WHNP reproductive health: AUB, pelvic pain, endometriosis, and STI management

FIGO PALM-COEIN classification system replaced older terminology (dysfunctional uterine bleeding, menorrhagia, metrorrhagia). AUB causes classified as structural (PALM) or non-structural (COEIN).

PALM (structural): Polyp, Adenomyosis, Leiomyoma (fibroids), Malignancy and hyperplasia

COEIN (non-structural): Coagulopathy, Ovulatory dysfunction, Endometrial (primary endometrial disorder), Iatrogenic (medications, IUD), Not yet classified

Evaluation: CBC, HCG (rule out pregnancy in reproductive-age women), TSH (thyroid dysfunction is a common cause of ovulatory dysfunction leading to AUB), coagulation studies (if heavy since menarche or family history — rule out von Willebrand disease in adolescents and young women). Pelvic ultrasound (structural evaluation — fibroids, polyps). Endometrial biopsy for: age ≥45 + AUB, age <45 with risk factors (obesity, PCOS, tamoxifen, unopposed oestrogen, anovulation, failed medical therapy).

Management: Ovulatory dysfunction AUB (most common in perimenopausal) → hormonal regulation (CHC, progestin-only, or cyclic progestins for structural/anovulatory). Fibroids → NSAIDs, CHC, LNG-IUD for symptom management; GnRH agonist for preoperative shrinkage; myomectomy or hysterectomy for definitive treatment. Polyps → hysteroscopic polypectomy. Endometrial hyperplasia without atypia → progestin therapy with surveillance; with atypia → surgical evaluation.

Chlamydia: Most common reportable STI in the US. Often asymptomatic. Diagnosis: NAAT (gold standard, urine or vaginal swab). Treatment: Doxycycline 100 mg PO BID × 7 days (preferred — superior efficacy for pelvic tract infection). Azithromycin 1 g PO × 1 dose is now second-line (concern about increased resistance). Report to public health; test and treat all partners.

Gonorrhoea: Co-infection with chlamydia is common — treat both empirically. NAAT for diagnosis. Treatment (CDC 2021): Ceftriaxone 500 mg IM × 1 dose (if <150 kg; 1 g if ≥150 kg) PLUS doxycycline 100 mg BID × 7 days (if chlamydia not excluded). Penicillin/fluoroquinolone resistance — do not use amoxicillin or ciprofloxacin empirically without susceptibility testing.

Syphilis: Primary (painless chancre), secondary (rash — palms and soles, condylomata lata), latent (no symptoms), tertiary (CVS, neurological). Screening: RPR or VDRL (non-treponemal — titre correlates with disease activity), confirm with FTA-ABS or TP-PA (treponemal). Treatment: Benzathine penicillin G (Bicillin L-A) — 2.4 million units IM × 1 dose for primary/secondary/early latent; 3 weekly doses for late latent/unknown duration. Jarisch-Herxheimer reaction is expected first-dose reaction (fever, chills, hypotension) — not allergy, not treatment failure.

Pelvic inflammatory disease (PID): Diagnose clinically in sexually active women with unexplained uterine/adnexal/cervical motion tenderness. Outpatient treatment: Ceftriaxone 500 mg IM × 1 dose + doxycycline 100 mg BID × 14 days ± metronidazole 500 mg BID × 14 days. Hospitalise for: severe illness, surgical emergency cannot be excluded, IUD (can be left in place initially), tubo-ovarian abscess, failure to respond to oral therapy.