Diagnostic approaches

External warts can be diagnosed clinically with the assistance of bright light and a handheld magnifying glass. In most patients, warts have a typical appearance and are not easily confused with other skin lesions. Biopsy should be used when lesions are indurated, fixed to underlying tissue, or heavily ulcerated. Biopsy should also be considered when individual warts are greater than 1 to 2 cm, are pigmented, or respond poorly to treatment. Patient-applied immune response modifier Results...

Diabetes and Pregnancy

Pregnancies complicated with gestational diabetes have an increased risk of maternal and perinatal complications, long-term maternal morbidity, and morbidity to the offspring. The causes of perinatal morbidity are neonatal hypoglycemia, hyperbilirubinemia, hypocalcemia, polycythemia, macrosomia birth weight more than 9 lbs (or 4 kg), and with that the problem shoulder dystocia, an abnormal apgar score, and Erb's palsy. Maternal age older than 30 years Pregravid weight more than 90 kg

Operative techniques

The incision used should provide maximum exposure of the pelvis and allow thorough evaluation of the upper abdomen. If present, ascites should be aspirated and sent for cytopathologic evaluation. A small amount of heparin should be added to prevent clotting of bloody or mucoid specimens. If ascites is not present, abdominal washings with saline should be obtained from the pericolic gutters, the suprahepatic space, and the pelvis. A Pap test of the diaphragm should be taken. b. The abdominal...

Other diagnoses causing vaginal symptoms

One-third of patients with vaginal symptoms will not have laboratory evidence of bacterial vaginosis, Candida, or Trichomonas. Other causes of the vaginal symptoms include cervicitis, allergic reactions, and vulvodynia. B. Atrophic vaginitis should be considered in postmenopausal patients if the mucosa appears pale and thin and wet-mount findings are negative. 1. Oral estrogen (Premarin) 0.625 mg qd should provide relief. 2. Estradiol vaginal cream 0.01 may be effective as 2-4 g daily for...

History of present pregnancy

Estimated date of confinement (EDC) is calculated as 40 weeks from the first day of the LMP. 2. Fetal heart tones are first heard with a Doppler instrument 10-12 weeks from the LMP. 3. Quickening (maternal perception of fetal movement) occurs at about 17 weeks. 4. Uterine size before 16 weeks is an accurate measure of dates. 5. Ultrasound measurement of fetal size before 24 weeks of gestation is an accurate measure of dates. 6. Prenatal history. Medical problems during this pregnancy should be...

Medical management of postpartum hemorrhage

Oxytocin (Pitocin) is usually given routinely immediately after delivery to stimulate uterine firmness and diminish blood loss. 20 units of oxytocin in 1,000 mL of normal saline or Ringer's lactate is administered at 100 drops minute. Oxytocin should not be given as a rapid bolus injection because of the potential for circulatory collapse. 2. If uterine massage and oxytocin are not effective in correcting uterine atony, methylergonovine (Methergine) 0.2 mg can be given IM, provided there is no...

Ovarian Cancer

A woman has a 1-in-70 risk of developing ovarian cancer in her lifetime. The incidence is 1.4 per 100,000 women under age 40, increasing to approximately 45 per 100,000 for women over age 60. The median age at diagnosis is 61. A higher incidence of ovarian cancer is seen in women who have never been pregnant or who are of low parity. Women who have had either breast or colon cancer or have a family history of these cancers also are at higher risk of developing ovarian cancer. Protective factors...

Human Papilloma Virus

Infections caused by human papillomavirus (HPV) account for 5.5 million, or more than one-third, of sexually transmitted diseases. More than 100 types of HPV have been identified in humans. HPV infections can cause genital warts and various benign or malignant neoplasias, or they can be entirely asymptomatic. B. Genital warts occur on the external genitalia and perianal area and can be visible in the vagina, on the cervix, and inside the urethra and anus. External genital warts (EGWs) are...

Additional contraceptive method

The patient uses an additional contraceptive method for the first 7 days after initially starting oral contraceptive pills. The patient uses an additional contraceptive method for 7 days if she is more than 12 hours late in taking an oral contraceptive pill. The patient uses an additional contraceptive method while she is taking an interacting drug and for 7 days thereafter. Contraindications to Use of Hormonal Contraceptive Methods Active liver disease, hepatic adenoma, thrombophlebitis,...

Acute uncomplicated cystitis in young women

Sexually active young women have the highest risk for UTIs. Their propensity to develop UTIs is caused by a short urethra, delays in micturition, sexual activity, and the use of diaphragms and spermicides. B. Symptoms of cystitis include dysuria, urgency, and frequency without fever or back pain. Lower tract infections are most common in women in their childbearing years. Fever is absent. C. A microscopic bacterial count of 100 CFU mL of urine has a high positive predictive value for...

Etiology and clinical pathogenesis

PID results when pathogenic microorganisms spread from the cervix and vagina to the upper portions of the genital tract to such structures as the salpinx, ovaries, and adjacent structures. Chlamydia has been shown to be responsible for 25-50 of all cases of PID. About 10-20 of female patients who are infected with gonorrhea will progress to PID. B. Mixed infections are responsible for up to 70 of cases with PID. These polymicrobial infections typically include both anaerobic and aerobic...

Unexplained Infertility

The term unexplained infertility should be used only after a thorough infertility investigation has failed to reveal an identifiable source and the duration of infertility is 24 months or more. History, physical examination, documentation of ovulation, endometrial biopsy, semen analyses, PCT, hysterosalpingogram, and laparoscopy should have been completed. 2. Because couples with unexplained infertility lack an identifiable causative factor of their infertility, empirical treatment with...

Treatment of candida vulvovaginitis

For severe symptoms and chronic infections, a 7-day course of treatment is used, instead of a 1- or 3-day course. If vulvar involvement is present, a cream should be used instead of a suppository. 2. Most C. albicans isolates are susceptible to either clotrimazole or miconazole. An increasing number of nonalbicans Candida species are resistant to the OTC antifungal agents and require the use of prescription antifungal agents. Greater activity has been achieved using terconazole, butoconazole,...

Screening for cervical cancer

Regular Pap smears are recommended for all women who are or have been sexually active and who have a cervix. B. Testing should begin when the woman first engages in sexual intercourse. Adolescents whose sexual history is thought to be unreliable should be presumed to be sexually active at age 18. C. Pap smears should be performed at least every 1 to 3 years. Testing is usually discontinued after age 65 in women who have had regular normal screening tests. Women who have had a hysterectomy,...

Pharmacologic therapy for symptoms of menopause

A hot flush is a flushed or blushed feeling of the face, neck and upper chest. The most severe hot flushes usually occur at night. Estrogen therapy can reduce hot flushes. B. Psychologic symptoms. Mood swings, depression and concentration difficulties are associated with menopause. Estrogen improves mood or dysphoria associated with menopause. C. Urogenital symptoms. Declining estrogen levels lead to atrophy of the urogenital tissues and vaginal thinning and...

Candida Vulvovaginitis

Candida is the second most common diagnosis associated with vaginal symptoms. It is found in 25 of asymptomatic women. Fungal infections account for 33 of all vaginal infections. B. Patients with diabetes mellitus or immunosuppressive conditions such as infection with the HIV are at increased risk for candidal vaginitis. Candidal vaginitis occurs in 25-70 of women after antibiotic therapy. C. The most common symptom is pruritus. Vulvar burning and an increase or change in consistency of the...

Sexually Transmissible Infections

Approximately 12 million patients are diagnosed with a sexually transmissible infection (STI) annually in the United States. Sequel la of STIs include infertility, chronic pelvic pain, ectopic pregnancy, and other adverse pregnancy outcomes. Direct fluorescent antibody, enzyme immunoassay, DNA probe, cell culture, DNA amplification Doxycycline 100 mg PO 2 times a day for 7 days or Azithromycin (Zithromax) 1 g PO Ofloxacin (Floxin) 300 mg PO 2 times a day for 7 days or erythromycin base 500 mg...

Delivery of the head

The fetal head is delivered by extension as the flexed head passes through the vaginal introitus. b. Once the fetal head has been delivered, external rotation to the occiput transverse position occurs. c. The oropharynx and nose of the fetus are suctioned with the bulb syringe. A finger is passed into the vagina along the fetal neck to check for a nuchal cord. If one is present, it is lifted over the vertex. If this cannot be accomplished, the cord is doubly clamped and divided. d. If...

Cervical Cancer

About 12,800 women in the United States developed cancer of the uterine cervix each year, and about 4,800 women died of the disease. The incidence of cervical cancer has dramatically decreased from 32 cases per 100,000 women in the 1940s to 8.3 cases per 100,000 women in the 1980s. Women who are at risk for developing cellular abnormalities include those who smoke and those with a history of sexually transmitted diseases, human papillomavirus (HPV) infection, low socioeconomic status, two or...

Cytologic screening

All women should receive screening Pap smears at the onset of sexual activity or at 18 years of age, because strong evidence supports the theory that routine screening with Pap smears will lower the rate of cervical cancer. B. Once three normal annual Pap smears are documented, the interval for continued surveillance with screening Pap smears may be lengthened. Pap smears that suggest invasive disease require further evaluation by colposcopy, colposcopic-directed biopsy and endocervical...

Ovarian factor infertility

An ovarian factor is suggested by irregular cycles, abnormal BBT charts, midluteal phase serum progesterone levels less than 3 ng mL, or luteal phase defect documented by endometrial biopsy. Ovulatory dysfunction may be intrinsic to the ovaries or caused by thyroid, adrenal, prolactin, or central nervous system disorders. Emotional stress, changes in weight, or excessive exercise should be sought because these disorders can result in ovulatory dysfunction. Luteal phase deficiency is most often...

Atypical glandular cells of undetermined significance AGUS

One-third of those for whom the report favors reactive will actually hsve dysplasia. For this reason, colposcopy, ECC (or cytobrush), and directed biopsies are recommended. If glandular neoplasia is suspected or persistent AGUS does not correlate with ECC findings, cold-knife conization perhaps with dilatation and curettage (D& C) is indicated. D& C with hysteroscopy is the treatment of choice for AGUS endometrial cells. E. Squamous cell carcinoma should be referred to a gynecologist or...

Management of glandular cell abnormalities

When a Pap smear is performed during menstruation, endometrial cells may be present. However, endometrial cells on a Pap smear performed during the second half of the menstrual cycle or in a post-menopausal patient may indicate the presence of polyps, hyperplasia, or endometrial adenocarcinoma. An endometrial biopsy should be considered in these women. B. Atypical glandular cells of undetermined significance (AGUS) . Colposcopically directed biopsy and...

Prevention and treatment strategies

A balanced diet including 1000-1500 mg of calcium, weight bearing exercise, and avoidance of alcohol and tobacco products should be encouraged. Daily calcium supplementation (1000-1500 mg) along with 400-800 IU vitamin D should be recommended. B. Estrogen therapy is recommended for most females. Females who are not willing or incapable of receiving estrogen therapy and have osteopenic bone densities may consider alendronate and raloxifene. After the age of 65, a bone density test should be...

Clinical evaluation of premenstrual syndrome

PMS involves an assortment of disabling physical and emotional symptoms that appear during the luteal phase and resolve within the first week of the follicular phase. Symptoms of PMS fall into four main categories mood, somatic, cognitive, and behavioral. B. No specific serum marker can be used to confirm the diagnosis. Premenstrual dysphoric disorder is diagnosed when mood symptoms predominate symptoms of PMS. C. The differential diagnosis includes hypothyroidism, anemia, perimenopause,...

Physical examination for the man

Height, weight, and hair distribution, gynecomastia, palpable lymph nodes or thyromegaly should be sought. 2. The consistency, size, and position of both testicles and the presence of varicocele or abnormal location of the urethral meatus on the penis should be noted. Testing for Chlamydia, Ureaplasma, and Mycoplasma should be completed. D. The cornerstone of any infertility evaluation relies on the assessment of six basic elements (1) semen analysis, (2) sperm-cervical mucus interaction, (3)...

Other diagnostic tests

Uterine curettage is performed only when serum hormones indicate a non-viable pregnancy (progesterone < 5 ng mL or falling plateauing beta-hCG). Typically, chorionic villi are identified (by floating tissue obtained in saline) when a failed intrauterine pregnancy is present. When villi are not seen, diagnosis of completed miscarriage can still be made if the beta-hCG level falls 15 or more 8-12 hours after the procedure. When no villi are seen and beta-hCG levels do not fall, EP is highly...

Cervical factor infertility

Cervical factor infertility is suggested when well-timed PCTs are consistently abnormal in the presence of a normal semen analysis. Cervical factor infertility results from inadequate mucus production by the cervical epithelium, poor mucus quality, or the presence of antisperm antibodies. 2. Patients with an abnormal PCT should be screened for an infectious etiology. The presence of immotile sperm or sperm shaking in place and not demonstrating forward motion is suggestive of immunologically...

Psychologic problems

Depressive disorders contribute to more than half of all cases of CPP. Frequently, the pain becomes part of a cycle of pain, disability, and mood disturbance. The diagnostic criteria for depression include depressed mood, diminished interest in daily activities, weight loss or gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, feelings of worthlessness, loss of concentration, and recurrent thoughts of death. 2. Somatoform disorders, including somatization disorder,...

Gynecologic problems

Endometriosis is present in approximately one-third of women undergoing laparoscopy for CPP and is the most frequent finding in these women. Typically, endometriosis pain is a sharp or crampy pain. It starts at the onset of menses, becoming more severe and prolonged over several menstrual cycles. It is frequently accompanied by deep dyspareunia. Uterosacral ligament nodularity is highly specific for endometriosis. Examining the woman during her menstruation may make the nodularity easier to...

Medical treatment

Initial therapy also should include a nonsteroidal anti-inflammatory drug. a. Naproxen (Naprosyn) 500 mg followed by 250 mg PO tid-qid prn 250, 375,500 mg . b. Naproxen sodium (Aleve) 200 mg PO tid prn. c. Naproxen sodium (Anaprox) 550 mg, followed by 275 mg PO tid-qid prn. d. Ibuprofen (Motrin) 800 mg, then 400 mg PO q4-6h prn. e. Mefenamic acid (Ponstel) 500 mg PO followed by 250 mg q6h prn. 2. Progestational agents. Progestins are similar to combination OCPs in their effects on FSH, LH and...

Pelvic factor infertility

Pelvic factor infertility is caused by conditions that affect the fallopian tubes, peritoneum, or uterus. Tubal factor infertility is a common sequela of salpingitis. Appendicitis, ectopic pregnancy, endometriosis, and previous pelvic or abdominal surgery can also damage the fallopian tubes and cause adhesion formation. 2. Endometriosis is another condition involving the peritoneal cavity that is commonly associated with infertility. Uterine abnormalities are responsible for infertility in...

Hormone replacement therapy administration and regimens

HRT should not be a universal recommendation. The benefits and risks associated with HRT must be weighed on an individual basis. A woman with significant risk factors for osteoporosis or CHD may benefit from long-term HRT. A woman with a personal or strong family history of breast cancer may not benefit from long-term HRT. B. Hormone users have a lower risk of death (relative risk, 0.63) than nonusers. This reduction is largest in women with cardiac risk factors. The benefit decreases with...

Clinical evaluation

Endometriosis should be considered in any woman of reproductive age who has pelvic pain. The most common symptoms are dysmenorrhea, dyspareunia, and low back pain that worsens during menses. Rectal pain and painful defecation may also occur. Other causes of secondary dysmenorrhea and chronic pelvic pain (eg, upper genital tract infections, adenomyosis, adhesions) may produce similar symptoms. Differential Diagnosis of Endometriosis Musculoskeletal causes (pelvic relaxation, Gastrointestinal...

Inflammation on Pap smear

Mild inflammation on an otherwise normal smear does not need further evaluation. b. Moderate or severe inflammation should be evaluated with a saline preparation, KOH preparation, and gonorrhea and Chlamydia tests. If the source of infection is found, treatment should be provided, and a repeat Pap smear should be done every 6 to 12 months. If no etiology is found, the Pap smear should be repeated in 6 months. c. Persistent inflammation may be infrequently the only manifestation of high-grade...

Approach to acute pelvic pain with a positive pregnancy test

In a female patient of reproductive age, presenting with acute pelvic pain, the first distinction is whether the pain is pregnancy-related or non-pregnancy-related on the basis of a serum pregnancy test. B. In the patient with acute pelvic pain associated with pregnancy, the next step is localization of the tissue responsible for the hCG production. Transvaginal ultrasound should be performed to identify an intrauterine gestation. Ectopic pregnancy is characterized by a noncystic adnexal...

Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) represents a spectrum of infections and inflammatory disorders of the uterus, fallopian tubes, and adjacent pelvic structures. PID may include any combination of endometritis, salpingitis, tubo-ovarian abscess, oophoritis, and in its more extreme manifestation, pelvic peritonitis. One out of every 10 women will have at least one episode of PID during her reproductive years. At least one-quarter of women with PID will have major complications, including...

Stress urinary incontinence

SUI due to sphincter insufficiency is treated with alpha-adrenergic agonists. Phenylpropanolamine or pseudoephedrine is the first line of pharmacologic therapy for women with SUI. Side effects include anxiety, insomnia, agitation, respiratory difficulty, headache, sweating, hypertension, and cardiac arrhythmia. Use caution with arrhythmias, angina, hypertension, or hyperthyroidism. b. Estrogen replacement restores urethral tone, and alpha-adrenergic response of urethral muscles. Combined...

Approach to acute pelvic pain in nonpregnant patients with a negative HCG

Acute PID is the leading diagnostic consideration in patients with acute pelvic pain unrelated to pregnancy. The pain is usually bilateral, but may be unilateral in 10 . Cervical motion tenderness, fever, and cervical discharge are common findings. B. Acute appendicitis should be considered in all patients presenting with acute pelvic pain and a negative pregnancy test. Appendicitis is characterized by leukocytosis and a history of a few hours of periumbilical pain followed by migration of...

Management of hypothalamic dysfunction

Amenorrheic women with a normal prolactin level, a negative progesterone challenge, with low or normal gonadotropin levels, and with a normal sella turcica imaging are considered to have hypothalamic dysfunction. B. Hypothalamic amenorrhea usually results from psychologic stress, depression, severe weight loss, anorexia nervosa, or strenuous exercise. C. Hypoestrogenic women are at risk for osteoporosis and cardiovascular disease. Oral contraceptives are appropriate in young women. Women not...

Oral contraceptives

Two types of oral contraceptives are avail able in the USA combination oral contraceptives that contain both an estrogen and a progestin, and progestin-only contraceptives, or mini-pills. All oral contraceptives marketed in the USA are similarly effective in preventing pregnancy. B. Combination oral contraceptives. Monophasic oral contraceptives contain fixed doses of estrogen and progestin in each active pill. Multiphasic oral contraceptives vary the dose of one or both hormones during the...

Athome methods of overcoming dysfunction

The patient should increase self-awareness by examining her body and genitals at home. The patient should identify sensitive areas that produce pleasurable feelings. The intensity and duration of psychologic stimulation may be increased by sexual fantasy. b. If, after completing the above steps, an orgasm has not been reached, the patient may find that the use of a vibrator on or around the clitoris is effective. c. Once masturbation has resulted in orgasm, the patient should masturbate with...

Diagnosis of gestational diabetes

The diagnosis of gestational diabetes is usually accomplished early in the third trimester of pregnancy. The one-hour glucola test is the screening test for gestational diabetes. Nonfasting women are given 50 grams of glucose in a flavored solution, and their blood is taken one hour after ingestion. If the blood sugar equals or exceeds 140 mg dL, then women are asked to take a three-hour glucose tolerance test (GTT). B. For the three-hour GTT, women are advised to consume an unrestricted...

Treatment of endometrial cancer

The treatment of endometrial cancer is usually surgical, such as total abdominal hysterectomy, bilateral salpingo-oophorectomy and evaluation for metastatic disease, which may include pelvic or para-aortic lymphadenectomy, peritoneal cytologic examination and peritoneal biopsies. The extent of the surgical procedure is based on the stage of disease, which can be determined only at the time of the operation. Staging for Carcinoma of the Corpus Uteri Invasion of less than one half of the...

Urinary Incontinence

Urinary incontinence is defined as the involuntary loss of urine in amounts or with sufficient frequency to constitute a social and or health problem. The prevalence of urinary incontinence is 15 to 35 percent in community-dwelling individuals older than age 60. Urinary Incontinence Types, Signs and Symptoms, and Causes With or without urgency, usually large volume loss Involuntary detrusor contraction, isolated or with cystitis, ureteritis, stones, neoplasia Detrusor hyperreflexia (DI with...

Pathophysiology

A The etiology of breast cancer remains unknown, but two breast cancer genes hsve been cloned-the BRCA-1 and the BRCA-2 genes. Only 10 of all of the breast cancers can be explained by mutations in these genes. B. Estrogen stimulation is an important promoter of breast cancer, and, therefore, patients who have a long history of menstruation are at increased risk. Early menarche and late menopause are risk factors for breast cancer. Late age at birth of first child or nulliparity also increase...

Antepartum Urinary Tract Infection

Four to 8 of pregnant women will develop asymptomatic bacteriuria, and 13 will develop symptomatic cystitis with dysuria. Pyelonephritis develops in 25-30 of women with untreated bacteriuria. I. Asymptomatic bacteriuria is diagnosed by prenatal urine culture screening, and it is defined as a colony count 105 organisms per milliliter. Patients with symptomatic cystitis should be treated with oral antibiotics without waiting for urine culture results. A. Approximately 80 of infections are caused...

Delivery of the placenta

The placenta usually separates spontaneously from the uterine wall within 5 minutes of delivery. Gentle fundal massage and gentle traction on the cord facilitates delivery of the placenta. 2. The placenta should be examined for missing cotyledons or blind vessels. The cut end of the cord should be examined for 2 arteries and a vein. The absence of one umbilical artery suggests a congenital anomaly. 3. Prophylaxis against excessive postpartum blood loss consists of external fundal massage and...

Estrogen replacement therapy

Postmenopausal women without contraindications should consider ERT. Contraindications include a family or individual history of breast cancer estrogen dependent neoplasia undiagnosed genital bleeding or a history of or active thromboembolic disorder. 2. ERT should be initiated at the onset of menopause. Conjugated estrogens, at a dose of 0.625 mg per day, result in increases in bone density of 5 . 3. Bone density assessment at regular intervals possibly every 3-5 years provides density data...