A 20-year-old G2P0020 with an LMP 5 days ago presents to the emergency department with a chief complaint of a 24-hour history of increasing pelvic pain. This morning she experienced chills and fever, although she did not take her temperature. She reports no changes in her bladder or bowel habits. She has had nausea or vomiting, and has not been able to tolerate liquids. She reports no medical problems, and her only surgery was a laparoscopy performed last year for an ectopic pregnancy. She reports regular menses without dysmenorrhea. She is currently sexually active with a new sexual partner, and had intercourse with him just prior to her last menstrual period. She reports no history of abnormal Pap smears or sexually transmitted diseases. Urine pregnancy test is negative. Urinalysis is normal. WBC is 18,000. Temperature is 38.8°C (102°F). On physical examination, her abdomen is diffusely tender in the lower quadrants with rebound and voluntary guarding. Bowel sounds are present but diminished.
Which of the following is the most appropriate initial antibiotic treatment regimen for this patient?
The patient is most likely to have PID. Ovarian torsion, appendicitis, and acute salpingitis are all commonly associated with fever, abdominal pain, and elevated white blood cell count. Ruptured ovarian cysts present with acute abdominal pain without fever. Ovarian torsion usually presents as waxing and waning pain that is associated with an adnexal mass. Pain from ruptured ovarian cysts may occur at any time throughout the menstrual cycle but often present around the time of ovulation. Although appendicitis is in the differential diagnosis in any woman presenting with abdominal pain and fever, this patients specific pain history, examination, and associated symptoms are less consistent with appendicitis. In cases of kidney stone, urinalysis usually indicates the presence of blood and there is often flank pain. PID should be managed as an inpatient with intravenous antibiotics in cases where the patient cannot tolerate oral therapy, has not been compliant with oral therapy, has failed oral therapy, or has severe illness with high fever and pain. Outpatient oral therapy may be appropriate for patients with PID who have more mild to moderate symptoms. The decision for inpatient versus outpatient treatment of a patient with PID depends on several factors such as patient compliance, tolerance of oral medications, and certainty of diagnosis. Given this patient’s symptoms, the best treatment for this patient is inpatient intravenous antibiotics. A TOA may form in a patient with untreated PID. A patient with a TOA should also be initially hospitalized and treated with intravenous antibiotics. Patients with TOAs, who do not improve on broadspectrum antibiotics, may require drainage of the abscesses by laparotomy, laparoscopy, or percutaneously under CT guidance.
The recommendation of Centers for Disease Control for inpatient management of PID includes the following:
1. Cefoxitin 2 g IV every 6 hours OR cefotetan 2 g IV every 12 hours PLUS doxycycline 100 mg PO or IV twice daily
OR
2. Clindamycin 900 mg IV every 8 hours PLUS gentamicin loading dose IV or IM (2 mg/kg) followed by maintenance dose (1.5 mg/kg) every 8 hours. Single daily dosing (3-5mg/kg) may be substituted.
The recommendation of Centers for Disease Control for the outpatient management of PID includes the following:
1. Cefoxitin 2 g IM plus probenecid 1 g PO in a single dose concurrently OR ceftriaxone 250 mg IM PLUS doxycycline 100 mg PO twice daily for 14 days WITH OR WITHOUT metronidazole 500 mg PO twice daily for 14 days.
A 43-year-old G2P2 comes to your office reporting intermittent right nipple discharge that is bloody. She says the discharge is spontaneous and not associated with any nipple pruritus, burning, or discomfort. On physical examination, you do not detect any dominant breast masses, skin changes, or axillary lymphadenopathy.
Which of the following conditions is the most likely cause of this patient’s problem?
Nipple discharge can occur in women with either benign or malignant breast conditions. Approximately 10% to 15% of women with benign breast disease complain of nipple discharge. Nipple discharge is present in only about 3% of women with breast malignancies. The most worrisome nipple discharges tend to be spontaneous, unilateral, and persistent. The color of nipple discharge does not differentiate benign from malignant breast conditions. The most common breast disorder associated with a bloody nipple discharge is an intraductal papilloma. However, breast carcinoma must always be ruled out in any patient complaining of a bloody nipple discharge. Sanguineous or serosanguineous nipple discharges can also be seen in women with duct ectasia and fibrocystic breast disease. Women with hyperprolactinemia caused by a pituitary adenoma experience bilateral milky white nipple discharges.
A 20-year-old G0, LMP 1 week ago, presents to your clinic reporting a mass in her left breast that she discovered during routine breast self-examination in the shower. When you perform a breast examination on her, you palpate a 2-cm firm, nontender mass in the upper inner quadrant of the left breast that is smooth, well-circumscribed, and mobile. You do not detect any skin changes, nipple discharge, or axillary lymphadenopathy.
Which of the following is the most likely diagnosis?
This patient’s breast mass is characteristic of a fibroadenoma. Fibroadenomas are the second most common benign breast disorder, after fibrocystic changes. Fibroadenomas are characterized by the presence of a firm, solid, well-circumscribed, nontender, freely mobile mass, and have an average diameter of 2.5 cm. These lesions most commonly occur in adolescents and women in their twenties. Fibrocystic changes occur in about one-third to one-half of reproductive-age women and represent an exaggerated response of the breast tissue to hormones. Patients with fibrocystic changes complain of bilateral mastalgia and breast engorgement preceding menses. On physical examination, diffuse bilateral nodularity is typically encountered. Cystosarcoma phyllodes are rare fibroepithelial tumors that constitute 1% of breast malignancies. These rapidly growing tumors are the most frequent breast sarcoma and occur most frequently in women in the fifth decade of life. Trauma to the breast can result in fat necrosis. Women with fat necrosis commonly present to the physician with a firm, tender mass that is surrounded by ecchymosis. Occasional skin retraction can occur, making this lesion difficult to differentiate from cancer. It is unlikely that this patient who presents in her twenties has breast cancer. Fine-needle aspiration or excisional biopsy may be performed to rule out the rare chance of malignancy, but breast cancer is not the most likely diagnosis based on the patient’s age and lack of any other breast changes consistent with carcinoma (such as a fixed mass, skin retraction, or lymphadenopathy).
A 55-year-old G3P3 with a history of fibroids presents to you complaining of irregular vaginal bleeding. Until last month, she had not had a period in over 9 months. She thought she was in menopause, but because she started bleeding again last month she is not sure. Over the past month she has had irregular, spotty vaginal bleeding. The last time she bled was 1 week ago. She also complains of frequent hot flushes and emotional lability. She does not have any medical problems and is not taking any medications. She is a nonsmoker and does not consume alcohol or drugs. Her gynecologic history is significant for cryotherapy of the cervix 10 years ago for mild dysplasia. She has had three cesarean deliveries and a tubal ligation. On physical examination, her uterus is 12 weeks in size, mobile, nontender, and irregularly shaped. Her ovaries are not palpable. A urine pregnancy test is negative.
Which of the following is the most reasonable next step in the evaluation of this patient?
Given this patient’s age and symptoms, she is probably undergoing menopausal transition or “perimenopause.” Menopause is defined as the absence of menses for 12 months. Women with perimenopausal or postmenopausal bleeding should be evaluated with an endometrial biopsy to rule out hyperplasia or malignancy. A pelvic ultrasound may also be helpful to provide information regarding the size and location of any uterine fibroids. In addition, the endometrial stripe thickness could be evaluated (it should be less than 5 mm in a postmenopausal patient). Endometrial polyps as a cause for her irregular bleeding may be diagnosed with an office hysteroscopy or a saline infusion sonohysterogram. Conization of the cervix is performed for evaluation and treatment of severe cervical dysplasia, and is not indicated in this patient. Progesterone-containing IUDs may be used for contraception or for the treatment of menorrhagia. Endometrial ablation is used to treat heavy menstrual bleeding in premenopausal patients. There is no indication for hysterectomy.
A 57-year-old menopausal patient presents to your office for evaluation of postmenopausal bleeding. She is morbidly obese and has chronic hypertension and adult onset diabetes. An office endometrial biopsy shows complex endometrial hyperplasia with atypia, and a pelvic ultrasound demonstrates multiple, large uterine fibroids.
Which of the following is the best next step in management for this patient?
Postmenopausal patients with atypical complex hyperplasia of the endometrium have a 25% to 30% risk of having an associated endometrial carcinoma in the uterus. Given the high risk of malignancy, the next best step in management is hysteroscopy with dilation and curettage. This allows the entire uterus to be evaluated for malignancy. If there is no malignancy on the D&C pathology, the next best step in a patient who has completed childbearing or who is menopausal is simple hysterectomy. If a malignancy is identified on the D&C specimen, the patient would be referred to a gynecologic oncologist for a staging surgery, which includes hysterectomy. If hysterectomy is not medically advisable, progesterone treatment can be used. Myomectomy, or surgical removal of fibroid, is a treatment option for premenopausal women with symptomatic uterine fibroids. There is no role for the use of oral contraceptives in the treatment of postmenopausal bleeding.
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