Uterine Bleeding, PID, and Uterine Fibroids

Question 1

Medical burden of abnormal uterine bleeding

Answer 1

• Accounts for 70% of all GYN visits for peri- and post-menopausal women
• May occur at any age, but most densely in 5 years before menopause

Question 2

“Normal” menses characteristics

Answer 2

• ~30 cc of blood lost
• Over the course of 4-6 days
• Some abdominal cramping and associated symptoms during this time, and symptoms should be relatively consistent from one menses to the next

Question 3

Mnemonic for causes of abnormal menstruation

Answer 3

• PALM COEIN
• Polyps
• Adenomyosis
• Leiomyoma
• Malignancy
• Coagulopathy
• Ovarian dysfunction
• Endometrial process
• Iatrogenic
• Not yet classified

Question 4

First steps if something abnormal is noted on pelvic exam, or if patient declines pelvic exam, when presenting with abnormal uterine bleeding

Answer 4

Pelvic ultrasound

Question 5

Options for patients with anovulatory uterine bleeding unassociated with coagulopathy

Answer 5

• Oral contraception
• Cyclic progesterone
• Levonorgestrel IUD
• Endometrial ablation (requires endometrial biopsy first)

Question 6

Options for long-acting reversible contraception with mechanisms

Answer 6

Question 8

Uterine fibroid

Answer 8

Fibroids and leiyomyomata are the same!

They are benign, hormonally responsive tumors, whose growth is stimulated by estrogen. High estrogen states predispose to fibroid development (pregnancy, being on the pill, etc). In most persons with a uterus, they are asymptomatic, but they may cause heavy periods, pelvic pressure, and dysmenorrhea/uncomfortable menses.

Diagnosed by physical exam w/ supportive findings from imaging studies (usually pelvic ultrasound). If asymptomatic, no treatment necessary. If heavy bleeding is the only symptom, oral contraceptive, progestins, prostaglandin synthesis inhibitors (NSAIDs), and GnRH agonists (the latter for short term only). If more severe, uterine artery embolization, surgical myomectomy, or surgical hysterectomy are options.

Question 9

How do we describe the size of the uterus on exam?

Answer 9

1. In relation to size associated with # of weeks pregnancy
2. In relation to finger breadths beneath the umbilicus

Question 10

Who should you not give the oral contraceptive pill to?

Answer 10

Patients over age 35 with untreated hypertension, history of stroke or otherwise hypercoagulatility, history of migraines.

Question 11

Uterine artery embolization

Answer 11

Minimally invasive interventional radiology procedure for devascularizing uterine fibroids.

Catheter is inserted into the femoral artery, then pushed up into the uterine artery. Local embolism of tiny spheres causes partial vascular occlusion, decreasing the local blood supply by just enough to prevent fibroid growth and development.

This option is safe and effective, but choice of eligible patients is very careful.

Question 12

Ligaments of the uterus

Answer 12

• In order to accomadate the function of the uterus, some of these ligaments need to be flexible and adaptable
  
  • The round ligament is mostly smooth muscle
  • The broad ligament is loose araeolar tissue
  • Thus, they are functional and do not provide the typical structural support of classic ligaments.
• The cardinal and uterosacral ligaments are true ligaments
• The cardinal, uterosacral, and round ligaments are all contained within the broad ligament

Question 13

Risk factors of pelvic floor insufficiency

Answer 13

• Multiparity (giving birth to more than one at a time)
• Delivery of large babies
• Chronic increased abdominal pressure (coughing, weight lifting)

Question 14

What vessel is closest to the sites of incision for inferior laporoscopic procedures?

Answer 14

The inferior epigastric artery, which branches off of the external iliac and comes in close proximity to the anterior abdominal wall

Question 15

Patient presents with unexectedly early delivery and is already in substantial dilation. There is no time for a spinal block for the pain. What alternative approach can you use in this acute setting, and how does it work?

Answer 15

• A pudendal nerve block
• Find the ischial spine, then find your target point 1 cm inferior and 1 cm medial to the ischial spine
• Aspirate at this point first to ensure you are not injecting into the pudendal artery and inferior gluteal artery at this level

Question 16

The most common site for an ectopic pregnancy

Answer 16

Within the fallopian tube proximal to the ovary and opening to the peritoneum

Question 17

Why are males more likely to have venous backup in the left testicle than the right testicle?

Answer 17

Because the left gonadal vein must drain into the left renal vein and is in a more dependent position relative to other abdominal arterial structures, while the right renal vein drains directly into the IVC and is not closeby to any large, high pressure arterial stuctures which may occlude it.

Keep in mind nutcracker syndrome as a specific example

Question 18

Vascular supply of ureter

Answer 18

• Vascular supply of the ureter depends on which ureter segment you are talking about!

Question 19

Most common bacterial STI

Answer 19

Chlamydia

Question 20

Basic C. trachomatis micribiology

Answer 20

• Obligate intracellular bacterium
• Closer related to gram +. BUT, unusual in that it has no peptidoglycan and has LPS instead, features more like gram -. As a consequence:
  
  1. C. trachomatis does not stain on gram stain
  2. C. trachomatis is not susceptible to beta lactams or vancomycin

Question 21

Clinical manifestations of chlamydia

Answer 21

• Many infections asymptomatic
• In men, urethritis, epididymitis, or reactive arthritis
• In women, cervicitis, urethritis, PID, perihepatitis (liver capsule)
• In infants, trachoma (leading to blindness), conjunctavitis, pneumonia, and urogenital infection
  
  • Remember, infants are exposed at the head, adults are exposed in the perineum!

Question 22

Treating urogenital chlamydia

Answer 22

• Single dose of 1g oral azithromycin

OR

• 7 days of 100 mg doxycycline 2x/day
• Note that these are not beta lactamases!
• All sexual partners of the individual should also receive the same treatment for presumptive infection
• Patients should refrain from sexual activity for one week with either treatment

Question 23

What is trachoma and how does C. trachomatis (note the name) cause it?

Answer 23

• Leading cause of preventable blindness in the world
• Occurs when chlamydia is brought to the eye by any means, including vaginal delivery in an infected but asymptomatic mother
• Starts as conjunctavitis, then progresses to involutional entropion (pictured) and ulceration, eventually leading to scarring of the cornea and loss of eye function
• Can be treated with a single dose of occular azithromycin

Question 24

Basic N. gonorrheae micribiology

Answer 24

• Gram negative diplococci, oxidase positive, facultative intracellular
• Infect epithelial cells
• Lots of antibiotic resistance

Question 25

Clinical manifestations of gonorrhea

Answer 25

• In men, urethritis, anorectal infections, and rarely epididymitis
• In women, cervicitis, urethritis, anorectal infection, PID, perihepatitis, or (often, ~50%) asymptomatic
  
  • Rarely in women may cause accessory gland infection (Bartholin’s)
• May disseminate to DGI, associated with skin lesions, arthralgia, tenosynovitis, and frank arthritis
• May cause severe non-purrulent conjunctavitis if it reaches the eye (non-purulent because it is intracellular!). Think “gonorrheye” (attached image)

Question 26

Treating gonorrhea

Answer 26

• Ceftriaxone + azithromycin (remember, these guys are resistant)
• Above is a good empiric start, but you will want to get culture resistance results back quickly to see what will really work best
• If just conjunctavitis, a single 1g intramuscular dose of ceftriaxone will do
• For DGI, repeat ceftriaxone + azithromycin every day until there is resolution (usually ~7 days)
  
  • Extend to 14 days past resolution of symptoms for meinigitis
  • Extend to 4 weeks past resolution of symptoms for endocarditis
• Recent sexual partners should be referred for evaluation and presumptive dual treatment
• All should be instructed to refrain from sexual activity until 1 week past end of treatment

Question 27

Characteristics of reactive arthritis

Answer 27

• Acute monoarthritis (or rarely a couple joints)
• Often the knee
• Similar appearance to septic arthritis, but there is no true joint infection in reactive
  
  • Instead, the immune system is responding to debris from a previous infection, usually an STI or gastrointestinal infection

Question 28

A patient presents with acute monoarthritis in the knee. They recently had history of STI. How does your reasoning and treatment change if this STI was chlamydia versus gonorrhea?

Answer 28

• If it was chlamydia, this is likely a reactive arthritis, which is not an active infection. As such, antibiotics are not helpful and you can advise the patient to take an antiinflammatory and that the disease will be self limited
• If it was gonorrhea, this could still be reactive arthritis, but it may be septic arthritis, in which case the individual is still infected with gonorrhea. This requires antibiotics and careful monitoring.

Question 29

Primary vs secondary HSV

Answer 29

• Primary:bilateralgenital ulcers, pain, itching, dysuria, vaginal or urethral discharge, and tender inguinal adenopathy. Without therapy, lasts~2-3 weeks.
• Seconary: unilateral genital vesicles, often with short prodrome of itching/tingling in area ~24 hours prior. Lasts ~3-5 days.

Question 30

Infection with HSV-1 and HSV-2 is. . .

Answer 30

. . . basically lifelong (especially HSV-2). They hide within neurons, but do not pronounce themselves dermatomally as VZV does.

Suppressive (low) dosage of acyclovir or related medication can prevent reactivation.

Question 31

HPV warts

Answer 31

Often described as “scalloped”. Appear this way on male or female, mucosal or keratinized epithelium.

Treated simply by removal, surgically, with cryotherapy, or with imiquimod gels and creams that patients may be given for home use (imiquimod is basically topical chemotherapy). There is no evidence that their persistence is associated with later development of dysplasia or cancer.

Patients often prefer to remove their own warts in private. It is recommended for external warts that the PCP or gynecologist discuss technique and options and ensure the patient knows proper technique, then let the patient do the rest privately if they so prefer.

Question 32

Etiologies of acute vs chronic PID

Answer 32

• Acute: N. gonorrheae, C. trachomatis, most organisms that colonize the vagina and cervix
• Chronic: M. tuberculosis, Actinomyces species
  
  • Actinomyes are the only normal inhabitants of the female genital tract which cause chronic PID. They are primarily opportunistic.
• It should be noted that most cases of PID, especially acute PID, are polymicrobial

Question 33

Clinical presentation of PID

Answer 33

• Wide range, may be asymptomatic or very sick
• Acute may present as nonspecific symptoms such as dyspareunia, dysuria, or gastrointestinal symptoms with lower abdominal/pelvic pain and cramping. In mild/moderate cases, fever/chills are often absent
• More severe cases will have fever, chills, purulent vaginal discharge, nausea, vomiting, and elevated WBC.

Question 34

Physical exam findings on female patients with acute mild to moderate PID

Answer 34

• No external symptoms
• Uterine tenderness
• Cervical motion pain
• Adnexal tenderness

Question 35

Potential long-term sequellae of PID

Answer 35

• Increased ectopic pregnancy risk
• Infertility
• Development of intraabdominal adhesions and fistulas
• Chronic pelvic pain

Question 36

Diagnosing PID

Answer 36

• Clinicians should have a low threshhold of suspicion given the benign nature of many cases
• Laporoscopy may aid in visual confirmation of diagnosis and sampling for bacterial culture
• In absence of feasibility for laporoscopy, clinical criteria may be met for a clinical diagnosis

Question 37

Treatment of PID

Answer 37

• Empiric, broad-range antibiotics that cover N. gonorrhoeae, C. trachomatis, anaerobes, gram-negative facultative bacteria, and streptococci
  
  • Think three buckets of infectious etiology: STI, fecal matter, and skin/vaginal/cervical
• Speed of antibiotic administration correlated with better outcomes and less sequellae
• Patient should be admitted if there is inability to exclude surgical emergencies (ectopic pregnancy, appendicitis, tubo-ovarian abscess) or if no response to oral therapy within 3 days
• In mild/moderate cases, intramuscular ceftriaxone + oral doxycycline may be given and the patient sent home. If at followup ~48 hr later there is no improvement, add metronidazole (to cover anaerobes) and consider admitting.
• In severe cases, cefotetan or cefoxitin (2nd gen cephalosporines that cover anaerobes) may be given IV
• Patients should abstain from sexual activity until 7 days past the end of their treatment and all sexual partners in last 60 days should be contacted and presumptively treated for chlamydia and gonorrhea

Question 38

Answer 38

Lying on the left side in left lateral decubitus position is optimal to prevent compression of the IVC

Question 39

Uterine-ovarian arterial anastomosis

Answer 39

Question 40

Endometrial biopsy

Answer 40

The only contraindication to this procedure is pregnancy

Question 41

Endometrial histology dating

Answer 41

Question 42

Any proliferation in post-menopausal endometrial biopsy is. . .

Answer 42

. . . malignant until proven otherwise

Question 43

Adenomyosis vs endometrial carcinoma

Answer 43

Can be difficult to tell apart, since endometrial cancer often winds up in the myometrium.
The only real way to tell is by histologic examination. Adenomyomas will cycle just like healthy endometrium and will not be hyperproliferative or dysplastic.

Question 44

Adenomyosis may cause ___ while endometriosis cannot.

Answer 44

Adenomyosis may cause uterine bleedin, while endometriosis cannot.

Question 45

How can you tell that a pap smear has adequately sampled the transformation zone?

Answer 45

Presence of both columnar cells and squamous cells

Question 46

Pap smear interpretation guide

Answer 46

Question 47

Advantages and disadvantages of different pelvic ultrasounds

Answer 47

• Transabdominal: Faster, better depth of view, but lower resolution
• Transvaginal: Better resolution, but not as good depth of view. Best for seeing endometrium.

Question 48

Fibroids as an etiology of AUB

Answer 48

Only submucosl (not really intramural or subserosal) fibroids cause AUB. This is because submucosal fibroids make the mucosa more friable.

Question 49

Use of MRI in endometrial cancer

Answer 49

Can be utilized to look for signs of invasion for staging and prognostic decisions

Question 50

hCG levels in pregnancy

Answer 50

Really go up quite dramatically

Upper normal is ~300,000