BGM 4

14 de março de 2024
16:56
Case 1
Learning Goals (vaginal discharge):A 36-year-old woman presents
with abnormal vaginal discharge and intense vulvar itching for 3
weeks. She doesn’t notice any smell and there is no bleeding or
abdominal pain but she also complains of pain with intercourse and
discomfort when urinating. She was diagnosed with urinary tract
infection a month ago and was medicated with antibiotic (does not
recall the name) and she is concerned she could have a new urinary
infection again. Medical History: She has 2 children (normal
deliveries) and for contraception she is currently on oral
contraception pills (OCP). She is healthy, no other medical history of
note. On examination the external genitalia were red. On speculum
examination a white thick curdy discharge coating vaginal walls was
noticed.
Learning Goals (vaginal discharge):
• Discuss the differential diagnosis.
Condition Pros Cons
Candidiasis - White thick curdy - No smell, no bleeding or
(Vaginal Thrush) discharge: The hallmark of abdominal pain: Unlike
candidiasis, often resembling bacterial vaginosis (BV),
cottage cheese. which may have a fishy odor.
- Intense vulvar itching: - Pain with intercourse and
Common in candidiasis due to discomfort when urinating:
local inflammation. These symptoms are not
specific to candidiasis alone.
- Risk factors: Recent - No other medical history:
antibiotic use (which can Lack of predisposing factors
disrupt normal vaginal flora) such as diabetes or
and oral contraceptive pills immunosuppression.
(OCPs) may contribute.
Bacterial - Fishy odor: BV often - No smell: In our case, the
Vaginosis (BV) presents with a characteristic absence of odor is intriguing.
fishy smell, especially after
sexual intercourse.
- Thin, gray-white discharge: - External redness: BV
Unlike the curdy discharge typically lacks significant
seen in candidiasis. external inflammation.
- Risk factors: Multiple sexual - No bleeding or abdominal
partners, douching, and recent pain: BV does not cause
 sexual activity. these symptoms.
Trichomoniasis - Frothy yellow-green - No smell: Similar to BV,
discharge: Trichomoniasis trichomoniasis usually has an
often presents with this distinct unpleasant odor.
discharge.
- Vulvar itching and - No bleeding or abdominal
discomfort: Common pain: Trichomoniasis can
symptoms due to cause spotting or bleeding.
inflammation.
- Risk factors: Sexual activity, - No history of STIs:
multiple partners, and lack of Trichomoniasis is a sexually
barrier protection. transmitted infection (STI).
Contact - External redness and - No discharge: Unlike
Dermatitis itching: Allergic or irritant infectious causes, contact
reactions can cause vulvar dermatitis doesn’t produce
inflammation. vaginal discharge.
- Recent exposure to - No bleeding or abdominal
irritants: Consider recent use pain: Contact dermatitis
of new soaps, detergents, or doesn’t typically cause these
hygiene products. symptoms.
Atrophic - Postmenopausal: Atrophic - Not applicable: Our patient
Vaginitis vaginitis occurs due to is not postmenopausal.
estrogen deficiency.
- Vaginal dryness and - No bleeding or abdominal
discomfort: Estrogen pain: Atrophic vaginitis may
deficiency leads to thinning of cause spotting but not
vaginal tissues. significant bleeding.
Sexually - Risk factors: Multiple sexual - May have other
Transmitted partners, recent unprotected symptoms: Dysuria, pelvic
Infections (STIs) sex, or new sexual contacts. pain, or systemic symptoms
may accompany STIs.
 Identify the most important clinical characteristics to help the
diagnosis.
Overgrowth of C. albicans
 Can be precipitated by the following risk factors:
 Pregnancy
 Immunodeficiency, both systemic (e.g., diabetes
mellitus, HIV, immunosuppression) and local (e.g., topical
corticosteroids)
 Antimicrobial treatment (e.g., after systemic antibiotic treatment)
 Clinical features
 White, crumbly, and sticky vaginal discharge that may appear like
cottage cheese and is typically odorless
 Erythematous vulva and vagina
 Vaginal burning sensation, strong pruritus, dysuria, dyspareunia
• Acknowledge the main agents associated with the diagnosis and
discuss the most appropriate management for this condition
 Azoles:
A group of antifungal agents that decreases fungal ergosterol
synthesis by inhibiting cytochrome P450. Typical adverse effects of
systemic use include testosterone synthesis inhibition (especially in
the case of ketoconazole) and liver dysfunction.

Case 2
 Age: 35, Female;
 Occupation: High School Teacher;
 No previous pregnancies
 Medical History: Regular menstrual cycles, no previous significant
illnesses, non-smoker, moderate alcohol consumption;
 Family History: Mother had a hysterectomy in her late 40s due to
fibroids; no other relevant family history.
 Complaints: number of symptoms that had progressively worsened
over the past six months.
 The primary complaint was heavy menstrual bleeding
(menorrhagia), which she described as significantly heavier than her
usual menstrual flow, resulting in the use of multiple sanitary
products and interfering with her daily activities.
 The patient also reported experiencing severe menstrual cramps
(dysmenorrhea), which were not adequately relieved by over-the-
counter pain medication.
 In addition to her menstrual concerns, the patient described a
feeling of pressure and fullness in her lower abdomen that
occasionally progressed to a dull, aching pain.
 She mentioned that this discomfort often radiated to her lower back
and was sometimes accompanied by a bloating sensation.
 The patient also noted occasional episodes of constipation and
urinary frequency, which she had not experienced previously.
 She expressed concern that these symptoms were affecting her
quality of life and was particularly concerned about the potential
impact on her fertility.
Learning Goals (abnormal genital bleeding):
• Discuss the differential diagnosis of abnormal genital bleeding.
• Identify the diagnostic tests could be useful to clarify the clinical
findings
• Learn the essential aspects to look for in the objective examination
• Discuss the therapeutic recommendations
• Discuss potential effects on fertility
Case 3
Learning Goals (contraception advise):A 23-year-old woman presents
for contraception advice. She has been sexually active since 17, and
on the pill since then but she believes she gets nauseated and
decided to stop the pill 4 months ago and rely on the irregular use of
condoms. She is concerned about taking hormones and would like to
try a non-hormonal method. Since she stopped the contraceptive pill
she has regular cycles, menstrual periods last 5-6 days with mild to
moderate dysmenorrhea. She has never been pregnant. Medical
History: no other medical history of note. No abnormal findings on
examination.
Learning Goals (contraception advise):
• Learn how to advise these patients
• Discuss between hormonal and non hormonal contraception
 Discuss potential specificities of contraception in a patient without
revious pregnancies
 Nulliparous women (those who haven’t been pregnant) can safely
use most contraceptive methods.
 IUDs are suitable even if she hasn’t had children.
 Emphasize the importance of regular follow-up visits.
 Discuss eventual additional tests
 Pregnancy Test: Rule out pregnancy before starting any
contraception.
 STI Screening: Since she’s sexually active, consider STI testing.

Case 4

Learning Goals (Infertility):

• Establish the definition of infertility

Discuss key points in the clinical history and examination of infertile

couples.
Comprehensive medical, reproductive, and family history of both partners,
including:
 Duration of infertility and results of previous diagnostic tests and/or treatments
 Coital frequency and history of sexual dysfunction
 Previous methods of contraception
 Sexual history, including sexually transmitted infections
 Previous surgery or illness
 Childhood development and illness
 Medications
 Family history of infertility
 Exposure to gonadal toxins (e.g., tobacco, alcohol, recreational drugs)
 Trauma (e.g., blunt or penetrating trauma to the testes)

Female infertility
Female infertility evaluation focuses on ovulatory function, ovarian reserve, and
structural abnormalities.
 Physical examination
 Weight, BMI, vital signs
 Thyroid abnormalities (e.g., nodules, diffuse enlargement)
 Secondary sex characteristics, including Tanner stages of breasts and pubic area
 Vaginal or cervical abnormalities (e.g., discharge)
 Abdominal or pelvic tenderness
 Uterine shape, size, mobility, position
 Adnexal abnormalities (e.g., masses, tenderness)
 Tenderness or masses in the pouch of Douglas

 Ovulatory function assessment

 Menstrual history
 Basal body temperature analysis

Male infertility
 Physical examination
 Penile abnormalities, including the location of the urethral meatus
 Palpation and measurement of the testes
 Palpation of ductus deferens and epididymis
 Presence of varicocele
 Secondary sex characteristics, including Tanner stages of genital and
pubic hair development

List the main diagnostic tests in the investigation of an infertile

couple.
 Midluteal serum progesterone measurement
 Luteinizing hormone tests (ovulation prediction test)
 Endocrine evaluation: prolactin levels, TSH levels
Ovarian reserve assessment
 FSH and estradiol levels (measured between the 2nd and 5th days of the cycle)
 Anti-Müllerian hormone levels
 Antral follicle count
 Clomiphene citrate challenge test

Structural uterine, tubal, and pelvic assessment

 Ultrasonography: used to screen for ovarian, uterine, and pelvic abnormalities
(e.g., adnexal adhesions, endometriosis)
 Hysterosalpingography: used to evaluate the morphology/patency of
the fallopian tubes (e.g., tubal occlusion) and uterine cavity abnormalities
(e.g., septate uterus, submucous fibroids, intrauterine adhesions)
 Sonohysterosalpingography
 Hysteroscopy: indicated for further evaluation and treatment of intrauterine
abnormalities or tubal occlusion

• Discuss therapeutic proposals for couples with idiopathic infertility.

Case 5
Learning Goals (pelvic pain):A 24- year-old woman presents to the
emergency department complaining of pelvic pain for the last 2 days.
The pain is constant and severe (8/10), mainly localized in the lower
abdomen. She also felt nauseated and noticed some increased
vaginal discharge. There were no bowel or urinary symptoms. She
took paracetamol 1g 1 h before. Medical History: She has been
pregnant twice (1 vaginal delivery 6 months ago and one abortion at
16) and for contraception she has a medicated intrauterine device
(IUD) for 1 month. No other medical history of note. On examination
the temperature was 37,9ºC, blood pressure 117/74, heart rate 102
bpm. On speculum examination the cervix and vagina were normal,
the IUD threads were visible has for some yellow discharge; on
bimanual examination the uterus and both adnexal areas were
tender, but no masses were palpable; she also had pain with cervical
motion.
Learning Goals (pelvic pain):
• Discuss the differential diagnosis of pelvic pain;

Condition Pros Cons

Pelvic - History of IUD - No history of recent sexual
Inflammatory insertion activity, multiple partners etc
Disease (PID) (increased risk)
- Increased
vaginal discharge
Endometriosis - Previous - No history of endometriosis
pregnancies  Discharge not common
(increased risk)
- No history of fertility treatment
Ectopic - Recent - No history of ovarian cysts
Pregnancy pregnancy
(increased risk)
- No gastrointestinal (GI)
symptoms (nausea, vomiting)
Ovarian Torsion - Sudden onset  Yellow discharge
of severe pain not common
with adnexal
pain
- Right lower
quadrant pain
(referred)
Appendicitis - Right lower  Yellow discharge not
 quadrant pain common
 Usally does not have
(referred) discharge and pain on
uterus, cervical motion

Urinary Tract - Increased - No dysuria or frequency

Infection (UTI) vaginal discharge  Usally does not have
discharge and pain on
uterus, cervical motion
- GI symptoms
(nausea)

Acknowledge the risk factors for pelvic inflammatory disease (PID)

and etiology.
 Risk Factors: Recent unprotected sexual activity, multiple sexual
partners, history of STIs, IUDs.
o Risk is lower during pregnancy
 Etiology: Ascending infection involving the upper genital tract
(uterus, fallopian tubes, ovaries).
 Discuss the work up investigation.
 Laboratory studies
 Vaginal and/or cervical swab testing
 NAAT and/or culture for N. gonorrhoeae and C. trachomatis
 Pregnancy test: to rule out intrauterine and ectopic pregnancy
 Blood tests
 HIV testing, RPR for syphilis
o Infection markers (nonspecific for PID) [10]
 Leukocytosis on CBC
 Elevated ESR and/or CRP

 Acknowledge the initial medical treatment.

 Partner Treatment: Treat sexual partners to prevent reinfection.