Dr seyed Mehdi Ahmadi OB & Gynecologist

2. Dr seyed Mehdi Ahmadi • OB & Gynecologist • Isfahan Fertility & Infertility Centre ( IFIC ) • Iran 17th Oct 2012

3. VulvovaginalCandidiasisClassification of VulvovaginalCandidiasis • Uncomplicated • Sporadic or infrequent in occurrence • Mild to moderate symptoms • Likely to be Candida albicans • Immunocompetent women • Complicated • Recurrent symptoms • Severe symptoms • Non-albicansCandida • Immunocompromised, e.g., diabetic women

4. Treatment The treatment of VVC is summarized as follows: 1. Topically applied azole drugs are the most commonly available treatment for VVC and are more effective than nystatin. Treatment with azoles results in relief of symptoms and negative cultures in 80% to 90% of patients who have completed therapy. Symptoms usually resolve in 2 to 3 days. Short-course regimens up to 3 days are recommended. Although the shorter period of therapy implies a shortened duration of treatment, the short -course formulations have higher concentrations of the antifungal agent, causing an inhibitory concentration in the vagina that persists for several days.

5. 2. The oral antifungal agent, fluconazole, used in a single 150-mg dose, is recommended for the treatment of VVC. It appears to have equal efficacy when compared with topical azoles in the treatment of mild to moderate VVC. Patients should be advised that their symptoms will persist for 2 to 3 days so they will not expect additional treatment. 3. Women with complicated VVC .benefit from an additional 150-mg dose fluconazolegiven 72 hours after the first dose. Patients with complications can be treated with a more prolonged topical regimen lasting 10 to 14 days. Adjunctive.

6. Vulvovaginal Candidiasis-Topical Treatment Regimens Butoconazole 2% cream, 5 g intravaginally for 3 days a.b Clotrimazole 1% cream, 5 g intravaginally for 7-14 days a.b 2% cream 5 g intravaginally for 3 days

7. Miconazole 2% cream, 5 g intravaginally for 7 days a.b 200-mg vaginal suppository for 3 days a 100-mg vaginal suppository for 7 days a.b 4% cream 5 g intravaginally for 3 days 1,200 mg vaginal suppository, one suppository for one day Nystatin 100,000-Uvaginal tablet, one tablet for 14 days

8. Tioconazole 6.5% ointment, 5 g intravaginally, single dosea Terconazole 0.4% cream, 5 g intravaginally for 7 daysa 0,8% cream, 5 g intravaginally for 3 daysa 80-mg suppository for 3 daysa a : Oil-based, may weaken latex condoms. b : Available as over-the-counter preparation. Treatment with a weak topical steroid, such as 1% hydrocortisone cream, may be helpful in relieving some of the external irrigative symptoms.

9. Recurrent VulvovaginalCandidiasis The treatment of patients with RVVC consists of inducing a remission of chronic symptoms withfluconazole(150 mg every 3 days for three doses). Patients should be maintained on a suppressive dose of this agent (fluconazole, 150 mg weekly) for 6 months. On this regimen, 90% of women with RVVC will remain in remission. After suppressive therapy, approximately half will remain asymptomatic. Recurrence will occur in the other half and should prompt reinstitution of suppressive therapy.

11. Bacterial Vaginosis Treatment: Ideally, treatment of BV should inhibit anaerobes but not vaginal lactobacilli. The following treatments are effective: 1. Metronidazole, an antibiotic with excellent activity against anaerobes but poor activity against lactobacilli, is the drug of choice for the treatment of BV.A dose of 500 mg administered orally twice a day for 7 days should be used. Patients should be advised to avoid using alcohol during treatment with oral metronidazole and for24 hours thereafter.

12. 2. Metronidazole gel, 0.75%, one applicator (5 g) intravaginally once daily for 5 days, may also be prescribed. The overall cure rates range from 75% to 84% with the aforementioned regimens. Clindamycin in the following regimens is effective in treating BV: 1. Clindamycin ovules, 100 mg, intravaginally once at bedtime for 3 days 2. Clindamycin bioadhesive cream, 2%, 100 mg intravaginally in a single dose 3. Clindamycin cream, 2%, one applicator full (5 g) intravaginally at bedtime for 7 days 4.Clindamycin, 300 mg, orally twice daily for 7 days

13. Many clinicians prefer intravaginaltreatment to avoid systemic side effects such as mild to moderate gastrointestinal upset and unpleasant taste. Treatment of the male sexual partner does not improve therapeutic response and therefore is not recommended.

14. TrichomonasVaginitis Treatment The treatment of trichomonal vaginitis can be summarized as follows: 1. Metronidazole is the drug of choice for treatment of vaginal trichomoniasis. Botha single-dose (2 g orally) and a multidose (500 mg twice daily for 7 days) regimen are highly effective and have cure rates of about 95%. 2. The sexual partner should be treated.

15. 3. Metronidazole gel, although effective for the treatment of BV, should not be used for the treatment of vaginal trichomoniasis. 4. Women who do not respond to initial therapy should be treated again with metronidazole, 500 mg, twice daily for 7 days. If repeated treatment is not effective, the patient should be treated with a single 2-g dose of metronidazole once daily for 5 days or tinidazole, 2 g, in a single dose for 5 days. 5. Patients who do not respond to repeated treatment with metronidazole or tinidazole and for whom the possibility of reinfection is excluded should be referred for expert consultation. In these uncommon refractory cases, an important part of management is to obtain cultures of the parasite to determine its susceptibility to metronidazole andtinidazole.

16. Inflammatory Vaginitis • Initial therapy is the use of 2% clindamycincream, one applicator full (5 g) intravaginally once daily for 7 days. Relapse occurs in about 30% of patients. who should be retreated with intravaginal2% clindamycin cream for 2 weeks. When relapse occurs in postmenopausal patients. supplementary hormonal therapy should be considered

17. Cervicitis Treatment: Treatment of cervicitis consists of an antibiotic regimen recommended for the treatment of uncomplicated lower genital tract infection with both chlamydia and gonorrhea. Fluoroquinoloneresistance is common in Neisseria gonorrhoeae isolates, and, therefore, these agents are no longer recommended for the treatment of women with gonococcal cervicitis. It is imperative that all sexual partners be treated with a similar antibiotic regimen. Cervicitis is commonly associated with BV, which, if not treated concurrently, leads to significant persistence of the symptoms and signs of cervicitis.

18. Treatment Regimens for Gonococcal and Chlamydial Infections Neisseria gonorrhoeaeendocervicitis Ceftriaxone, 250 mg 1Min a single dose, or, if not an option Cefexime, 400 mg in a single dose Chlamydia trachomatis endocervicitis Azithromycin, 1 g orally (single dose), or Doxycycline, 100 mg orally twice daily for 7 days

19. Pelvic InflammatoryDisease Clinical Criteria for the Diagnosis of Pelvic Inflammatory Disease: Symptoms: None necessary Signs: Pelvic organ tenderness leukorrhea and/or mucopurulentendocervicitis

20. Additional criteria to increase the specificity or the diagnosis: Endometrial biopsy showing endometritis Elevated C-reactive protein or erythrocyte sedimentation rate Temperature higher than 38°C (1OOAOF) leukocytosis Positive test for gonorrhea or chlamydia Elaborate criteria: Ultrasound documenting tubo-ovarian abscess laparoscopy visually confirming salpingitis

21. Guidelines for Treatment of Pelvic Inflammatory Disease Outpatient Treatment Cefoxitin, 2 g intramuscularly, plus probenecid, 1 g orally concurrently, or Ceftriaxone, 250 mg intramuscularly, or Equivalent cephalosporin Plus: Doxycycline, 100 mg orally 2 times daily for 14 days, or Azithromycin, 500 mg initially and then 250 mg daily for a total of 7 days

22. Inpatient Treatment: Regimen A: Cefoxitin, 2 g intravenously every 6 hours, or Cefotetan, 2 g intravenously every 12 hours Plus: Doxycycline, 100 mg orally or intravenously every 12 hours Regimen B: Clindamycin, 900 mg intravenously every 8 hours Plus: Ceftriaxone, 1-2 g intravenously every 12 hours, or Gentamicin, loading dose intravenously or intramuscularly (2 mg/kg of body weight) followed by a maintenance dose (1.5 mg/kg) every 8 hours

24. Genital Ulcer Disease Treatment: Chancroid: Recommended regimens for the treatment of chancroid include azithromycin, 1 g orally in a single dose; ceftriaxone, 250 mg intramuscularly in a single dose; ciprofloxacin, 500 mg orally twice a day for 3 days; or erythromycin base, 500 mg orally four times daily for 7 days. Patients should be reexamined 3 to 7 days after initiation of therapy to ensure the gradual resolution of the genital ulcer, which can be expected to heal within 2 weeks unless it is unusually large.

25. Herpes: A first episode of genital herpes should be treated with acyclovir, 400 mg orally three times a day; or famciclovir, 250 mg orally three times a day; or valacyclovir, 1.0 orally twice a day for 7 to 10 days or until clinical resolution is attained. Although these agents provide partial control of the symptoms and signs of clinical herpes, it neither eradicates latent virus nor affects subsequent risk, frequency, or severity of recurrences after the drug is discontinued. Daily suppressive therapy (acyclovir, 400 mg orally twice daily; or famciclovir, 250 mg twice daily; or valacyclovir, 1.0g orally once a day) reduces the frequency of HSV recurrences by at least 75% among patients with six or more recurrences of HSV per year. Suppressive treatment partially, but not totally, decreases symptomatic and asymptomatic viral shedding and the potential for transmission.

26. Syphilis Parenteral administration of penicillin G is the preferred treatment of all stages of syphilis. Benzathine penicillin G, 2.4 million units intramuscularly in a single dose, is the recommended treatment for adults with primary, secondary, or early latent syphilis. The Jarisch-Herxheimerreaction-an acute febrile response accompanied by headache, myalgia, and other symptoms mayoccur within the first 24 hours after any therapy for syphilis; patients should be advised of this possible adverse reaction.

27. Genital Warts Human Papillomavirus (HPV) Papillomavirus Treatment • Primary goal for treatment of visible warts is the removal of symptomatic warts • Therapy may reduce but probably does not eradicate infectivity • Difficult to determine if treatment reduces transmission • No laboratory marker of infectivity • Variable results utilizing viral DNA

28. HPV Treatment Options • Chemical agents • Cryotherapy • Electrosurgery • Surgical excision • Laser surgery • Imiquimod (Aldara) • Defer treatment • Natural therapies

29. Papillomavirus • Surgical removal • Patient-applied Podofilox (Condylox) 0.5% solution or gel Apply 2x/day for 3 days, followed by 4 days of no therapy. Repeat as needed, up to 4x or Imiquimod (Aldara) 5% cream Apply 1x/day @ bedtime 3x/week for up to 16 weeks • Provider-administered Cryotherapy (liquid nitrogen) *repeat every 1-2 weeks or Podophyllin resin 10-25% *thoroughly wash off in 1-4 hrs or Trichloroacetic or Bichloroacetic acid 80-90% *can be repeated weekly

30. Papillomavirus Vaginal warts Cryotherapy or TCA/BCA 80-90% Urethral meatal warts Cryotherapy or podophyllin 10-25% Anal warts Cryotherapy or TCA/BCA 80-90%

31. Papillomavirus • Therapy choice needs to be guided by preference of patient, experience of provider, and patient resources (time and/or money) • No evidence exists to indicate that any one regimen is superior • An acceptable alternative may be to do nothing but watch and wait; possible regression/uncertain transmission

32. HumanImmunodeficiency Virus • Decisions regarding the initiation of antiretroviral therapy should be guided by monitoring the laboratory parameters of HIV RNA (viral load) and CD4+ T-cell count, and the clinical condition of the patient. The primary goals of antiretroviral therapy are maximal and durable suppression of viral load, restoration or preservation of immunologic function, improvement of quality of life, reduction of mV-related morbidity and mortality, and prevention of mv transmission.

33. Antiretroviral therapy should be initiated in all women with a history of an AIDS-defining illness or with a CD4 count less than 350 cells per mm3. • Antiretroviral treatment should be started regardless of CD4 count in women with the following conditions: pregnancy, HIV-associated nephropathy, and hepatitis B coinfection when treatment of hepatitis B is indicated. Patients must be willing to accept therapy to avoid the emergence of resistance caused by poor compliance.

34. Dual nucleoside regimens used in addition to a protease inhibitor or non nucleoside reverse transcriptase inhibitor provide a better durable clinical benefit than monotherapy. • Patients with less than 200 CD4+ T cells per µ,L should receive prophylaxis against opportunistic infections, such as trimethoprim/sulfamethoxazoleor aerosolpentamidinefor the prevention of PCP pneumonia. Those with less than 50 CD4+ T cells per uL should receive azithromycinprophylaxis for mycobacterial infections.

35. Aberrations of Pubertal Development I. Delayed or interrupted puberty A. Anatomic abnormalities of the genital outflow tract 1. Mulleriandysgenesis (Rokitansky-Kuster-Hauser syndrome) 2. Distal genital tract obstruction a. Imperforate hymen b. Transverse vaginal septum B. Hypergonadotropic (follicle-stimulating hormone >30 mlUlmL) hypogonadism (gonadal "failure") 1. Gonadal dysgenesis with stigmata of Turner syndrome 2. Pure gonadal dysgenesis a. 46,XX b. 46,XY 3. Early gonadal "failure" with apparent normal ovarian development

36. C. Hypogonadotropic (luteinizing hormone and follicle stimulating hormone < 10 mlU/mL) hypogonadism 1. Constitutional delay 2. Isolated gonadotropin deficiency a. Associated with midline defects (Kallmann syndrome) b. Independent of associated disorders c. Prader-Labhart-Willi syndrome d. Laurence-Moon-Bardet-Biedl syndrome e. Many other rare syndromes 3. Associated with multiple hormone deficiencies 4. Neoplasms of the hypothalamic-pituitary area a. Craniopharyngiomas b. Pituitary adenomas c. Other

37. 5. Infiltrative processes (Langerhans cell-typehistiocytosis) 6. After irradiation of the central nervous system 7. Severe chronic illnesses with malnutrition 8. Anorexia nervosa and related disorders 9. Severe hypothalamic amenorrhea (rare) 10. Antidopaminergic and gonadotropin-releasing hormone-inhibiting drugs (especially psychotropic agents, opiates) 11. Primary hypothyroidism 12. Cushing syndrome 13. Use of chemotherapeutic (especially alkylating) agents

38. II. Asynchronous pubertal development A. Complete androgen insensitivity syndrome (testicular feminization) B. Incomplete androgen insensitivity syndrome III. Precocious puberty A. Central (true) precocious puberty 1. Constitutional (idiopathic) precocious puberty 2. Hypothalamic neoplasms (most commonly hamartomas) 3. Congenital malformations 4. Infiltrative processes (Langerhans cell-type histiocytosis) 5. After irradiation 6. Trauma 7. Infection

39. B. Precocious puberty of peripheral origin (precocious pseudopuberty) 1. Autonomous gonadal hypersecretion a. Cysts b. McCune-Albright syndrome 2. Congenital adrenal hyperplasia a. 21-Hydroxylase (P450c21) deficiency b. 11,ß-Hydroxylase (P450cll) deficiency c. 3ß-Hydroxysteroid dehydrogenase deficiency 3. Iatrogenic ingestion/absorption of estrogens or androgens 4. Hypothyroidism 5. Gonadotropin-secreting neoplasms

41. a. Human chorionic gonadotropin secreting i. Ectopic germinomas (pinealomas) ii. Choriocarcinomas iii. Teratomas iv. Hepatoblastomas b. Luteinizing hormone-secreting (pituitary adenomas) 6. Gonadal neoplasms a. Estrogen-secreting i. Granulosa-theca cell tumors ii. Sex-cord tumors b. Androgen-secreting i. Sertoli-Leydig cell tumors (arrhenoblastomas) ii. Teratomas 7. Adrenal neoplasms a. Adenomas b. Carcinomas

42. IV. Heterosexual puberty A. Polycystic ovarian syndrome B. Nonclassic forms of congenital adrenal hyperplasia C. Idiopathic hirsutism D. Mixed gonadal dysgenesis E. Rare forms of male pseudohermaphroditism (Reifenstein syndrome, Sa-reductase deficiency) F. Cushing syndrome (rare) G. Androgen-secreting neoplasms (rare)

43. Differential Diagnosis of Acute Pelvic Pain

44. Acute Pain 1. Complication of pregnancy a. Ectopic pregnancy b. Abortion, threatened or incomplete 2. Acute infection a. Endometritis b. Pelvic inflammatory disease (acute PID) or salpingo-oophoritis c. Tubo-ovarian abscess 3. Adnexal disorders a. Hemorrhagic functional ovarian cyst b. Torsion of adnexa C. Rupture of functional, neoplastic, or inflammatory ovarian cyst

45. Recurrent Pelvic Pain 1. Mittelschmerz (midcycle pain) 2. Primary dysmenorrhea 3. Secondary dysmenorrhea Gastrointestinal 1. Gastroenteritis 2. Appendicitis 3. Bowel obstruction 4. Diverticulitis 5. Inflammatory bowel disease 6. Irritable bowel syndrome

46. Genitourinary1. Cystitis2. Pyelonephritis3. Ureteral lithiasis Musculoskeletal 1. Abdominal wall hematoma 2. Hernia Other 1. Acute porphyria 2. Pelvic thrombophlebitis 3. Aortic aneurysm 4. Abdominal angina

47. Leaking or Rupture of anOvarian Cyst Management: Orthostatic, significant anemia, hematocrit of the culdocentesis fluid of greater than 16%, or a large amount of free peritoneal fluid on ultrasound suggests significant hemoperitoneum and usually requires surgical management by laparoscopy or laparotomy. Patients who are not orthostatic or febrile, who are not pregnant or anemic, and who have only a small amount of fluid in the cul-de-sac can often be observed in the hospital, without surgical intervention, or even discharged home from the emergency room after observation.

48. Adnexal Torsion Adnexal torsion must be treated surgically. The adnexa may be untwisted and a cystectomy Performed if appropriate. Even if it appears that necrosis occurred, there is evidence that it remains functional and sparing the adnexa can preserve its hormonal and reproductive function. Treatment can be accomplished by laparoscopy or laparotomy, depending on the size of the mass.

49. Tubo-Ovarian Abscess Tubo-ovarian abscesses should always be treated as an inpatient, and conservative medical therapy with broad spectrum antibiotics can be attempted . In one study, this yielded a treatment success rate of 75% . If the patient is persistently febrile or not improving clinically, CT or ultrasound-guided drainage of the abscesses should be undertaken.

50. CT-guided percutaneous drainage can be achieved trans abdominally or Trans vaginally. Drainage along with intravenous antibiotics is considered first-line therapy. If fertility is not desired, bilateral salpingo-oophorectomy and hysterectomy will provide definitive therapy.