Women's Health Issues (12)

menstrual disorders

• Amenorrhea: absence of period 

• Dysmenorrhea: very painful period 

• Premenstrual Dysphoric Disorder (PMDD)

• Endometriosis

• Uterine Fibroids

• Abnormal Uterine Bleeding (AUB) 

• Dysfunctional Uterine Bleeding (DUB)

• Polycystic Ovarian Syndrome (PCOS)

amenorrhea (primary + secondary)

absence of period

• primary: Absence of menses at age 15 years in the presence of normal growth and secondary sex characteristics

  • OR: if at 13 years old, no menses has occurred and absence of secondary sex characteristics (e.g. breast development) 

  • etiology: chromosomal/anatomical abnormalities

• secondary: Absence of menses for more than three cycles of six months in women who previously had a menses

  • Etiology

    • Pregnancy

    • Stress

    • Severe weight loss, eating disorders

    • Strenuous Exercise

    • Disorders of the hypothalamic-pituitary-ovarian-uterine axis

treatment for amenorrhea

• Identify and treat underlying cause 

• Possible hormonal management 

  • Progesterone (Provera) given to induce menses

    • 10 mL Provera PO for 10 days → withdrawal bleed after stopping Provera 

    • No withdrawal bleed = concern for possible damage to endometrium, obstructive issue, low estrogen

  • Oral Contraceptives to regulate cycle 

    • Only COMBINED oral contraceptives will regulate cycle 

  • Calcium supplement in women with history of eating disorder or exercise induced amenorrhea

primary dysmenorrhea

• Pain during or shortly before menses 

• Primary: Noticed 6-12 months after menarche (first ever period)

• Recurrent, crampy, lower abdominal pain during menses 

• Seen 6-12 months after first period

• Most often noted in women who are late teens, early 20s

• Incidence declines with age

• Absence of demonstrable disease

• Associated with ovulatory cycles

• Pain triggered with release of prostaglandins during luteal phase (uterine contractions, backache, weakness, sweating, GI symptoms, CNS symptoms)

• Pain starts with menses: May last 8-48 hours

primary dysmenorrhea treatment

• provide adequate relief of pain

  • Heat

  • Massage

  • Exercise

  • Dietary changes

    • Decrease in salt, refined sugars, and caffeine before menses

    • Increase natural diuretics – cranberry juice, peaches, watermelon

    • Decrease red meat consumption

  • Medication

    • NSAIDS - taking 3-5 days before onset of menses can help (Ibuprofen, Motrin)

    • OCPs - COMBINED oral contraceptive pill

      • Hormonal IUDS: decrease rates of dysmenorrhea 

secondary dysmenorrhea

• Begins later in life (usually after 25 years old)

• Associated with pelvic pathology/disease

  • Adenomyosis: endometrial grows into uterine muscle 

  • Endometriosis: endometrial glands outside uterine cavity

  • Pelvic Inflammatory Disease (PID): infection of upper genital tract in women (ovaries, fallopian tube, etc.)

  • Polyps: overgrowth of uterine tissue in uterus 

  • Fibroids

  • IUD

• Symptoms

  • Dull lower abdominal aching

  • Radiates to back or thighs

  • Bloating

  • Pelvic Fullness

• Onset may begin with ovulation, start of menses and during menses

secondary dysmenorrhea treatment

• treat underlying cause

  • Some treatments of primary dysmenorrhea may be helpful 

premenstrual syndrome

• One or more of the 150 physical or psychological symptoms 

• Symptoms begin in luteal phase in menstrual cycle 

• Mildly interfere with some aspects of a woman’s life

premenstrual dysphoric disorder

• Severe form of PMS in which symptoms of anger, irritability and internal tension are prominent

• Must have 5 symptoms (1 must be psychological)

• Symptoms begin in luteal phase and resolve within few days of menstrual onset 

• Symptom-free in follicular phase 

• symptoms:

  • anger

  • anxiety

  • depression

  • forgetful

  • fatigue

  • poor concentration

  • headache

  • bloating

  • sleep disturbances

Premenstrual Dysphoric Disorder (PMDD) treatment

• Lifestyle changes

  • Diet (decreasing sodium, refined sugars, alcohol, red meat)

  • Vitamins (B6, Vitamin E, calcium)

  • Exercise (release endorphins and offset negative mood)

  • Decrease tobacco, alcohol, caffeine

  • Counseling

  • Stress management 

• Medication

  • NSAIDs - before onset of menses 

  • OCPs - combined 

  • SSRIs (Prozac, Paxil, Lexopro) - do not stop abruptly 

endometriosis (+ symptoms)

• Growth of endometrial tissue outside of uterus 

• symptoms:

  • Dysmenorrhea

  • Deep Dyspareunia: painful intercourse 

  • Chronic non-cyclic pain: pain not just associated with menses (happens any time)

  • Pelvic heaviness

  • Pain radiating to thighs and rectum

  • Bowel symptoms (diarrhea, pain with bowel movement, etc.)

  • Abnormal bleeding

  • Infertility/Ectopic Pregnancies

  • Symptoms may vary and/or change over time 

endometriosis treatment

• based on severity of symptoms and childbearing intentions 

  • NSAIDS

  • OCPs

    • Can skip the placebo week (don’t need withdrawal week)

    • No withdrawal week → can help decrease endometrial tissue 

  • Hormonal (GnRH) antagonists – suppresses ovulation and reduces endogenous estrogen production

    • Ex: Lupron, Synarel, Zoladex (menopausal side effects)

    • For women who do not intend to get pregnant soon (pregnancy category X)

    • Limited to 3-6 months, and second choice for women (after OCPs)

  • Steroids – Damizol (androgenic side effects, menopausal side effects)

    • Lowers estrogen and increases androgen 

    • Can shrink endometriosis growth

    • Only really use when other hormone therapies don’t work

    • Only use for 9 months at a time 

  • Surgical intervention 

    • Laparoscopy: gold standard diagnosis 

      • Take out endometrial tissue right before getting pregnant (for someone with childbearing intention)

    • Hysterectomy

      • For women with NO childbearing intention

      • Usually not an option for women of childbearing age unless serious (e.g. cancer)

    • Removal of fallopian tubes and ovaries

      • Automatic menopause - can’t bear children 

uterine fibroids (+ symptoms)

• Benign tumors of the smooth muscle of the uterus

  • Slow growing 

  • Occur most often 50+ years, but also possible in younger ages 

• symptoms:

  • Irregular Bleeding

  • Abdominal/pelvic pressure when enlarged or near other organs 

    • Bladder

    • Colon

  • Pain - only if it becomes twisted 

  • Abdominal enlargement

uterine fibroids complications

• Premature labor 

• Spontaneous abortion

• Infertility 

• Anemia - can have very heavy bleeding 

uterine fibroids treatment

• depends on symptoms and desire for pregnancy

  • COCs

  • Hormonal IUD

  • GnRH agonists - reduce size of fibroid 

  • Fe supplement - if anemic

  • Surgery

    • Myomectomy - removes fibroid while preserving fertility 

      • May be told she needs C-secttion (scar on uterus may cause uterine rupture)

Total hysterectomy - Only for people with non-childbearnig intention

abnormal uterine bleeding

• Umbrella term for many menstrual irregularities

• Differs in quantity or timing than usual menstrual flow (ex: heavier one period and lighter the next; spotting between periods)

• Risk Factors: Any woman

dysfunctional uterine bleeding

• Related to hormones

• Most common cause – anovulation

  • Estrogen is secreted but an egg never develops.  Progesterone is not produced by the corpus luteum because the egg is never released, which allows the uterine lining to slough off

  • Can occur later in reproductive life due to lower levels or progesterone, even if an egg is developed and released

• Risk Factors

  • Under 20 and Over 40 (Beginning and end of reproductive lives = hormonal imbalance and anovulation)

  • Obesity

  • Thyroid Disorders

  • Polycystic Ovary Disease (PCOS)

dysfunctional uterine bleeding treatment

• Hormone therapy

  • OCPs - combined OCPs to regulate cycle; progesterone-only pills may make bleeding better

  • Lupron 

  • Synthroid - if due to thyroid disorder 

• IUD

• NSAIDs

• Treat cause → surgery 

polycystic ovarian syndrome (PCOS)

• One of the most common reproductive tract problems in women under 30

• Wide variety of clinical presentation

  • Irregular cycles (45-90 days)

  • Anovulatory cycles

  • Infertility

  • Hyperandrogenicity (hirtuism (hair growth on upper lip/chin), acne, alopecia)

  • Increased waist to hip ratio

  • Hyperpigmentation (neck, axillae, inguinal areas)

PCOS labs

• LH: FSH ratio (2:1) or (3:1) (normal is 1:1)

• Glucose & Insulin

• Dehydroepiandosterone sulfate (DHEAS)

• Transvaginal ultrasound - see polycystic ovaries 

• TSH

• Lipid profile 

• HCG (pregnancy test)

PCOS complications

• Metabolic syndrome → T2 Diabetes

• Infertility

• Endometrial cancer

• Ovarian cancer

• Cardiovascular disease → atherosclerosis, HTN, increased triglycerides 

PCOS treatment

• Weight loss/exercise

• Low dose, low androgenic combination of OCP to restore cyclic menses

• Insulin-sensitizing agents → metformin (PCOS is an endocrine disorder)

  • Good for women who are trying to get pregnant and can’t take OCPs

• Ovulation induction 

  • For women who are trying to get pregnant (need her to ovulate to conceive)

bacterial STIs

• Chlamydia

• Gonorrhea

• Syphilis

viral STIs

• Human Papilloma Virus (HPV)

• Herpes Simplex Virus (HSV)

• Hepatitis

• HIV

protozoa and parasitic STIs

• Protozoa

  • Trichomoniasis

• Parasites 

  • Scabies

  • Pediculosis

chlamydia S/S

• Mucopurulent discharge

• Painful intercourse

• Fever/Nausea

• BTB (breakthrough bleeding during cycle) or post coital bleeding

• Friable cervix - cervix bleeding if very little pressure applied (e.g. QTip)

• Suprapubic tenderness

• S/S of UTI

• S/S of PID

• Pain/bleeding from anus

• Oral – cough, sore throat, fever

• Or might not have any symptoms at all!

chlamydia diagnosis

• Culture (females), pap, urine (males)

chlamydia complications

• PID

• Infertility

• Cervicitis

• Reactive arthritis

• Increased risk for miscarriage and ectopic pregnancy

• Can pass to babies causing eye infections and pneumonia in newborn

gonorrhea S/S

• Cervical and vaginal discharge (Watery, creamy or slightly green)

• Break through bleeding (BTB)

• Painful intercourse

• Sore throat

• Fever, chills, low pelvic pain

• Painful urination and frequency

gonorrhea diagnosis

• Culture, pap, urine

gonorrhea complications

• Associated with other STIs

• PID

• Ectopic Pregnancy

• Infertility

• Conjunctivitis

• Tubo-ovavarian abscesses

• Pregnancy related (PROM, PTL, Chorioamnionitis)

• Neonatal Complications (ophthalmia neonatorum, pneumonia, sepsis, bone infections)

syphilis stages

• Primary: 1-12 weeks of infection

  • Small, painless open sore or ulcer (chancre) - heals by itself in 3-6 weeks

  • Enlarged lymph nodes

• Secondary: 2-8 weeks after primary stage

  • Skin rash

  • Sores in/around mouth/vagina

  • Fever

  • Loss of appetite

  • Muscle aches

  • Joint pain

  • Swollen lymph nodes

  • Vision changes

  • Hair loss 

• Latent: years after initial infection

  • No signs or symptoms

  • May last for years

  • S/S may never return or the disease may progress into tertiary stage 

• Tertiary: years later 

  • Heart aneurysm or valve disease

  • Central nervous system disorders (neurosyphilis)

  • Tumors of skin, bones, liver

syphilis diagnosis

• (+)Dark field microscopy (Primary or Secondary lesion)

• Serologic testing (Latent or late infection)

  • RPR & VDRL (Non-Treponemal Tests)-correlates with disease activity, usually decrease with treatment; may be reactive for life

  • Trepomonal (FTA-ABS, MHA-TP) used to confirm + result

• Lumbar punctures

HPV transmission

• Transmitted through skin-to-skin contact

  • Found on external and internal genitalia

  • Some types produce nasal, oral and laryngeal warts

  • Most commonly spread during vaginal or anal sex. 

  • Can be passed even when an infected person has no signs or symptoms.

  • Symptoms can develop years after you having sex with someone who is infected

• can cause cervical cancer

HPV S/S

• Painless, wart-like bumps

  • In the genital region, cervix groin, thigh, or anus. 

  • Small or large

  • Singular or coalesced (cauliflower appearance)

  • Flat, inverted, soft, pale, pink, or flesh colored

HPV diagnosis

• Pap test

• If pap test is abnormal: Colposcopy (visualizing cervix and illuminates area of lesions) and biopsy

• DNA typing 

HPV prevention

• Vaccination

  • Recommendation 11-12 years old; 2 doses 6-12 months apart

  • Those who started >15 years old will need 3 injections

  • Now protects against 9 strains of HPV-6, 11, 16, 18, 31, 33, 45, 52 and 58  (up from 4)

    • 16 & 18: cervical cancer 

    • 6 & 11: genital warts 

  • Only STI with vaccine 

Herpes Simplex Virus (HSV) - Types

• Type I: mostly oro-facial lesions (“cold sores”); resides in trigeminal ganglion

• Type II: mostly genital HSV lesions; resides in dorsal root ganglia

HSV primary outbreak

• first episode

  • Multiple painful lesions/blisters

  • Flu-like symptoms

  • Vulvar pain/swelling

  • Dysuria and retention

  • Sx. last 12-20 days

HSV secondary/recurrent outbreaks

• *Prodrome of itching, burning, tingling

• Less severe outbreaks

• Shorter than primary

• Triggered by stress, sun exposure, menses, pregnancy, trauma, HIV

• With time, outbreaks become less frequent and severe

• Infectious when prodrome begins until lesions resolve

HSV diagnosis

• Culture of lesions

• Based on symptoms 

• Only tested if they have a genital outbreak 

Hepatitis

• Hepatitis A Virus

  • Acquired primarily through fecal-oral route 

  • Ingestion of contaminated food, milk, polluted water, or shellfish

  • Influenza-like symptoms

  • Vaccination is most effective means of preventing HAV transmission

  • Rarely fatal 

  • No chronic form 

• Hepatitis B virus

  • Most threatening to fetus and neonate

  • Disease of liver; often a silent infection 

  • Transmitted parenterally, perinatally, orally (rarely), and through intimate contact 

  • Vaccination series

• Hepatitis C virus 

  • Most common blood-borne infection in United States

  • Most are asymptomatic; flu-like symptoms 

  • Responsible for 50% of cases of hepatitis

  • 2.7 million people are now chronically infected

  • Risk factor for pregnant women is history of injecting intravenous drugs

HIV + AIDs

• Infection mainly by sexual contact (anal, vaginal, oral), contaminated blood and blood products, including needle and syringe sharing, contaminated semen used for artificial insemination, intrauterine acquisition (baby of a woman with AIDS), breast milk

• Heterosexual transmission now most common means of transmission in women

HIV S/S

• Fever

• Headache

• night sweats

• Malaise

• generalized lymphadenopathy

• Myalgias

• nausea, diarrhea, weight loss

• sore throat

• Rash

HIV screening/diagnosis

• Antibody testing

• Routine voluntary testing

scabies (+ symptoms and diagnosis)

• adult female burrows into the outer layer of the skin

  • Feeds and lays eggs

  • Eggs hatch in 3-4 days (nymphs burrow into the skin and feed – major cause of itching)

• The majority of mites are found in skin folds

  • Between the fingers, on the sides of the feet, on the wrists and genitals, and in the bends of elbows and knees

• Scabies mites are readily transmitted within families and within institutions

  • Personal contact most infectious

• symptoms: itching

• diagnosis: visualization of burrows

trichomoniasis (+ diagnosis and symptoms)

• Considered the most common curable STD

• symptoms: Diffuse, malodorous, yellow-green discharge with vulvar irritation, friable cervix, “strawberry cervix”

• diagnosis: Microscopy of vaginal secretions

• Swab or pap 

• Need to visualize trichomonias

pediculosis (+ diagnosis)

• State of being infested with lice that may be found on the skin, particularly the hairy areas (scalp, pubis,) and causes intense pruritis

• Usually transmitted through close contact, usually sexual

• “Crab louse” or “pubic louse” inhabits the genital area but may colonize to other areas including axillae, eyelashes, head hair 

• diagnosis: locating nits or adult lice on hair shaft

bacterial vaginosis

• vaginal infection (vaginitis)

• Not considered STI, but can be sexually associated

  • Women who engage in intercourse are more likely to get bacterial vaginosis 

• Most common form of vaginitis in women of reproductive age

• pH of vagina becomes alkaline: normal bicarb producing lactobacilli is replaced with anaerobic bacteria

S/S of bacterial vaginosis

• Malodor (especially post-coitus) - fishy smell

• Abnormal vaginal discharge (thin, white-gray, profuse)

• 50% do not report symptoms

diagnosis of bacterial vaginosis

• pH > 4.5 (normal pH is 3.8-4.2)

• (+) Amine Test - “Whiff test”

  • Put KOH on the swab and take a whiff - if it smells like fish, it’s positive

• (+) Clue cells (on microscope)

treatment of bacterial vaginosis

• Don’t necessarily need to treat if she isn’t bothered by it

• Always treated in pregnancy! (can → preterm labor)

• Intravaginal

  • Metronidazole gel 0.75%, one full applicator (5 g), QD x  5 days, OR

  • Clindamycin cream 2%, one full applicator (5 g) QHS x 7 days, OR

  • Clindamycin ovules 100 g QHS x3 days.

• Oral

  • *Metronidazole 500 mg PO BID x 7 days, OR (no alcohol!)

  • Tinidazole 2 g PO x2 days, OR

  • Clindamycin 300 mg PO BID x 7 day

candida

• Yeast-like fungal infection of the vagina that results from change in vaginal flora

  • Not a STI, but can be transmitted between partners

• vaginitis

• Predisposing Factors

  • Pregnancy

  • antibiotics

  • Diabetes, high carbohydrate intake

  • HIV infection

  • poor hygiene

  • hypersensitivity/allergen 

S/S of candida

• Vulvar pruritus - itching!

• Vaginal discharge

• Burning, irritation, soreness

• Dyspareunia - painful intercourse 

• Dysuria 

diagnosis of candida

• pH testing 3.8-4.2 - pH will be normal 

• Negative amine test “the Whiff Test”

• Positive KOH – presence of hyphae and yeast building - diagnosis 

• Culture-differentiates types

t

treatment of candida

• Diagnosed by health care provider

• Intravaginal Gyne-Lotrimin, Monistat, Terconazole

• Oral Diflucan PO x 1 (fluconazole) - caution medication reactions

pelvic inflammatory disease (PID)

• Most commonly involves fallopian tubes, uterus

• Uncreated C. trachomatis (Chlamydia) most common cause!!

• Can be acute, subacute or chronic

• Single most frequent serious infection encountered by women

• Results from ascending spread of microorganisms from vagina and endocervix to upper genital tract

• INCREASE RISK FOR

  • Ectopic pregnancy

  • Infertility

  • Chronic pelvic pain

pelvic inflammatory disease exams and treatment

• Exams:

  • Lower abdominal pain

  • Pain when moving cervix: positive cervical motion tenderness (CMT)

    • Typically no pain when slightly moving cervix 

  • pain/bleeding with intercourse 

• Treat: cephalosporin and doxycycline for 14 days 

Zika virus (+ symptoms, transmission, treatment)

• Arthropod-borne flavivirus 

• Related to other flaviviruses including yellow fever, West Nile, dengue

• Outbreaks in the Americas, the Caribbean, and the Pacific

• Symptoms: low grade fever with maculopapular rash, arthralgia, conjunctivitis 

• Transmission

  • mosquito carrying the virus

  • semen

• Associated with neurologic complications; these include congenital microcephaly and other congenital problems among babies born to women infected during pregnancy, Guillain-Barre syndrome, myelitis, and meningoencephalitis

• CDC advises pregnant women to avoid travel to areas below 6500 feet where mosquito transmission of Zika virus is ongoing.

• Treatment: No specific treatment 

fibrocystic breast changes (+ symptoms)

• Lumpiness with or without tenderness in both breasts 

• Symptoms

  • Single or multiple

  • Firm, well defined, mobile

  • Most upper outer quadrant and axillary tail

  • ⭑ Bilateral

  • Dull heavy pain

  • Feeling of fullness

  • Tenderness

  • ⭑ Begin 1 weeks before menses

  • ⭑ End 1 week after menses ends

  • (changes occur in changes in hormones)

fibrocystic breast changes diagnosis

• Breast ultrasound (<35) - younger women have less dense breasts 

• Mammogram (>35)

• Fine needle aspiration (FNA)

• Excision and biopsy

Fibrocystic Breast Changes treatment

• Analgesics

• Heat application

• Vitamin E supplements

• Diuretics

• Avoid caffeine, tea, cola, chocolate

• Supportive bra

• OCPs

fibroadenoma

• Most common benign breast condition

• Ages 15-25 years-old most common

  • Discrete, single unilateral mass

  • Usually non-tender

  • Round to lobular

  • Typically no change with menses

  • Increase in size with pregnancy; decrease with age

fibroadenoma diagnosis + treatment

• Diagnosis

  • Ultrasound

  • Mammogram

  • biopsy

• Treatment

  • Observation if young

  • Possible surgical removal (suspicious lump or severe symptoms)

nipple discharge

• Physiologic, Endocrine, Malignancy

• Galactorrhea - normal in pregnancy, but abnormal if not pregnant 

  • Elevated prolactin level – caused by thyroid, pituitary, surgery, trauma

  • Prolactin: measure at 8 or 10 in the morning (do not do after any breast manipulation - e.g. breast exams, intercourse, etc.)

• Spontaneous, bloody discharge is especially concerning 

mammary duct ectasia

• Dilated ducts in nipple inversions 

• Ducts fill with secretions and fill with bacteria - mimic mastitis (e.g. greenish nipple discharge, pain, etc.)

• Inflammation of duct behind nipple

• Disorder of peri or postmenopausal aged women

• Mimics mastitis 

• Diagnosis: Mammogram, fluid culture

• Treatment: Heat therapy, local excision

breast cancer risk factors

• Obesity

• Lack of physical exercise

• Alcohol

• HRT during menopause

• Early age at first menstruation

• Having children late or not at all 

signs of breast cancer

• Lump in breast

• Change in breast shape

• Dimpling of the skin

• Fluid from the nipple

• Red, scaly patches of skin

management of breast cancer

• Lumpectomy - removal of small part of breast (tumor)

• Simple (Total) mastectomy - entire breast but not all lymph nodes 

• Modified radical mastectomy - entire breast AND axillary lymph nodes 

• Radical mastectomy - everything (breast, muscle, lymph nodes, etc.)

• Radiation

• Chemotherapy

• Hormonal therapy - Tamoxifen (lowers chances of cancer coming back)

• Breast reconstruction - plastic surgery

UTI risk factors

• Sexual activity 

• Diaphragm use 

• Known structural abnormality/stone

• Immunosuppression

• Pregnancy

• Sickle cell trait/disease

UTI S/S

• Dependent on location of infection

  • Urethritis - urethra 

  • Cystitis - bladder 

  • Pyelonephritis - kidneys 

UTI diagnosis

• Urine microscopy

• Urine Analysis (blood, nitrites, leukocytes)

  • Send to lab to see if it’s resistant or sensitive to (antibiotics)

• Cystoscopy

• Imaging/X-Ray

UTI patient teaching

• Finish all medication

• OTC pain medication do not cure UTIs 

• Pregnant women may have asymptomatic bacteria (need treatment)

• Teach proper hygiene and prevention measures (front to back)

climcateric/peri menopause

• Transitional period

• Ovarian function and hormone production decline

• May span 10-15 years

• Irregular menses and symptoms (e.g. hot flashes)

• After reproductive years but before cessation of menses

menopause

• ⭑ One full year without menses

• Average age 51.4 (35-60)

menopause physical + psychological changes

Physical:

• Alteration in menstrual pattern

• Vasomotor instability (hot flashes, night sweats)

• Urogenital atrophy due to loss of estrogen

• Skin changes

• Thinning of skin, decrease in scalp, pubic, and axillary hair

• Increased bone loss-osteoporosis

Psychological:

• changes in mood

• libido changes

• insomnia

menopause patient teaching

• Nutrition

• Aerobic and weight-bearing exercise

• Contraception - until 12 months period-free

• Routine health assessment and screening - pap smears, mammograms

• Sexual health - STIs, intercourse, lubrication, vaginal moisurizers, etc.

• ? Hormone Replacement Therapy (HRT) - estrogen and progesterone

  • Can help with symptoms of menopause, but it can increase risk of heart disease

  • Low-dose, not on it forever 

• Calcium and Vitamin D 

infertility (+ primary and secondary)

• Inability of a couple of reproductive age to conceive after 12 MONTHS or more of regular coitus without using contraception if under the age of 35

  • Over 35: no conception in six months 

• Primary: never able to conceive

• Secondary: inability to conceive after previously being pregnant

causes of infertility

female: anovulation, anatomic defects of female reproductive tract

male: abnormal spermatogenesis (abnormal count, morphology, motility, volume)

elements of infertility evaluation

• Semen analysis

• Ovulation

• Tubal Patency

• Uterine abnormalities 

• Peritoneal abnormalities

• Hormonal Panels - thyroid, prolactin, progesterone in second half menstrual cycle

semen analysis (infertility)

examine:

• Appearance (one head, one tail)

• Count

• Morphology

• Forward progression

ovulation assessment (infertility)

• basal body temperature (temperature rise of 0.4 × 3 days = ovulation)

• detecting LH in urine (ovulation 24-36 hours after LH surge)

• mid luteal phase progesterone concentration

  • 7 days after ovulation

assessment of tubal latency hysterosalpingography (HSG)

• X ray study of internal female genital tract

  • Depicts tract’s architecture and integrity

  • Outlines uterine cavity, fallopian tubes, and peritoneal cavity

• Injection of radiopaque dye through cervix - see how it flows through fallopian tubes

• Performed 2-5 days after menses

  • Decreases risk of retrograde menstruation and disruption of ovum transport, fertilization, and implantation

treatment of infertility: correction of anovulation or poor ovulation (S/S and treatment)

• S/S

  • Irregular cycles

  • Abnormal BBT

  • Mid-luteal phase serum progesterone <3 ng/ml 

  • Thyroid, adrenal, prolactin, of CNS system disorders

  • Emotional stress, changes in weight, exercise

• Treatment 

  • ⭑ Clomiphene citrate (Clomid)

    • 50 mg/day x 5 days (day 5)  - days 1-5 of cycle 

    • Ovulation should occur 7-10 days after completing medication 

    • Increased 50 mg next cycle if unsuccessful

    • Max dose 150 mg/day

    • D/C after 6th cycle

    • Tricks body into thinking progesterone (?) is low → pituitary gland creates more FSH and LH → create LH surge and ovulation 

treatment of infertility: anatomic abnormalities

• Impacts fallopian tubes, peritoneum, or uterus

  • Infertility caused by PID, appendicitis, ectopic pregnancy, endometriosis, previous pelvic or  abdominal surgery

  • Uterine abnormalities: congenital deformities and fibroids

• Treatment

  • Laparoscopy and HSG

  • Tubal reconstruction, lysis of adhesions, ablation of endometriosis

treatment of infertility: inadequate spermatogenesis

• Eliminate alterations in thermoregulation

• Intercourse every other day during fertile period

• If no improvement, artificial insemination using donor sperm or assisted reproduction