OB Unit 2: Women's health, contraception, abortion, & infertility

what are the primary external structures of the female reproductive system?

• mons pubis

• labia majora

• labia minora

• clitoris

• bartholin’s glands

• hymen

• urethral meatus

mons pubis

fat pad located over the pubic bone

labia majora

large, fleshy skin folds that enclose and protect outer genitalia

labia minora

small inner skin folds that protect the urethral meatus and vaginal orifice (opening that leads to vaginal canal)

clitoris

stimulates sexual arousal

bartholin’s glands

two small glands located on either side of the vaginal orifice that secrete lubricating fluid during arousal

hymen

fetal tissue remnant partially covering the vaginal entrance; changes with age/hormones and hold no reproductive function or proof of sexual history

urethral meatus (urethra)

tube opening located above the vaginal orifice that excretes urine

what are the internal female reproductive organs?

• ovaries

• fallopian tubes

• uterus

• cervix

• vaginal canal

ovaries

site of egg maturation/release (ovulation) and sex hormone production (estrogen & progestrone)

fallopian tubes

transport mature ova from the ovaries to the uterine cavity

uterus

muscular organ where fetal implantation and growth occur

• fundus (dome shaped top of uterus)

• corpus (upper triangular portion)

• isthmus (lower uterine segment separating corpus from cervix)

• cervix (lower cylindrical portion opening into the vagina)

cervix

dilates during labor to allow passage of the fetus into he vaginal canal

vaginal canal

connects the cervix to the outside; site of sexual intercourse, menstural flow exit, and infant delivery

menstruation

periodic uterine bleeding controlled by a feedback system between the endometrial, hypothalamic-pituitary, and ovarian cycles. Average length is 28 days, average duration is 5 days, and average blood loss is 50 mL.

menarche

first menstruation, average age of onset is 12-13

climacteric/perimenopause

transitional stage preceding menopause (average onset age 47 and lasts 4-5 years) marked by irregular cycles, declining estrogen, elevated FSH, hot flashes, night sweats, mood alterations, vaginal dryness, decreased bone density, and adverse lipid changes

menopause

permanent cessation of menses retroactively diagnosed after 12 consecutive months of amenorrhea without underlying cause; average age is 51

hypothalamic-pituitary cycle

hypothalamus secretes GnRH, stimulating the anterior pituitary to release FSH (follicle growth) and LH (triggers ovulation)

ovarian cycle

follicular phase (days 1-14; FSH recruits follicles, dominant follicle matures, estrogen rises) → ovulation (day 14; LH surge cause follicle rupture) → luteal phase (days 15-28; empty follicle forms corpus luteum, secreting high progesterone)

endometrial cycle

menstrual phase (days 1-4; shedding of functional lining) → proliferative phase (rapid growth under estrogen influence) → secretory phase (post-ovulation lining thickens under progesterone) → ischemic phase (if unfertilized; corpus luteum degenerates, hormone levels plummet, causing vascular constriction and breakdown)

what clinical indicators confirm taht ovulation is occuring?

• basal body temperature: slight dip right before ovulation followed by slight elevation when ovulation begins and remains elevated for several days

• cervical mucus: at peak fertility, mucus becomes abundant, clear, watery, slippery, and high stretchable (resembling egg whites)

• mittelschmerz: mild, localized lower abdominal pain or cramping accompanying follicle rupture

• diagnostic testing: mid-luteal serum progesterone evalulation and positive home urinary LH surge kits

what primary preventative measures and habit changes are required during preconception care?

• timeline & supplements: begin preparation 3 months prior to active attempts. Initiate daily folic acid (400-800 mcg/ 0.4-0.8 mg) to ptrvent neural tube defects (like spina bifida)

• substance cessation: immediately stop smoking, vaping, and alcohol consumption

• weight & nutrition: maintain healthy BMI (18.5-24.9) bc elevated BMI increases disease risk and fertility issues

• medical & environmental risks: manage preexisting conditions (like diabetes, HTN, thyroid disorders), review medications for fetal safety, reduce occupational exposures to toxic chemicals, ensure vaccines are up to date

what are the guideline for HPV vaccination?

recommended routinely at ages 11-12 through age 26. Ages 27-45 utilize shared clinical decision making with provider.

what are the screening guidelines for cervical cancer (pap smears)?

• start at age 21

• ages 21-29: pap test alone very 3 years

• ages 30-65: pap test combined with HPV co-testing every 5 years or pap test alone every 3 years

• age > 65: screenings discontinued if 3 consecutive negative pap tests and no high-risk history

breast cancer screening guidelines

mammography: biennial (every 2 years) starting at age 40 for average-risk patients. Individualized decision making after age 75

Breast awareness encouraged over rigid self-exams

STI screening guidelines

sexually active patients starting at age 15; annual screening for chlamydia and gonorrhea in all sexually active females < 25 years old or older high-risk patients

thyroid function screenings

evaluated in patients presenting with irregular menses, weight gain, or menopausal manifestations

hypothyroidism symptoms closely mimic menopausal symptoms

what is the mechanism for combination oral contraceptives (COCs)?

synthetic estrogen + progestin suppress FSH/LH to inhibit ovulation and thicken cervical mucus (basically body thinks its always pregnant)

• non-contraceptive benefits: decreases acne, regulates menses, reduces dysmenorrhea, and lowers risk for ovarian and endometrial cancers

what are absolute contraindications for combined oral contraceptives (COCs)?

• age > 35 years AND current smoker

• history of thromboembolic disorders (DVT, PE, stroke)

• coronary artery disease

• uncontrolled HTN

• vascular diabetes

• migraines with aura

• breast cancer

• active liver disease

what efficacy-lowering interactions are associated with combined oral contraceptives (COCs)?

• antibiotics (penicillins, tetracyclines, rifampin)

• anti-seizure drugs (carbamazepine, phenytoin, topiramate)

• St. Johns Wart

complication warnings for combined oral contraceptives?

ACHES

• A: abdominal pain

• C: chest pain/SOB

• H: headache (severe)

• E: eye changes (blurred vision)

• S: severe leg pain/swelling

progestin-only pills (“mini pill)

must be taken at the exact time every day; safe for breastfeeding mothers and those with estrogen contraindications

depo-provera injection

injected IM or SC every 11-13 weeks. Causes bone mineral density loss (instructed to take calcium + vit d), weight gain, and amenorrhea

transdermal patch

applied weekly for 3 weeks, 1 week off. Contraindicated in patients with a BMI > 30.

sub dermal implant (nexplanon)

flexible rod in upper arm releasing progestin for 3 years

hormonal IUD

thickens mucus and inhibits ovulation. Requires string check follow-up 4-6 weeks post-insertion

copper IUD

non-hormonal; damages sperm viability/motility for up to 10-12 years. Requires string check follow-up 4-6 weeks post-insertion

external & internal condoms

only methods that protect against STIs

diaphragms/cervical caps

require provider fitting and must not remian > 24-48 hours due to toxic shock syndrome risk

natural family planning

calendar method calculated fertile window (18 days before end of shortest cycle through 11 days from end of longest). Sperm survive up to 3 days in the female tract.

emergency contraception

delays/prevents ovulation; does NOT induce abortion. Most effective if taken within 72 hours (and up to 120 hour/ 5 days) post-unprotected sex. Reported vomiting within 3 hours requires repeat dose.

vasectomy

male sterilization; does not produce immediate sterility. Patents must use backup contraception until follow-up semen analysis confirms zero sperm count

medical abortion

uses mifepristone (blocks progesterone receptors) followed by misoprostol (prostaglandin inducing uterine contractions) for early gestations

procedural abortion

vacuum aspiration or dilation performed depending on gestational age

infertility

the inability to conceive after 12 months of unprotected sex (if age < 35) or 6 months (if age > 35)

semen analysis protocol

non-invasive first-line test. Patient must abstain from ejaculation for 2-7 days, avoid lubricants/salvia, and deliver sample quickly (sperm die within 1 hour outside the body)

causes of infertility

male factors: spermatogenesis defects, varioceles, hypogonadotropic hypogonadism

female factors: ovarian dysfunction, PCOS, fallopian tube obstruction from PID/chlamydia/endometriosis, uterine fibroids/polyps

ovulation induction medications

• clomiphene citrate (SERM): induces ovulations (occurs 5-9 days post-medication). Instruct patient to stop immediately and report visual disturbances

• letrozole: blocks estrogen synthesis, increasing FSH; lowers risk of multiple gestations

• bromocriptine: dopamine agonist for hyperprolactinemia; monitor for orthostatic hypotension

• gonadotropins: high efficacy but significantly increases risks for multiple gestations and Ovarian Hyperstimulation Syndrome (OHSS)

Ovarian hyperstimulation syndrome emergency symptoms?

• severe ovarian enlargement

• ascites

• pleural effusion

• hypovolemic shock

• ARDS

• renal failure

report sudden abdominal pain/swelling or dyspnea immediately

Intrauterine insemination (IUI)

washed, concentrated sperm injected 6 cm into uterus; requires at least one patent fallopian tube

in vitro fertilization (IVF)

1. Ovarian stimulation

2. ultrasound guided egg retrieval under conscious sedation 36 hrs post-hCG

3. laboratory fertilization

4. embryo transfer 3-5 days post-retrieval supported by daily progesterone

Intracytoplasmic Sperm Injection (ICIS)

single sperm injected directly into an egg via microneedle; indicated for sever male-factor infertility

GIFT

transfers unfertilized eggs + sperm into fallopian tubes (in vivo fertilization)

ZIFT

transfers in vitro fertilized zygotes into fallopian tubes

polycystic ovarian syndrome

endocrine disruption causing ovulatory dysfunction, androgen excess, and polycystic ovaries (> 20 peripheral follicles on TVUS)

signs and symptoms of PCOS

• anovulatoin/irregular menses

• histrutism

• acne

• alopecia

• obesity

• marked insulin resistance

• type 2 diabetes

• dyslipidemia

• HTN

management of PCOS

• educating on lifestyle changes (diet/exercise) to reduce long-term diabetic /cardiovascular risks

• prescribe COCs for non-pregnant patients to lower hyperandrogenism

• administer metformin to decrease hepatic glucose production, reduce insulin, and restore ovulation

endometriosis

chronic inflammatory condition where endometrial tissue grown outside the uterine cavity, responding to cyclic hormones with thickening, breakdown, and bleeding

signs and symptoms of endometriosis

• dysmenorrhea

• dyspareunia (painful intercourse)

• infertility

management of endometriosis

• NSAIDs

• COCs

• continuous progestins

• leuprolide (induces chemical menopause): diabetic patients must monitor blood sugar closely since it can cause hypoglycemia

pelvic inflammatory disease

ascending infection of the upper genital tract most commonly caused by untreated Neisseria gonorrheae or chlamydia trachomatis

signs and symptoms of pelvic inflammatory disease

• fever

• lower abdominal/pelvic pain

• dyspareunia

• abnormal uterine bleeding

• purulent discharge

• cervical motion tenderness (chandelier sign)

complications of pelvic inflammatory disease

• tubal factor infertility

• ectopic pregnancy

• chronic pelvic pain

• tubo-ovarian abcesses

management of pelvic inflammatory disease

• broad-spectrum IV parenteral antibiotics

• IUDs slightly increased PID risk only during the first 3 weeks post-insertion

cervical cancer

high-risk human papillomavirus (HPV types 16 and 18 usually). Non-HPV risk factors include smoking, low socioeconomic status, early age of first intercourse, and multiple partners

diagnostics for cervical cancer

abnormal pap cytology → colposcopy with 3%-5% acetic acid application (turns lesions white) → cervical biopsy for confirmative histology

treatment for cervical cancer

• conization/LEEP or cryotherapy for precancerous lesions

• surgical hysterectomy

• pelvic radiation

• chemotherapy

trichomoniasis

non-viral protozoal. Presents with thin, yellow-green, frothy, malodorous discharge, vulvar burning/itching, dysuria, and strawberry cervix

diagnostics for trichomoniasis

wet mount microscopy showing motile protozoa

treatment for trichomoniasis

• single oral dose of metronidazole

• must treat all sexual partners

• instruct patient to avoid alcohol during therapy due to severe disulfiram-like reaction

vulvovaginal candidiasis (yeast infection)

overgrowth of candida albicans. Presents with intense vulvar pruritus, erythema, edema, and thick, white, curdy (cottage-cheese-like) discharge with a normal vaginal pH (< 4.5)

diagnostics for vulvovaginal candidiasis

wet mount microscopy visualizing hyphae/spores

treatment for vulvovaginal candidiasis

• short-course topical intravaginal creams/suppositories

• single dose fluconazole

• Teaching: topical azole creams contain mineral oil and weaken latex condoms or diaphragms, wear loose cotton underwear, avoud douching/hoy tubs

syphilis

treponema pallidum

• primary stage: single painless ulcer (chancre) lasting 3-6 weeks

• secondary stage: rough red/brown non-pruritic rash on palms of hands and soles of feet, fever, lymphadenopathy

• latent stage: asymptomatic phase

• tertiary phase: gummas, cardiovascular syphilis, and neurosyphilis

diagnostics for syphillis

two-step serologic testing: non-treponemal screening (RPR or VDRL) confirmed by treponemal antibody test

treatment for syphillis

penecillin G benzathine IM

Human Immunodeficiency virus (HIV)

Retrovirus taregting CD4 T-lymphocytes. Acute infection (2-4 weeks post-exposure) presents as mild flu-like illness (fever, rash, lymphadenopathy)

• diagnosed via serum Ag/Ab assay

treatment for HIV

PrEP (pre-exposure prophylaxis): daily oral medication (tenofovir/emtricitabine) for uninfected high-risk patients; reduces sexual transmission risk by 99%

• monitor bone mineral density and renal function

PEP (post-exposure prophylaxis): emergence 3-drug antiretroviral regimen initiated within 72 hours of potential exposure, taken for 28 days

Perinatal HIV care

• Combination ART (zidovudine/AZT) during pregnancy

• newborn receives 6 weeks ARV therapy and must be bathed immediately before any invasive procedures to remove maternal blood