General Gynecology and Genital Tract Infections
What the exam tests
Abnormal uterine bleeding, pelvic inflammatory disease, vaginitis, sexually transmitted infections, and vulvar dermatoses.
Core rules
- Abnormal uterine bleeding is classified by PALM-COEIN: polyp, adenomyosis, leiomyoma, malignancy/hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not otherwise classified.
- PID: lower abdominal pain plus cervical motion tenderness, uterine or adnexal tenderness. Treat empirically with ceftriaxone plus doxycycline and metronidazole; test for HIV and syphilis.
- Bacterial vaginosis: Amsel criteria (three of four: homogeneous discharge, clue cells, pH >4.5, positive whiff test). Treat with metronidazole; partners are not routinely treated.
- Vulvovaginal candidiasis: itch and thick discharge; treat with fluconazole or topical imidazole.
- Trichomonas: motile flagellates on wet mount; treat with metronidazole and partners.
Worked example
A 24-year-old presents with 5 days of lower abdominal pain, purulent discharge, temperature 38.2°C, and cervical motion tenderness. Diagnosis: PID. Give ceftriaxone 500 mg IM plus doxycycline 100 mg twice daily and metronidazole 400 mg twice daily for 14 days; arrange STI testing and partner notification. The reasoning: empirical treatment is justified because delayed treatment risks tubal infertility; hospitalise if pregnant, systemically unwell, or a tubo-ovarian abscess is suspected.
Traps
Missing ectopic pregnancy; treating BV with antifungals; not treating partners of trichomonas; and attributing postcoital bleeding to infection without examining the cervix.