unit 5

Menstrual Cycling and Puberty

  • Puberty
      - Starts before menarche.
      - Signs of Puberty:
        - Increasing height and weight.
        - Widening of hips.
        - Growth of breasts (thelarche).
        - Development of pubic and axillary hair.
        - Change in body odor.
        - Development of acne.
      - Key Points:
        - There is a minimum BMI required for the onset of puberty.
        - Environmental factors (e.g., nutrition, exposure to endocrine-disrupting chemicals) may influence the onset of puberty.
        - Menarche typically occurs 2-3 years after thelarche.
        - Guidance should be provided regarding good hygiene practices.
        - Menarche begins around ages 12-13 in well-developed countries.

Education on Menstrual Cycling

  • Menstrual Cycle:
      - Normal cycles range from 21-45 days.
      - Periods usually last 2-7 days.
      - Menstrual products (pads or tampons) should be changed every 4-8 hours.
      - Irregular cycles in the first 1-2 years following menarche are common.

  • Toxic Shock Syndrome:
      - A bacterial infection that arises from leaving menstrual products in for too long.
      - Complications may include shock, sepsis, and organ failure.

Problems with Menstruation

  • Possible Issues:
      - No bleeding.
      - Irregular bleeding.
      - Heavy bleeding.
      - Pain associated with bleeding.

  • Amenorrhea:
      - Definition: Absence of menstrual flow, affects 1 in 25 females.
      - Types:
        - Primary Amenorrhea:
          - Never had a period or no period by age 16.
          - Potential issues with the HPO axis (Hypothalamic-Pituitary-Ovarian axis).
          - Testing: Requires blood work and ultrasound.
          - Treatment: May include exogenous hormones or surgery.
        - Secondary Amenorrhea:
          - Occurs after menstruation has begun.
          - Common causes include ovarian dysfunction, thyroid dysfunction, excessive exercise, or eating disorders.
          - Treatment: Address the root cause.

  • Abnormal Uterine Bleeding (AUB):
      - Characterized by unpredictable timing and variability in menstrual flow amounts.
      - Anovulation: Egg not released leading to abnormal cycles.
      - Associated factors include illnesses affecting the HPO axis, eating disorders, and mental stress.

  • Menorrhagia:
      - Defined as heavy menstrual bleeding.
      - Anemia can develop if blood loss exceeds 80 mL/cycle (normal being 30 mL).
      - Signs include needing to change menstrual products every 1-2 hours or experiencing prolonged bleeding lasting over 7 days.
      - Causation Factors:
        - Structural dysfunctions leading to excessive surface area or lining buildup.
        - Coagulopathy, hepatic failure, or malignancy could also contribute.
        - Menorrhagia may be a side effect of some medications.

  • Dysmenorrhea:
      - Definition: Pain around menstruation.
      - Types:
        - Primary Dysmenorrhea: Caused by excess prostaglandins appearing at menarche.
        - Secondary Dysmenorrhea: Pain occurring after menarche, potentially caused by conditions such as Crohn’s disease or urinary disorders.
      - Diagnosis: Typically involves lab testing and ultrasound.
      - Management:
        - NSAIDs to reduce prostaglandin production.
        - Oral contraceptive pills (OCPs).
        - Surgery in severe cases.

  • Premenstrual Syndrome (PMS):
      - Definition: A constellation of physical, psychological, and/or behavioral symptoms cyclically appearing up to five days before menses and resolving within four days after onset.
      - Causative Factors: May include depression, anxiety, chronic fatigue syndrome, Irritable Bowel Syndrome (IBS), and thyroid dysfunction.
      - Diagnosis: Achieved through lab tests and menstrual cycle charting.
      - Management: Involves lifestyle changes (diet, exercise, stress reduction) and potential pharmaceuticals (including herbal supplements or OCPs).

  • Premenstrual Dysphoric Disorder (PMDD):
      - A severe variant of PMS that negatively impacts work and personal relationships.

Cessation of Menses

  • Climacteric:
      - The transitional phase marked by a decline in ovarian function and hormone production.

  • Menopause:
      - Defined as the final menstrual period, marking a point of 12 consecutive months without menstruation.

  • Perimenopause:
      - The time preceding menopause, lasting approximately four years.

  • Surgical Menopause:
      - Resulting from the surgical removal of the ovaries.

  • Perimenopausal Complaints:
      - Symptoms include hot flashes, excessive sweating, palpitations, vaginal dryness, sexual dysfunction, mood swings, and sleep disturbances.
      - Inquiries into how routine activities are affected by these symptoms can shed light on their significance.

  • Issues During Perimenopause:
      - While ovulation can still occur and there may be periodic hormone fluctuations, this can lead to:
        - Unintended pregnancy.
        - Deterioration in quality of life.
        - Increased risk for cardiovascular issues (myocardial infarctions and strokes).
        - Osteoporosis risk.

  • Treatment for Perimenopausal Complaints:
      - Hormone Replacement Therapy: Administering estrogen or progestin, keeping in mind that breakthrough bleeding can raise the risk of endometrial cancer.
      - Various antidepressants (to help manage hot flashes).
      - Other medications like Gabapentin or Clonidine can treat hot flashes and sleep disturbances.

Sexually Transmitted Infections (STIs) & Infertility Management

  • Contributing Factors to STIs:
      - Behavioral risks include early sexual initiation, multiple partners, substance abuse, and the exchange of sex for goods or services.
      - Counseling Strategies: Confirm partner’s STI status before intimacy, promote monogamous relationships, and ensure both partners undergo treatment with abstinence until confirmation of cure.
      - Safer Sex Practices: Contraceptive methods that prevent STI transmission, as well as adherence to serial monogamy.

  • Assessment & Treatment Plan for STIs:
      - Initial assessment includes a thorough history, physical exam, and laboratory testing for confirmation of diagnosis.
      - Management involves initial treatment, confirmation of cure, and patient education on safe sex practices.

  • Specific STIs:
      - Trichomoniasis:
        - Signs/Symptoms: Green discharge, pruritus, cervicitis.
        - Potential complications include ascending infections leading to UTIs and preterm labor during pregnancy.
        - Diagnosis: Microscopic evaluation, KOH testing.
        - Treatment: Metronidazole.
        - Follow-Up: Test of Cure.

      - Chlamydia:
        - Typically asymptomatic; may present with discharge from the cervix or symptoms of dysuria and frequency from the urethra.
        - Potential complications include ascending infections leading to Pelvic Inflammatory Disease (PID) and conjunctivitis or pneumonia in infants.
        - Diagnosis: Culture of discharge or infected tissue.
        - Treatment: Azithromycin or Doxycycline.
        - Follow-Up: Test of Cure.

      - Gonorrhea:
        - Involves cervix infection that mimics bladder infections, with complaints of vaginal discharge, irregular bleeding, sore throat, and rectal bleeding/pain.
        - Potential complications include ascending infections that lead to PID and transmission during childbirth possibly leading to blindness and sepsis.
        - Diagnosis: Culture of discharge or urinalysis.
        - Treatment: Ceftriaxone (IM).
        - Follow-Up: Test of Cure.

  • Pelvic Inflammatory Disease (PID):
      - Involves infection of uterus, fallopian tubes, and ovaries.
      - Symptoms include fever, malaise, pelvic pain, cervical motion tenderness, and vaginal discharge.
      - Can be a result of ascending chlamydia and gonorrhea infections leading to tubal scarring.
      - Diagnosis: Culture of vaginal discharge.
      - Treatment: Outpatient regimen of oral antibiotics, or inpatient IV antibiotics.
      - Follow-Up: Test of Cure

  • Syphilis:
      - Stages of Syphilis:
        - Primary: Characterized by a painless chancre.
        - Secondary: Skin rashes on palms and soles, fever, swollen lymph nodes.
        - Tertiary: Can cause organ damage.
        - Latent: Symptoms disappear, but the bacteria remain in the body.
        - Pregnancy Complications: Congenital syphilis can result in stillbirth, developmental delays, seizures, and newborn death.
      - Diagnosis: RPR testing followed by treponema-specific antibody testing.
      - Treatment: Penicillin (IM).
      - Follow-Up: Test of Cure.

  • Herpes Simplex Virus (HSV):
      - Types: HSV-1 or HSV-2.
      - Signs/Symptoms: Vesicles that blister & ulcerate, fever, chills, dysuria.
      - Can recur with prodromal symptoms (tingling, pain).
      - Pregnancy Complications: Lesion exposure can lead to blindness, seizures, and motor delay in neonates.
      - Diagnosis: Culture of lesions, antibody testing.
      - Treatment: Anti-viral medications and suppression therapy during pregnancy.

  • Human Papillomavirus (HPV):
      - Presentation: Painless growths that may become warts; associated with cervical cancer risk.
      - Diagnosis: Visual inspection, HPV testing on a Pap smear.
      - Treatment: Anti-viral medications or removal; frequent screening recommended for high-risk types to prevent cervical cancer.

Impact of STIs and Pregnancy

  • Pregnancy Effects of STIs:
      - Miscarriage, preterm premature rupture of membranes (PROM), preterm labor, dystocia, and postpartum infections.
  • Fetal/Neonatal Effects of STIs:
      - Risks include stillbirth, systemic infections, congenital infections, or pneumonia.

Infertility

  • Egg Cryopreservation:
      - Used to delay childbirth for various reasons such as cancer treatment or personal choice.

  • Types of Infertility:
      - Primary Infertility: Includes conditions resulting in amenorrhea, PCOS, genetic factors, and tubal disease.
      - Secondary Infertility: Occurs when previous pregnancies were achieved, linked to male factors, tubal factors, aging, endometriosis, and more.

  • Preliminary Testing for Infertility:
      - Semen analysis.
      - Hysterosalpingogram.
      - Laboratory tests including TSH, AMH, OB panel.
      - Ultrasound.
      - Genetic testing.
      - Comprehensive medical history and physical exam.

  • Fertility Medications:
      - Clomid/Letrozole:
        - Induces ovulation; side effects include potential for twins (7-10% chance), hot flashes, and nausea.
        - Starting dose for Clomid: 50 mg, Letrozole: 2.5 mg.
        - Monitoring via ultrasound for follicle maturation or measuring serum progesterone levels.
      - Gonadotropins:
        - Stimulate ovaries/testes; can lead to ovarian hyperstimulation syndrome (OHSS if too many eggs develop).
        - Require ultrasound monitoring for follicular development.
        - Consider options for IUI or IVF.

  • Intrauterine Insemination (IUI):
      - Aims to increase the number of sperm that reach the fallopian tubes, ideal for unexplained infertility or mild male factor issues.

  • Use of Donor Products: Includes sperm or eggs from donors, subject to testing of health history and STIs, including psychological evaluations if necessary.

  • Gestational Carrier options available for surrogacy.

Contraception Methods

  • Considerations for Choosing Contraception:
      - Health status, future fertility plans, risk of STIs, failure rates, financial resources, and societal issues.

  • Benefits of Contraception: Prevent complications arising from pregnancies, both physical and emotional.

  • Risks of Contraception: Some methods may be contraindicated for certain medical conditions, necessitating discussions in cases of partner abuse.

  • Fertility Awareness Methods:
      1. Periodic abstinence during ovulation.
      2. Calendar tracking of cycle lengths.
      3. Ovulation signs tracking (BBT or home predictor tests for LH).
      - Failure Rate: Approximately 24% due to user errors or cycle variability.

  • Coitus Interruptus (Withdrawal Method):
      - Failure Rate: Estimated 22% due to semen in pre-ejaculate.

  • Barrier/Device Methods:
      - Mechanical/Chemical methods prevent sperm from fertilizing an egg.
      - Benefits: Greater user control, but can require negotiation with partners.

  • Types of Barrier Methods:
      1. Spermicide: Chemical that kills or disables sperm; effectiveness is short-lived.
      2. Cervical Cap: Blocks sperm; higher failure rates.
      3. Diaphragm: Must be fitted; requires spermicide for effectiveness.
      4. External Condom: Must avoid oil-based lubricants that break down the condom material.
      5. Internal Condom: High failure rate but protects against STIs; requires water-based lubricants only.

  • Hormonal Medication Methods:
      - Mimic natural cycles while preventing ovulation. Can help regulated bleeding patterns.
      - Examples:
        1. Combination Pills (Estrogen & Progestin).
        2. Patch (monthly).
        3. Ring (monthly).
        4. Depo-Provera (injection every 3 months).
        5. Nexplanon (progestin-only implant).
      - Failure Rates: Depend on adherence to schedules for each method; progestin-only requires strict timing to avoid triggering ovulation.

  • Estrogen-related Stroke Risk:
      - Estrogen can heighten clot or stroke risks depending on medical conditions; contraindicated in cases of hypertension, clotting disorders, or smoking.
      - Warning Signs for Stroke:
        - ACHES: Abdominal pain, Chest pain, Headaches, Eye problems, Severe leg pain.

  • Long-Acting Reversible Contraception:
      - Intrauterine Devices (IUDs):
        - Options include Paraguard (copper, non-hormonal) and Mirena/Kyleena/Liletta (progestin-only). 99% effective but no STI protection.

  • Permanent Sterilization:
      1. Tubal Ligation: Ties off the fallopian tubes to prevent eggs from meeting sperm.
      2. Salpingectomy: Complete or partial removal of fallopian tubes; can be performed during C-sections.
      3. Vasectomy: Sealing of the vas deferens; post-operative sperm count confirmation essential to exclude pregnancy.

  • Special Circumstances:
      - Lactational Amenorrhea Method: Prolactin from breastfeeding suppresses ovulation for up to six months post-birth.

  • Future Trends in Contraception:
      - Lower dose combined oral contraceptives, biodegradable implants, injectable male contraceptives, and male pills that target sperm production or vas deferens muscles.

  • Emergency Contraception:
      - Must be utilized within 72-120 hours after unprotected intercourse.
      - Options include:
        1. 1.5 mg levonorgestrel (available over-the-counter).
        2. 30 mg Ulipristal acetate (prescription).
        3. Combined standard oral contraceptive pills (prescription).
        4. Insertion of copper IUD (prescription).

  • Selective Estrogen Receptor Modulators (SERMs):
      - Used to treat hot flashes and dyspareunia (pain during sexual intercourse).

  • Herbal Supplements or Bioidentical Hormones:
      - Can stimulate estrogen receptors to alleviate menopausal symptoms.