CHAPTER 25

WOMENS HEALTH FOR THE PHYSICIAN

Andrew Korda

ABNORMAL UTERINE BLEEDING

CHAPTER OUTLINE Diagnosis
INFERTILITY Management
Age and infertility DYSMENORRHEA
Anovulatory infertility
Hyperprolactinemia VULVAR CONDITIONS
Infertility due to anatomical abnormalities of Management
the reproductive tract Conditions with abnormalities on examination
Male factor infertility SEXUALLY TRANSMITTED INFECTIONS
Unexplained infertility (STIs)
CONTRACEPTION Chlamydia
Steroidal contraception Gonorrhea
Non-steroidal contraception PELVIC INFLAMMATORY DISEASE (PID)
Emergency contraception
Clinical features
MENOPAUSAL SYMPTOMS Treatment
PREMENSTRUAL SYNDROME SEXUAL PROBLEMS
Treatment

Primary infertility implies no previous pregnancy; secondary

INFERTILITY
CLINICAL PEARL
Infertility is the failure of a couple to conceive:
after 12 months of regular intercourse without use
of contraception in women less than 35 years of
age
after 6 months of regular intercourse without use
of contraception in women 35 years and older.
infertility is defined by an inability to conceive following a
history of any antecedent pregnancy, including abortion,
and ectopic pregnancies.
Overall, the great majority (8090%) of apparently nor-
mal couples will conceive within the first year of trying.
The prevalence of infertility is approximately 7% in the
general population.
In developed countries, the various sources of infertility
are classified as shown in Table 25-1 (overleaf).

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Essentials of internal medicine

Table 25-1 Types of infertility Investigation of infertility should commence in couples

who have not been able to conceive after 12 months of
TYPE PREVALENCE unprotected and frequent intercourse, but earlier assess-
ment (after 6 months) can be started in women over
Female factor infertility 4055% 35years of age.
Male factor infertility 2540% The timing of the initial investigation into infertility
also depends on the couples risk factors.
Both male and female factor infertility 10%
Infertility is stressful for most couples. It is important to
Unexplained infertility 10% appreciate that couples may have multiple factors contrib-
uting to their infertility; therefore, a complete initial diag-
Age and infertility nostic evaluation, including a detailed history and physical
An increasing number of women older than 35 years will examination, should be performed. This will detect the
seek treatment for infertility, as a womans fertility is known most common causes of infertility. Evaluation of both part-
to decline with age, and the number of women wishing to ners should be performed concurrently.
conceive between 35 and 45 years old is increasing. The following tests are valuable in most couples with
infertility:
The possibility for oocytes to be fertilized and develop
naturally is compromised with increasing age. menstrual history
There is a clear inverse relationship between fertility semen analysis
and female age, and spontaneous pregnancies are rarely assessment of LH (luteinizing hormone) surge prior to
reported after the age of 45. ovulation
Significant changes in ovarian and uterine physiology a hysterosalpingogram to assess tubal patency and the
also occur with advancing age, specifically loss of oocyte uterine cavity
integrity and decreased uterine receptiveness. day 3 serum FSH (follicle-stimulating hormone) and
As women age, there is also an increase in the prevalence estradiol levels
of gynecological and systemic disease, such as endo-
serum prolactin estimation
metriosis, pelvic infection, fibroids, diabetes, obesity,
hypertension and smoking-related diseases. evaluation of thyroid function
In women older than 35 who seek infertility treatment, pelvic ultrasound examination to determine the pres-
prompt and complete investigation of fertility should be ence of uterine fibroids and ovarian cysts
offered so that any correctible conditions can be treated diagnostic laparoscopy to identify endometriosis, or
as soon as possible. other pelvic pathology such as tubal disease hydro-
Some causes of infertility, such as azoospermia, longstand- tubation for tubal patency
ing amenorrhea, or bilateral tubal obstruction, are easy to assessment of ovarian reserve in women over 35 years of
determine. However, the situation is often less clear: sperm
age, which may involve a clomiphene (clomifene) chal-
may be reduced in number, but not absent; there may be oli-
lenge test, ultrasound for early follicular antral follicle
gomenorrhea with some ovulatory cycles; the woman may
count, day 3 serum inhibin B12 levels, or anti-Mllerian
have partial tubal obstruction; or a menstrual history may
suggest intermittent ovulation. hormone measurements.
In general terms, the likelihood of causes is as given in The utility of measurement of anti-sperm antibodies is not
Table 25-2. established.
Once the cause of infertility is identified, therapy is
Table 25-2 Causes of infertility aimed at correcting reversible causes and overcoming irre-
versible factors.
APPROXIMATE The couple should also be counseled on lifestyle modi-
CAUSE INCIDENCE fications to improve fertility, such as cessation of smoking,
reducing excessive caffeine and alcohol consumption, loss
Male factor hypogonadism, post- 26% of weight (especially in overweight women), and the appro-
testicular defects, seminiferous priate timing and frequency of intercourse (every 12 days
tubule dysfunction around the expected time of ovulation).
Ovulatory dysfunction 21%
Tubal damage 14%
Anovulatory infertility
Ovulatory dysfunction and anovulation affect 1525% of all
Endometriosis 6% infertile couples seeking therapy.
Coital problems 6% Treatment of ovulation disorders, if isolated, remains
one of the most successful of all infertility treatments.
Cervical factor 3%
Post-treatment conception at 2 years is between 78%
Unexplained 28% and 96%.

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Initial treatment is most commonly with clomiphene
citrate (clomifene), a selective estrogen receptor modu-
lator which stimulates ovulation induction.
Patients with some degree of insulin resistance might
require some adjuvant therapy to clomiphene. Cor-
rection of hyperinsulinemia will increase the rate of
spontaneous ovulation, and also increase the response
to clomiphene. This is best achieved by the use of met-
formin, an insulin-sensitizing agent.
Prior to metformin treatment, a patient should be
screened for insulin resistance.
In the event that patients do not conceive on clomi-
phene citrate and metformin, other medications have
been useful; such as adrenal steroid therapy, and gonad-
otropins, with or without gonadotropin-releasing hor-
mone (GnRH) agonists or GnRH antagonists.
Hyperprolactinemia
Hyperprolactinemia is present in 23% of patients with
amenorrhea, and 8% of patients with oligomenorrhea. Ele-
vated prolactin is believed to be a cause of anovulation by
impairing gonadotropin pulsatility, and the arrangement of
the estrogen-positive feedback effect of LH secretion.
CLINICAL PEARL
Prolactin can be increased by physiological events, such
as stress, or a normal breast or pelvic examination.
Patients who have elevated prolactin levels should also
be screened for hypothyroidism and for a pituitary gland
mass.
Treatment is usually with bromocriptine, an ergot-alkaloid
dopamine-receptor agonist, which directly inhibits prolac-
tin secretion.
Infertility due to anatomical
abnormalities of the reproductive tract
In the event of tubal pathology, surgical treatment
of tubal disease or assisted conception to overcome
thetubal obstruction are the treatments of choice.
If fibroids involve a significant portion of the endo-
metrium or obstruct the tubal ostium, their removal
is warranted. Additionally, a submucous fibroid larger
than 2cm needs to be removed as it is associated with
increased risk of abortion.
Ashermans syndrome, a condition characterized by
adhesive scarring of the endometrium, needs to be
treated with hysteroscopic resection of adhesions.
Endometrial polyps, if diagnosed by imaging studies,
should be removed.
Endometriosis, if minimal to mild, should be treated
surgically. There is no supportive literature to undergo
surgical treatment for moderate to severe endometriosis,
and therefore these women should be offered fertility
treatments.
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Chapter 25 Womens health for the physician
Male factor infertility
Only 6% of infertile men have conditions for which therapy
of confirmed benefit is available.
Treatment of most infertile men mostly involves tech-
niques that use available sperm, rather than fruitless
efforts to improve sperm concentration or motility.
There is some evidence that repairing a varicocele may
improve pregnancy rates.
Intra-uterine insemination will sometimes be used in
cases of asthenospermia.
Use of a sperm donor bank will sometimes be chosen by
a couple after a few attempts at conception.
CLINICAL PEARL
At least 2540% of infertility is attributable to abnor-
malities in male reproductive function. It is, therefore,
important to evaluate the male partner as an integral
part of the infertility work-up.
Unexplained infertility
Unexplained infertility is diagnosed when other causes have
been excluded. It is a term applied to an infertile couple for
whom standard investigations yield normal results.
Without treatment, up to 60% of couples with unex-
plained infertility will conceive within 3 years.
After 3 years of infertility, the pregnancy rate without
treatment decreases by 2% every month of infertility.
The most sensible option for unexplained infertility is
assisted conception such as IVF (in-vitro fertilization).
It is important to understand that women who use
infertility therapies such as IVF appear to have a small
but statistically significant increase in risk of pregnancy
complications, such as pre-term birth and abnormal
placentation.
Compared with the general population, an increased
risk of poor pregnancy outcomes has been observed
among untreated subfertile women who conceive
naturally.
CONTRACEPTION
About half of all pregnancies in the United States are
unplanned and almost a half of these occur in women using
contraception. About half of women aged 1544 years have
experienced an unwanted pregnancy.
Fertility control is an important contributor to repro-
ductive health. It has been well documented that fertility
regulation has significantly decreased maternal mortality.
An understanding of the available contraceptive methods
allows clinicians to advise women about the methods that
are most consistent with their routine and viewpoint, and
therefore most likely to be successful.
The most popular contraceptive methods are given in
Table 25-3 (overleaf).
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Essentials of internal medicine

Table 25-3 Methods of contraception Cerebrovascular disease

Oral contraceptives are contraindicated in the presence of
APPROXIMATE cerebrovascular disease, as they increase the risk of stroke in
CONTRACEPTIVE METHOD RATE OF USE women with other underlying risk factors.
Oral contraception 31% Migraine and headache
Female sterilization 27% Patients with a history of migraine and headache should use
oral contraceptives circumspectly.
Condoms 18% It has been traditionally thought that women who have
a history of classic focal migraines have an increased poten-
Injectables/implants/patch 9%
tial for strokes when using oral contraceptives. However, the
Male sterilization 9% evidence for this is poor. Women with a history of migraines
have a two- to threefold increased risk of ischemic stroke
Other 8% regardless of oral contraceptive use.

No method of contraception is perfect. The effective-
ness of contraception is often quantified by the Pearl index,
which is defined as the number of unintended pregnancies
per 100 women per year of use (i.e. the number of pregnan-
cies in 1200 observed months of use).
The most effective contraceptive methods are intrauter-
ine contraception, contraceptive implants, and steriliza-
tion.
The next most effective methods are injectables, oral
contraceptives, transdermal contraceptive systems, and
the vaginal ring.
The least effective contraception systems are dia-
phragms, cervical caps, condoms, spermicides, and
withdrawal.
Natural family planning, also known as the rhythm
method, has a high failure rate of around 2030% per
year.
One of the newer methods is the hysteroscopic steriliza-
tion of the fallopian tubes (e.g. Essure).
Steroidal contraception
Oral contraceptives
The development and widespread use of the oral contracep-
tive pill was a major breakthrough in reproductive health in
the 20th century.
Benefits of oral contraception
Known benefits of oral contraception include:
the very low likelihood of extrauterine pregnancies
a reduction in pelvic inflammatory disease, ovarian
cysts, and iron-deficiency anemia
a decrease in the rate of ovarian and endometrial cancers.
Epilepsy
Oral contraceptives have no impact on the pattern or fre-
quency of fits; however, some anticonvulsants decrease
serum concentrations of estrogen and thus increase the like-
lihood of intermenstrual bleeding, and pregnancy. Women
with epilepsy should start on a high-dose oral contraceptive
formulation.
Cardiovascular disease
Women who are older than 35 years, and who smoke,
should not use oral contraceptives, as in this group there is
an increased incidence of cardiovascular complications such
as myocardial infarction.
Deep vein thrombosis
There is controversy surrounding the use of oral contracep-
tives in women who have deficiencies in protein C, protein
S, or anti-thrombin 3. There is no evidence that women
with a factor V Leiden mutation who use oral contracep-
tives have an increased incidence of venous thromboembolic
disease.
Women with a body mass index of >29 kg/m2 have an
independent increased risk of venous thromboembolic dis-
ease, and in such women oral contraception should only be
used if they are 35 years of age or younger.
Hypertension
Oral contraceptives have a potential to aggravate hyperten-
sion, hence blood pressure should be controlled prior to
their commencement. If blood pressure is controlled and no
vascular disease is present, the use of oral contraceptives is
not contraindicated.
A history of pregnancy-induced hypertension is not a
contraindication to the use of oral contraceptives, provided
the blood pressure returns to normal after delivery.

Side-effects of oral contraception Dyslipidemia

Side-effects are a major source of patient non-adherence
and discontinuation. Estrogen commonly produces breast
tenderness and nausea; these symptoms usually decline after
3 months of use. Caution should be exercised when pre-
scribing oral contraceptives to patients with certain under-
lying conditions.
All oral contraceptives increase triglyceride levels to some
extent. If a womans triglycerides are 350 mg/dL (3.95
mmol/L), or in patients with familial hypertriglyceridemia,
oral contraceptives should be avoided because they may pre-
cipitate pancreatitis or increase the risk of cardiovascular
disease.

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Angina
Oral contraceptives do not stimulate the atherosclerotic pro-
cess, and may actually inhibit plaque formation. On the other
hand, they are contraindicated in the presence of coronary
disease. There is an increased incidence of cardiovascular
disease secondary to atherosclerosis in past oral contraceptive
users. Smoking, when combined with oral contraceptive use,
markedly increases the risk of atherosclerosis.
Women with known angina and suspected athero-
sclerosis, but with no history of prior myocardial infarcts
or additional risk factors, may safely use low-dose oral
contraceptives.
Mitral valve prolapse
In general, oral contraceptives can be used in women with
mitral valve prolapse who are symptom-free.
Diabetes mellitus
Women with diabetes mellitus who do not have reti-
nopathy, nephropathy or hypertension can use low-
dose oral contraceptives.
Women with a history of gestational diabetes during
their last pregnancy can safely take low-dose oral
contraceptives.
Sickle-cell disease
The risk of pregnancy in this condition is much greater than
the risk posed by the use of oral contraceptives.
Cancer risk with oral contraception
Breast cancer
There is no association between oral contraceptive use and
an increased relative risk of breast cancer. The risk of breast
cancer in women who take oral contraceptives up until the
age of 55 is no different to that of the rest of the population.
Oral contraceptive use in women with a history of breast
cancer in a first-degree relative does not increase the risk of
breast cancer.
Cervical cancer
There is no association between the use of oral contracep-
tives and the development of cervical cancer, except maybe
for the potential higher exposure to human papillomavirus
(HPV).
Endometrial cancer
It is well established that combined oral contraceptive use is
protective against endometrial cancer.
Ovarian cancer
Oral contraceptive use is thought to be protective for ovarian
cancer, and the degree of protection is related to the duration
of use. Women who use oral contraceptives for 10 years or
more have an 80% reduction in their risk of ovarian cancer.
Estrogen dose
When choosing an oral contraceptive, the higher the dose of
estrogen then the better the cycle control.
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Chapter 25 Womens health for the physician
In general, oral contraceptives with 25 microg of estro-
gen have an 11% incidence of intermenstrual bleeding,
while 3035 microg of estrogen reduces intermenstrual
bleeding to 4%.
The use of oral contraceptives containing 50 microg of
estrogen should be reserved for women requiring addi-
tional estrogen to prevent intermenstrual bleeding, or
women who have recurring functional ovarian cysts in
order to significantly suppress ovarian function.
Breastfeeding
Breastfeeding women should avoid the use of combined
oral contraceptive medications, as small amounts of steroids
are excreted in the milk, and estrogen may suppress milk
production.
Progesterone-only contraceptive pill
These pills are an excellent choice for breastfeeding women,
and for women with medical conditions where the use of
estrogen is contraindicated. Their efficacy is decreased com-
pared with combined oral contraceptives, so rigorous timing
of their intake is important.
They also often cause breakthrough bleeding.
Interaction with other drugs
Certain antibiotics, particularly penicillins and tetracyclines,
may diminish the effectiveness of oral contraceptives.
Discontinuation of an oral contraceptive
Conception is rapid after cessation of oral contraceptives.
Injectable contraceptivesdepot
medroxyprogesterone acetate
Injectable contraception is highly effective, reversible, and
reduces the need for adherence. One injection is given
every 12 weeks. Additionally, progestin injections reduce
the risk of endometrial cancer and the volume of menstrual
bleeding.
There is no proven relationship between depot medroxy
progesterone acetate and weight gain.
Women with sickle-cell anemia, congenital heart dis-
ease, or those older than 35 are excellent candidates for
contraception with depot medroxyprogesterone acetate.
Women with a history of long-term use of depot
medroxyprogesterone acetate have reduced bone density.
Depot medroxyprogesterone acetate is not teratogenic,
and is safe during lactation.
Contraceptive implants
Implanon
This is a single-rod progestin implant releasing etonoges-
trel over a 3-year period. It is well tolerated and effective
and has a very minimal reported failure rate. No pregnan-
cies have been reported in 70,000 cycles of use.
Side-effects are irregular bleeding and amenorrhea.
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Essentials of internal medicine
Implanon has no major impact on lipid profile, carbohy-
drate metabolism, coagulation factors or liver function.
Contraceptive vaginal ring
Contraceptive vaginal rings are based on the principle
that the vaginal epithelium can absorb steroids released
from the silicone elastomer at a constant rate.
The ring releases minimal amounts of estrogen into
the circulation, yet maintains efficacy and cycle control
comparable to that of oral contraceptives.
The vaginal ring has an outside diameter of 54 mm, and
is inserted by the woman and worn continuously for
3 weeks, after which time it is removed for 1 week to
allow for withdrawal bleeding. After this week, a new
device is inserted.
A disadvantage of the ring is that some 1830% of men
report feeling the ring during intercourse and some
women report an increase in leukorrhea. If this is a
problem, the ring can be removed for intercourse but
must be replaced within 3 hours. If the ring remains
outside the vagina for longer than 3 hours, its effective-
ness is compromised.
Pregnancy rates are reported to be 12 per 100 women
years of use.
Transdermal contraception
Transdermal drug delivery provides continuous, sus-
tained release of hormonal contraception over several
days, thereby avoiding fluctuations in hormone levels
and the need for daily patient action.
The benefits, risks and contraindications of transder-
mal contraception are similar to those of combined oral
contraceptives, except that the transdermal device is
associated with more estrogen-related adverse events,
including venous thromboembolism.
Obese women should be counseled about reduced effi-
cacy but obesity is not a contraindication.
Non-steroidal contraception
Intrauterine contraception
Intrauterine contraception is safe and effective.
Currently, intrauterine contraceptives release either
copper or a synthetic progestin.
The progestin-releasing intrauterine contraceptives
have additional advantages such as decrease in men-
strual blood loss, relief of dysmenorrhea, and cure of
endometriosis.
Modern intrauterine devices are not associated with a
higher rate of expulsion, or the risk of pelvic inflamma-
tory disease that was caused by previous models.
Intrauterine devices decrease the probability of preg-
nancy; however, if it occurs, the incidence of ectopic
pregnancy rates increase. It is therefore important to
determine the site of pregnancy when, and if, it occurs.
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Barrier methods
Barrier methods of contraception such as a diaphragm, cer-
vical cap, male condom and female condom have a much
higher pregnancy rate than hormonal methods. They are
not recommended for women with serious medical condi-
tions in whom pregnancy is life-threatening. Such women
should be advised about the availability of emergency
contraception.
Emergency contraception
Emergency contraception is also known as post-coital con-
traception. Women who have had unprotected intercourse,
including those who have had a failure of another method,
are potential candidates for this intervention. It has the
potential to reduce abortion rates.
This method of contraception is indicated after unpro-
tected intercourse and for couples who experience, and
recognize, a failure of a barrier method.
Emergency contraception utilizing progestin-only pills
is available without a prescription in many countries.
The mechanism of emergency contraception is uncer-
tain, and may vary depending upon the day of the men-
strual cycle and the drug administered. It is likely to
inhibit or delay ovulation, interfere with fertilization or
tubal transport, prevent implantation by altering endo-
metrial receptivity, and may cause regression of the
corpus luteum.
CLINICAL PEARL
A routine follow-up visit with a pregnancy test is essen-
tial after emergency contraception to ensure that, if
bleeding has not occurred, an intrauterine or ectopic
pregnancy is not present.
MENOPAUSAL SYMPTOMS
Post-menopausal hormone treatment continues to play a
role in the management of menopausal symptoms such as
hot flushes, vaginal atrophy and mood changes.
While it is no longer recommended that hormone
therapy in women over the age of 60 should be used
to prevent illness, the use of hormone therapy to treat
menopausal symptoms is not inappropriate. This
should, however, be re-evaluated after 5 years of use
because of the increased risks of complications after
this period.
There is evidence for a benefit of unopposed estrogen
use in women who have undergone hysterectomy,
in that the incidence of breast cancer in this group is
reduced.
Hormone therapy results in a definite reduction of
recurrent urinary tract infection, and improves quality
of life and balance.
The risks of stroke, venous thromboembolism, breast
cancer, and cholecystitis are increased.

As a result of the mixture of risks and benefits, post-
menopausal hormone therapy is currently only recom-
mended for the short-term management of moderate to
severe vasomotor symptoms.
If there is no history of breast cancer, coronary heart
disease, or a previous thromboembolic event, estrogen
therapy is appropriate. Active liver disease and migraine
headaches are also contraindications.
If a patient has not had a hysterectomy then a progestin
should be added, as endometrial hyperplasia and endo-
metrial cancer can develop after as little as 6 months of
unopposed estrogen therapy.
The best preparation to use is a combined preparation of
conjugated estrogen and a synthetic progestin. The drugs
can be delivered either orally or transdermally, as they are
equally effective for the treatment of vasomotor symptoms.
The treatment should involve the lowest possible dose of
estrogen and progestin that controls the symptoms.
In addition to vasomotor symptoms, vaginal atrophy
often needs treatment.
Vaginal atrophy results in vaginal dryness, itching, and
dyspareunia.
It can be treated with systemic hormone replacement
therapy, but intravaginal estrogen in either a cream, tab-
let or ring form is the most effective therapy and can
be administered indefinitely, as systemic absorption is
negligible.
PREMENSTRUAL SYNDROME
Premenstrual syndrome is characterized by symptoms that
occur monthly in the second half of the menstrual cycle.
Although most women experience mild emotional and
physical symptoms just prior to the onset of menstrual peri-
ods, the term premenstrual syndrome implies that these
symptoms lead to economic or social dysfunction that occurs
for at least 5 days before the onset of menstrual periods, and
includes:
symptoms such as depression, anger, irritability, anxiety,
breast pain, bloating, and headaches
an impairment in quality of life, a decrease in productiv-
ity, and increased absenteeism.
There are no physical signs associated with premenstrual
syndrome. Diagnosis is made when there is at least one
symptom, either psychological or behavioral, that impairs
functioning in some way.
If untreated, premenstrual symptoms can last throughout
reproductive life and only disappear with the menopause.
Treatment with selective serotonin reuptake inhibitors
such as fluoxetine has been demonstrated to be better
than placebo. These agents are usually administered
during the luteal phase, and discontinued after the onset
of the menstrual period.
There is no evidence that other antidepressants and lith-
ium have any benefit in the treatment of premenstrual
syndrome.
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Chapter 25 Womens health for the physician
Benzodiazepines such as alprazolam are effective, but
side-effects limit their use.
GnRH agonists and danazol (an androgen) suppress
ovulation and therefore control symptoms, but side-
effects preclude their use on a prolonged basis.
Hormonal oral contraceptives can also be effective.
ABNORMAL UTERINE BLEEDING
CLINICAL PEARL
Abnormal uterine bleeding is responsible for as many
as one-third of all outpatient gynecological visits. The
majority occurs just after the menarche or in the peri-
menopausal period.
Most cases of abnormal uterine bleeding are related to preg-
nancy, structural uterine pathology, anovulation or, rarely,
disorders of hemostasis or neoplasia.
Symptoms of ovulation should be noted, as well as the
commencement of abnormal bleeding. As an example,
menorrhagia since the menarche suggests a coagulation
disorder, while anovulation as a cause is more common
around the menarche and the perimenopause.
Any precipitating factor such as trauma should be
sought, as well as a family history of bleeding or sys-
temic disorders. The possibility of pregnancy should be
considered.
Changes in bodyweight should be elicited, as eating dis-
orders, excessive exercise, illness or stress may interfere
with ovulation.
The amount of bleeding is difficult to evaluate, as a patients
self-reports are often inaccurate indicators of the quantity of
blood loss:
around 25% of women with normal periods consider
their blood loss excessive
around 40% of women with excessive bleeding consider
their periods as light or moderate
only about 33% of women who consider that their peri-
ods are heavy have blood loss which is truly excessive.
Diagnosis
Physical examination should involve a general examination
to detect systemic illness, and then a gynecological examina-
tion which should determine any obvious bleeding sites on
the vulva, vagina, cervix, urethra or anus.
Suspicious findings such as a mass, ulceration, laceration
or foreign body should be noted, and the size, contour
and tenderness of the uterus as well as the possibility of
an adnexal mass should be determined.
All women of reproductive age should have a pregnancy
test to exclude either an intrauterine or an ectopic
pregnancy.
Cervical cytology should be obtained to exclude cervical
cancer, and any visible cervical lesion should be biopsied.
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Essentials of internal medicine
After a pregnancy is excluded, an endometrial sample
should be obtained to exclude endometrial cancer or
hyperplasia.
Both transabdominal and transvaginal ultrasound
examinations should be performed to demonstrate
any subserosal or intramyometrial pathology such as
fibroids, adenomyosis or neoplastic change. An ultra-
sound examination can also detect ovarian neoplasm.
Hysteroscopy provides excellent visualization of the
endometrial cavity. It also allows targeted biopsy or
excision of lesions.
Other investigations such as thyroid function tests,
coagulation profile, full blood count, serum prolac-
tin, and androgen levels may be indicated. The initial
approach to the management involves treatment of
underlying conditions such as fibroids, polyps or arte-
riovenous malformations, often with surgery.
Management
Estrogenprogestin contraceptives are usually the first
line of medical therapy in most women. In addition to
reducing blood flow, they regulate cycles, provide con-
traception, prevent the development of hyperplasia in
anovulatory patients and treat dysmenorrhea.
The second line of therapy is the insertion of a levo-
norgestrel intrauterine device, which releases a high
local concentration of progestin which thins out the
endometrium. This treatment is more effective than
hormonal oral contraception, and is as effective as sys-
temic progestogens. It is superior to non-hormonal
medical therapy.
Non-steroidal anti-inflammatory drugs (NSAIDs)
reduce the volume of menstrual blood loss by 2050%,
via reduction of the rate of prostaglandin synthesis in the
endometrium, leading to vasoconstriction and reduced
bleeding.
Antifibrinolytic agents such as tranexamic acid reduce
menstrual flow 3050% from baseline. The risk of
thrombosis with these drugs is controversial, so they
should be used when other therapies have failed in
women who have a low thrombosis risk.
If medical treatment fails, then surgery can be used; this
involves either endometrial ablation or a hysterectomy.
DYSMENORRHEA
Dysmenorrhea is a common problem experienced by
women of reproductive age. When severe, it interferes with
the performance of daily activities, often leading to absen-
teeism from school, work or other responsibilities.
Primary dysmenorrhea, defined as abdominal pain during
menses without any identifiable pathology, is mainly a
clinical diagnosis.
It is likely to be due to the release of prostaglandins
from the endometrium during menstrual periods.
Symptoms usually begin during adolescence, after
ovulatory cycles become established.
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Secondary dysmenorrhea is due to pathological processes
such as endometriosis, adenomyosis, fibroids, ovarian
cysts, intrauterine or pelvic adhesions, chronic pelvic
inflammatory disease, obstructive endometrial polyps,
cervical stenosis, an intrauterine device, or pelvic con-
gestion syndrome.
Inflammatory bowel disease, irritable bowel syn-
drome, and various psychogenic disorders can also
generate secondary dysmenorrhea.
The goal of treatment of dysmenorrhea is to provide ade-
quate relief of pain.
In primary dysmenorrhea, the treatment is empirical.
NSAIDs are the most effective agents.
In secondary dysmenorrhea, the associated pathological
entities will need to be specifically treated.
Hormonal contraception to suppress ovulation is also
effective.
CLINICAL PEARL
The prevalence of dysmenorrhea is very high; between
50% and 90% of women describe some degree of dys-
menorrhea. The majority of these women are young,
and have primary dysmenorrhea. The prevalence of
primary dysmenorrhea decreases with age.
VULVAR CONDITIONS
CLINICAL PEARL
Benign conditions of the vulva and vagina are com-
mon. About one-fifth of women have significant vulval
symptoms lasting for >3 months at some time in their
lives.
Symptoms of vulvar conditions are common, often chronic,
and can cause significant sexual dysfunction.
Itch is a common symptom. If itching is worse before or
during menstrual periods, then recurrent vulval candi-
diasis is likely.
Various dermatoses can also be intermittent, with flare-
ups associated with precipitant factors.
The history is sometimes difficult to elicit because of anxi-
ety and frustration about ineffective treatment. A thorough
examination with good illumination is vital. Key features of
the history and examination can pinpoint diagnosis. Investi-
gations will ultimately deliver the diagnosis.
A vaginal or vulval swab for culture and sensitivity
should be taken in all patients.
If fissures or ulcers are present, testing for herpes sim-
plex virus (HSV) should be performed.
Biopsy is required for any abnormal findings that persist
without a clear diagnosis, and is mandatory to rule out
malignancy.
 Chapter 25 Womens health for the physician

Management also common. It is common for symptoms to worsen

before menstrual periods.
It is important to advise the woman that vulval condi-
Examination usually reveals erythema of the vulva,
tions respond slowly to treatment, usually over weeks
with some swelling and occasional longitudinal fissures
to months, and that the aim of treatment is to control
(Figure 25-1); a discharge is a common association.
symptoms rather than to cure the condition.
Some 50% of women have negative microscopy on
Sometimes a multidisciplinary approach is required, such
swabbing.
as a physiotherapist with experience in biofeedback, and
sexual counselors, especially in the case of vulvodynia. Most cases are caused by Candida albicans, but C. glabrata,
C.tropicalis and C. parapsilosis can also occur and may be dif-
Good vulval skin care should be part of the treatment of
ficult to treat.
all conditions. This involves the avoidance of irritants,
including soap, and moisturizing the skin with creams 90% of uncomplicated cases respond to topical
such as sorbolene or aqueous cream. If there is incon- antifungals.
tinence or a vaginal discharge, a barrier cream should Resistant cases may respond to oral fluconazole or
be used. Scratching can be reduced by applying cold ketoconazole.
compresses. If there is significant dermatitis, the addition of 1%
hydrocortisone cream may be useful.
Conditions with abnormalities on Women who have C. glabrata are usually not sensitive to
examination standard antifungal treatment, and respond to intravagi-
nal boric acid.
Dermatitis There is no clinical evidence that dietary modification
Dermatitis is common, and is present in about half of women for the elimination of Candida spp. from the gastrointes-
who present with chronic vulval symptoms. It is even more tinal tract, or the treatment of asymptomatic male sexual
common in individuals with vulval atrophy, in whom the partners, is useful.
skin is less able to tolerate environmental insults. Low-dose oral contraceptives can be used to prevent
Clinical signs may be subtle and are associated with ery- recurrence.
thema, scale, fissures, lichenification, and excoriation.
Itch is a common presenting symptom, although burn- CLINICAL PEARLS
ing can occur if the mucosa is involved.
Vaginitis due to bacterial vaginitis from Gardnerella
Contact allergens such as deodorant soaps, bubble-bath
vaginalis has a fishy odor when mixed with potas-
products, or perfumed feminine hygiene products can sium hydroxide, and clue cells are present (epithelial
be irritating, and can intensify symptoms. Ongoing cells with bacteria adhering).
avoidance of irritants is helpful. Trichomonas vaginalis causes a frothy, fishy-smelling
If urinary incontinence is present it should be addressed, discharge that is yellow-green, and a strawberry-
as urine is a major vulval irritant. colored cervix.
Initial treatment involves identification and elimination of
the irritating agent, the use of cotton underwear washed in
a bland detergent, the taking of sitz baths using plain tepid
water twice a day, and applying a thin, plain petrolatum film
or zinc oxide 1020% ointment after bowel movements.
Tricyclic antidepressants such as doxepin may be con-
sidered for treatment of pruritus.
Topical corticosteroids may be used for 23 weeks to
reduce inflammation and to promote healing.
Methylprednisolone aceponate is useful until symptoms
have resolved, after which a weaker corticosteroid such
as 1% hydrocortisone can be continued for a further
3months. The cycle can be repeated if disease activity
flares.

Recurrent vulvo-vaginal candidiasis

Vulvo-vaginal candidiasis is considered to be recurrent
if at least four discreet documented episodes occur in
12months. The pathophysiology of recurrent infections
is unclear.
Recurrent vulvo-vaginal candidiasis presents primarily
with itch; but burning, especially after intercourse, is
Figure 25-1 The most common presentation for
acute vaginal candidiasis is a red inflamed vulva and
vagina, and a white, thick discharge
From Habif TP. Clinical dermatology, 5th ed. St Louis: Elsevier, 2009.

751

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Essentials of internal medicine
Lichen sclerosis
Lichen sclerosis is a common vulval disorder. The mean age
of onset is 50 years, although it can occur in children and
pre-pubertal girls. The etiology is unknown.
Lichen sclerosis presents most commonly with an itch;
burning and dyspareunia can also occur.
There is an association with autoimmune disease in
20% of patients.
Lichen sclerosis is characterized by thinning and whit-
ening of the perianal and perivaginal skin, with an
accompanying loss of mucocutaneous markings and
skin elasticity. There is atrophy of the involved tissues
and a loss of vulval architecture (Figure 25-2).
There may be associated purpura, hyperpigmenta-
tion, erosion, fissures and edema.
Routine vulvar biopsy for diagnosis is debated. Biopsy
only after failure of empirical treatment is acceptable.
Treatment should aim to control symptoms, minimize scar-
ring, and detect malignant change early.
Potent topical corticosteroids are symptomatically
effective in more than 90% of women, providing rapid
symptomatic relief.
Betamethasone dipropionate ointment 0.05% should
be used initially twice daily for a month, then daily for
2months, and gradually tapered to use as needed.
Annual follow-up is recommended, as the lifetime risk of
squamous cell carcinoma within the affected area is about
4%. Annual biopsy of the vulva is prudent.
Psoriasis
Psoriasis of the vulva occurs in about 5% of women who
present with chronic vulval symptoms. It can be easily
Figure 25-2 Vulvar lichen sclerosis. The crease
areas are atrophic and wrinkled, the labia is
hyperpigmented, and the introitus is contracted
andulcerated
From Habif TP. Clinical dermatology, 5th ed. St Louis: Elsevier, 2009.
752
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mistaken for atopic dermatitis. One-third of patients with
psoriasis have a family history of the disease.
Clinically, psoriasis on the vulva lacks the typical silver
scale, and usually appears as red or reddish yellow pus-
tules on the intertriginous areas (Figure 25-3).
Genital psoriasis often appears in the mons and the labia.
Treatment usually requires mid- to high-potency topical
steroids, injectable corticosteroids, as well as weak-potency
preparations such as 3% liquor picis carbonis in aqueous
cream twice daily. This helps to provide a break from pro-
longed corticosteroid use.
Vulvar intraepithelial neoplasia
Vulvar dysplasia, or vulvar intraepithelial neoplasia (VIN),
is reported as VIN I, II or III. VIN III is synonymous with
carcinoma-in-situ.
The incidence of VIN has increased significantly in
women who are young, and those who smoke. This
increased incidence reflects the higher prevalence of the
human papillomavirus in women.
The most common symptom of VIN is localized
itching and burning, although some 60% of cases are
asymptomatic.
VIN is usually multifocal and looks like raised or kerati-
nized skin, or a macule usually on mucosal areas.
VIN III can progress to vulvar cancer.
A biopsy is necessary for any raised hyperpigmented
lesion.
The treatment for VIN is wide local excision, or laser
therapy.
Figure 25-3 Psoriasis of perineum and vulva. Flexural
psoriasis often lacks the typical parakeratotic scale
ofpsoriasis on other body sites. Painful erosion of the
natal cleft is common
From Robboy SJ, Anderson MC and Russell P (eds). Pathology of the
female reproductive tract. Edinburgh: Elsevier, 2002.

Erosive vulvovaginitis
Chronic painful erosions and ulcers with superficial bleed-
ing can be seen in the vulvar vestibule. Causes include:
Crohns disease
Behets syndrome
neurofibromatosis
cicatricial pemphigoid
pemphigus vulgaris
vulvar pyoderma gangrenosum
desquamative inflammatory vaginitis.
As vulvar and vaginal adhesions can occur in these condi-
tions if they are not properly managed, specialist referral is
recommended.
Atrophic vaginitis
Estrogen deficiency causes the vaginal epithelium to become
thin, pale and dry. Symptoms include dyspareunia, minor
vaginal bleeding, and pain from splitting caused by friction.
Topical vaginal estrogen creams are useful.
Vulvar vestibular syndrome (vulvodynia)
Apart from dyspareunia, these patients usually have focal
erythema and localized vulvar dysesthesia. Many women
have associated urinary symptoms such as frequency and
bladder irritability.
This condition may be associated with the presence of
interstitial cystitis.
Diagnosis is usually made by the touch test. A cotton-
tip swab is used to firmly touch the labia majora, the
sulci and the lateral labia minora. This is followed by
firmly touching the ostia of the Skenes glands, and the
major and minor vestibular glands. Women with vulvo-
dynia classically have a heightened sensitivity associated
with the touch of the gland openings.
Management is difficult and very often prolonged, and
involves both behavioral and medical interventions that are
common in many pain syndromes.
Dysesthetic vulvodynia
Dysesthetic vulvodynia, also known as generalized vulvo
dynia, occurs mainly in older patients.
The etiology is unclear. Neuropathic pain, pudendal
neuralgia, chronic reflex pain syndrome, pelvic floor
abnormalities, and referred visceral pain have been sug-
gested as causes.
The predominant symptom is chronic, localized burn-
ing or pain in the vulva, with no abnormalities on
examination but hypersensitivity and altered perception
to light touch.
Patients with this condition often have psychosexual
dysfunction.
Treatment with low-dose tricyclic antidepressants can
be helpful.
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Chapter 25 Womens health for the physician
SEXUALLY TRANSMITTED
INFECTIONS (STIs)
CLINICAL PEARLS
The sexually transmitted infections that present with
vulvar ulceration are lymphogranuloma venereum,
chancroid, herpes simplex, primary syphilis, and
granuloma inguinale.
The sexually transmitted infections that present
with cervicitis are chlamydia, gonorrhea, and pelvic
inflammatory disease.
Sexually transmitted infections are more common in:
the young
the unmarried
women who have recently had a new sexual partner
those with multiple sexual partners
women with a previous sexually transmitted
infection
recreational drug users
women who have contact with sex workers
women who meet partners on the internet.
All patients who seek screening for STIs should receive
testing and counseling for human immunodeficiency
virus (HIV) and hepatitis B and C infection.
The optimal interval for screening is uncertain, but
rescreening at three months after a diagnosed infection
is recommended.
Other sexually transmitted diseases and infections
include condylomata acuminata (genital warts), mollus-
cum contagiosum, and pediculosis pubis.
Complications of sexually transmitted infections include
upper genital tract infections, infertility, cervical and
vulvar cancer, and enhanced transmission of HIV.
Chlamydia
Chlamydia trachomatis is a small Gram-negative intracellular
bacterium, and is the most common bacterial agent of sexu-
ally transmitted infections.
A large percentage of women are carriers of C. trachoma-
tis and are asymptomatic, thereby providing an ongoing
reservoir. Rates of chlamydial infection are highest in
adolescent women.
The incubation period of symptomatic disease ranges
from 7 to 14 days.
Symptoms of chlamydial infection include cervicitis,
discharge and urethritis.
Cervicitis causes a vaginal discharge, and intermen-
strual and post-coital bleeding.
Cervical discharge is frequently mucopurulent.
Urethritis commonly accompanies cervicitis, with
concomitant symptoms such as urinary frequency
and dysuria.
Infants born to mothers who have an infected birth
canal may develop conjunctivitis and pneumonia.
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Essentials of internal medicine
Chlamydia cannot be cultured on artificial media; tradition-
ally, tissue culture has been required to establish a diagnosis.
Although tissue culture is the gold standard in identifying
chlamydial infection, rapid diagnostic testing using nucleic
acid amplification technology is now readily available, and
reasonably accurate.
The natural history of chlamydial infection is not clearly
established. Rates of spontaneous resolution, persistence
and progression are difficult to establish.
Occasionally patients with chlamydial infection develop
peri-hepatitis and inflammation of the liver capsule and
adjacent peritoneal surfaces, known as Fitz-Hugh
Curtis syndrome.
Approximately 30% of women with chlamydial infec-
tion develop upper genital tract involvement such as
pelvic inflammatory disease and, if left untreated, this
results in infertility.
Treatment
Chlamydia trachomatis is highly susceptible to tetracyclines
and macrolides. The first-line agents are doxycycline and
azithromycin.
The recommended regimen is 100 mg of doxycycline
orally twice daily for 7 days, or azithromycin 1 g orally
in a single dose.
Alternative regimens include erythromycin, ofloxacin,
or levofloxacin.
Except in pregnant women, it is not recommended that
patients have a test-of-cure 3 weeks after completing treat-
ment if the recommended or alternative regimens were used.
Gonorrhea
Gonorrhea is the second most commonly reported commu-
nicable disease in the United States, accounting for more
than 300,000 cases annually. It is estimated that an equal
number of cases are unreported.
Although men are often symptomatic, and usually pres-
ent early for therapy, symptoms in women may not be
apparent until complications such as pelvic inflamma-
tory disease develop.
In women, the most common complaints are a vaginal
discharge, dysuria and/or abnormal vaginal bleeding.
Infection of Skenes glands, Bartholins glands, the anus
and the pharynx are common.
Disseminated gonococcal infection occurs in 12% of
women.
Untreated gonorrhea is a common cause of infertility,
chronic pelvic pain and an increased incidence of ecto-
pic pregnancy.
Diagnosis of gonorrhea is made by either culture or nucleic
acid amplification tests. Rapid diagnostic tests are highly
sensitive, detecting up to 98% of infections. However,
nucleic acid amplification tests of swabs taken from the rec-
tum and pharynx yield poor results.
Culture for Neisseria gonorrhoeae is processed on Thayer-
Martin agar, which prevents the overgrowth of other
endogenous flora.
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Swabs should be obtained from the urethra, cervix, rec-
tum and pharynx for culture. Culture with sensitivity
testing is particularly important for detection of resistant
organisms.
Treatment needs to have an efficacy rate of greater than
95%, as treatment failure has significant public health
implications.
Approximately 20 drugs within the cephalosporin,
quinolone, macrolide and tetracycline classes of anti
biotics demonstrate high rates of gonococcal eradication
with single-dose therapy. Single-dose therapy decreases
the reliance on patient adherence.
The preferred therapeutic agents are cefixime 400 mg
orally in a single dose, ceftriaxone 250 mg intramuscu-
larly in a single dose, ciprofloxacin 500 mg orally in a
single dose, ofloxacin 400 mg orally in a single dose, or
levofloxacin 250 mg orally in a single dose.
Treatment should also include antibiotics for chlamydial
infection, as coexistence of C. trachomatis is common.
PELVIC INFLAMMATORY
DISEASE (PID)
Pelvic inflammatory disease is defined as sexually transmit-
ted pelvic infection, between the menarche and the meno-
pause. It does not include vulvar or vaginal infections. It is
often used synonymously with salpingitis, but in fact is the
infection of the uterus, uterine tubes, adjacent parametrium
and overlying pelvic peritoneum.
The list of causative organisms is long, but includes
C.trachomatis, Gram-negative bacilli, Haemophilus influ-
enzae, group B and D streptococci, Mycoplasma hominis,
and various anaerobic organisms including anaerobic
Gram-positive cocci and bacteroides species. Poly
microbial infection is common.
It is possible that viruses including coxsackievirus B5,
echovirus 6, and HSV may cause PID, but their role
is not clearly established. Mycobacteria have also been
implicated.
Pelvic infection is found more frequently in some sec-
tors of the community than others. It is most common
between 15 and 19 years of age.
Approximately 25% of women with PID will experi-
ence long-term complications such as infertility, chronic
pelvic pain, dyspareunia, and an increased incidence of
ectopic pregnancy.
PID is never seen in prepubertal females, and very rarely
seen after the menopause.
Clinical features
The most important presenting feature is abdominal pain.
The pain is continuous and bilateral, involving both lower
abdominal quadrants.
While pain is usually present in patients with PID, not
all patients with lower abdominal pain will have an
infection.

Pain is increased with movement and coitus.
The pain is also present during menstruation and
micturition.
Some 35% of patients also have irregular bleeding, but
this feature is not helpful when considering a differential
diagnosis.
Many patients have increased vaginal discharge.
Those with severe infection have nausea, vomiting,
malaise, and fever.
Examination may reveal pyrexia, tachycardia, abdominal
tenderness and, during pelvic examination, pain on moving
the cervix. An adnexal mass may be palpable.
An increasing number of women with PID will not
have classic features. It is estimated that cases of silent
PID now outnumber clinically apparent cases by a ratio
of 3:1.
Abdominal ultrasound is useful to differentiate an ecto-
pic pregnancy or complications of early pregnancy from
PID.
Laparoscopy is the gold standard for diagnosis.
CLINICAL PEARL
A pregnancy test is essential to exclude ectopic preg-
nancy in women with abdominal pain, in the repro-
ductive age, even if pelvic inflammatory disease is the
suspected cause.
To establish the diagnosis of PID, all three of the following
clinical features must be met:
1 abdominal tenderness (and/or rebound)
2 tenderness with movement of the cervix and uterus
3 adnexal tenderness
and one or more of the following can be included:
1 Gram stain of the endocervix positive for Gram-
negative intracellular diplococci
2 temperature greater than 38C
3 leukocytosis greater than 10,000/mm3
4 purulent material (white cells present) from the perito-
neal cavity by laparoscopy or laparotomy
5 pelvic abscess of inflammatory complex on bimanual
examination or observed by pelvic ultrasound.
Treatment
The aim of treatment is to prevent infertility, ectopic
pregnancy, and other long-term sequelae. If the patient is
extremely ill, hospitalization will be necessary.
Treatment regimens include levofloxacin 500 mg orally
once daily for 14 days, with metronidazole 500 mg
twice a day for 14 days to enhance anaerobic coverage.
If the patient is an inpatient, then intravenous cefotetan
2g 12-hourly, and doxycycline 100 mg orally or intra-
venously every 12 hours, with intravenous metronida-
zole 500 mg every 8 hours should be administered.
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Chapter 25 Womens health for the physician
SEXUAL PROBLEMS
Sexual problems are common. Approximately 40% of
women have sexual concerns, and some 12% have distress-
ing sexual problems.
Although it is thought that the frequency of sexual
activity declines with age, population-based studies
indicate that sexual activity continues in women aged
between 66 and 71 years, and in a third of women over
the age of 78. With the advent of treatment of male sex-
ual dysfunction, the likelihood that women will con-
tinue sexual activity well into their 80s will be a feature
of modern life.
The average frequency of sexual activity is 6 times per
month for women compared with 7 for men, with vag-
inal intercourse the most common sexual practice and
oral sex a distant second.
An understanding of normal sexual response is necessary
for the evaluation and treatment of sexual dysfunction. The
sexual response is complex, involving social, psychological,
neurological, vascular and hormonal processes, and includes
complex interactions of sexual stimulation with the central
nervous system, the peripheral neurovascular system, and
hormonal influences that are not completely understood.
The female sexual response is divided into four phases:
1 Desirethe desire to have sexual activity, including
sexual thoughts, images and wishes.
2 Arousalwhich includes physiological changes such
as genital vascular congestion, and systemic changes
such as tachycardia, elevation in blood pressure, and
increased respiratory rate.
3 Orgasmwhich is a peaking of sexual pleasure and a
release of sexual tension with rhythmic contractions of
the perineal muscles and reproductive organs.
4 Resolutionwhich involves both emotional and physi-
cal satisfaction.
Within this framework, for many women there is a differ-
ence in sequence.
Most women report inability to achieve orgasm with
vaginal intercourse, and require direct stimulation of the
clitoris. About 20% have coital climaxes, and 80% climax
before or after vaginal intercourse when stimulated. Only
30% of women almost always, or always, achieve orgasm
with sexual activity, in contrast to 75% of men.
Female sexual dysfunction can be classified into four
areas:
1 Sexual arousal disorderthe persistent inability to reach
sexual excitement.
2 Orgasmic disorder difficultyinability to reach orgasm
after sexual stimulation and arousal.
3 Sexual desire disorderthe lack of desire for sexual activ-
ity and/or the absence of sexual thought and fantasy,
as well as a fear of and avoidance of sexual thought and
situations.
4 Sexual pain disorder, including dyspareunia, vaginismus,
or genital pain that occurs with any type of sexual
stimulation.
755
Essentials of internal medicine
Female sexual dysfunction is multifactorial, often with sev-
eral different etiologies contributing to the problem.
Patients should be evaluated for associated physical or
psychological issues.
The medical history is important, as certain illnesses
or medications affect sexual function. For instance,
spinal cord injuries, thyroid disease, diabetic neuropa-
thy, surgical or medical castration with accompanying
decreased estrogen and testosterone levels, and depres-
sion may interfere with sexual function.
Antidepressants, antipsychotics and sedatives alter the
blood flow to the genitals, decreasing arousal and/or
lubrication.
Recreational drugs and alcohol are often associated with
sexual dysfunction.
Excessive smoking may lead to vascular insufficiency
and decreased genital blood flow.
A previous vaginal delivery or vaginal surgery may result
in interference with nerve supply, and dyspareunia.
Vaginal blood flow and vaginal secretions are estrogen-
dependent. Low estrogen levels are associated with
significant decreases in clitoral, vaginal, and urethral
blood flow, and thinning of the mucosa in the geni-
tal region. Any medical condition or medication that
interferes with estrogen levels can contribute to sexual
dysfunction.
Women with urinary incontinence, fecal incontinence,
or uterovaginal prolapse often have difficulty with sex-
ual function.
When assessing women with sexual dysfunction, routine
laboratory testing is not recommended unless endocrinopa-
thy is suspected.
Treatment
The treatment of sexual dysfunction is complex and time-
intensive, and requires special expertise.
A team approach with the use of psychotherapists, sex
therapists and physiotherapists is sometimes needed to
address specific aspects of treatment.
If associated medical conditions are found, these should
be treated before or during sexual dysfunction therapy.
For instance, a woman with depression may require an
antidepressant.
Relationship problems often exacerbate or underlie
sexual dysfunction in women. Couples counseling may
be effective when there is relationship conflict or poor
communication.
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Hormone therapy
Estrogen improves vaginal and clitoral blood flow,
increasing lubrication. Dyspareunia caused by atrophy
is treated best by vaginal estrogens. The ability of sys-
temic estrogens to enhance sexual function has not been
established.
Testosterone has been linked to increased libido,
although the data on testosterone use for the treatment
of female sexual function is poor, partly because of the
side-effect profile.
Dehydroepiandrosterone (DHEA) has been shown to
improve sexual interest and satisfaction in some women.
It is important to counsel patients that androgen therapy
can result in androgenic, metabolic and adverse endocrine
effects, and therefore should be used with caution in women
who are at risk of cardiovascular disease, hepatic disease,
endometrial hyperplasia or cancer, or breast cancer. Addi-
tionally, women should be warned of the possibility of sig-
nificant hirsutism, acne, voice deepening and clitoromegaly.
Pelvic-floor disorders
Pelvic-floor disorders such as urinary and fecal incontinence
and pelvic organ prolapse are common, and have a negative
impact on the sexual function of women. Multiple studies
have shown that surgical treatment of the underlying dis-
order, such as repair of prolapse and treatment of urinary or
fecal incontinence, improves sexual function.
Hysterectomy
There is no evidence that hysterectomy alters sexual
function. Multiple studies have demonstrated a positive
effect from total and subtotal abdominal and vaginal
hysterectomy on sexual function.
There is no benefit for sexual function by preservation
of the cervix during hysterectomy.
Pregnancy and childbirth
Sexual dysfunction is very common after childbirth; up
to 86% of women report sexual problems in the first
3months after vaginal delivery.
Most women resume normal sexual function 6 months
after childbirth.
Continued breastfeeding, and severe genital tract trauma
sustained during childbirth, may lead to prolonged sex-
ual problems.
 Chapter 25 Womens health for the physician

SELF-ASSESSMENT QUESTIONS
1 A 55-year-old woman is having hot flushes and is requesting hormone replacement therapy. She has a history of a
previous deep vein thrombosis in her right calf. Which of the following statements is true for managing this patient?
A This patient could use unopposed estrogen therapy for 5 years.
B The best preparation to use is a combined preparation of conjugated estrogen and synthetic progestin.
C Hormone therapy is recommended for the prevention of cardiovascular disease.
D With a history of previous thromboembolic disease, hormone replacement is inappropriate.
2 A 70-year-old woman, a smoker with a previous history of cervical cancer, presents with vulval itching, burning and
irritation. On examination of her vulva there is a raised hyperpigmented lesion visible on the labium majus. Which of
the following statements is true for this woman?
A A vulval biopsy should be performed to determine the exact pathology.
B She should be treated with topical antifungal agents.
C She should be treated with topical corticosteroids.
D She should be encouraged to use oatmeal baths.
3 A 60-year-old obese woman who has hypertension and type 2 diabetes mellitus develops vaginal bleeding for the first time
since the menopause 9 years previously. Which of the following statements is true for the management of this woman?
A The most likely explanation for this womans symptoms is the presence of an arteriovenous malformation in the
uterine wall.
B She probably has fibroids.
C She has engaged in energetic sexual intercourse.
D She needs to be evaluated with a pelvic examination and transvaginal ultrasound, and needs referral for
endometrial sampling.
4 Which four of the following options are the investigations that are valuable in most couples with infertility?
A Semen analysis
B Measurement of testicular volume
C Day 3 serum FSH (follicle-stimulating hormone)
D Papanicolaou smear
E Serum prolactin estimation
F Magnetic resonance imaging of the brain
G Thyroid function tests
5 Which four of the following can influence the measurement of serum prolactin level in the evaluation of infertility?
A Sexual intercourse an hour before the measurement
B Hyperthyroidism
C Adenoma of the pituitary gland
D Psychological stress
E Breast examination
F Pelvic examination
6 Which two from the following list are the most common causes of infertility?
A Male factors
B Tubal pathology
C Fibroids
D Endometrial polyps
E Unexplained
7 Which four of the following options may be side-effects of hormonal oral contraceptive agents?
A Cardiovascular disease
B Migraine headaches
C Epilepsy
D Deep vein thrombosis
E Worsening hypertension
F Angina
G Mitral valve disease
H Diabetes mellitus
I Stroke
8 Which of the following explains the mechanism of action of emergency contraception?
A Inhibits or delays ovulation
B Interferes with fertilization
C Interferes with tubal transport
D Prevents implantation
E Causes regression of the corpus luteum
F All of the above.
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Essentials of internal medicine

ANSWERS

1 D.
If there is a history of a previous thromboembolic event, the use of estrogen therapy is inappropriate. Unopposed estrogen
therapy in a woman who still has a uterus is dangerous as it can predispose to endometrial cancer. There is no evidence
that hormone replacement prevents any disease process except osteoporosis.

2 A.
Any woman with a history of previous papillomavirus infection, as evidenced by the diagnosis of cervical cancer, is at risk
of developing vulvar intraepithelial neoplasia, and when this is associated with a raised hyperpigmented lesion the risk of
malignancy is significant.

3 D.
In a postmenopausal woman, especially with diabetes, obesity and hypertension, the risk of endometrial cancer is high and
needs to be excluded.

4 A, C, E, G.

5 C, D, E, F.

6 B, E.

7 B, D, E, I.

8 F.
While the mechanism is not fully known, all or any are possibly correct.

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