Medical brain notes 42

  Sexually Transmitted Diseases Sexually transmitted diseases  (STDs) are one of   the most common gynecologic problems in sexu-ally active women. STDs can be transmitted by oral, vaginal, or anal sex. The transmission of an STD may  have varied consequences, including infertility, cancer, and even death. STDs are the most common cause of pre-ventable infertility and are strongly associated with ectopic pregnancy. Sexually transmitted infections may increase the risk of HIV acquisition; preventing STDs is therefore an important strategy in preventing HIV infections. STDs can also take an individual toll, resulting in pain, discomfort, and strain on personal relationships.   Most STDs require skin-to-skin contact or exchange of body fluids for transmission. Anal sex poses a particu-larly high risk, because tissues in the rectum break easily, and organisms can be transmitted through these breaks. Several STDs can be transmitted through oral-genital con-tact. Some ...

  GENERAL DIAGNOSTIC PRINCIPLES   Many sexually transmitted infections are asymptomatic in women or are asymptomatic during the initial stages of the infection.  The signs and symptoms of many STDs may be char-acterized by genital ulcers or infection of the cervix (cervicitis), ure-thra (urethritis), or both  (Table 27.2). Because 20% to 50% ofpatients with one STD have a coexisting infection, when one infection is confirmed, other infections must be suspected.   Because of the variations in signs and symptoms and the asymptomatic presentation of STDs, a thorough sexual history and physical examination are essential in detecting the presence of an STD. The findings obtained through a systematic physical assessment, combined with the patient’s history, usually help make the proper diagnosis. The inguinal region should be evaluated for rashes, lesions, and adenopathy. The vulva, perineum, and perianal areas should be inspected for lesions or ulcerations, and palpa...

  SCREENING   STD screening for nonpregnant women depends on the age of the patient and assessment of risk factors (Box 27.1).   The diagnosis of certain STDs should also prompt screen-ing for other sexually transmitted infections. When a patient is diagnosed with cervicitis, she should also be screened for PID, chlamydial infection, gonorrhea, bacterial vaginosis, and trichomoniasis and treated, if necessary. A woman diag-nosed with PID should be tested for chlamydial infection, gonorrhea, and HIV. Box 27.1 ACOG STD Screening Recommendations Routine Screening: Sexually active women 25 years and younger should be routinely screened for chlamydial infection. All sexually active adolescents should be routinely screened for gonorrhea. Women with developmental disabilities should be screened for STDs. HIV screening is recommended for all women who are or ever have been sexually active. (Physicians should be aware of and follow their states’ HIV screening requirements.) Screen...

  PREVENTION   Prevention of STDS involves educating patients about delaying sexual activity, limiting the number of sexual partners, and the use of condoms. For some STDs, immu-nizations are available to reduce or prevent transmission, including human papillomavirus (HPV) and hepatitis B.   Patient notification is an important part of prevention. When an STD is diagnosed, the patient’s sexual partner(s) should also be evaluated. In the United States, cases of gon-orrhea, chlamydial infection, and syphilis must be reported to local health departments. Treatment of male sexual part-ners is important in the prevention of reinfection with cer-tain STDs.  In expedited partner therapy, a patient’s sexualpartner receives drug therapy for an STD without undergoing physical evaluation or testing.  Although in most cases thisform of therapy does not result in adverse reactions, it can pose a significant risk. Sexual partners should always be encouraged to seek medical ev...

  Chlamydia Trachomatis   Chlamydia trachomatis  is a gram-negative obligate intracel-lular bacterium that lacks the metabolic and biochemical ability to produce adenosine triphosphate (ATP) and pref-erentially infects columnar epithelial cells. Chlamydial infection is the most frequently reported infectious disease in the United States. In 2006, over one million cases were reported to the Centers for Disease Control and Pre-vention. Despite the high number of reported cases, most cases of chlamydial infection are unreported. It is estimated that over 1.7 million cases of chlamydial infections remain undiagnosed each year.  If untreated, up to 40% of women withchlamydia will develop  pelvic inflammatory disease (PID),  which can result in significant complications, including ectopic pregnancy, chronic pelvic pain, and infertility.  Chlamydialinfections are also responsible for nongonococcal urethritis and inclusion conjunctivitis. Because of the seriou...

  Neisseria gonorrhoeae  (Gonorrhea)   Infections with  N. gonorrhoeae,  a gram-negative intra-cellular diplococcus, are the second most common STD in the United States. It is estimated that 600,000 new cases of gonorrhea occur each year in the United States, and less than half of them are reported to the Centers for Disease Control. The emergence of  antimicrobial-resistant strains,  an increased frequency of asympto-matic infections, and changing patterns of sexual behavior have all contributed to a rise in its incidence.  The highestrates of infection are seen in adolescents and young adults. N. gonorrhoeae  infection can lead to PID with its concur-rent risks of infertility caused by adhesion formation, tubal damage, and hydrosalpinx formation. Studies also suggest that infection with N. gonorrhoeae may facilitate trans-mission of HIV. Infections with  N. gonorrhoeae  are easily acquired by women and can affect the genital tract...

  Pelvic Inflammatory Disease   Pelvic inflammatory disease  (PID) represents the mostserious form of sexually transmitted disease. It involves infection of the upper genital tract (endometrium, fallopian tubes, ovaries, and pelvic peritoneum) as a result of direct spread of pathogenic organisms along mucosal surfaces after initial infection of the cervix. The predominant organ-isms responsible for PID are  C. trachomatis  and  N. gonor-rhoeae.  Other organisms that have been isolated from thefallopian tubes of patients with PID include  Mycoplasma,Streptococcus, Staphylococcus, Haemophilus, Escherichia coli, bac-teroides, Peptostreptococcus, Clostridium,  and  Actinomyces.   Timing of cervical infection in relation to the menstrual cycle is important; the endocervical mucus resists upward spread, especially during the progesterone-dominant part of the cycle. Oral contraceptives mimic this effect, which explains in part their action...

  Genital Herpes   Genital herpes  is caused by infection with the herpes sim-plex virus (HSV), a DNA virus. This condition affects more than 50 million persons in the United States, and as many as 75% of primary infections go unrecognized by either patient or provider. Herpes simplex infections are highly contagious. There are two types of HSV—HSV-1, which is associated with cold sore lesions of the mouth but may also cause genital lesions, and HSV-2. Most HSV genital infections are caused by HSV-2, but genital HSV-1 infec-tions are becoming increasingly common, particularly among adolescent and young women.  Up to 80% of new gen-ital infections among women may be due to HSV-1, with the highest rates occurring in adolescents and young adults.  Womeninfected with HSV-1 remain at risk for acquiring HSV-2 infection.   Box 27.3 Suggested Criteria for Hospitalization for Pelvic Inflammatory Disease ·          Surgical eme...