● Dysmenorrhea
○ painful menstruation
■ attributed to prostaglandin activity
■ increased leukotriene levels
○ one of the most common complaints
○ pain prevents normal activity and requires medication
○ 3 types of dysmenorrhea:
■ primary (no organic cause)
■ secondary (pathologic cause)
● endometriosis, adenomyosis, pelvic inflammatory disease, cervical stenosis, fibroids, and
endometrial polyps
■ membranous (cast of endometrial cavity shed as a single entity
● rare; it causes intense cramping pain due to passage of a cast of the endometrium
through an undilated cervix
○ Clinical Findings
■ almost always is associated with ovulatory cycles, it does not usually occur at menarche but
rather later in adolescence
■ 14–26% of adolescents miss school or work
■ pain occurs on the first day of the menses - about the time the flow begins
● may not be present until the second day.
■ Nausea
■ Vomiting
■ Diarrhea
■ Headache
■ No significant pelvic disease
■ When symptomatic - generalized pelvic tenderness, perhaps more so in the area of the uterus
than in the adnexa.
■ Occasionally, ultrasonography or laparoscopy is necessary to rule out pelvic abnormalities such
as endometriosis, pelvic inflammatory disease, or an accident in an ovarian cyst.
○ Treatment
■ continuous heat to the abdomen in addition to NSAIDs decreases pain significantly
● Ibuprofen and Naproxen are prefered - First Line
■ Severe Pain
● Codeine or stronger pain medications
● cyclooxygenase-2 (COX-2)
○ Rofecoxib, valdecoxib, and lumiracoxib are effective for treating primary
dysmenorrhea
■ must be used at the earliest onset of symptoms, usually at the onset of, and sometimes 1–2 days
prior to, bleeding or cramping
■ Cyclic administration of oral contraceptives, usually in the lowest dosage but occasionally with
increased estrogen, prevents pain in most patients who do not obtain relief from
antiprostaglandins or cannot tolerate them
● given for 6–12 months. Many women continue to be free of pain after treatment has been
discontinued
● Cystocele aka Anterior Vaginal Prolapse
○ vaginal wall weakens and stretches and allows the bladder to bulge into the vagina
○ Causes-
■ childbirth
■ chronic constipation
■ violent coughing
■ heavy lifting
■ Overweight
■ Age
■ hysterectomy (increased vag weakness)
, ○ Sx
■ felling of fullness or pressure in vagina
■ increased discomfort when you strain/cough/bear down
■ feeling of incomplete empty
■ repeated bladder infection
■ pain or urinary leak during sex
■ bulge of tissue into vaginal opening
○ Prevention
■ Kegels
■ prevent constipation
■ avoid heavy lifting
■ avoid wt gain
● Rectocele aka Posterior Vaginal Prolapse
○ When thin tissue of vagina separates the vaginal and rectum allowing vaginal wall to bulge
○ Sx
■ soft bulge of tissue in vaginal
■ difficult BM
■ sensation of rectal pressure
■ incomplete emptying after BM
■ sexual concerns-dyspareunia
○ Causes
■ constipation/strain
■ chronic cough
■ heavy lifting
■ Overweight
■ Childbirth
■ age
○ Prevention
■ Kegels
■ prevent constipation
■ avoid heavy lifting
■ Cough
■ avoid wt gain
● Uterine prolapse aka Apical Prolapse
○ pelvic floor muscles and ligaments stretch and weaken and no longer provide support for uterus and
protrude into vagina.
○ Causes
■ Pregnancy
■ large baby delivery
■ lower estrogen level after menopause
■ obesity
■ Common in postmenopausal and one or more childbirth
○ Sx
■ heaviness or pulling into pelvis
■ tissue protruding from vagina
■ urinary probs (leakage, retention)
■ trouble having BM
■ feeling of sitting on small ball
■ sexual concerns
○ Prevention
■ Kegels
■ treat constipation
■ correct lifting
■ avoid wt gain
, ○ Tx
■ pessary
● STDs
○ Chlamydia Trachomatis
■ Reportable
■ Most infections are asymptomatic
■ 25+ yoa most prevalent
■ Most common STD in USA
■ Annual screening of all sexually active women < 25 as is screening in older women at increased
risk for infection (new sexual partner, more than 1 partner, sexual partner with STI)
■ Sites of infection
● Females: Cervicitis, endometritis, salpingitis, PID
● Males: epididymitis, prostatitis
● Both genders: urethritis, pharyngitis, proctitis
■ Complications:
● PID
● tubal scarring
● ectopic pregnancy
● Infertility
● Reiter’s Syndrome
● Fits-Hugh-Curtis Syndrome
■ Labs
● NAATs- gold standard
● negative whiff w/ mucopurulent d/c and + clue cells
■ Treatment:
● Azithromycin 1g PO single dose OR
● Doxycycline 100mg BID PO x 7d
● Treat partner too.
● Abstain from sex for 7 days after tx.
● Can tx partner without seeing partner in most states
● Pregnant women
○ Do test of cure 3 weeks after tx then again within 3 months
○ Azithromycin 1g PO single dose OR
○ Amoxicillin 500mg TID x 7d.
● Complicated Infections (PID)
○ Rocephin 250 mg IM x 1 dose plus Doxycycline PO BID x 14d with or without
Metronidazole PO BID x 14d.
○ Syphilis
■ chronic, systemic disease caused by a sphirochete transmitted via contact with infectious moist
lesion.
■ Sexually acquired or vertically transmitted from infected mom.
■ Reportable disease
■ Prevention
● Condom
● wash w/ soap and water after sex
● screen ppl @ high risk (men that have sex with men, drug trafficers, correctional facilities)
■ Screen for syphilis if HIV infection, MSM, presence of genital ulcer, previous STD, pregnancy,
intravenous drug use, or high risk.
■ Primary:
● Painless chancre (heals in 6-9 wks if not tx)
● Chancre has clean base, well demarcated with indurated margins
○ Women can have on cervix or inside vagina.
○ Any mucus membrane
■ Secondary:
○ painful menstruation
■ attributed to prostaglandin activity
■ increased leukotriene levels
○ one of the most common complaints
○ pain prevents normal activity and requires medication
○ 3 types of dysmenorrhea:
■ primary (no organic cause)
■ secondary (pathologic cause)
● endometriosis, adenomyosis, pelvic inflammatory disease, cervical stenosis, fibroids, and
endometrial polyps
■ membranous (cast of endometrial cavity shed as a single entity
● rare; it causes intense cramping pain due to passage of a cast of the endometrium
through an undilated cervix
○ Clinical Findings
■ almost always is associated with ovulatory cycles, it does not usually occur at menarche but
rather later in adolescence
■ 14–26% of adolescents miss school or work
■ pain occurs on the first day of the menses - about the time the flow begins
● may not be present until the second day.
■ Nausea
■ Vomiting
■ Diarrhea
■ Headache
■ No significant pelvic disease
■ When symptomatic - generalized pelvic tenderness, perhaps more so in the area of the uterus
than in the adnexa.
■ Occasionally, ultrasonography or laparoscopy is necessary to rule out pelvic abnormalities such
as endometriosis, pelvic inflammatory disease, or an accident in an ovarian cyst.
○ Treatment
■ continuous heat to the abdomen in addition to NSAIDs decreases pain significantly
● Ibuprofen and Naproxen are prefered - First Line
■ Severe Pain
● Codeine or stronger pain medications
● cyclooxygenase-2 (COX-2)
○ Rofecoxib, valdecoxib, and lumiracoxib are effective for treating primary
dysmenorrhea
■ must be used at the earliest onset of symptoms, usually at the onset of, and sometimes 1–2 days
prior to, bleeding or cramping
■ Cyclic administration of oral contraceptives, usually in the lowest dosage but occasionally with
increased estrogen, prevents pain in most patients who do not obtain relief from
antiprostaglandins or cannot tolerate them
● given for 6–12 months. Many women continue to be free of pain after treatment has been
discontinued
● Cystocele aka Anterior Vaginal Prolapse
○ vaginal wall weakens and stretches and allows the bladder to bulge into the vagina
○ Causes-
■ childbirth
■ chronic constipation
■ violent coughing
■ heavy lifting
■ Overweight
■ Age
■ hysterectomy (increased vag weakness)
, ○ Sx
■ felling of fullness or pressure in vagina
■ increased discomfort when you strain/cough/bear down
■ feeling of incomplete empty
■ repeated bladder infection
■ pain or urinary leak during sex
■ bulge of tissue into vaginal opening
○ Prevention
■ Kegels
■ prevent constipation
■ avoid heavy lifting
■ avoid wt gain
● Rectocele aka Posterior Vaginal Prolapse
○ When thin tissue of vagina separates the vaginal and rectum allowing vaginal wall to bulge
○ Sx
■ soft bulge of tissue in vaginal
■ difficult BM
■ sensation of rectal pressure
■ incomplete emptying after BM
■ sexual concerns-dyspareunia
○ Causes
■ constipation/strain
■ chronic cough
■ heavy lifting
■ Overweight
■ Childbirth
■ age
○ Prevention
■ Kegels
■ prevent constipation
■ avoid heavy lifting
■ Cough
■ avoid wt gain
● Uterine prolapse aka Apical Prolapse
○ pelvic floor muscles and ligaments stretch and weaken and no longer provide support for uterus and
protrude into vagina.
○ Causes
■ Pregnancy
■ large baby delivery
■ lower estrogen level after menopause
■ obesity
■ Common in postmenopausal and one or more childbirth
○ Sx
■ heaviness or pulling into pelvis
■ tissue protruding from vagina
■ urinary probs (leakage, retention)
■ trouble having BM
■ feeling of sitting on small ball
■ sexual concerns
○ Prevention
■ Kegels
■ treat constipation
■ correct lifting
■ avoid wt gain
, ○ Tx
■ pessary
● STDs
○ Chlamydia Trachomatis
■ Reportable
■ Most infections are asymptomatic
■ 25+ yoa most prevalent
■ Most common STD in USA
■ Annual screening of all sexually active women < 25 as is screening in older women at increased
risk for infection (new sexual partner, more than 1 partner, sexual partner with STI)
■ Sites of infection
● Females: Cervicitis, endometritis, salpingitis, PID
● Males: epididymitis, prostatitis
● Both genders: urethritis, pharyngitis, proctitis
■ Complications:
● PID
● tubal scarring
● ectopic pregnancy
● Infertility
● Reiter’s Syndrome
● Fits-Hugh-Curtis Syndrome
■ Labs
● NAATs- gold standard
● negative whiff w/ mucopurulent d/c and + clue cells
■ Treatment:
● Azithromycin 1g PO single dose OR
● Doxycycline 100mg BID PO x 7d
● Treat partner too.
● Abstain from sex for 7 days after tx.
● Can tx partner without seeing partner in most states
● Pregnant women
○ Do test of cure 3 weeks after tx then again within 3 months
○ Azithromycin 1g PO single dose OR
○ Amoxicillin 500mg TID x 7d.
● Complicated Infections (PID)
○ Rocephin 250 mg IM x 1 dose plus Doxycycline PO BID x 14d with or without
Metronidazole PO BID x 14d.
○ Syphilis
■ chronic, systemic disease caused by a sphirochete transmitted via contact with infectious moist
lesion.
■ Sexually acquired or vertically transmitted from infected mom.
■ Reportable disease
■ Prevention
● Condom
● wash w/ soap and water after sex
● screen ppl @ high risk (men that have sex with men, drug trafficers, correctional facilities)
■ Screen for syphilis if HIV infection, MSM, presence of genital ulcer, previous STD, pregnancy,
intravenous drug use, or high risk.
■ Primary:
● Painless chancre (heals in 6-9 wks if not tx)
● Chancre has clean base, well demarcated with indurated margins
○ Women can have on cervix or inside vagina.
○ Any mucus membrane
■ Secondary:
