RHEUMATOLOGY 662 FIGURE 17.11. The 18 tender points used in the diagnosis of fibromyalgia. Classification criteria are those of the American College of Rheumatology. (Reproduced, with permission, from Imboden JB et al. Current Diagnosis & Treatment in Rheumatology, 2nd ed. New York: McGraw-Hill, 2006.) Low cervical: at the anterior aspect of the interspaces between the transverse processes of C5–C7 Lateral epicondyle: 2 cm distal to the lateral epicondyle Second rib: just lateral to the second costochondral j unctions Supraspinatus: above the scapular spine near the medial border Occiput: at the insertions of one or more of the following muscles: trapezius, sternocleidomastoid, splenius capitis, semispinalis capitis Trapezius: at the midpoint of the upper border Gluteal: at the upper outer quadrant of the buttocks at the anterior edge of the gluteus maximus Greater trochanter: posterior to the greater trochanteric prominence Knee: at the medial fat pad proximal to the joint line Posterior view Anterior view RHEUMATOLOGY 663 ■ Trigger-point injections and myofascial release are of uncertain benefit. Randomized, controlled clinical trials of dry needling, saline injec- tions, anesthetic injections, botulinum toxin, acupuncture, and sham acupuncture as therapies have not shown significant benefit beyond nonspecific, placebo-related effects. Ultrasound treatment of myofas- cial “trigger points” is no more effective in reducing pain than sham ul- trasound. Pharmacologic treatment includes the following: ■ First-line agents: Low-dose TCAs (e.g., amitriptyline) at bedtime in com- bination with a centrally acting muscle relaxant (e.g., cyclobenzaprine) di- vided 2–4 times daily. Studies show conflicting results regarding the effi- cacy of SSRIs in fibromyalgia. ■ Sleep disturbances: If good sleep hygiene and sleep medications are inef- fective, request a formal sleep study to identify sleep apnea and restless leg syndrome, which are particularly common in fibromyalgia. ■ Depression: Encourage formal or informal counseling and treat pharma- cologically. COMPLICATIONS The adverse impact of fibromyalgia on the patient, family, and society is high. More than 25% of patients receive some type of disability or other compensa- tion payment. TABLE 17.16. Differential Diagnosis of Fibromyalgia DISEASE CATEGORY EXAMPLES Endocrine disorders Hypothyroidism, a Addison’s disease, Cushing’s disease, hyperparathyroidism. Autoimmune Polymyalgia rheumatica, a RA, SLE, polymyositis. disorders Medications Lipid-lowering drugs, antiviral agents, tapering of corticosteroids. Infection HCV, a HIV, parvovirus, Lyme disease, subacute bacterial endocarditis. Malignancy Myeloma; breast, lung, or prostate cancer. Neurologic disorders Carpal tunnel syndrome, a MS, a sleep apnea, a cervical stenosis. a Psychiatric disorders Vitamin D deficiency a Commonly encountered diagnoses. RHEUMATOLOGY 664 MISCELLANEOUS DISEASES Adult Still’s Disease ■ Sx/Exam: Presents with high-spiking fevers, diaphoresis, chills, sore throat, an evanescent salmon-colored rash coincident with fevers, erosive arthritis, serositis, and lymphadenopathy. ■ Dx: Laboratory findings include leukocytosis, anemia, seronegativity, transaminitis, and hyperferritinemia. ■ Tx: Treat with NSAIDs and corticosteroids. Sarcoidosis ■ Arthritis associated with sarcoidosis is either acute or chronic. See the Pul- monary Medicine chapter for nonarticular manifestations of sarcoidosis. ■ Acute sarcoid arthritis = Löfgren’s syndrome, which presents with peri- arthritis (most commonly of the ankle/knee), erythema nodosum, and hi- lar adenopathy on CXR. Resolution of acute disease occurs in 2–16 weeks with minimal therapy, NSAIDs, and colchicine. ■ Chronic sarcoid arthritis usually involves minimally inflamed joints with synovial swelling/granulomata. Treat with NSAIDs, corticosteroids, and immunosuppressants. Cholesterol Emboli Syndrome Precipitated by invasive arterial procedures in patients with atherosclerotic disease. Features include fever, livedo reticularis, cyanosis/gangrene of the digits, vasculitic/ischemic ulcerations, eosinophilia, renal failure, and other end-organ damage. Musculoskeletal Complications of Diabetes Mellitus Include the following: ■ CPPD: Pseudogout; acute symptomatic chondrocalcinosis. ■ Diabetic cheiroarthropathy: Diabetic stiff hand syndrome plus prayer sign on exam. ■ Carpal tunnel syndrome: Median nerve neuropathy. ■ Flexor tenosynovitis: “Trigger finger.” ■ Adhesive capsulitis: “Frozen shoulder.” ■ Neuropathic arthritis: Charcot joint, diabetic osteoarthropathy. ■ Other: Diffuse idiopathic skeletal hyperostosis, Dupuytren contractures, diabetic muscle infarction. Consider Still’s in a young adult with fever of unknown origin and markedly elevated ferritin (usually > 1000) whose workup for infection and malignancy is ᮎ. CHAPTER 18 Women’s Health Deborah Lindes, MD Linda Shiue, MD Breast Masses 666 Contraception 666 Preconception Care 666 TESTING 666 MANAGEMENT 666 Medical Conditions in Pregnancy 667 TERATOGENIC DRUGS 667 HYPERTENSION IN PREGNANCY 669 DIABETES IN PREGNANCY 672 THYROID DISEASE IN PREGNANCY 673 Infertility 674 Menstrual Disorders 675 ABNORMAL PREMENOPAUSAL VAGINAL BLEEDING 675 AMENORRHEA 676 Menopause 677 Postmenopausal Bleeding 678 Osteoporosis 678 Hirsutism 680 Polycystic Ovarian Syndrome 681 Chronic Pelvic Pain 682 Domestic Violence 682 STD Screening 683 CHLAMYDIA 683 CERVICITIS 683 PELVIC INFLAMMATORY DISEASE 684 Urinary Tract Infection 685 Vaginitis 685 665 Copyright © 2008 by Tao Le. Click here for terms of use. WOMEN’S HEALTH 668 TABLE 18.1. Contraceptive Methods METHOD DESCRIPTION SIDE EFFECTS Behavioral methods Coitus interruptus Withdrawal of the penis before ejaculation. High failure rate. Calendar/rhythm method Determines the fertile period on the basis of the LMP. High failure rate; cannot be used by women with irregular cycle lengths. Ovulation method Uses basal body temperature, cervical mucus High failure rate. consistency, and/or urine LH levels to predict fertile periods. Barrier methods Diaphragm, cervical cap A domed sheet of latex filled with spermicide and Allergy to latex or spermicide; ↑ risk of placed over the cervix. Must be fitted by a physician UTI. and remain in the vagina 6–8 hours after intercourse. Condom A latex or polyurethane sheath placed over the Allergy to latex or spermicide. penis during intercourse. Intrauterine devices The risk of infertility does not appear to be ↑ among users at low risk for STDs. Ideal IUD candidates are parous women in monogamous relationships. Copper IUD (ParaGard) A copper device placed into the endometrial ↑ vaginal bleeding/cramping. The cavity. Produces a local inflammatory reaction device may be expelled or may that has a spermicidal effect and also impairs perforate the uterus. implantation. Levonorgestrel IUD Local effects are the same as those of the copper Menstrual blood loss ↓, and (Mirena) IUD. Additionally, local progestin release thins the amenorrhea may occur. A small endometrium and thickens cervical mucus. percentage of users have systemic progestin side effects. Progestin effects may be beneficial for women with menorrhagia or dysmenorrhea. Hormonal methods OCPs Suppress ovulation by inhibiting FSH/LH; thicken Nausea, breast tenderness, acne, mood cervical mucus (impede sperm passage into the changes, hypertension, hepatic uterus); thin the endometrium (inhibit adenoma, weight gain, ↑ risk of implantation). venous thromboembolism and arterial thrombosis (MI, CVA), particularly among women with other cardiovascular risk factors. Postcoital/emergency Progestin (+/− estrogen) taken within five days Nausea, vomiting, fatigue, headache, contraception of intercourse to suppress ovulation or discourage dizziness, breast tenderness. implantation. Levonorgestrel alone (Plan B) is more effective and has fewer side effects than combined estrogen/progestin formulations. WOMEN’S HEALTH 670 T REATMENT ■ See Table 18.3 for an outline of preeclampsia management. ■ For women with chronic hypertension, the BP regimen should be evalu- ated prior to conception with the following factors in mind: ■ Elimination of teratogenic agents (e.g., ACEIs and ARBs). TABLE 18.2. Teratogenic/Fetotoxic Drugs DRUG EFFECT Alcohol Fetal alcohol syndrome, intrauterine growth retardation (IUGR), cardiac defects. Cocaine Bowel atresias, IUGR, microcephaly. Tobacco Low birth weight, placental abruption, preterm labor, SIDS. Streptomycin CN VIII damage/ototoxicity. Tetracycline Tooth discoloration, inhibition of bone growth, small limbs, syndactyly. Sulfonamides Kernicterus. Quinolones Cartilage damage. Isotretinoin Heart and great vessel defects, craniofacial dysmorphism, deafness. Iodide Congenital goiter, hypothyroidism, mental retardation. Methotrexate CNS malformations, craniofacial dysmorphism, IUGR. DES Clear cell adenocarcinoma of the vagina/cervix, genital tract abnormalities (cervical hood, T-shaped uterus, hypoplastic uterus), cervical incompetence. Thalidomide Limb reduction (phocomelia), ear and nasal anomalies, cardiac and lung defects, pyloric or duodenal stenosis, GI atresia. Warfarin Stippling of bone epiphyses, IUGR, nasal hypoplasia, mental retardation. NSAIDs Premature closure of the ductus arteriosus; ↑ risk of spontaneous abortion. ACEIs Oligohydramnios; fetal renal damage. Benzodiazepines Possible congenital defects, IUGR, “floppy infant” syndrome, neonatal withdrawal syndrome. Lithium Ebstein’s anomaly; other cardiac disease. Carbamazepine Fingernail hypoplasia, IUGR, microcephaly, neural tube defects. Phenytoin Nail hypoplasia, IUGR, mental retardation, craniofacial dysmorphism, microcephaly. Valproic acid Neural tube defects; craniofacial and skeletal defects. WOMEN’S HEALTH 671 ■ Diuretics are usually avoided despite a lack of clear evidence regarding their potential ill effects. ■ β-blockers and calcium channel blockers are generally considered ac- ceptable for use during pregnancy. ■ Methyldopa has the longest record of safety during pregnancy but has many side effects. HELLP SYNDROME ■ Consists of Hemolysis, Elevated Liver enzymes, and Low Platelets. Con- sidered a variant of preeclampsia. ■ May be associated with renal dysfunction (but this is not required for diag- nosis). TABLE 18.3. Hypertensive Disorders of Pregnancy CHRONIC HYPERTENSION PREECLAMPSIA/ECLAMPSIA GESTATIONAL HYPERTENSION Timing Present before pregnancy or Onset after 20 weeks’ gestation Onset after 20 weeks’ gestation. persisting > 6 weeks postpartum. (can occur up to six weeks Resolves after delivery. postpartum). Clinical features Known hypertension prior to Preeclampsia: Hypertension May resemble preeclampsia, but pregnancy. (> 140/90) and proteinuria proteinuria is absent. Normal uric acid level (usually). with onset after 20 weeks. Often no proteinuria. Often associated with edema. Uric acid level is often elevated. Eclampsia = preeclampsia + seizures. Complications ↑ risk of preeclampsia. Fetal: Intrauterine growth May develop into preeclampsia. IUGR, placental abruption, fetal restriction, oligohydramnios, ↑ risk of subsequent essential demise. demise. hypertension. Maternal: Edema, HELLP syndrome (hemolysis, elevated liver enzymes, low platelets), seizures, death. Treatment Treat BP if > 145–150/95–100. After 36 weeks’ gestation: Same as that for chronic Target DBP 80–100. Immediate delivery. hypertension. Methyldopa, β-blockers, Before 36 weeks: Bed rest, close hydralazine, and calcium monitoring of mother and channel blockers are often fetus, BP management (goal used. DBP 90–100). Hospitalization and delivery at any stage of gestation for severe preeclampsia, HELLP, or eclampsia. Magnesium sulfate given after delivery to prevent seizures. WOMEN’S HEALTH 679 plications of hip fractures is equal to that from breast cancer in women > 50 years of age. Risk factors and disease associations include the following: ■ White or Asian ethnicity ■ Low weight ■ Menopause (especially early or surgical menopause) ■ Glucocorticoid use or Cushing’s syndrome ■ Estrogen deficiency states (e.g., anorexia nervosa) ■ Tobacco or alcohol use ■ A family history of osteoporosis ■ Older age ■ A history of falls ■ Poor eyesight ■ Immobilization ■ Calcium/vitamin D deficiency or malabsorption (e.g., celiac disease, IBD) ■ Thyrotoxicosis or levothyroxine overreplacement ■ Hyperparathyroidism ■ Medications (antiepileptic drugs, heparin) See the Endocrinology chapter for further details on the 2° causes of osteo- porosis and osteoporosis in men. SYMPTOMS/EXAM ■ May be asymptomatic or may present with back pain, loss of height, or nonspinal fractures. ■ Exam may be normal. Patients may be thin and have a “dowager’s hump” (kyphosis). DIAGNOSIS ■ DEXA imaging measures bone mineral density (BMD) at the spine and hip. ■ Osteoporosis is diagnosed if BMD (as measured by the T-score) is ≥ 2.5 standard deviations below that of a young, normal woman (T-score <−2.5). ■ Osteopenia is defined as a T-score between −1.0 and −2.5. ■ Z-scores compare a patient’s BMD with age- and gender-matched norms. A low Z-score (<−2) should raise suspicion for 2° causes of osteoporosis. ■ Osteoporosis can be diagnosed clinically in the presence of vertebral or other fragility fractures (e.g., hip fractures, Colles’ fracture of the wrist). ■ Quantitative CT and ultrasound are other methods sometimes used to di- agnose osteoporosis. TREATMENT ■ Calcium 1500 mg QD; vitamin D 800 IU QD; weight-bearing exercises for all women unless contraindications exist. ■ Smoking cessation. ■ Fall prevention measures (handrails, assistive devices for ambulation, bal- ance exercises) for frail patients. ■ Bisphosphonates (alendronate, risedronate) are first-line agents. They im- prove BMD and ↓ the incidence of vertebral and hip fractures by up to > 50%. ■ Estrogen slows BMD loss and thus helps prevent osteoporosis, but it is not generally recommended for this indication because of its adverse effects. Osteopenia is defined as a T-score of −1.0 to −2.5. Osteoporosis is diagnosed when the T-score is <−2.5. WOMEN’S HEALTH EXAM Conduct a pelvic exam, particularly for the following: ■ Vulvar edema/erythema. ■ Discharge: Quantity, color, adherence, odor. ■ Cervicitis: Friability, purulent discharge, “strawberry cervix” (petechiae in trichomonal infection). DIFFERENTIAL UTI, normal (physiologic) discharge, cancer, noninfectious/irritants (spermi- cide, douching), atrophy. DIAGNOSIS ■ Wet mount (pH and microscopy in saline and KOH) (see Table 18.6 and Figure 18.2). ■ Consider UA and/or STD testing. TABLE 18.6. Wet Mount Criteria in Diagnosing Vaginitis DIAGNOSIS DISCHARGE CELLS PHWHIFF Bacterial Grayish-white, thin, Clue cells > 4.5 ᮍ with KOH vaginosis fishy odor Yeast Thick, white, clumpy, Pseudohyphae 3.5–4.5 ᮎ adherent (“cottage with KOH cheese”) Trichomoniasis Profuse, yellow-green, Motile > 4.5 ᮍ frothy, malodorous trichomonads FIGURE 18.2. Causes of vaginitis. (A) Pseudohyphae in candidal vaginitis. (B) Clue cells in bacterial vaginosis. (Reproduced, with permission, from DeCherney AH et al. Current Obstetric & Gynecologic Diagnosis & Treatment, 9th ed. New York: McGraw-Hill, 2003: 652, 653.) A B 686 [...]... infarction, complications of, 100 103 approach to hypotensive patients with, 104 arrhythmias, 103 cardiogenic shock, 102 embolic complications, 103 ischemic complications, 103 left ventricular aneurysm, 102 left ventricular free wall rupture, 102 papillary muscle rupture, 101 102 pericarditis, early, 102 103 pericarditis, late (Dressler’s syndrome), 103 ventricular septal defect (VSD), 100 101 Acute pain management,... 99 107 acute coronary syndromes, 99 acute myocardial infarction, complications of, 100 103 arrhythmias, 103 cardiogenic shock, 102 embolic complications, 103 ischemic complications, 103 left ventricular aneurysm, 102 left ventricular free wall rupture, 102 papillary muscle rupture, 101 102 pericarditis, early, 102 103 pericarditis, late (Dressler’s syndrome), 103 ventricular septal defect (VSD), 100 101 ... ventricular septal defect (VSD), 100 101 cardiogenic shock, 103 105 chest pain, diagnostic strategies and risk stratification for, 106 evaluation of patient with, 106 risk stratification, 106 chronic stable angina, 105 106 management of, 107 elective revascularization, indications for, 107 pharmacologic therapy, 107 Coronary stents, 96 Corrigan (water-hammer) pulse, 85 Corynebacterium, 454 Cough, 604–605... Chalazion, 41, 42 Chancroid, 56, 57, 384, 460 Charcot-Marie-Tooth disease, 542 Charcot’s triad, 290 Chest pain, diagnostic strategies and risk stratification for, 106 evaluation of patient with, 106 risk stratification, 106 Chest x-ray, 602 infiltrates found on, 603 masses found on, 604 699 Chickenpox, 477, 478 Child-Turcotte-Pugh classification, 308 Child-Turcotte-Pugh scoring, 308 Chlamydia, 264, 413, 643, 683,... heart failure (CHF), 107 –111, 607, 616 systolic vs diastolic dysfunction, 107 109 diastolic dysfunction, 108 109 diastolic dysfunction, heart failure with, 108 stages of, 108 systolic dysfunction, heart failure with, 107 108 treatment of, 109 –111 diastolic dysfunction, 111 systolic dysfunction, 109 – 110 Coniosporium, 9 Conjunctivitis, 7, 38 allergic, 40 bacterial, 40 chlamydial, 38 gonorrheal, 38 viral,... glomerular filtration rate γ-glutamyltransferase growth hormone γ-hydroxybutyrate growth hormone–releasing hormone gastrointestinal gastrointestinal stromal tumor glucose-like peptide granulocyte-macrophage colonystimulating factor glomerulonephritis gonadotropin-releasing hormone glucose-6-phosphate dehydrogenase DI DIC DIP DJD DKA DLCO DM DMARD DNA DNase DNR DOC 2,3-DPG DPOA-HC DPP DRE dsDNA DTRs DTs... chain reaction low-dose helical CT lactate dehydrogenase low-density lipoprotein low-dose unfractionated heparin loop electrosurgical excision procedure Lambert-Eaton myasthenic syndrome GU H&P HAART HACEK HAV HbA1c HBeAg HBIG HBsAg HBV hCG HCO3 HCTZ HCV 25-HD HDL HDV HELLP HEV HF HGA HHV 5-HIAA HIDA HIPA HIPAA HIT HIV HL HLA HME HMG-CoA HNPCC HP hpf HPV HR HRCT HRS HRT 11β-HSD HSV 5-HT HTLV HUS IABP... (stavudine) 3,4-diaminopyridine Dietary Approach to Stop Hypertension (study) diastolic blood pressure double-contrast barium enema Diabetes Control and Complication Trial ductal carcinoma in situ 1-deamino (8-D-arginine) vasopressin dideoxycytidine dideoxyinosine diethyltoluamide diethylstilbestrol dual-energy x-ray absorptiometry discriminant factor direct fluorescent antibody 1,25-dihydroxycholecalciferol... reserve capacity follicle-stimulating hormone Federation of State Medical Boards free triiodothyronine free thyroxine fluorescent treponemal antibody–absorbed 5- uorouracil fever of unknown origin forced vital capacity γ-aminobutyric acid group A β-hemolytic streptococcus glutamic acid decarboxylase glomerular basement membrane Guillain-Barré syndrome gonococcal granulocyte colony-stimulating factor gestational... high-power field human papillomavirus heart rate high-resolution computed tomography hepatorenal syndrome hormone replacement therapy 11β-hydroxysteroid dehydrogenase herpes simplex virus 5-hydroxytryptamine human T-cell leukemia virus hemolytic-uremic syndrome intraaortic balloon pump IAHG International Autoimmune Hepatitis Group inflammatory bowel disease irritable bowel syndrome inspiratory capacity internal . hormone replacement therapy 11β-HSD 11β-hydroxysteroid dehydrogenase HSV herpes simplex virus 5-HT 5-hydroxytryptamine HTLV human T-cell leukemia virus HUS hemolytic-uremic syndrome IABP intraaortic. attention-deficit hyperactivity disorder ADPKD autosomal-dominant polycystic kidney disease ADPW adjusted-dose perioperative warfarin AF atrial fibrillation AFB acid-fast bacillus AFP α-fetoprotein AI. ductal carcinoma in situ DDAVP 1-deamino ( 8- D-arginine) vasopressin ddC dideoxycytidine ddI dideoxyinosine DEET diethyltoluamide DES diethylstilbestrol DEXA dual-energy x-ray absorptiometry DF discriminant