A 23-year-old woman presents to your office with the complaint of a red splotchy rash on her chest that occurs during intercourse. It is nonpuritic and painless. She states that it usually resolves within a few minutes to a few hours after intercourse.
Which of the following is the most likely cause of the rash?
The response of women to sexual stimulation is generalized and affects many different organ systems. During the excitement or seduction phase, vasocongestion leads to breast engorgement and possibly the development of a rash on the breasts, chest, and epigastric area, which is called the “sex flush.” Heart rate and blood pressure also increase during this phase. Vasocongestion also occurs in the clitoris, labia, and vagina, and a transudative lubricant develops in the vagina. The plateau phase is marked by greater vasocongestion throughout the body and retraction of the clitoris. During the orgasmic phase, the sexual tension is released via muscular contractions throughout the body, but notably in the vagina, anus, and uterus. Changes in hormones such as estrogen are not part of the sexual response.
A 19-year-old woman presents for elective termination of pregnancy at 8 weeks’ gestation. She previously had regular menses every 28 days. Pregnancy is confirmed by β-human chorionic gonadotropin (β-hCG), and ultrasound confirms expected gestational age.
Which of the following techniques for termination of pregnancy would be safe and effective in this patient at this time?
Surgical abortion is a safe and effective method for pregnancy termination, with a serious complication rate in the first trimester of less than 1%. It is the most common form of termination for pregnancies less than 14 weeks. Outpatient medical abortion is a safe and acceptable alternative to surgical abortion in select women with pregnancies less than 10 weeks’ gestation. Three medications have been used. These are: mifepristone (antiprogestin), methotrexate (antimetabolite), and misoprostol (prostaglandin). Various regimens have been found to be effective. Usually mifepristone or methotrexate is initially administered followed by misoprostol. Intra-amniotic injection of hypertonic saline is no longer used regularly, because it has a much higher incidence of serious complications, including death, hyperosmolar crisis, cardiac failure, peritonitis, hemorrhage, and coagulation abnormalities. D&E is a surgical procedure similar in concept to a D&C. However, instead of curettage (scraping) to remove the products of conception, various forceps are placed into the uterine cavity to remove the products of conception. D&E is performed for termination of later pregnancies, generally those in the second trimester. Hysterotomy is a surgical procedure in which the uterus is opened transabdominally and the contents evacuated. It is a procedure done for termination of more advanced pregnancies when all other methods of termination are unsuccessful or contraindicated.
A 48-year-old woman presents to your office with the complaint of vaginal dryness during intercourse. She reports no medical problems or prior surgeries, and she does not take any medications. She has regular menstrual cycles every 28 days, and has never had asexually transmitted disease. She describes her sexual relationship with her husband as satisfying. Her physical examination is normal.
Components of the natural lubrication produced by the female during sexual arousal and intercourse include which of the following?
Masters and Johnson initially observed a transudate-like fluid emanating from the vaginal walls during sexual response. This mucoid material, which is sufficient for complete vaginal lubrication, is produced by transudation from the venous plexus surrounding the vagina and appears seconds after the initiation of sexual excitement. No activity by Skene glands was noted, and production of cervical mucus during sexual stimulation was observed in only a few subjects. Fluid from Bartholin glands appears long after vaginal lubrication is well established; in addition, it appears to make only a minor contribution to lubrication in the late plateau phase. Uterine and tubal secretions do not contribute to this lubrication.
A 62-year-old woman presents for annual examination. Her last menstrual period was 9 years ago, and she never used postmenopausal hormone replacement because of a strong family history of breast cancer. She now complains of diminished interest in sexual activity.
Which of the following is the most likely cause of her complaint?
Sexuality continues despite aging. However, there are physiologic changes that must be recognized. Lack of estrogen from diminished ovarian function leads to decreased genital blood flow, decreased vaginal lubrication, and atrophy of vaginal tissues. These can lead to discomfort with intercourse. Vaginal lubricants and topical estrogen therapy may help. Topical estrogen has been shown to improve lubrication, blood flow, and vaginal compliance. Sexual dysfunction can be physiologic (ie, from decreased libido). Because aging does not alter the capacity for orgasm or produce vaginismus, further evaluation should be initiated if these symptoms persist after treatment is initiated.
A 22-year-old nulliparous woman has recently become sexually active. She consults you because of painful intercourse. She says her pain occurs with insertion, and is accompanied by cramping of her pelvic muscles. She says it is so painful that she does not want to have intercourse with her boyfriend, which is causing problems in their relationship. Other than confirmation of these findings, the pelvic examination is normal.
Which of the following is the most common cause of this condition?
Vaginismus is both an emotional and pain disorder. It involves involuntary painful spasm of the pelvic muscles and vaginal outlet that precludes intercourse, and causes stress or interpersonal difficulty. The patient is averse to vaginal penetration due to anticipated or actual pain. It usually has a large psychogenic component. It is different from dyspareunia, which is defined as genital pain associated with sexual activity that is not caused by a problem with lubrication or vaginismus. Treatment of vaginismus is primarily a combination of cognitive and behavioral therapy
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