Pediatric Nurse Practitioner Exam Questions, Exams of Nursing

Download Pediatric Nurse Practitioner Exam Questions and more Exams Nursing in PDF only on Docsity! NR 602 WEEK 4 MIDTERM EXAM LATEST 2023/2024 VERSION 1 • Role-play with equipment during the course of a physical examination would be most beneficial with which of the following groups? • Preschoolers/Toddlers • What is the Ortolani Sign? -Assess for congenital hip dysplasia • When performing a physical examination of a toddler, which of the following body parts would examine last? • Ears and throat • What are three findings using Jones criteria for Rheumatic Fever? -Streptococal infection, carditis, and erythema marginatum • While examining a 4-month-old boy, you are unable to palpate one of his testes. The next most appropriate step is: • Refer the child to a urologist • Concurrent Otitis media and Conjunctivitis is likely due to which? • Haemophilus influenza • What is the appropriate management of a child with asthma who presents with acute wheezing and/or coughing? • Administer a short-acting beta agonist • Sandra, age 12 years, has several vesicles and honey-colored crusted lesions on her face above the right nares. She has a history of having a bad scratch in the same area several days ago. What condition do you suspect? -Impetigo • The most appropriate management of a 5-year old with a firm nontender nodule in the mid- upper eyelid for 3 weeks would be: -Topical ophthalmic ointment • A 10-month-old child has been diagnosed with gastroenteritis. He attends a child care facility. What is the most likely cause of illness? -Rotavirus • If a child or any patient describes a “pop” in the knee. What is this indicative of? • Anterior cruciate ligament tear • A 7-year-old African American female presents with several hyperkeratotic raised, periungual lesions on the two middle fingers of her left hand. She has a history of nail biting. The most likely diagnosis is: • Verruca vulgaris • Management of scoliosis depends on the severity of curve as well as the age of the child. Which of the following would require surgical intervention? • Thoracic curve • Treatment of true central precocious puberty is best achieved with: • Gonadotropin-releasing hormone agonist • Baby Sally was in your office last week for her 6-month checkup. Her weight was 7 kg. Today she presents with diarrhea and vomiting for 4 days. Today her weight is 6.5 kg. What is her percentage of dehydration? -7% • Which of the following would be the most appropriate initial management of a newborn diagnosed with developmental dysplasia of the hip? -Pavlik harness • When considering catch up vaccination in children for IPV vaccinations, it is important to understand one of the following considerations is NOT a consideration when administering the vaccine: • IPV is can be given routinely beyond the age of 18 years of age in the U.S. • An essential test in the evaluation of a 2-year-old being managed for Kawasaki disease is: • An echocardiogram • A 4-week-old presents to your office in mid=January with a 1-week history of nasal congestion and occasional cough. On the evening prior to this visit, the infant developed a temperature of 102, refused to breastfeed, and had proximal coughing and noisy, labored breathing. On exam, you note an ill-appearing infant who is lethargic with tachypnea. • RSV bronchiolitis • What needs to be included when educating parents about a febrile seizure? • Children may experience repeated seizures • A 4-year-old boy is brought in by his mother, who is concerned about the sudden onset of a painful limp in his right leg 2 days ago? Today he has a low-grade fever. Which of the following diagnoses is most likely? • Transient synovitis of the hip • In addition to penicillin, all of the following antibiotics can be used to treat strep pharyngitis except: • Bactrim • Primary dysmenorrhea is due to: • Elevated prostaglandin level • Which behavior would NOT be expected in a two-year old? • Draws a circle • The most common congenital heart defect in children is: • Ventricular septal defect • Michael is a 15-year-old high school student who presents for a school sports physical. He appears to be in good health but is concerned about a bad headache he had a few weeks ago. He is concerned because his mother’s friend dried of a brain tumor. You tell Michael • The appropriate management of Osgood-Schlatter disease includes: • Decreasing activity, applying ice, and taking prescribing NSAIDS • The organism that causes hand, foot, mouth syndrome is what virus? • Coxsackle virus • Judy has a history of remission and exacerbation of acne that has followed the pattern of menses for 2 years. However, the condition over the last 6 months has worsened to a moderate degree of severity and has been chronic and persistent. You prescribe… • Hydroquinoa • Which malignancy is associated with genitourinary anomalies? -Wilm’s tumor • A 15-month-old failed treatment with amoxicillin for otitis media. AT his 2-week recheck, his TM remained red and distorted….. -A 10-day course of Augmentin • Which of the following is not considered preventative management for iron0deficiency anemia? -No cow’s milk until 1 year of age • In mild to moderate attacks of asthma, albuterol should be given every 4-5 hours PRN and routine medications should be: -Continued as usual • In addition to penicillin, all of the following antibiotics can be used to treat strep pharyngitis except: -Bactrim • The most definitive feature or features for a diagnosis of “growing pains” includes: • Exclusion of other causes of lower extremity pain • Which of the following foods would be appropriate for a child with celiac disease? • Boiled rice with butter • When performing a physical examination of a toddler, which of the following body parts would you examine last? • Ears and throat • Daily eyelid cleaning with diluted baby shampoo and a cotton-tipped applicator would be appropriate in the treatment of which of the following conditions? • Blepharitis • Primary dysmenorrhea is due to: • Elevated prostaglandin level • Management of scoliosis depends on the severity of curve as well as the age of the child. Which of the following would require surgical intervention? • Thoracic curve greater than 50 degrees or lumbar curve than 40 degrees • A 10-year old has marked ear pain, not wanting anyone to touch his ear. The canal is edematous and exudate is present. TM Is normal. How should this be managed? -Topical fluoroquinolone • Patients with otitis externa should be instructed to do which of the following? • Keep ear dry until symptoms improve • A 2-year-old female has lymphedema of the hands and feet, with low posterior hairline, cubitus valgus, and a history of intrauterine growth restrictions. Which of the following defects is the most common among the children with these signs? -Coarctation of the aorta VERSION 2 1. Turner’s syndrome can be suspected when the patient has primary amenorrhea and Short stature and webbed neck 2. A 21-year-old woman comes into your practice seeking birth control. She has only recently become sexually active and has consistently used condoms for safe sex. Your history reveals that she does not use tampons during her menses and has very little knowledge about female reproductive anatomy. Based on this information, which of the following birth control choices would be least likely to meet her needs for contraceptive management? Nuvaring 3. The most common type of invasive breast carcinoma is Infiltrating ductal 4. Measuring waist circumference is most appropriate when the client’s BMI places her in which of the following categories? Overweight 5. The American Cancer Society recommends yearly mammogram screening beginning at age:45 6. A dancer from an adult club down the street comes in for a renewal of her birth control pill prescription. She says that everything is fine. On examination, you find grayish-white vaginal discharge, greenish cervical discharge and cervical motion tenderness. All of the following differential diagnoses except? Constant vulvar burning and discomfort 18. If you diagnose a cervical gonoccocal infection, which other infection is probably present? Chlamydia 19. HPV testing is indicated for a (n) 30-year-old-female with no history of genital warts as adjunct to routine Pap test. 20. A vaginal pH less than 4.5 is an expecting finding in a: Healthy reproductive-age woman 21. USPSTF recommendations for routine breast cancer screening include: Biennial mammograms starting at age 50 22. The new ACOG pap smear guidelines reflect a change in all of the following except: The age at which Pap smears are initiated, The frequency of Pap smear screening, The follow-up to abnormal Pap smear results, The endpoint for pap smear testing 23. A 16-year-old- woman has not yet begun menstruating but does have pubic hair. She is best described as having: Primary amenorrhea 24. Dysfunctional uterine bleeding is usually associated with Anovulation 25. A 17-year-old client presents at the clinic with the following reason for seeking care. “I have been sick for three days. I feel sick to my stomach and I have diarrhea”. Which of the following would be most appropriate to document as her reason for her visit/chief complaint? “I feel sick to my stomach and I have diarrhea” 26. First line treatment for polycystic ovary syndrome is: A combination of diet modification, weight loss, and stress management 27. A 24-year-old woman presents with complaints of nontender mass in her left breast that does not change with the menstrual cycle. On examination, you note a freely movable, 0.5 cm x 1 cm, firm, rubbery nontender mass. The most likely diagnosis is: Fibroadenoma 28. According to ACOG guidelines, which of the following physical examination and screening tests should be part of the routine well-woman visit every year for females ages 30 to 39 years? Clinical breast examination 29. In a premenopausal woman, the biggest heart attack risk factor is: Cigarette smoking 30. A 16-year-old patient comes the office because she has never had a menstrual period. She has normal breast development, scant pubic hair, and a blind vaginal pouch with no palpable uterus or ovaries. The most likely diagnosis: Androgen insensitivity/resistance syndrome 31. What is the position of the uterus when the cervix is on the anterior vaginal wall? Anteverted 32. A 26-year-old woman presents with multiple, painless, umbilicated papules on her mons pubis. The most likely diagnosis is: Molluscum contagiosum 33. A woman who is currently pregnant, has had two full-term deliveries, and had one first-trimester abortion would be considered. Gravida 4 para 2 34. Pelvic findings on examination of a 22-year-old nulliparous woman are uterus 7 cm in length and ovaries 3cmx2x1cm. These findings are consistent with: Normal size uterus and normal size ovaries. 35. A 66-year-old- woman with a history of pruritus presents with an ulceration of the vulva. The most likely diagnosis is: Vulvar carcinoma 36. Characteristic “strawberry spots” on the cervix may be seen with Trichomonas 37. A 45 year-old-female presents with complaint of lower abdominal pain with urinary urgency and frequency for the past three months. The pain is worse during sexual intercourse and relieved somewhat when she urinates. Physical exam reveals suprapubic tenderness as well as tenderness along the anterior vaginal wall and urethra. The remainder of her exam is normal. What best fits these findings? Interstitial cystitis/ painful bladder syndrome 38. Primary dysmenorrhea can best be treated with: Prostaglandin inhibitors VERSION 3 What is the ASCCP recommended management for an ASCUS (atypical squamous cells of undetermined significance) pap result with a positive high-risk HPV 16 cotest in a 26-year-old woman without a history of abnormal pap smears? • Colposcopy A well-woman visit for an adolescent should include which of the following? • A general health history focusing on reproductive and sexual health concerns (menses, gynecologic, and pregnancy related) and psychosocial (family related, peer related, emotional, and physical as well as related to abuse, drug use, and alcohol use) concerns Physical exam, screening tests, and immunizations as indicated by the health history and gynecologic considerations for an external-only inspection of the genitalia ACOG Pap smear guidelines A Bethesda system Pap smear report that reads LSIL is most consistent with which classification? • CIN 1 A single Pap smear reading of ASCUS in a patient negative for HPV infection should have what as follow-up? • Routine screening A female patient is 35 years old. She has never had an abnormal PAP smear and has had regular screening since age 18. If she has a normal PAP smear with HPV testing today, when should she have the next cervical cancer screening? • 5 years A young sexually active client at the family planning clinic is advised to have a Papanicolaou (Pap) smear. She has never had a Pap smear before. What should the nurse include in the explanation of this procedure? • The Pap smear can detect cancer of the cervix Lab results on your 26-year-old patient show a negative Pap smear with a positive human papillomavirus (HPV) screen. Which procedure will be required next? • Repeat Pap and HPV screen Which of the following is not part of the criteria for an older woman to cease having any future Pap tests performed? • Over 55 years of age Amenorrhea (Primary and Secondary) You are evaluating a 17-year-old Emily who presented with amenorrhea and normal secondary sex characteristics. The purpose of the progesterone challenge is to ascertain the presence of? • Endogenous estrogen A 17-year-old female patient presents with amenorrhea for 4 months she did experience menarche at age 15 but had not had a menstrual cycle since. On physical examination, it is noticed that she has normal secondary sexual characteristics. The nurse practitioner will consider a progesterone challenge to determine the presence of adequate • Endogenous estrogen A teenage patient presents with amenorrhea and moral secondary sex characteristics. A progesterone challenge is ordered. The purpose is to determine the presence of ? • Endogenous estrogen A 16year old girl who comes to your office with a history of secondary amenorrhea. She experienced menarche at age 10, regular cycles for 2 years. She has not menstruated now for 4 years. In your initial consideration of differential diagnoses, what is the most frequent etiology of this problem: • Eating disorder 18yo female c/o secondary amenorrhea. On exam, there is normal secondary sex characteristics and normal genitalia. Pregnancy is ruled out. What would necessitate further eval? • Galactorrhea Primary amenorrhea is best described as: • Failure to menstruation to occur by 13 yr A nurse practitioner is caring for a woman with primary and secondary amenorrhea. The pelvic exam was normal. Which of the following may be the cause if etiology originates in the hypothalamus? • Sheehan’s syndrome American Cancer Society recommendations A nurse practitioner is participating in a women’s health fair. When educating the women about risk factors for breast cancer, which of the following statements is incorrect? • Fibrocystic breast disease When educating women about breast cancer risk factors, which statement is incorrect? • Fibrocystic breast disease A woman with lobular carcinoma in situ has a relative risk of developing invasive breast cancer of • 8.0 Androgen insensitivity/resistance syndrome Changes in hormonal regulation during menopause result in the gradual cessation of menstruation. From which gland is Androstenedione secreted? • Adrenals ASCUS/HSIL results from Paper Test Report A Pap smear result of atypical squamous cells of undetermined significance—rule out high-grade squamous intraepithelial lesion (ASCUS r/o HGSIL) will require which procedure next? • Colposcopy A Pap smear result of atypical squamous cells of undetermined significance (ASCUS) will require which procedure next? • Follow up pap smear Bartholin glands and cysts A 25-year-old presents with a report of a very tender area just near her introitus and to the left of her perineum. Very painful sex is how she knew "something wasn't right." She showered and when washing, she felt a "pea-sized" painful lump on the left side of her "bottom." She tells you she looked at it with a mirror and it was very small, but now it is the size of a ping-pong ball and getting worse. When you inspect her external genitalia, you are amazed at the size and appearance of the "lump." You note what appears to be an abscess on the left medial side of the labia minora, and there is some edema extending into the perineum. Your diagnosis for this presentation is: • Bartholin’s cyst You explain to this young woman what this "lump" is and let her know you will be referring her to a gynecologist you consult with regularly. You explain to her the likely treatment as follows: • A possible incision might be necessary and a catheter placed for two to four weeks to allow for drainage and appropriate healing. A client at the women's health clinic complains of swelling of the labia and throbbing pain in the labial area after sexual intercourse. For what condition does the nurse anticipate the client will be treated? • Bartholinitis 25yo female c/o tender area near her introitus and to the L of her perineum. Very painful sex was first sign. Initially bump was very small, but now is ping-pong ball size. On exam, abscess is present on L medial side of labia minora and there's edema extending into perineum. What is dx? • Bartholin’s cyst Which of the following choices represents a disorder of the reproductive tract that causes pain, erythema, dyspareunia, and a perineal mass? • Bartholin’s cyst A nurse practitioner instructor is reviewing the anatomy of the external genitalia. At the opening of the vagina are the Bartholin's glands. Which of the following describes the function of these glands? • Production of alkaline secretions for sperm viability BMI CDC recommendations regarding STDs and PID Cervical cancer screening A 23-year-old women presents to your practice with a chief complaint of postcoital bleeding. Which of the following would NOT be included in the initial assessment of this patient? • Uterine biopsy menses and has very little knowledge about female reproductive anatomy. Based on this information, which of the following birth control choices would be least likely to meet her needs for contraceptive management? • Nuvaring Cystocele Cystocele is best defined as • Descent or prolapse of the bladder While a speculum is retracting the posterior vaginal wall, a 51-year-old patient is asked to strain down. There is a bulge from the anterior vaginal wall. This is most likely • Cystocele The situation where the bladder forces the anterior vaginal wall down and out is termed • Cystocele Which of the following is an effect of estrogen deficiency on paravaginal tissue? • Cystocele A woman is admitted for repair of cystocele and rectocele. She has nine living children. In taking her health history, which of the following would the nurse expect to find? • Stress incontinence with feeling low abdominal pressure Dysmenorrhea Which of the following substances is responsible for the symptoms of dysmenorrhea? • Prostaglandins the first line treatment of severe menstrual cramps that having been occurring for 4 months in a patient with primary dysmenorrhea includes which of the following? • Ibuprofen A 40-year-old female presents with an abnormal menstrual cycle with menorrhagia and intermenstrual bleeding. The nurse practitioner suspects the patient may have dysfunctional uterine bleeding (DUB) and orders tests for follicle stimulating hormone (FSH) and luteinizing hormone (LH) levels. Both of these lab values are elevated. What is the most likely cause of DUB in this patient? • Onset of climacteric A patient who a nurse practitioner is seeing for the first time has the past medical history of primary dysmenorrhea. She recalls that which of the following is considered as the primary etiology? • Prostaglandin production Dysfunctional uterine bleeding (DUB). She is concerned about why this is happening to her. You recall which of the following is the most common cause of DUB? • Anovulation Sylvia is 44-year-old women with dysfunctional uterine bleeding (DUB) and is unable to use oral contraceptives. Which of the following medications can be used for management of DUB? • Medroxyprogesterone a 24-year-old female patient has been diagnosed with primary dysmenorrhea. Which of the following medications would be would be used as a first line to help control her symptoms? • Non-steroidal anti-inflammatory drugs A nurse practitioner is teaching an undergraduate course in women’s health. A student asks about the etiology of the pain that occurs with primary dysmenorrhea. Which of the following response is correct? • Prostaglandin release and synthesis Anna, 25-year-old, presents with dysmenorrhea. She states that her sister and mother have endometriosis, so she would like to be evaluated for it. Which of the following is consistent with a diagnosis of endometriosis? • Pelvic pain and dyspareunia Which is not a common cause of irregular menstrual bleeding? • Anovulation Which of the following is a "classic" symptom of endometriosis? • Progressive dysmenorrhea • VERSION 4 1. A sexually active 18-years old presents with postcoital spotting, dysuria and a yellow discharge. On exam you find her cervix is erythematous and bleeds with contact. The most likely diagnosis is a. Cervical cancer b. Chlamydia c. Primary syphilis d. Tampon injury 2. One of the leading causes of female infertility, Stein-Leventhal syndrome is a. Pelvic inflammatory disease b. Polycystic ovary disease c. Multiple sex partners d. Ectopic pregnancy syndrome 3. HIV test is indicated for a (n) a. 18-year-old female whose sex partner has a history of genital warts b. 24-year-old female with current genital warts as adjunct to routine pap test c. 30-year-old female with no history of genital warts as adjunct to routine pap test d. 67-year old female with new sex partner in past year who has history of genital warts 4. Which of the following contraceptive methods would be best for a woman with sickle cell anemia? a. Combination oral contraceptives b. Transdermal contraceptive patch c. Progestin-only contraceptives d. Female condom 5. A Patient taking metronidazole and cimetidine at the same time is at risk for: a. Bothersome side effect from the metronidazole b. Decreased effectiveness of cimetidine c. Renal impairment d. Severe disulfiram type reaction 6. A 58-year old woman complain of severe vulvular pruritis. On examination of the vulva, you note thinning of the epidermis and loss of pigmentation, as well as maculopapular lesions. You suspect the diagnosis may be a. Lichen sclerosus b. Local allergic reaction c. Lichen simplex chonicus d. Vulvodynia 7. Measuring waist circumference is most appropriate when the client’s BMI place her in which of the following categories? Valvovaginal edema and erythema 18. The most common type of invasive breast carcinoma is: Infiltrating ductal Medullary Lobular Infiltrating papillary 19. A dancer from an adult club down the street comes in for a renewal of her birth control pill prescription. She says everything is fine. On exam, you find grayish-white vaginal discharge, greenish cervical discharge, and cervical motion tenderness. All of the following are differential diagnoses except? Gonorrhea Interstitial cystitis Bacterial vaginosis Chlamydia 20. A 26-year old woman presents with multiple painless, umbilicated papules on her mons pubis. The most likely diagnosis is: Condyloma acuminate Condyloma lata Lumphogranuloma venereum Molluscum contagiosum 21. A 26- year old female has a Pap test report of ASC-US. This is her first abnormal Pap test. Recommended first steps in follow- up would include: Colposcopy within the next six months Co-testing with Pap and HPV tests in one year Reflex HPV now Repeat Pap test alone in three years 22. USPSTF recommendations for routine breast cancer screening include: Biennial mammograms starting at age 50 Breast self-examination starting at age 21 Clinical breast examination annually starting at age 30 Discontinue mammograms at age 65 23. A 22- year old female presents with complaint of malodorous vaginal discharge and vulvar itching. On examination, a watery, yellowish-green vaginal discharge is noted, along with vulvar and vaginal erythema. The most likely findings on a wet mount examination will be: Clue cells Lactobacilli Pseudohyphae Trichomonads 24. The American cancer society recommends yearly mammogram screening beginning at age: 40 45 50 55 25. According to USPSTF recommendations, an 80 year old female should get A clinical breast examination and screening mammogram annually A clinical breast examination annually but no screening mammogram Neither a clinical breast examination nor a screening mammogram A screening mammogram biennially but no cervical breast examination 26. A 22 year old female has a Pap test report of HSIL. Recommended first stems in follow up would include: Colposcopy Co-test with Pap and HPV tests in one year Reflex HPV test now Repeat Pap test alone in six months 27. Characteristics of polycystic ovary syndrome include: Hirsutism, thinness, hypoinsulinemia Menopausal onset, vitiligo Alopecia, thinness, abdominal cramping Premenarchial onset, obesity, hyperinsulinemia 28. A 22 year old experiences six months of amenorrhea. Laboratory test results include normal prolactin and thyroid stimulating hormone and negative pregnancy test. The next action will be to: Administer a progestin challenge test Measure testosterone Order a hysterosalpingogram Order an MRI or CT scan of pituitary gland 29. A 66 year old woman with a history of pruritis presents with an ulceration of the vulva. The most likely diagnosis is: Chancroid Secondary trauma Syphilis Vulvar carcinoma 30. A 17 year old client presents at the clinic with the following reason for seeking care: “I have been sick for three days. I feel sick to my stomach and have diarrhea”. Which of the following would be the most appropriate to document as her reason for visit/ chief complaint? Flulike symptoms Gastrointestinal distress “I feel sick to my stomach and have diarrhea” Possible pregnancy, needs further evaluation 31. A 16 year old patient comes to the office because she has never had a menstrual period. She has normal breast development, scant pubic hair, and blind vaginal pouch with no palpable uterus or ovaries. The most likely diagnosis is: Androgen insensitivity/resistance syndrome Muscarian agenesis Sheehan’s syndrome Turner’s syndrome 32. Characteristic “strawberry spots” on the cervix may be seen with: Bacterial vaginosis Chlamydia Herpes genitalis Short stature and webbed neck 43. Primary dysmenorrhea can best be treated with Dopamine agonists GnRh agonists Prostaglandin inhibitors Tricyclic antidepressants 44. What is the position of the uterus when the cervix is on the anterior vaginal wall? Midposition Retroverted Retroflexed Anteverted 45. According to ACOG guidelines, which of the following examination and screening tests should be a part of the routing well-woman visit every year for the females age 30 to 39 years? Chlamydia test Clinical breast examination Mammogram Pap test 46. A woman who is currently pregnant, has has two full-term deliveries, and has had one first trimester abortion would be considered Gravida 2 Para 2 Gravida 3 para 2 Gravida 3 para 3 Gravida 4 para 2 47. a vaginal pH less than 4.5 is expected finding in a Healthy reproductive age woman Menopausal woman with atropic vaginitis Reproductive age woman with trichomoniasis Healthy prepubertal age girl 48. a 68 year old had her last cervical cancer screening fone at age 65 and results were normal. She has no history of abnormal screenings. She has recently started having sexual intercourse with a new male partner and asks if she should start having cervical cancer screening again. An appropriate answer would be that she Does not need pap tests but should have HPV testing every five years Does not need to resume either pap tests or HPV testing Should resume pap test with HPV co-testing every five years 49. the new ACOG Pap smear guidelines reflect a change in all of the following except The age at which pap smears are initiated The frequency of pap smear screenings The follow-up to abnormal pap smear results The endpoint for pap smear tastings 50. During a vaginal examination, you observe bulging of the anterior wall when you ask the patient to bear down. This is most likely a Congenital abnormality Cystocele Rectocele Uterine prolapse MIDTERM STUDYGUIDE Signs of pregnancy presumptive (subjective signs) Amenorrhea, nausea, vomiting, increased urinary frequency, excessive fatigue, breast tenderness, quickening at 18–20 weeks probable (objective signs) Goodell sign (softening of cervix) Chadwick sign (cervix is blue/purple) Hegar’s sign (softening of lower uterine segment) Uterine enlargement Braxton Hicks contractions (may be palpated by 28 weeks) Uterine soufflé (soft blowing sound due to blood pulsating through the placenta) Integumentary pigment changes Ballottement, fetal outline definable, positive pregnancy test (could be hydatidiform mole, choriocarcinoma, increased pituitary gonadotropins at menopause) positive (diagnostic signs) Fetal heart rate auscultated by fetoscope at 17–20 weeks or by Doppler at 10–12 weeks Palpable fetal outline and fetal movement after 20 weeks Visualization of fetus with cardiac activity by ultrasound (fetal parts visible by 8 weeks) Pregnancy and fundal height measurement Signs of pregnancy (presumptive, probable, positive) Pregnancy and fundal height measurement As pregnancy progresses, the fundus rises out of the pelvis (Figure 29-1 ). At 12 weeks’ gestation, the fundus is located at the level of the symphysis pubis. By week 16, it rises to midway between symphysis pubis and the umbilicus. By 20 weeks’ gestation, the fundus is typically at the same height as the umbilicus. Until term, the fundus enlarges approximately 1 cm per week. As the time for birth approaches, the fundal height drops slightly. This process, which is commonly called lightening, occurs for a woman who is a primigravida around 38 weeks’ gestation but may not occur for the woman who is a multigravida until she goes into labor (RBC). The blood volume changes result in hemodilution, which leads to a state of physiologic anemia during pregnancy. As the RBC volume increases, iron demands also increase. Leukocytosis occurs in pregnancy, with white blood cell counts increasing to as much as 14,000 to 17,000 cells per mm3 of blood (Table 29-3 ). Clotting factors increase as well, creating a risk for clotting events during pregnancy. Systemic vascular resistance is reduced due to the effects of progesterone, prostaglandins, estrogen, and prolactin. This lowered systemic vascular resistance, in combination with inferior vena cava compression, is partly responsible for the dependent edema that occurs in pregnancy. Epulis of pregnancy, or hypertrophy of the gums accompanied by bleeding, may also occur and is due to decreased vascular resistance and increase in the growth of capillaries during pregnancy (Jarvis, 2016 ). Indications and contraindications for prescribing combined estrogen vs. progesterone-only birth control Progestin-only contraceptives are used continuously; there is no hormone- free interval, as occurs with combined methods. These contraceptive methods have minimal effects on coagulation factors, blood pressure, or lipid levels and are generally considered safer for women who have contraindications to estrogen, such as cardiovascular risk factors, migraine with aura, or a history of VTE. In spite of this belief, the product labeling for some progestin-only products mimics the labeling for products containing estrogen. The U.S. Medical Eligibility Criteria for Contraceptive Use (CDC, 2010 ; see Appendix 11-A ) can be used to identify appropriate candidates for progestin- only contraception. Progestin-only contraceptives do not provide the same cycle control as methods containing estrogen, and unscheduled bleeding is common with all progestin-only methods. Typically, unscheduled bleeding occurs most frequently during the first 6 months of method use, with a substantial number of users becoming amenorrheic by 12 months of use (Hubacher, Lopez, Steiner, & Dorflinger, 2009 ). Overall blood loss decreases over time, making progestin-only methods protective against iron- deficiency anemia. With appropriate counseling, many women see amenorrhea as a benefit of these methods. All progestin-only methods are likely to improve menstrual symptoms, including dysmenorrhea, menorrhagia, premenstrual syndrome, and anemia (Burke, 2011 ). The thickening of cervical mucus seen with progestin methods is protective against PID. Progestin-only contraceptives include the progestin-only pill (POP), an injection, an implant, and three progestin- containing intrauterine devices. The implant and devices are covered in the section on long-acting reversible contraception. The U.S. Medical Eligibility Criteria for Contraceptive Use (CDC, 2010 ) is a comprehensive, evidence-based guide for determining whether women have relative or absolute contraindications to contraceptive methods. The Medical Eligibility Criteria uses the following four classification categories of whether a person can use or should not use a method: • Category 1: a condition for which there is no restriction for the use of the contraceptive method • Category 2: a condition where the advantages of using the method generally outweigh the theoretical or proven risks • Category 3: a condition where the theoretical or proven risks usually outweigh the advantages of using the method • Category 4: a condition that represents an unacceptable health risk if the contraceptive method is used Menstrual cycle physiology The initiation of menstruation, called menarche, usually happens between the ages of 12 and 15. Menstrual cycles typically continue to age 45 to 55, when menopause occurs. Many women find themselves reluctant to discuss the existence and normality of menstruation. The word menstruation has been replaced by a variety of euphemisms, such as the curse, my period, my monthly, my friend, the red flag, or on the rag. Most women experience deviations from the average menstrual cycle during their reproductive years. As a result, it is not uncommon for women to display certain preoccupations regarding their menstrual bleeding, not only in relation to the regularity of its occurrence, but also in regard to the characteristics of the flow, such as volume, duration, and associated signs and symptoms. Unfortunately, society has encouraged the notion that a woman’s normalcy is based on her ability to bear children. This misperception has understandably forced women to worry over the most miniscule changes in their menstrual cycles. Indeed, changes in menstruation are one of the most frequent reasons why women visit their clinician. Numerous patterns in the secretion of estrogens and progesterone are possible; in fact, it is difficult to find two cycles that are exactly the same. Studies that include women of different ethnicities, occupations, genetics, nutritional status, and age have demonstrated that the length and duration of the menstrual cycle vary widely (Assadi, 2013; Johnson et al., 2013 ; Karapanou & Papadimitriou, 2010 ). Menarche is the most readily evident external event that indicates the end of one developmental stage and the beginning of a new one. It is now believed that body composition is critically important in determining the onset of puberty and menstruation in young women (Ferin & Lobo, 2012). The ratio of total body weight to lean body weight is probably the most relevant factor, and individuals who are moderately obese (i.e., 20– 30% above their ideal body weight) tend to have an earlier onset of menarche (Johnson et al., 2013 ). Widely accepted standards for distinguishing what are regular versus irregular menses, or normal versus abnormal menses, are generally based on what is considered average and not necessarily typical for every woman. According to these standards, the normal menstrual cycle is 21 to 35 days with a menstrual flow lasting 4 to 6 days, although a flow for as few as 2 days or as many as 8 days is still considered normal (Ferin & Lobo, 2012 ). The amount of menstrual flow varies, with the average being 50 mL; nevertheless, this volume may be as little as 20 mL or as much as 80 mL. Tetanus, diphtheria, pertussis (Tdap) After maternal vaccination, antibodies cross the placenta and decrease the risk of pertussis infection in the newborn. Third trimester (ideally 27– 36 weeks’ gestatio n) Advised If at Risk Rationale Timing Hepatitis B If the woman is at risk for acquiring HBV, she should be vaccinated. Indications include risk of occupational exposure to blood, treatment for a sexually transmitted infection, more than 1 sex partner in the past 6 months, recent intravenous drug use, and HBsAg– positive sex partner. 3 injections beginning at any point in gestation Contraindicated Rationale Measles, mumps, rubella This live virus vaccine has a (theoretical) risk to the fetus. Varicella This live virus vaccine has a (theoretical) risk to the fetus. Abbreviations: HBsAg, HBV surface antigen; HBV, hepatitis B virus. a Live attenuated influenza vaccine (LAIV [FluMist]) should not be given to pregnant women. Emergency contraception Sperm can live for up to 5 days in the female reproductive tract, and pregnancy can occur with intercourse 5 days prior to ovulation. The highest risk of pregnancy is in the 48 hours immediately preceding ovulation (Wilcox, Dunson, & Baird, 2000 ). However, due to the uncertainty of ovulation timing, emergency contraception is offered if unprotected intercourse (UPI) occurs at any time in the menstrual cycle. The Yuzpe, levonorgestrel, and ulipristal acetate emergency contraceptive pill (ECP) regimens as well as the copper IUD may all be used within 120 hours of UPI. The Yuzpe and levonorgestrel methods have a dramatic decline in their effectiveness with time and should be used as soon as possible after an event of UPI. The Yuzpe regimen consists of combined ECPs that The Yuzpe regimen consists of combined ECPs that must contain at least 100 mcg of ethinyl estradiol and 0.50 mg of levonorgestrel, repeated in 12 hours. A dedicated combined ECP product is not available in the United States, but numerous COCs can be used as combined ECPs (see Table 11- 1, footnote i). COCs containing norgestrel are preferable to those with norethindrone, as failure rates are slightly higher with norethindrone (Zieman et al., 2015 ). Because the high dose of ethinyl estradiol causes unpleasant side effects, this regimen has largely fallen out of favor. Until recently, the most widely used emergency contraception method was levonorgestrel ECPs, which contain either a 1.5-mg single dose (Plan B One- Step) or two doses of 0.75 mg taken 12 hours apart (Next Choice and Plan B). Women can take both doses in the two-dose products (Next Choice and Plan B) as a single dose. Levonorgestrel ECPs are available over the counter to women and men age 17 and older; women 16 and younger need a prescription to obtain them. Levonorgestrel ECPs are more effective than the Yuzpe regimen and have fewer side effects. Ulipristal acetate (ella), a selective progesterone receptor modulator provided as a single 30-mg dose, is the most effective oral emergency contraception method. The effectiveness of this medication does not decline within the 120-hour window after UPI, as is the case for levonorgestrel and combined ECPs (Fine et al., 2010). Ulipristal acetate is available only by prescription. The copper IUD can be inserted as long as 5 days after unprotected intercourse. Some contraceptive guidelines recommend its use up to 7 days after UPI (Dunn et al., 2013). This method is rarely utilized as emergency contraception in the United States; however, recent evidence suggests some women might choose the copper IUD if it is offered as an option (Turok et al., 2011 ). It has the advantage of being highly effective in obese women and providing ongoing contraception. Efficacy and Effectiveness Factors influencing the risk of pregnancy when ulipristal acetate or levonorgestrel is used for emergency contraception include body mass index (BMI), the day of the cycle, and further intercourse during the same menstrual cycle after use of emergency contraception (Glasier et al., 2011 ). Women with a BMI greater than 30 have a 2- to 40-fold higher risk of pregnancy after ECP use. Levonorgestrel may be completely ineffective at reducing pregnancy risk in obese women. The efficacy of levonorgestrel and ulipristal acetate further vary according to the stage of the cycle. Levonorgestrel and ulipristal acetate inhibit ovulation in 96% and 100% of cycles, respectively, when used prior to the onset of the LH surge (Brache, Cochon, Deniaud, & Croxatto, 2013 ). However, if given after the onset of the LH surge, these medications inhibit ovulation in 14% and 79% of cycles, respectively (Glasier, 2013 ). Levonorgestrel is no more effective than placebo when used in the critical 5 days preceding ovulation. The risk of pregnancy with ulipristal acetate use is half that seen with use of levonorgestrel (Glasier, 2014). Both levonorgestrel and ulipristal acetate delay ovulation. If women have repeated acts of UPI after using ECPs, they are at a 4-fold increased risk of pregnancy compared with women who do not have further intercourse within the same cycle. Depot Medroxyprogesterone Acetate (DMPA) • Depo-Provera® (progestin only); given via injection; lasts 3 months • Prevent LH surge which inhibits ovulation, thickens cervical mucus and causes the endometrium to atrophy which reduces the likelihood of implantation; minimal effects on coagulation, blood pressure and lipid levels • Benefits: Highly effective; reduces menstrual flow and within a year most women have amenorrhea • Contraindications: Suspected or confirmed pregnancy, known or suspected malignancy of the breast, significant liver disease undiagnosed vaginal bleeding, history of anorexia, active thrombophlebitis, or current or past history of thromboembolic disorders or cerebrovascular disease • Risks: Loss of bone mineral density (black box warning: avoid use for more than 2 years), delayed return of fertility • Side Effects: Headache, depression, breakthrough bleeding and weight gain • Educate woman calcium with vitamin D and weight bearing exercise to prevent bone mineral loss • Benefits: Safe for breastfeeding women, considered safer for women who have contraindications to estrogens • MUST check for pregnancy before starting; Disadvantages: Requires pregnancy testing if the patient does not return every 12 weeks • Give ONLY within the 1st 5 days of a normal menstrual period-less likely to ovulate during these times Progestin Implants Used with permission of Mayo Foundation for Medical Education and Research, all rights reserved. • Nexplanon® is a single rod etonogestrel subcutaneous implant, an active metabolite of desogestrel which is effective up to 3 years • Norplant II® has 2 rods and is effective up to 5 years • Slow release of progestin to suppress ovulation by inhibiting LH surge • Benefits: highly effective, removes the factor of user consistency and error, long- acting and reversible, reduces menstrual flow and decreases dysmenorrhea symptoms • Contraindications: Suspected or confirmed pregnancy, undiagnosed vaginal bleeding, known or suspected malignancy of the breast, significant liver disease, active thrombophlebitis, or current or past history of thromboembolic disorders or cerebrovascular disease • Risks: Procedural associated risks are very low; insertion site bruising possible • Disadvantages: Requires provider training for insertion, high initial cost • Side Effects: Similar to other progestin-only methods (breakthroughbleeding, amenorrhea, breast tenderness, weight gain) Sterilization (Tubal ligation or Vasectomy) • Tubal ligation: Surgical procedure to block the fallopian tubes; various methods of mechanical occlusion which are generally effective immediately;Essure® is the only transcervical method that can be performed in an office setting by hysteroscopy; Essure ® requires a hysterosalpingogram (HSG) to be done 3 months after the procedure to confirm tubal occlusion; decreased risk of ovarian cancer • Vasectomy: Surgical procedure to occlude the vas deferens; various methods of occlusion; vasectomy is less invasive than female sterilization; not immediately effective - the man must wait 3 months before relying on sterilization; usually advised to perform a sperm count before stopping other contraceptive methods Tier 2 methods essentially include hormonal contraception other than LNG- IUSs and implanted devices. These include: • Combined oral contraceptive (COC) pills- estrogen and progesterone • Oral contraceptive pill- progestin only "Minipill" • Emergency contraception • Benefits: Effective, does not require daily dosing, decreased risk of PID and ectopic pregnancies, decreased risk of ovarian and endometrial cancer, improves dysfunctional uterine bleeding (DUB) and dysmenorrhea and improves acne • Start on 1st day of period or 1st Sunday after period; requires back-up method for 1 week • Disadvantages: Must remember to change patch the same day every week and remove for 1 week, less effective in women over 200 lbs. • Contraindications: Same as COC pills • Risks: Same as COC pills • Side effects: Same as COC pills Cervical Ring • NuvaRing® • Plastic cervical ring that is placed inside the vagina for 3 weeks which provides a slow release of estrogen and progesterone; removed for 1 week at which time a withdrawal bleed should occur • Benefits: Effective, does not require daily administration, decreased risk of PID and ectopic pregnancies, decreased risk of ovarian and endometrial cancer, improves dysfunctional uterine bleeding (DUB) and dysmenorrhea and improves acne • Disadvantages: Woman must be educated on how to apply and remove ring (should fit snugly around the cervix), may be noticeable by patient or partner during intercourse, not good for woman who is not comfortable with insertion and removal; can be removed prior to intercourse but should be replaced within 3 hours • Contraindications: Same as COC pills • Risks: Same as COC pills • Side effects: Same as COC pills Tier 3 methods include all of your barrier methods, natural family planning and coitus interruptus. These methods are the least effective in terms of preventing pregnancy with variable rates between them which are outlined in your textbook. The biggest advantage that the barrier methods offer in addition to preventing pregnancy is that they offer protection in preventing STDs. Etiology, diagnosis, and treatment of amenorrhea Amenorrhea simply means absence of menses and is part of the spectrum of ovulatory disorders classified as AUB-O. The most common causes of amenorrhea are pregnancy, hypothalamic amenorrhea, and PCOS (American College of Obstetricians and Gynecologists, 2014). According to Fritz and Speroff (2011, p. 436), women meeting any of the following criteria should be evaluated for amenorrhea: No menses by age 14 in the absence of growth or development of secondary sexual characteristics No menses by age 16 regardless of the presence of normal growth and development of secondary sexual characteristics In women who have menstruated previously, no menses for an interval of time equivalent to a total of at least three previous cycles, or 6 months Amenorrhea typically is categorized as either primary or secondary. Primary amenorrhea is the failure to begin menses by the age of 16. A number of disorders can be treated as soon as they are diagnosed, however, so any girl who has not reached menarche by age 15 years or who has not had a menses within 3 years of thelarche should be evaluated (American College of Obstetricians and Gynecologists, 2014). Secondary amenorrhea is defined as 3 months without a menses once menses has been established. The American Society for Reproductive Medicine recommends that any woman experiencing 3 months of amenorrhea once the menses is established should be evaluated (American College of Obstetricians and Gynecologists, 2014). Because primary and secondary amenorrhea can have the same causes, the initial investigation for both is similar. Physiologic causes of amenorrhea include anatomic defects, ovarian failure, chronic anovulation, anterior pituitary disorders, and central nervous system disorders. Age is an important criterion in making the differential diagnosis of primary versus secondary amenorrhea, and is relevant in determining the types of questions to ask when taking the medical history. Primary amenorrhea in a young woman may be indicative of HPOA disorder or anatomic factors, such as outflow tract obstruction. With primary amenorrhea, the physical examination should focus on identifying the maturation of secondary sex characteristics (e.g., Tanner staging for breast development and pubic hair pattern; see Chapter 2) and establishing outflow tract patency. The question “Have you had any bleeding from the vagina?” can assist in determining primary, secondary, and potential causes. Other important interview questions to consider relate to lifestyle patterns (e.g., exercise, medication, and drug use) and eating habits (e.g., possible eating disorders). A family history of anatomic or genetic abnormalities should be explored as well. Normal menstrual function requires that four anatomic and structural components are in working order: uterus, ovary, pituitary, and hypothalamus (Fritz & Speroff, 2011). The clinician can then categorize the amenorrhea according to the site or level of disturbance (Fritz & Speroff, p. 438): Disorders of the genital outflow tract Disorders of the ovary Disorders of the anterior pituitary Disorders of the hypothalamus or central nervous system The differential diagnosis for women who are not pregnant and who present with amenorrhea is either primary amenorrhea or secondary amenorrhea, although Fritz and Speroff (2011) warn that premature categorization of amenorrhea can lead to diagnostic omissions and, in many cases, unnecessary and expensive diagnostic testing. Athletic women, particularly long-distance runners, gymnasts, and professional ballet dancers, are at risk for amenorrhea, as are women who have anorexia and other eating disorders (Fritz & Speroff, 2011; o Since the etiology of primary dysmenorrhea is thought to be due to the overproduction of prostaglandins, Non- Steroidal Anti- inflammatory Drugs (NSAIDs) are very effective in minimizing pain along with the application of heat over the abdomen. o The use of herbals and vitamin supplements (particularly Vitamin E) may provide some anecdotal relief but has not been consistently shown in studies. o Combined Oral Contraceptives (COCs) are also used in the treatment of primary dysmenorrhea. Primary dysmenorrhea, which is more common than secondary dysmenorrhea, often begins 6 to 12 months after menarche. Typically symptoms are experienced with the onset of bleeding and continue for 8 to 72 hours into the menstrual cycle. Increased endometrial prostaglandin production is believed to be the cause of the associated pain (Lentz, 2007). It is associated with multiple symptoms, including abdominal cramps, headache, backache, general body aches, continuous abdominal pain, and other somatic discomforts. The difference between primary dysmenorrhea and normal somatic and psychological changes prior to menses is that primary dysmenorrhea is perceived as more severe, with chronic, sometimes debilitating symptoms. There is no evidence of organic pathology in the uterus, fallopian tubes, or ovaries with primary dysmenorrhea. Women usually report repeated symptomology with each cycle. When charting their cycles, it is evident that that pain, bleeding, and disruption of lifestyle occur at regular times in the cycle. Dysmenorrhea can be classified into 2 categories: 1. Primary-Cyclical menstrual pain with no identifiable pelvic disease 2. Secondary-Cyclical menstrual pain that results from pelvic pathology Primary dysmenorrhea is almost always associated with ovulatory cycles so it usually does not occur immediately at menarche, but rather within the first 6 months. Typically the age of onset is between 16-25 years and becomes more severe with age. Associated primary dysmenorrhea is a diagnosis of EXCLUSION, in other words, secondary causes must be ruled out before rendering the diagnosis. Primary dysmenorrhea is likely based on history as well as an unremarkable physical exam and a negative pregnancy test. The most common MISDIAGNOSIS of primary dysmenorrhea is secondary dysmenorrhea due to endometriosis. Dysmenorrhea that is caused by pelvic pathology is referred to as secondary dysmenorrhea. Diagnosis of secondary dysmenorrhea includes pelvic pathology such as adenomyosis, leiomyomata, irritable bowel syndrome, interstitial cystitis, and endometriosis (Hoffman, 2008). Almost any process that can affect the pelvic viscera and cause acute or intermittent recurring pain might be a source of cyclic premenstrual pain, including urinary tract infection, pelvic inflammatory disease, hernia, and pelvic relaxation or prolapse Secondary dysmenorrhea is pain due to an underlying pelvic pathology which may include, but is not limited to: pelvic inflammatory disease, endometriosis, uterine fibroids and adenomyosis. However, almost any pathology that causes irritation to the pelvic viscera may be a source of pain including bladder and bowel disorders. Endometriosis is the MOST common cause of secondary dysmenorrhea. Endometriosis, the most common cause of secondary dysmenorrhea, is a growth or multiple growths (polyps) of endometrial tissue that are found outside of the uterine cavity. Because the lesions are uterine tissue, they respond to the cyclic hormones of the menstrual cycle which result in bleeding and pain. The lesions can also attach to adjacent organs such as the ovaries, bowel, bladder or peritoneum. Uterine fibroids are benign tumors of the uterine myometrium, the smooth muscle of the uterus. Fibroids can range in size from microscopic to very large. Single or multiple fibroids are possible. Like endometriosis, fibroids can be associated with menorrhagia, infertility and bowel and bladder complaints. Uterine fibroids are the most common indication for hysterectomy in the United States. o COCs, as you may recall, work by suppressing ovulation and endometrial tissue proliferation, which minimizes prostaglandin release and the amount of menstrual flow with each period. o Options include traditional or continuous use of COCs. A mutual decision should be made between the patient and the provider after assessing risks and benefits of use. o Additionally, other methods of hormonal contraception include implants, vaginal rings, patches and Lev norges rel-R leasing Intrauterin System (LNG-IUS) o Testing should include ruling out pregnancy and sexually transmitted infections first, followed by ordering a transvaginal ultrasound which may identify pelvic abnormalities. o A definitive diagnosis for secondary dysmenorrhea however is made via laparoscopic biopsy and histology. o The goal of medical management for secondary dysmenorrhea should include pain relief and cycle regulation and which are similar to the recommendations provided for primary dysmenorrhea. o Conservative surgical management may be tried in women who do not respond to medication treatment which may include excision or destruction of the lesion(s) with laser or heat and lysis of adhesions if indicated. o Hysterectomy is reserved for women who have not responded to drug treatment or conservative surgery Risk factors include heredity, obesity, african american ancestry and a primiparous status (giving birth to only 1 child). Differentiate between PMS & PMDD. Symptom s PMS PMDD Physical symptoms Abdominal bloating and pain Mild weight gain from water retention Constipation followed by diarrhea at the onset of the menses Headache Pelvic pain and cramping Fatigue Extremity edema Physical: same as PMS but may be more severe Symptoms can begin immediately after ovulation Abdominal bloating and pain Headache Pelvic pain and cramping Fatigue Extremity edema Nausea/food cravings Nausea/food cravings Psychologic symptoms Depression Anxiety Anger/irritability Insomnia Marked affective lability Marked irritability or anger or increased interpersonal conflicts Markedly depressed mood, feelings of Changes in libido hopelessness, or self-deprecating thoughts Abnormal uterine bleeding terminology Abnormal Uterine Bleeding (AUB) is a term used to refer to uterine bleeding that is atypical in the frequency, regularity, duration and timing and is a common gynecological disorder. "Normal" menstruation can be classified into the following parameters: Frequency Every 24-38 days Regularity +/- 2-20 days Duration 3-8 days Quantity 5-80 mL (roughly 3-6 pads per day) AUB occurs in various “patterns” which are important to first understand before we discuss etiologies. Match the description to each pattern of AUB: ‘Menomhagia = heavy or prolonged menstrual bleeding “Metrorrhagia =) “irregular” intermenstrual bleeding or bleeding between menstrual periods ie _ . : “Menometrorthagia “irregular” and heavy intermenstrual bleeding ‘Postooitl = bleeding that occurs after intercourse Post-menopausal bleeding that occurs after a menopausal woman has not had a period for at least 12 months Structural vs. Nonstructural etiologies of abnormal uterine bleeding Structural Abnormalities associated with AUB coincide with the acronym “PALM” and include: Non-Structural @ Abnormalities oO which can cause AUB : coincide with the acronym “COEIN” and include: 33 ‘Coagulopathy * Conditions causing coagulopathy which result in heavy men- strual bleeding include thrombocytopenia, chronic liver disease, leukemias, anticoagulant use and vonWillebrand’s disease = Copper |UD can be associated with heavy menstrual bleeding * LNG-IUS can be associated with intermenstrual bleeding and irregular bleeding * Menopausal hormone therapy & hormonal contraception can cause. intermenstrual and irregular bleeding * Other medications which can disrupt the HPOA can be implicated (.e., tricyclic antidepressants, and phenothiazines) Ovulatory dysfunction « Most common cause of AUB * Encompasses the 3 subcategories of anovulatory uterine bleeding, amenorrhea and ovulatory uterine bleeding ® May result from (but not limited to) endocrine disorders, obesity, excessive exercise and mental stress ® Patients may present with periods of amenorrhea followed by scant or heavy menstrual bleeding Not yet classified « Conditions that do not fit into any of the other aforementioned cate- gories (i.¢., arterial-venous mal- formation) (Endometrial « Endometrial causes are associated with regular ovulatory cycles (predictable bleeding) that are without structural abnor- mality AND presents with heavy menstrual bleeding * Infections may contribute to some forms of endometrial causes | of abnormal uterine bleeding Evaluation and management of abnormal uterine bleeding History A pelvic exam should be performed on any woman who is or has been sexually active and has irregular or heavy bleeding. • Visual inspection of the external genitalia (may reveal signs of androgen excess, trauma, or vaginal atrophy due to lack of estrogen) • A speculum examination should be performed to assess the vagina for foreign bodies, evidence of infection or trauma, as well as to assess the cervix for signs of abnormal growths, lesions or infection • A bimanual examination should be performed to assess the size and position of the uterus, presence of palpable masses, uterine tenderness and adnexal masses or tenderness Diagnostic Studies Testing decisions should be based on the differential diagnosis that is derived from the patient's history and physical. There are MANY tests and procedures that are available but not all should be performed. Generally speaking, perform the least invasive tests to narrow your differential and start with the most likely causes first. Table 24-4 in your textbook provides an excellent guide to ordering tests according to the condition that you are trying to rule out. Laboratory tests should be ordered selectively and must always include the patient in the testing and management plan. Tests that may be considered include: • Pregnancy test (qualitative vs. quantitative; asses for pregnancy or threatened abortion) • CBC with differential (assess for anemia or clotting disorder) • PT, aPTT (assess for bleeding disorder) • Serum ferritin (assess for iron deficiency; only necessary IF anemia is present) • TSH with reflex FT4 (assess for thyroid dysfunction) • Prolactin (assess for prolactinoma/pituitary adenoma) • FSH (assess for menopause or premature ovarian failure) • Cervical cytology (assess for atypical cells suggestive of dysplasia or cancer; follow current cervical screening guidelines) • Microscopic exam of vaginal secretion (assess for vaginal candidiasis orbacterial vaginosis) • STI testing of vaginal secretions (gonorrhea, chlamydia, trichomoniasis) • Ultrasonography (assess for abnormal masses) • Endometrial sampling* (assess for endometrial hyperplasia or cancer) • Hysteroscopy or Laparoscopy* (for biopsy and histology of an identified mass) (*) Requires a referral to OB/GYN Provider Tips • Unopposed estrogen stimulation of the endometrium results in endometrial hyperplasia which increases a woman's risk of endometrial cancer. The most common symptom is post-menopausal bleeding. Therefore, providers should assume that ALL women with post-menopausal bleeding OR women ≥ 45 years with AUB have endometrial cancer UNTIL proven otherwise with endometrial biopsy • In women of reproductive age, a complication of pregnancy must always be considered as a cause for abnormal uterine bleeding. Therefore, all women with AUB should be considered pregnant UNTIL proven otherwise Management and Treatment Definitive management of AUB should focus on normalizing bleeding, correcting anemia (if present), preventing cancer and restoring quality of life for the patient. The treatment options that are available for AUB are based on the cause and may include pharmacologic measures such as contraceptives, GnRHs, NSAIDs and antifibrinolytics. Non-pharmacological interventions typically include surgical methods such as endometrial ablation, thermal endometrium destruction, uterine artery embolization and hysterectomy. Referral is indicated for an unidentified cause of AUB, complicated cases, refractory treatment, and surgery. Breast mass types and diagnostic studies The most common benign breast masses are fibroadenomas and cysts. Lipomas, fat necroses, phyllodes tumors, hamartomas, and galactoceles may also be encountered. Fibroadenomas, which are composed of dense epithelial and fibroblastic tissue, are usually nontender, encapsulated, round, movable, and firm. They are the most common type of breast mass in adolescents and young women. Their incidence decreases with increasing age, but they still account for 12% of Diagnoses of Gynecologic Origin Nongynecologic Diagnoses Endometriosis Chronic pelvic inflammatory disease (PID) Dysmenorrhea, primary and secondary Gastrointestinal Irritable bowel syndrome (IBS) Pelvic adhesions Pelvic congestion Mittelschmerz Vulvodynia Uterine prolapse Ovarian cyst Ovarian remnant syndrome Adenomyosis Fibroids Ovarian cancer Cervical cancer Torsion of adnexa Tubo-ovarian abscess Uterine fibroids Ectopic pregnancy Abortion, threatened or incomplete • Diverticulitis • Constipation • Bowel obstruction • Appendicitis • Colon cancer • Gastroenteritis Genitourinary • Interstitial cystitis • Urinary tract infection • Urinary retention • Renal calculi • Pyelonephritis • Ureteral lithiasis • Bladder neoplasm Musculoskeletal • Scoliosis • Radiculopathy • Arthritis • Herniated disk • Hernia • Abdominal wall hematoma Other • Aortic aneurysm • Pelvic thrombophlebitis • Acute porphyria • Abdominal angina • Psychiatric, depression • Somatization disorder • Prior or current physical or sexual abuse • Diagnoses of Gynecologic Origin Nongynecologic Diagnoses Endometriosis Chronic pelvic inflammatory disease (PID) Dysmenorrhea, primary and secondary Gastrointestinal Irritable bowel syndrome (IBS) Pelvic adhesions Pelvic congestion Mittelschmerz Vulvodynia Uterine prolapse Ovarian cyst Ovarian remnant syndrome Adenomyosis Fibroids Ovarian cancer Cervical cancer Torsion of adnexa Tubo-ovarian abscess Uterine fibroids Ectopic pregnancy Abortion, threatened or incomplete • Diverticulitis • Constipation • Bowel obstruction • Appendicitis • Colon cancer • Gastroenteritis Genitourinary • Interstitial cystitis • Urinary tract infection • Urinary retention • Renal calculi • Pyelonephritis • Ureteral lithiasis • Bladder neoplasm Musculoskeletal • Scoliosis • Radiculopathy • Arthritis • Herniated disk • Hernia • Abdominal wall hematoma Other • Aortic aneurysm • Pelvic thrombophlebitis • Acute porphyria • Abdominal angina • Psychiatric, depression • Somatization disorder • Prior or current physical or sexual abuse • Diagnoses of Gynecologic Origin Nongynecologic Diagnoses Endometriosis Chronic pelvic inflammatory disease (PID) Dysmenorrhea, primary and secondary Gastrointestinal Irritable bowel syndrome (IBS) Pelvic adhesions Pelvic congestion Mittelschmerz Vulvodynia Uterine prolapse Ovarian cyst Ovarian remnant syndrome Adenomyosis Fibroids Ovarian cancer Cervical cancer Torsion of adnexa Tubo-ovarian abscess Uterine fibroids Ectopic pregnancy Abortion, threatened or incomplete • Diverticulitis • Constipation • Bowel obstruction • Appendicitis • Colon cancer • Gastroenteritis Genitourinary • Interstitial cystitis • Urinary tract infection • Urinary retention • Renal calculi • Pyelonephritis • Ureteral lithiasis • Bladder neoplasm Musculoskeletal • Scoliosis • Radiculopathy • Arthritis • Herniated disk • Hernia • Abdominal wall hematoma Other • Aortic aneurysm • Pelvic thrombophlebitis • Acute porphyria • Abdominal angina • Psychiatric, depression • Somatization disorder • Prior or current physical or sexual abuse • Diagnoses of Gynecologic Origin Nongynecologic Diagnoses Endometriosis Chronic pelvic inflammatory disease (PID) Dysmenorrhea, primary and secondary Gastrointestinal Irritable bowel syndrome (IBS) Pelvic adhesions Pelvic congestion Mittelschmerz Vulvodynia Uterine prolapse Ovarian cyst Ovarian remnant syndrome Adenomyosis Fibroids Ovarian cancer Cervical cancer Torsion of adnexa Tubo-ovarian abscess Uterine fibroids Ectopic pregnancy Abortion, threatened or incomplete • Diverticulitis • Constipation • Bowel obstruction • Appendicitis • Colon cancer • Gastroenteritis Genitourinary • Interstitial cystitis • Urinary tract infection • Urinary retention • Renal calculi • Pyelonephritis • Ureteral lithiasis • Bladder neoplasm Musculoskeletal • Scoliosis • Radiculopathy • Arthritis • Herniated disk • Hernia • Abdominal wall hematoma Other • Aortic aneurysm • Pelvic thrombophlebitis • Acute porphyria • Abdominal angina • Psychiatric, depression • Somatization disorder • Prior or current physical or sexual abuse • Diagnoses of Gynecologic Origin Nongynecologic Diagnoses Endometriosis Chronic pelvic inflammatory disease (PID) Dysmenorrhea, primary and secondary Gastrointestinal Irritable bowel syndrome (IBS) Pelvic adhesions Pelvic congestion Mittelschmerz Vulvodynia Uterine prolapse Ovarian cyst Ovarian remnant syndrome Adenomyosis Fibroids Ovarian cancer Cervical cancer Torsion of adnexa Tubo-ovarian abscess Uterine fibroids Ectopic pregnancy Abortion, threatened or incomplete • Diverticulitis • Constipation • Bowel obstruction • Appendicitis • Colon cancer • Gastroenteritis Genitourinary • Interstitial cystitis • Urinary tract infection • Urinary retention • Renal calculi • Pyelonephritis • Ureteral lithiasis • Bladder neoplasm Musculoskeletal • Scoliosis • Radiculopathy • Arthritis • Herniated disk • Hernia • Abdominal wall hematoma Other • Aortic aneurysm • Pelvic thrombophlebitis • Acute porphyria • Abdominal angina • Psychiatric, depression • Somatization disorder • Prior or current physical or sexual abuse • Diagnoses of Gynecologic Origin Nongynecologic Diagnoses Endometriosis Chronic pelvic inflammatory disease (PID) Dysmenorrhea, primary and secondary Gastrointestinal Irritable bowel syndrome (IBS) Pelvic adhesions Pelvic congestion Mittelschmerz Vulvodynia Uterine prolapse Ovarian cyst Ovarian remnant syndrome Adenomyosis Fibroids Ovarian cancer Cervical cancer Torsion of adnexa Tubo-ovarian abscess Uterine fibroids Ectopic pregnancy Abortion, threatened or incomplete • Diverticulitis • Constipation • Bowel obstruction • Appendicitis • Colon cancer • Gastroenteritis Genitourinary • Interstitial cystitis • Urinary tract infection • Urinary retention • Renal calculi • Pyelonephritis • Ureteral lithiasis • Bladder neoplasm Musculoskeletal • Scoliosis • Radiculopathy • Arthritis • Herniated disk • Hernia • Abdominal wall hematoma Other • Aortic aneurysm • Pelvic thrombophlebitis • Acute porphyria • Abdominal angina • Psychiatric, depression • Somatization disorder • Prior or current physical or sexual abuse • Diagnoses of Gynecologic Origin Nongynecologic Diagnoses Endometriosis Chronic pelvic inflammatory disease (PID) Dysmenorrhea, primary and secondary Gastrointestinal Irritable bowel syndrome (IBS) Pelvic adhesions Pelvic congestion Mittelschmerz Vulvodynia Uterine prolapse Ovarian cyst Ovarian remnant syndrome Adenomyosis Fibroids Ovarian cancer Cervical cancer Torsion of adnexa Tubo-ovarian abscess Uterine fibroids Ectopic pregnancy Abortion, threatened or incomplete • Diverticulitis • Constipation • Bowel obstruction • Appendicitis • Colon cancer • Gastroenteritis Genitourinary • Interstitial cystitis • Urinary tract infection • Urinary retention • Renal calculi • Pyelonephritis • Ureteral lithiasis • Bladder neoplasm Musculoskeletal • Scoliosis • Radiculopathy • Arthritis • Herniated disk • Hernia • Abdominal wall hematoma Other • Aortic aneurysm • Pelvic thrombophlebitis • Acute porphyria • Abdominal angina • Psychiatric, depression • Somatization disorder • Prior or current physical or sexual abuse • Diagnoses of Gynecologic Origin Nongynecologic Diagnoses Endometriosis Chronic pelvic inflammatory disease (PID) Dysmenorrhea, primary and secondary Gastrointestinal Irritable bowel syndrome (IBS) Pelvic adhesions Pelvic congestion Mittelschmerz Vulvodynia Uterine prolapse Ovarian cyst Ovarian remnant syndrome Adenomyosis Fibroids Ovarian cancer Cervical cancer Torsion of adnexa Tubo-ovarian abscess Uterine fibroids Ectopic pregnancy Abortion, threatened or incomplete • Diverticulitis • Constipation • Bowel obstruction • Appendicitis • Colon cancer • Gastroenteritis Genitourinary • Interstitial cystitis • Urinary tract infection • Urinary retention • Renal calculi • Pyelonephritis • Ureteral lithiasis • Bladder neoplasm Musculoskeletal • Scoliosis • Radiculopathy • Arthritis • Herniated disk • Hernia • Abdominal wall hematoma Other • Aortic aneurysm • Pelvic thrombophlebitis • Acute porphyria • Abdominal angina • Psychiatric, depression • Somatization disorder • Prior or current physical or sexual abuse • Diagnoses of Gynecologic Origin Nongynecologic Diagnoses Endometriosis Chronic pelvic inflammatory disease (PID) Dysmenorrhea, primary and secondary Gastrointestinal Irritable bowel syndrome (IBS) Pelvic adhesions Pelvic congestion Mittelschmerz Vulvodynia Uterine prolapse Ovarian cyst Ovarian remnant syndrome Adenomyosis Fibroids Ovarian cancer Cervical cancer Torsion of adnexa Tubo-ovarian abscess Uterine fibroids Ectopic pregnancy Abortion, threatened or incomplete • Diverticulitis • Constipation • Bowel obstruction • Appendicitis • Colon cancer • Gastroenteritis Genitourinary • Interstitial cystitis • Urinary tract infection • Urinary retention • Renal calculi • Pyelonephritis • Ureteral lithiasis • Bladder neoplasm Musculoskeletal • Scoliosis • Radiculopathy • Arthritis • Herniated disk • Hernia • Abdominal wall hematoma Other • Aortic aneurysm • Pelvic thrombophlebitis • Acute porphyria • Abdominal angina • Psychiatric, depression • Somatization disorder • Prior or current physical or sexual abuse • Diagnoses of Gynecologic Origin Nongynecologic Diagnoses Endometriosis Chronic pelvic inflammatory disease (PID) Dysmenorrhea, primary and secondary Gastrointestinal Irritable bowel syndrome (IBS) Pelvic adhesions Pelvic congestion Mittelschmerz Vulvodynia Uterine prolapse Ovarian cyst Ovarian remnant syndrome Adenomyosis Fibroids Ovarian cancer Cervical cancer Torsion of adnexa Tubo-ovarian abscess Uterine fibroids Ectopic pregnancy Abortion, threatened or incomplete • Diverticulitis • Constipation • Bowel obstruction • Appendicitis • Colon cancer • Gastroenteritis Genitourinary • Interstitial cystitis • Urinary tract infection • Urinary retention • Renal calculi • Pyelonephritis • Ureteral lithiasis • Bladder neoplasm Musculoskeletal • Scoliosis • Radiculopathy • Arthritis • Herniated disk • Hernia • Abdominal wall hematoma Other • Aortic aneurysm • Pelvic thrombophlebitis • Acute porphyria • Abdominal angina • Psychiatric, depression • Somatization disorder • Prior or current physical or sexual abuse • The most common gynecologic-related causes of chronic pelvic pain identified by laparoscopy are endometriosis (see Chapter 26 ) and adhesions (Rapkin & Nathan, 2012). Other common causes include ovarian remnant, retained ovary syndrome, pelvic congestion syndrome, pelvic relaxation causing prolapse of gynecologic organs (e.g., uterine prolapse; see Chapter 25), subacute salpingo- oophoritis (see Chapter 20), cancer of gynecologic origin (see Chapter 27 ), and ovarian hyperstimulation syndrome (OHSS). Pelvic adhesions are coarse bands of tissue that connect organs to other organs or to the abdominal wall in places where there should be no connection. Adhesions can be caused by previous surgeries, infection, or endometriosis (Hoffman, 2012 ; Rapkin & Nathan, 2012; Styer, 2013). They may be the etiology for infertility, dyspareunia, and bowel obstruction (Styer, 2013 ). Currently, the causal role of adhesions in pelvic pain is unknown. The myriad of symptoms range from mild intermittent abdominopelvic pain to constant pain with gastrointestinal (constipation, bloating, dyschezia), gynecologic (dyspareunia, dysmenorrhea, focal lateral or central pelvic and adnexal pain), and musculoskeletal symptoms (abdominal wall tenderness) (Styer, 2013 ). If symptoms are exacerbated during specific portions of the menstrual cycle (e.g., menses, luteal phase, follicular phase), then medical therapy should be considered with use of hormonal suppression of the cycle (Styer, 2013 ). If symptoms are constant, then use of nonsteroidal anti-inflammatory drugs (NSAIDs) and other forms of analgesics should be considered, with possible referral to a pain specialist (Styer, 2013 ). Etiology, diagnosis, and treatment of common breast disorders Clinical signs and symptoms of ectopic pregnancy Ectopic pregnancy is a potentially life-threatening form of pregnancy complication resulting from implantation of the fertilized egg outside the uterus, usually in the fallopian tube. With a prevalence of approximately 2% of reported pregnancies (Marion & Meeks, 2012), ectopic pregnancy is a leading differential diagnosis when a woman has lower abdominal pain in the first trimester. Risk factors include a history of pelvic inflammatory disease or infertility. However, if a woman who is newly pregnant is experiencing lower quadrant pain, it is important to rule out ectopic pregnancy even if she does not have risk factors. Any women with cervical motion tenderness on bimanual examination should be evaluated for ectopic pregnancy, as should any woman early in pregnancy with pelvic or abdominal pain. Bleeding, ranging from spotting to the amount that occurs during a menstrual period, can also be a symptom (Crochet et al., 2013). If the woman’s hCG level is more than 3,000 mIU/mL, a gestational sac should be visible within the uterus. Ectopic pregnancies tend to have slowly rising hCG levels that increase but do not double within 48 hours. Ectopic pregnancy is the implantation of a fertilized ovum in locations other than the uterine cavity. It is the second leading cause of maternal mortality in the United States (Marion & Meeks, 2012 ). Approximately 95% of all ectopic pregnancies occur in the fallopian tube (American College of Obstetricians and Gynecologists, are available for the treatment of VVC (Table 19-2 ), and no single brand is significantly more effective than another. Vaginal creams and suppositories recommended for treatment of this condition are oil based, so they may weaken latex condoms and diaphragms. Many effective topical azole drugs are available as OTC products; they have cure rates ranging from 80% to 90% (Sobel, 2007). Only women who have been previously diagnosed with VVC and who are experiencing the same symptoms should attempt self-treatment with OTC medications. Any woman whose symptoms persist or who develops a recurrence of symptoms within 2 months of treatment should be evaluated by a clinician (CDC, 2015). Unnecessary or inappropriate use of OTC preparations is common and can lead to delays in treating other causes of vulvovaginitis. BOX 19-1 Criteria for Clinical Diagnosis of Bacterial Vaginosis Clinical diagnosis of bacterial vaginosis is based on the presence of three out of four of the following Amsel criteria: • White, thin adherent vaginal discharge • pH ≥ 4.5 • Positive whiff/KOH test • Clue cells on microscopic examination (more than 20% of epithelial cells are clue cells) Vaginitis Recommended Regimens Alternative Regimens BV Metronidazole 500 mg orally twice a day for 7 days OR Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, daily for 5 days OR Clindamycin cream 2%, one full applicator (5 g) intravaginally, at bedtime for 7 days Pregnant Women Metronidazole 500 mg orally twice a day for 7 days OR Metronidazole 250 mg orally three times a day for 7 days OR Clindamycin 300 mg orally twice a day for 7 days Tinidazole 2 g orally once daily for 2 days OR Tinidazole 1 g orally once daily for 5 days OR Clindamycin 300 mg orally twice a day for 7 days OR Clindamycin ovules 100 g intravaginally once at bedtime for 3 days Pregnant Women None Recurrent BV Retreat with original therapy Metronidazole 0.75% intravaginally once weekly for 4–6 months OR Metronidazole 2 g orally and fluconazole 150 mg orally in a single dose once monthly Uncomplicated VVC Over-the-Counter Intravaginal Agents Clotrimazole 1% cream 5 g intravaginally for 7–14 days OR Clotrimazole 2% cream 5 g intravaginally for 3 days OR Miconazole 2% cream 5 g intravaginally for 7 days OR Miconazole 4% cream 5 g intravaginally for 3 days OR Miconazole 100 mg vaginal suppository, one suppository daily for 7 days OR Miconazole 200 mg vaginal suppository, one suppository daily for 3 days OR Miconazole 1,200 mg vaginal suppository, one suppository for 1 day OR Tioconazole 6.5% ointment 5 g intravaginally in a single application Prescription Intravaginal Agents Butoconazole 2% cream (single-dose bioadhesive product), 5 g intravaginally for a single application OR Terconazole 0.4% cream 5 g intravaginally for 7 days OR Terconazole 0.8% cream 5 g intravaginally for 3 days OR Terconazole 80 mg vaginal suppository, one suppository for 3 days Oral Agent Fluconazole 150 mg oral tablet, one tablet in single dose Pregnant Womena Topical azole therapy, applied for 7 days Complicated VVC Recurrent VVC Initial Therapy Longer duration of initial therapy, such as topical azole for 7–14 days OR Fluconazole 150 mg orally every third day for a total of 3 doses (days 1, 4, and 7) OR Itraconazole 200 mg orally twice daily for 3 days Recurrent VVC Maintenance Therapy Fluconazole 150 mg orally weekly for 6 months OR Itraconazole 100–200 mg daily for 6 months OR Miconazole 1,200 mg vaginal suppository, one suppository weekly for 6 months OR Intermittent use of topical treatments Severe VVC Topical azole for 7–14 days OR Fluconazole 150 mg in 2 sequential doses, second dose 72 hours after initial dose Non-albicans VVC Initial Therapy about a week after exposure, peak within 4 days, and subside over the next week. Multiple genital lesions develop at the site of infection, which is usually the vulva, but may be present anywhere in the anogenital area. Other commonly affected sites are the perianal area, vagina, and cervix. The lesions begin as small painful blisters or vesicles that become “unroofed,” leaving behind ulcerated lesions (see Color Plate 20 ). Individuals with a primary herpes infection often develop bilateral, tender, inguinal lymphadenopathy; vulvar edema; vaginal discharge; and severe dysuria (Hawkins et al., 2016 ). Ulcerative lesions last 4 to 15 days before crusting over, and new lesions may develop over a period of 10 days during the course of the infection. Cervicitis is also common with initial HSV-2 infections. The cervix may appear normal, or it may be friable, reddened, ulcerated, or necrotic if cervical lesions are present. A heavy, watery to purulent vaginal discharge is possible. Extragenital lesions may be present because of autoinoculation. Urinary retention and dysuria may occur secondary to autonomic involvement of the sacral nerve root (Hawkins et al., 2016 ). Women experiencing recurrent episodes of genital herpes typically develop only local symptoms that are less severe than those associated with the initial infection due to the initial immune response. Systemic symptoms are usually absent with recurrences, although the characteristic prodromal genital tingling is common. Recurrent lesions are unilateral, are less extensive than the original lesions, and usually last 7 to 10 days without prolonged viral shedding. Lesions begin as vesicles and progress rapidly to ulcers (Hawkins et al., 2016 ). Very few women with recurrent infection have cervicitis. Establishing a diagnosis of genital HSV can be challenging. Many individuals with HSV do not have overt symptoms. Thus, in making the diagnosis of genital herpes, a history of exposure to a person with HSV infection is important, although infection from an asymptomatic individual is common. A history of viral symptoms, such as malaise, headache, fever, or myalgia, is suggestive of HSV infection. Likewise, local symptoms such as vulvar pain, dysuria, itching, or burning at the site of infection, and painful genital lesions that heal spontaneously are very suggestive of HSV infection. The clinician should also ask about prior history of a primary infection, prodromal symptoms, vaginal discharge, dysuria, and dyspareunia. During the physical examination, the clinician should assess for inguinal and generalized lymphadenopathy and elevated temperature. Carefully inspect the entire vulvar, perineal, vaginal, and cervical areas for vesicles, ulcers, or crusted areas. A speculum examination may be very difficult for the patient because of the extreme tenderness often associated with genital herpes. Any genital lesion that is extremely tender should be tested for HSV even if the appearance is not consistent with the classic herpes lesions. Although a diagnosis of HSV infection may be suspected from the woman’s history and physical examination, it can be confirmed only by laboratory studies. Isolation of HSV in cell culture or by polymerase chain reaction (PCR) is the preferred test in women who have genital ulcers or other mucocutaneous lesions. Viral culture is less sensitive than PCR, with the best culture yield being found during a primary infection or if the specimen is taken during the vesicular stage of the infection—the sensitivity of a culture declines rapidly as lesions begin to heal. Both culture and PCR can be negative in a person with HSV infection because the virus is shed only intermittently (CDC, 2015d ). Type-specific serologic tests are useful in confirming a clinical diagnosis given the frequency of false-negative HSV cultures, especially in women with healing lesions or recurrent infection. Antibodies are present within the first several weeks after infection and persist indefinitely. Clinicians should be certain to specifically request serologic type-specific glycoprotein G (IgG)–based assays. Serologic test options include laboratory-based assays and point-of-care tests using capillary blood or serum during a clinic visit. The sensitivity of these tests varies from 80% to 98%, and false-negative results can occur, especially in early-stage infection when antibodies are still developing. If there is a strong clinical suspicion of HSV in the presence of a negative result, testing can be repeated within a few months. The specificity of these assays is 96% or greater, and false-positive results can occur in individuals with a low likelihood of HSV infection. Serologic screening for HSV is not recommended for the general population, but should be considered in women who experience recurrent or atypical genital symptoms with negative HSV cultures, have a clinical diagnosis of genital herpes without laboratory confirmation, present for STI evaluation (especially if they have multiple sexual partners), or have HIV. Testing should also be considered for asymptomatic partners of women with HSV infection (CDC, 2015d ). All women with genital herpes should be tested for other STIs, including chlamydia, gonorrhea, syphilis, and HIV. These drugs do not cure the infection, however, nor do they alter the subsequent risk, frequency, or rate of recurrence after discontinuation. Three antiviral medications provide clinical benefits for genital herpes: acyclovir, valacyclovir, and famciclovir (Table 20-4 ). Topical antiviral therapy is not recommended due to its minimal benefits (CDC, 2015d). TABLE 20-4 Treatment of Genital Herpes Primary Infectiona Recurrent Infection Suppressive Therapy Acyclovir 400 mg Acyclovir 400 mg orally 3 Acyclovir 400 mg orally 2 times a day orally 3 times a day times a day for 5 days or for 7–10 days or Famciclovir 250 mg orally 2 times a day or Acyclovir 800 mg orally 2 or Acyclovir 200 mg times a day for 5 days Valacyclovir 500 mg orally once a day (may be orally 5 times a day or less effective than other valacyclovir or for 7–10 days Acyclovir 800 mg orally 3 acyclovir dosing regiments in patients who or times a day for 2 days have 10 or more episodes per year) Famciclovir 250 mg or or orally 3 times a day Famciclovir 125 mg orally Valacyclovir 1 gm orally once a day for 7–10 days 2 times a day for 5 days or or Valacyclovir 1 gm Famciclovir 1,000 mg orally 2 times a day orally 2 times a day for