasts • Increased levels of E2 or E1 are seen in: o Female: early (precocious) puberty, tumors of the ovary or adrenal glands o Male: enlarged breasts (gynecomastia), tumors of the testicles (testicular cancer) or adrenal glands, delayed puberty 10 NPLEX II – REPRODUCTIVE SYSTEM • o Both women and men: hyperthyroidism, cirrhosis In women, decreased levels of estrogen are seen in: Turner syndrome, hypopituitarism, female hypogonadism, failing pregnancy (estriol), eating disorders such as anorexia nervosa, after menopause, PCOS, extreme endurance exercise Follicle-Stimulating Hormone (FSH): hormone that helps control reproduction, egg production, and sexual development; stimulates the maturation of germ cells in both male and female individuals • Indications: determine the cause of infertility, diagnose conditions associated with dysfunction of the ovaries or testicles, aid in the diagnosis of pituitary or hypothalamus disorders, which can affect FSH production • In women o FSH levels are also useful in investigation of menstrual irregularities, predicting when or if a woman is entering menopause o High levels of FSH and LH are consistent with conditions affecting the ovaries themselves. Some examples include failure to develop ovaries (ovarian agenesis), Turner syndrome, 17 alpha-hydroxylase deficiency, damage to the ovaries due to radiation exposure, chemotherapy, autoimmune disease, underlying conditions that affect ovary function, like PCOS, adrenal disease, thyroid disease, ovarian tumor o When a woman enters menopause, and her ovaries stop working, FSH levels will rise. o Low levels of FSH and LH are consistent with a pituitary disorder or problem with the hypothalamus. o Low FSH serum levels have been associated with an increased risk of ovarian cancer. • In men: FSH levels help determine the reason for a low sperm count in men. o High FSH levels are due to conditions affecting the testicles themselves. Some examples include: viral infection (mumps), trauma, injury, radiation exposure, chemotherapy, autoimmune disease, germ cell tumor, gonadal agenesis, Klinefelter’s syndrome o Low levels are consistent with pituitary or hypothalamic disorders. Anti-Mullerian Hormone: hormone made in the ovaries that plays a role in the development of a fetus • Indications: evaluate a woman’s fertility, predict onset of menopause, suspects PCOS, or wants to evaluate the cause of male characteristics in a female (virilization); sometimes prior to some assisted reproductive procedures; periodically when a woman is undergoing treatment for an AMH-producing ovarian cancer; when it is suspected that the testicles of an infant boy are absent, hidden, or not functioning properly • A decreasing level and/or significant decline in AMH may signal the imminent onset of menopause or that a woman has entered menopause. Negative to low levels of AMH are normal in a female during infancy and after menopause. • In a male infant, absence or low levels of AMH may indicate a problem with the AMH gene located on chromosome 19 that directs AMH production and may be seen with absent or dysfunctional testicles. • An increased level of AMH is often seen with PCOS but is not diagnostic of this condition. Testosterone: hormone produced by people of all sexes but found in higher levels in men and people assigned male at birth • Testosterone in the blood can be either bound or free: o Bound testosterone is attached to proteins such as albumin or sex hormone-binding globulin (SHBG). Most testosterone is bound to SHBG. o Free testosterone, the active form, is all the remaining testosterone that is not bound to other substances. • Indications for testing in women: irregular periods, loss of periods, changes in hair growth patterns, voice changes, skin changes such as oily skin or acne, enlarged clitoris • Indications for testing in men: early or late onset of puberty, erectile dysfunction, fertility problems, osteoporosis or thinning of the bones, decrease in sex drive Prolactin: hormone made by the pituitary gland related to breast development and milk production (secreted by lactotropic cells) • Function: ↑ Breast tissue growth and lactation, inhibits GnRH secretion • Elevated prolactin seen in infertility, change in sex drive, breast milk production that is not related to pregnancy or childbirth, erectile dysfunction, irregular menstrual cycles, and may indicate a prolactinoma o Female individuals: inhibition of ovulation, amenorrhea, galactorrhea, decreased libido o Male individuals: inhibition of spermatogenesis, decreased libido 11 NPLEX II – REPRODUCTIVE SYSTEM 17-Hydroxyprogesterone: hormone made in the adrenal glands that can be related to abnormal development of sex organs • Indications: to screen for, detect, and monitor treatment for congenital adrenal hyperplasia (CAH) • The 17-OHP test is routinely ordered as part of newborn screening in the United States to detect CAH due to 21hydroxylase deficiency. • The 17-OHP test may be used to screen for CAH in older children or adults before symptoms appear or to confirm a CAH diagnosis in people with symptoms. Progesterone: hormone made in the ovaries in the second half of the menstrual cycle that prepares the body for pregnancy • Indications: determine the cause of infertility, track ovulation, help diagnose an ectopic or failing pregnancy, monitor the health of a pregnancy, monitor progesterone replacement therapy, diagnose the cause of abnormal uterine bleeding • Low levels of progesterone may be associated with: ectopic pregnancy, fetal death/miscarriage, pre-eclampsia, decreased function of ovaries, lack of menstruation (amenorrhea) • Increased progesterone levels are seen occasionally with: ovarian cysts, molar pregnancies, rare forms of ovarian cancer, overproduction of progesterone by the adrenal glands, adrenal cancer, congenital adrenal hyperplasia DHEAS: male sex hormone that may be elevated in disorders involving the adrenal glands or ovaries • Indications: evaluate whether the adrenal glands are working properly, distinguish between DHEA-S-secreting conditions caused by the adrenal glands and those that originate in the testicles — or rarely, in the ovaries (ovarian tumors), diagnose tumors in the cortex of the adrenal gland (adrenocortical tumors) and adrenal cancers, diagnose congenital adrenal hyperplasia and enlargement of the adrenal glands (hyperplasia) in adults • An elevated DHEA-S may indicate: congenital adrenal hyperplasia, adrenal tumor, • A low level of DHEA-S may be due to: adrenal insufficiency or Addison’s disease, adrenal dysfunction, hypopituitarism Androstenedione: adrenal hormone that can be associated with menstrual abnormalities, infertility, and excess body and facial hair • Elevated level: increased adrenal, ovarian or testicular production, adrenal tumor, adrenal cancer, adrenal hyperplasia, or congenital adrenal hyperplasia (CAH). o Not diagnostic of a specific condition; it usually indicates the need for further testing to pinpoint the cause. • Low levels: adrenal gland dysfunction, adrenal insufficiency, or to ovarian or testicular failure. Sex hormone-binding globulins (SHBGs): a group of transporter proteins required for the transport of lipophilic sex hormones • Hyperestrogenism (e.g., pregnancy, OCP use) causes increased SHBG levels. • Female individuals with low levels of SHBG (e.g., PCOS) have higher levels of free testosterone, which is responsible for the development of hirsutism in these patients. • Male individuals with high estrogen levels (e.g., in liver cirrhosis) are at risk of developing gynecomastia because of increased SHBG levels and decreased free testosterone levels. 12 NPLEX II – REPRODUCTIVE SYSTEM Fertility Testing Male Infertility Workup • Semen analysis • Mixed antiglobulin reaction test for antisperm antibodies: form in disruption of the blood-testis barrier (composed of Sertoli cell tight-junctions), can lead to immobilization and agglutination of sperm or have a spermatotoxic effect. • TSH levels • Prolactin levels • Karyotype test (Klinefelter syndrome) Semen Analysis • Indications: evaluation of male fertility, confirmation of sterility after vasectomy • Pathological findings o Apermia: no ejaculate o Hypospermia: low ejaculate volume (< 1.5 mL) o Azoospermia: no spermatozoa in the ejaculate o Cryptozoospermia: < 1 million spermatozoa/mL of ejaculate o Oligospermia: < 15 million spermatozoa/mL of ejaculate o Asthenozoospermia: < 32% of spermatozoa show progressive motility o Teratozoospermia: increased amorphous spermatozoa o Oligoasthenoteratozoospermia: low concentration, insufficient motility, and increased amorphous spermatozoa Female Fertility Workup • Assess ovulatory function: menstrual history, body temperature analysis to monitor menstrual cycle • Hormone tests o Midluteal serum progesterone levels: progesterone should increase shortly after ovulation → failure of progesterone levels to rise indicates anovulation o Ovulation prediction test (detect LH levels) o Androgen levels: elevated levels induce negative feedback to the hypothalamus → inhibition GnRH secretion → decreased estrogen levels and suppression of ovulation o Ovarian reserve § Early follicular FSH levels: elevated in ovarian insufficiency and indicate reduced ovarian reserve § Early follicular estradiol levels § Anti-Müllerian hormone levels o TSH levels: elevated levels in hypothyroidism o Prolactin levels: hyperprolactinemia • Ovarian sonography: antral follicle count • Endometrial biopsy: usually performed 1–3 days before menstruation to determine thickness of endometrium o A flat endometrial lining indicates a defect in the luteal phase of the menstrual cycle. • Imaging: assess the patency of fallopian tubes and uterus, done if the initial workup does not reveal any abnormalities and no history suggestive of tubal obstruction, or to screen for tubal occlusion and structural uterine abnormalities (e.g., septate uterus, submucous fibroids, intrauterine adhesions) • Examine cervix: physical examination, Pap smear, testing for antisperm antibodies in cervical mucus 13 NPLEX II – REPRODUCTIVE SYSTEM Reproductive System Pathology 1 | Neoplasms Cervical Cancer Epidemiology • 3rd most common gynecological malignancy in the US after endometrial and ovarian cancer, and 3rd most common cause of death due to gynecological malignancy after endometrial and ovarian • Peak incidence: 35–44 years of age • Cervical intraepithelial neoplasia (CIN), a precursor of cervical cancer, typically occurs in young adults (25–35 years) Etiology • Human papillomavirus virus (HPV) infection with high risk strains HPV 16 & 18 is found in 70% of patients. • Risk factors • Associated with HPV infection: multiple sexual partners (strongest risk factor) early-onset of sexual activity, multiparity, immunosuppression (e.g., HIV infection, post-transplantation), history of sexually transmitted infections (e.g., herpes simplex, chlamydia) • Environmental risk factors: cigarette smoking, in-utero exposure to diethylstilbestrol (DES), use of OCPs (indirectly as they suppress folate levels) Clinical Features • Asymptomatic in early stages • Cervical discharge (initially watery, becoming brown or red) • Abnormal vaginal bleeding • • • Oligomenorrhea Post-coital or cervical bleeding Dyspareunia • • • Pelvic or back pain Bowel or bladder symptoms Friable, raised, reddened or ulcerated cervical lesions Diagnostics • Cervical exam: ulceration, induration or abnormalities seen on cervix • PAP smear: identifies abnormal cells on the cervix • Endocervical curettage: done when abnormalities noted, usually alongside colposcopy • Colposcopy shows cervical leukoplakia (collection of atypical cells that form white membrane on the cervix unable to be scraped off) Differential Diagnosis • Condyloma acuminata, cervical polyps, Nabothian cyst Treatment • Excision of lesion • Oncologist referral and naturopathic oncology support • Herbs: topical sanguinaria Monitoring & Follow Up • Repeat PAP 3-6 months following treatment Complications • Metastasis, complications from radiation or chemotherapy treatment 14 NPLEX II – REPRODUCTIVE SYSTEM Ovarian Cancer Epidemiology • Second most common gynecologic malignancy in the US (after endometrial cancer). • Median age at diagnosis: 63 years Etiology • Malignancy of the ovary • Risk factors: incidence of ovarian cancer increases with age, genetic predisposition (BRCA1/BRCA2 mutation, HNPCC syndrome, family history), hormonal factors (elevated number of lifetime ovulations, low fertility, early menarche; and late menopause, low number of pregnancies), endometriosis • Protective factors: surgical intervention (bilateral salpingo-oophorectomy), hormonal factors (oral contraceptives, breastfeeding, parity) Clinical Features • Post-menopausal bleeding • Adnexal mass • Increased abdominal girth • Vague, non-specific abdominal symptoms: nausea, vomiting, dyspepsia, anorexia, early satiety • • Constipation Urinary frequency Diagnostics • Bimanual exam • Liver function test • Imaging (transvaginal or pelvic ultrasound, CT) • CA-125 is elevated in 80% of malignant tumors (only used to monitor disease progression, not for diagnosis) Differential Diagnosis • Irritable bowel syndrome, colon cancer, gastric cancer, adenocarcinoma, colonic obstruction, adnexal tumors , ectopic pregnancy, ovarian cysts, ovarian torsion, uterine fibroids Treatment • Surgical excision • Oncologist referral and naturopathic support Complications • Metastasis Prostate Cancer Epidemiology • 2nd most common cancer in men in the US • Second leading cause of cancer deaths in the US after lung cancer Etiology • Risk factors: age >50, family history, African-American descent, genetic predisposition Clinical Features • Asymptomatic • Constitutional symptoms due to metastasis • Urinary retention • • • Hematuria Back pain Bony tenderness • • • Lower-extremity lymphedema, deep venous thrombosis Adenopathy Bladder distension due to outlet obstruction 15 NPLEX II – REPRODUCTIVE SYSTEM Diagnostics • Urinalysis • PSA levels: used in cases of suspected prostate cancer, monitoring for reoccurrence following treatment • DRE: should be performed in those with elevated PSA levels; may be normal in early disease or if located in area unpalpable. Features suggestive of prostate cancer = localized indurated nodules, prostate enlargement, aysymetry, obliteration of sulcus, hard, non-tender nodes • Uroflowmetry (decreased flow rates) • Digital rectal exam (asymmetric nodules) • Biopsy Differential Diagnosis • Prostatitis, prostatic abscess, benign prostatic hypertrophy, bladder cancer, urinary tract retention, Reiter’s syndrome Treatment • Alpha-adrenergic antagonist (tamsulosin, terazosin, doxazosin,alfuzosin) • 5-alpha reductase inhibitors (finasteride, dutasteride) • Prostatectomy • Radiation therapy • Herbs: cucurbita pepo, hydrangea arborescens, prunus africanum, serenoa repens, urtica dioica (root) Monitoring & Follow Up • Monitor PSA levels every 6 months for first 5 years Complications • Urinary retention, overflow incontinence, hydronephrosis and renal compromise, renal colic, calculi, metastasis Seminoma Epidemiology • Peak incidence: 20-35 years of age Etiology • Germ cell tumor of the testicle that originates in the germinal epithelium of the seminiferous tubules. • Risk factors: cryptorchidism, contralateral testicular cancer Clinical Features • Painless testicular nodule or swelling • Negative transillumination test • • Dull lower abdominal or scrotal discomfort Gynecomastia • In metastatic disease: cough, shortness of breath, chest pain, low back or bone pain Diagnostics • Ultrasound: hypoechoic, homogenous, sharp margins • Macroscopic findings: uniform white cut section • Microscopy: fried egg cell appearance, cells have an abundance of watery cytoplasm, fibrous septae divide the tumor into lobules Differential Diagnosis • Hydrocele, varicocele, spermatocele, scrotal hernia 16 NPLEX II – REPRODUCTIVE SYSTEM Treatment • Radiotherapy and chemotherapy Monitoring & Follow Up • Overall prognosis is excellent, 5-year survival rate >95% Leiomyoma Etiology • Benign smooth muscle tumors of the uterus • Fibroids in a post-menopausal woman should prompt consideration of malignancy). Pathophysiology • Estrogen stimulates monoclonal smooth muscle proliferation and progesterone à inhibition of apoptosis. Clinical Features • Abnormal uterine bleeding, menorrhagia • Dysmenorrhea • • • Acute pelvic pain Dyspareunia Pelvic mass, pressure or heaviness • • Increased abdominal girth Bladder symptoms: frequency, urgency, retention Diagnostics • Bimanual exam: symmetrically enlarged uterus • Imaging: transvaginal or transabdominal ultrasound • Endometrial biopsy: rule out uterine cancer Differential Diagnosis • Dysmenorrhea, endometrial polyps, endometriosis, endometrial hyperplasia, endometrial, uterine or ovarian cancer, pelvic inflammatory disease Treatment • Prostaglandin synthetase inhibitors (Anaprox) • Oral contraceptive pills (suppress ovulation and reduce menstrual flow) • Surgical (uterine artery embolization, myomectomy, endometrial resection) • Herbs: Mitchella repens Complications • Infertility and pregnancy complications Endometrial Cancer Epidemiology • Most common gynecological malignancy and the 4th most common cancer in women. Etiology • Risk factors: unopposed estrogens, postmenopausal women most affected, white race, nulliparous, early menarche, late menopause, irregular menses of significant duration, obesity, diabetes, hypertension, infertility • Prevention: avoid use of unopposed estrogens unless uterus has been removed 17 NPLEX II – REPRODUCTIVE SYSTEM Clinical Features • Tends to be asymptomatic • Post-menopausal bleeding • Pelvic pressure Abnormal uterine bleeding (menorrhagia, spotting) in premenopausal women • • • Bloating Bowel dysfunction Diagnostics • Endometrial sampling and biopsy • Pelvic ultrasound (increase thickness) Differential Diagnosis • Hormone imbalance, endometriosis, fibroids, leiomyoma, uterine polyps, adenomyosis, copper IUD Treatment • Hysterectomy • Bilateral salpingo-oophorectomy • Chemotherapy Monitoring & Follow Up • Repeat Pap every 3 months for 2 years, then every 6 months for 3 years, yearly chest films and clinical exams to check for malignancy Complications • Metastasis, complications from radiation or chemotherapy treatment Vulvar Cancer Epidemiology • Rare (0.7% of female cancers) • Squamous cell carcinoma in 80% of cases Etiology • Risk factors: HPV infection (strains 16, 18, 31, and 33), vulvar dystrophy or cervical intraepithelial neoplasia, smoking, precancerous lesions (e.g., lichen sclerosus), immunosuppression Clinical Features • Asymptomatic • Local pruritus, possible burning sensation and pain • • Reddish, black, or white patches of discoloration Wart-like lesions or ulcers • • • Vulvar bleeding or discharge Dysuria, dyspareunia Lymphadenopathy in groin Diagnostics • Pelvic exam and colposcopy, biopsy Differential Diagnosis • Lichen sclerosus, vulvar intraepithelial neoplasia Treatment • Surgery, radiotherapy, chemotherapy Complications • Metastasis, death 18 NPLEX II – REPRODUCTIVE SYSTEM 2 | Infections O Pelvic Inflammatory Disease Epidemiology • PID is one of the most common causes of infertility Etiology • Inflammation of the upper genital tract (above the cervix), including the endometrium, fallopian tubes, ovaries, pelvic peritoneum and contiguous structures • Commonly associated with gonorrhea and chlamydia. Clinical Features • Constitutional symptoms (fever) • Lower abdominal pain • • • Dyspareunia Uterine, adnexal tenderness Menorrhagia, metrorrhagia • • Cervical motion tenderness Mucopurulent cervical discharge Diagnostics • Pregnancy test: to rule out ectopic pregnancy • Speculum and bimanual exam, vaginal swab (gonorrhea, chlamydia) • Urinalysis (leukocytosis) • Cervical motion tenderness: severe cervical pain elicited by pelvic examination. • Ultrasound: free fluid, abscesses Differential Diagnosis • Ectopic pregnancy, endometriosis, complications of ovarian cysts (rupture, hemorrhagic), acute appendicitis Treatment • Antibiotics (cefoxitin and doxycycline) Complications • Infertility, abscess, chronic pelvic pain, ectopic pregnancy, peritonitis, intestinal obstruction, disseminated infection (septicemia, septic, arthritis, endocarditis, meningitis) O Toxic Shock Syndrome Etiology • Risk factors: high absorbency tampons, prolonged placement of tampons, menstrual and vaginal sponges Pathophysiology • Very small amounts of superantigens can rapidly activate excessive numbers of T cells, triggering a massive release of proinflammatory cytokines Clinical Features • Prodrome: high fever, dermal rash (transient, erythematous macular rash commonly involving the palms and soles, typically desquamates 1-2 weeks after onset) • Shock and end organ dysfunction: tachycardia, tachypnea, high fever, altered mental status • Late symptoms: hypotension, delayed capillary refill, worsening altered mental state, evidence of organ failure Diagnostics • CBC: thrombocytopenia • Liver chemistries: ↑ ALT/AST, ↑ total bilirubin 19 NPLEX II – REPRODUCTIVE SYSTEM Treatment • Antibiotics, ICU admission Complications • End organ damage, death 3 | Uterine & Pelvic Disorders Endometrial Hyperplasia Etiology • Increased estrogen stimulation à excessive proliferation of the endometrium • Due to follicle persistence in anovulatory cycles (e.g., perimenopause, PCOS), granulosa cell tumors, HRT without progestin administration, obesity, tamoxifen therapy in post-menopausal women Clinical Features • Post-menopausal bleeding, vaginal bleeding (intermenstrual or constant) Diagnostics • Pelvic exam & cytologic smear • Imaging (transvaginal sonography): can assess endometrial thickening Differential Diagnosis • Endometrial cancer, cervical cancer, adenomyosis, leiomyoma (uterine fibroids), blood dyscrasias (myelosuppression, bone marrow hypoplasia, leukopenia, thrombocytopenia, pancytopenia, aplastic anemia) Treatment • Hormone therapy Complications • Cancer potential, complications from radiation or chemotherapy treatment Endometritis Etiology • Infection and inflammation of the endometrium, which can be acute or chronic. Clinical Features • Constitutional symptoms: fever, malaise, anorexia • Abnormal vaginal bleeding • • • Vaginal discharge Abdominal pain Dyspareunia • • • Uterine tenderness Vaginal discharge Infertility Diagnostics • Hormone panel: LH, FSH, prolactin, TSH, DHEA, testosterone, estradiol, androstenedione • Imaging: laparoscopy showing mulberry spots, “chocolate” ovarian cysts Differential Diagnosis • Urinary tract infection, pyelonephritis, vaginitis, appendicitis, sexually transmitted infection, pelvic abscess 20 NPLEX II – REPRODUCTIVE SYSTEM Treatment • Prostaglandin synthetase inhibitors • Oral contraceptive pills to suppress ovulation and reduce menstrual flow • Surgical: ablation or resection, lysis of adhesions, bilateral salpingo-oophorectomy, hysterectomy Complications • Infertility Endometriosis Epidemiology • Age of onset: 20–40 years • Incidence: 2–10% of all women Etiology • Presence of endometrial tissue outside of the uterine cavity, causing cyclic symptoms due to growth and bleeding of the ectopic endometrium. • Risk factors: nulliparity, prolonged exposure to endogenous estrogen (early menarche, late menopause), short menstrual cycles (<27 days), menorrhagia (> 1 week), family history Pathophysiology • Endometrial tissue occurs outside of the uterus à reacts to the hormone cycle; proliferates under the influence of estrogen • Endometriotic implants result in: ↑ Production of inflammatory and pain mediators, anatomical changes (e.g., pelvic adhesions) → infertility Clinical Features • Chronic or cyclic pelvic pain • Dysmenorrhea • Dyspareunia • Sacral backache • Characteristic sharp, firm, exquisitely tender nodular “barb” on the uterosacral ligament • • Bowel and bladder symptoms: frequent, dysuria, hematuria, diarrhea, constipation Rectovaginal tenderness and palpable adnexal mass Diagnostics • Hormone panel: LH, FSH, prolactin, TSH, DHEA, testosterone, estradiol, androstenedione • Imaging: transvaginal ultrasound, laparoscopy showing mulberry spots, “chocolate” ovarian cysts Differential Diagnosis • Dysmenorrhea, adenomyosis, leiomyoma (uterine fibroids), hemorrhagic corpus luteum, ectopic pregnancy, ovarian cysts, neoplasm, pelvic inflammatory disease Treatment • Prostaglandin synthetase inhibitors • Oral contraceptive pills to suppress ovulation and reduce menstrual flow • Surgical: ablation or resection, lysis of adhesions, bilateral salpingo-oophorectomy, hysterectomy • Herbs: angelica sinensis, dioscorea villosa, leonurus cardiaca, medicago sativa, pulsatilla vulgaris, viburnum opulus Complications • Adhesion formation, infertility 21 NPLEX II – REPRODUCTIVE SYSTEM Uterine Polyps Epidemiology • Most common in post-menopausal women Etiology • Focal overgrowth of localized benign endometrial tissue • Risk factors: hypertension, obesity, tamoxifen, HRT Pathophysiology • Localized within the uterine wall, extends into the uterine cavity • Can be pedunculated or sessile, single or multiple, and can express both estrogen and progesterone receptors (estrogen stimulates growth) Clinical Features • Menorrhagia spotting • Visible polyps protruding from cervix • Infertility Diagnostics • Imaging: transvaginal ultrasound • Endometrial biopsy to rule out other conditions Differential Diagnosis • Endometrial cancer, hormonal imbalance, fibroids, leiomyoma, adenomyosis, copper IUD Treatment • Electrocautery and excision Complications • Infection, obstruction of menstrual flow, obstetric complications Uterine Prolapse Epidemiology • Common in older women Etiology • Insufficiency of pelvic floor muscles and ligaments causing protrusion of the pelvic organs into or out of the vagina • Includes uterine prolapse (protrusion of the cervix and uterus into the vagina), cystocele (protrusion of the bladder into the anterior vaginal wall) and enterocele (protrusion of the small bowel into the upper posterior vaginal wall). • Risk factors: multiple vaginal deliveries or traumatic births, low estrogen levels (during menopause), increased intraabdominal pressure (e.g., obesity), previous pelvic surgery Clinical Features • Vaginal protrusion, bulge • Sensation of pressure • Urinary symptoms: frequency, incontinence, incomplete voiding • • Rectal fullness, constipation, or incomplete rectal emptying Lower back and pelvic pain • • Anterior prolapse is more common than prolapse to posterior vaginal wall Weakened pelvic floor muscle and anal sphincter tone Diagnostics • Speculum and bimanual exam 22 NPLEX II – REPRODUCTIVE SYSTEM Differential Diagnosis • Cystocele, rectocele, enterocele, pelvic floor dysfunction Treatment • Kegel exercises and pelvic floor physiotherapy • Local vaginal estrogen therapy • Vaginal pessary • Herbs: chamaelirium luteum, caulophyllum thalictroides Complications • Ureter obstruction, ulcerations 4 | Vaginal Disorders Bartholin Cyst Epidemiology • Peak incidence: women in the reproductive age group Etiology • Bacterial infection of the Bartholin’s gland, often due to blockage of the duct. Pathophysiology • Blockage of the duct by inflammation or trauma → accumulation of secretions from gland → cyst formation Clinical Features • Vulvar or perineal mass • Often asymptomatic • Unilateral swelling and pain in the inferior lateral opening of the vagina • • Dyspareunia Painful sitting and walking Diagnostics • Clinical exam: unilateral, palpable mass in the posterior introitus Differential Diagnosis • Urethritis, vaginitis, cystitis, vulvar lesions (hematoma, fibroma, lipoma), malignant lesion of Bartholin’s gland Treatment • Antibiotics • Incision and drainage • Hydrotherapy (sitz bath, warm compress) Complications • Bartholin-rectal fistula, infection of deeper tissue or other reproductive organs 23 NPLEX II – REPRODUCTIVE SYSTEM Colpocele Epidemiology • Common disorder in older women Etiology • Vaginal hernia or prolapse: insufficiency of the pelvic floor muscles and the ligamentous supportive structure of the uterus and vagina • Risk factors: multiple vaginal deliveries and/or traumatic births (greatest risk factor), low estrogen levels (e.g., during menopause), increased intraabdominal pressure (due to, e.g., obesity, previous pelvic surgery Clinical Features • Feeling of pressure on or discomfort around the perineum (“sensation of vaginal fullness”) • Lower back and pelvic pain • • Diagnostics • Clinical exam Rectal fullness, constipation, incomplete rectal emptying Prolapse of the anterior (most common) or the posterior vaginal wall • • Possibly with excessive vaginal discharge on inspection Weakened pelvic floor muscle and anal sphincter tone Treatment • Pelvic floor exercises, pessary, surgical repair if indicated Cystocele Epidemiology • Common disorder in older women Etiology • Anterior vaginal prolapse, or prolapsed bladder (bladder drops from usual position and pushes on wall of vagina) • Risk factors: multiple vaginal deliveries and/or traumatic births (greatest risk factor), low estrogen levels (e.g., during menopause), increased intraabdominal pressure (due to, e.g., obesity, previous pelvic surgery Clinical Features • Feeling of pressure on or discomfort around the perineum (“sensation of vaginal fullness”) • Lower back and pelvic pain • • Rectal fullness, constipation, incomplete rectal emptying Prolapse of the anterior (most common) or the posterior vaginal wall • • Possibly with excessive vaginal discharge on inspection Weakened pelvic floor muscle and anal sphincter tone Diagnostics • Clinical exam • Postvoid residual urine measurement • Voiding cystourethrogram Differential Diagnosis • Cystocele, rectocele, enterocele, pelvic floor dysfunction Treatment • Pelvic floor exercises, pessary, surgical repair if indicated 24 NPLEX II – REPRODUCTIVE SYSTEM Dyspareunia Etiology • Pain that occurs during or after sexual intercourse and is due to organic and/or psychogenic factors • Psychogenic factors: severe relationship stress, intimate partner violence, lack of desire/arousal • Superficial dyspareunia (organic): pain limited to the vulvar or vaginal entrance (vulvodynia, vaginal dryness , vulvovaginal atrophy, vulvovaginitis, genital lichen planus, lichen sclerosus, perineal laceration, episiotomy, and/or perineal repair, congenital anomalies (e.g., hymenal variants), urethral diverticulum • Deep dyspareunia (organic): pain in deeper parts of the vagina or the lower pelvis (pelvic inflammatory disease, urinary tract infections, endometriosis, interstitial cystitis) Clinical Features • Superficial or deep pain before, during, or after sexual intercourse • Pain is often reproducible e.g., during any sexual activity involving the genitals, gynecologic exams (e.g., speculum insertion), insertion of a tampon or menstrual cup • Chronic vulvar pain, burning, and irritation may indicate an underlying vulvovaginal condition e.g., vulvodynia, vulvovaginal atrophy Diagnostics • Complete patient history and physical exam • Gynecologic examination: inspection, palpation of the external genitals with a cotton swab to elicit pain, careful palpation of the vaginal walls • Diagnostic criteria: persistent or recurrent difficulty with ≥ 1 of the following: vaginal penetration during sexual intercourse, severe vulvovaginal or pelvic pain during vaginal intercourse or attempted penetration, severe anticipatory anxiety related to vulvovaginal or pelvic pain during attempted vaginal intercourse or attempted penetration, severe tightening of pelvic floor muscles during attempted vaginal penetration Treatment • Treatment of the underlying cause (e.g., vaginal estrogen therapy for vulvovaginal atrophy) • Symptomatic management: topical analgesics, non-hormonal vaginal moisturizers and lubricants • Pelvic floor physical therapy: considered best initial treatment option ; consists of a combination of modalities, such as patient education, internal manual techniques, dilatation exercises, local tissue desensitization, and home exercises (e.g., Kegel exercises). • Psychotherapy • Local botox injections for refractory cases Rectocele Epidemiology • Common disorder in older women Etiology • Posterior vaginal prolapse, associated with descent of the rectum • Risk factors: multiple vaginal deliveries and/or traumatic births (greatest risk factor), low estrogen levels (e.g., during menopause), increased intraabdominal pressure (due to, e.g., obesity, previous pelvic surgery Clinical Features • Feeling of pressure on or discomfort around the perineum (“sensation of vaginal fullness”) • Lower back and pelvic pain • • Rectal fullness, constipation, incomplete rectal emptying Prolapse of the anterior (most common) or the posterior vaginal wall • • Possibly with excessive vaginal discharge on inspection Weakened pelvic floor muscle and anal sphincter tone 25 NPLEX II – REPRODUCTIVE SYSTEM Diagnostics • Clinical exam Differential Diagnosis • Cystocele, rectocele, enterocele, pelvic floor dysfunction Treatment • Pelvic floor exercises, pessary, surgical repair if indicated Vaginitis – Bacterial Epidemiology • Most common vaginal infection in women Etiology • Pathogen: Gardnerella vaginalis (a pleomorphic, gram-variable rod) • Risk factors: sexual intercourse (primary risk factor, but it is not considered an STD), intrauterine devices, vaginal douching, pregnancy Pathophysiology • Lower concentrations of Lactobacillus acidophilus lead to overgrowth of Gardnerella vaginalis and other anaerobes Clinical Features • Minimal vaginal irritation • Vulvodynia • Dyspareunia • • • Grey, diffuse discharge Fishy odor Pruritus/pain uncommon • • Dysuria Strawberry cervix Diagnostics • Whiff test • KOH wet mount (clue cells, positive whiff test, pH > 4.5) • Cervical swab (rule out gonorrhea, chlamydia) Differential Diagnosis • Gonorrhea, chlamydia, candidiasis, trichomoniasis, pinworms, polyps, lichen planus, condyloma acuminata Treatment • Antibiotics (metronidazole, clindamycin) • Herbs: Echinacea spp., Commiphora myrrha, Melaleuca alternifolia Complications • Pelvic inflammatory disease Vaginitis - Candida Epidemiology • Second most common cause of vulvovaginitis Etiology • Overgrowth of C. albicans • Can be precipitated by the following risk factors: pregnancy, immunodeficiency, both systemic (e.g., diabetes mellitus, HIV, immunosuppression) and local (e.g., topical corticosteroids), antimicrobial treatment 26 NPLEX II – REPRODUCTIVE SYSTEM Clinical Features • Intense pruritus • Swollen, inflamed genitals • Vulvodynia, vulvar burning • Vaginal burning sensation, strong pruritus, dysuria, dyspareunia • • Diagnostics • KOH wet mount (pseudohyphae, spores, pH < 4.5) • Cervical swab (rule out gonorrhea, chlamydia) White, crumbly, and sticky vaginal discharge that may appear l