Persistent Vulvar Pain

Reading: Committee Opinion No. 673 - Persistent Vulvar Pain 

What is persistent vulvar pain? 

• Persistent vulvar pain is a complex disorder and often very frustrating to both the patient and the provider 

• Because it is difficult to treat and even with appropriate treatment, pain may not resolve completely 

• Terminology and Classification - from 2015 Consensus Terminology and Classification of Persistent Vulvar Pain 

• From the International Society for Study of Vulvovaginal Disease: 

• Can be caused by a specific disorder or it can be idiopathic 

• Idiopathic vulvar pain = vulvodynia

• Vulvar pain caused by specific disorder: 

• Infectious (ie. recurrent candidiasis, herpes) 

• Inflammatory (lichen sclerosus, lichen planus, etc.) 

• Neoplastic (ie. Paget disease, SCC) 

• Neurologic (postherpetic neuralgia, nerve compress or injury) 

• Trauma

• Iatrogenic (postoperative, chemotherapy, radiation) 

• Hormonal deficiencies (ie. genitourinary syndrome of menopause, lactational amenorrhea) 

• Vulvodynia = vulvar discomfort, most often reported as burning pain, which occurs in the absence of relevant visible findings or a specific, clinically identifiable neurological disorder for at least 3 months 

• Descriptors 

• Localized (ie. vestibulodynia, clitorodynia), general, or mixed (can be localized or generalized) 

• Provoked (ie. insertional, contact), spontaneous, or mixed (provoked and spontaneous) 

• Onset (primary or secondary) 

• Temporal pattern (intermittent, persistent, constant, immediate, delay) 

How do we evaluate what the cause of vulvar pain is? 

• Exclude other causes before assigning vulvodynia 

• Vulvodynia = diagnosis of exclusion 

• History

• Do your normal OPQRS – how long has the patient been having pain? Where is it? 

• Also obtain medical and surgical history

• Sexual history - make sure to ask permission 

• Allergies 

• Previous treatment 

• Physical exam 

• Know your anatomy!  

View fullsize

UPTODATE

• Cotton swab test

  • Using a cotton swab and moving across the labia → start on thighs → labia majora → interlabial sulci. Then test vestibule in the 2, 4, 6, 8, 10 o’clock position 

• R/o infection  

• Wet mount, vaginal pH, fungal culture, and gram stain 

• Vulvoscopy - usually not needed 

• If there is concern, you can also biopsy an area - can find dermatoses 

• Musculoskeletal evaluation 

• Palpation of the different muscles within the pelvis to see if there is referred pain

• Palpation of the pubovaginalis portion of the levator ani, obturator internus, and urethrovaginal sphincter 

Treatment 

• Unfortunately, the evidence for treating vulvodynia is based on clinical experience and observational studies - few randomized studies exist 

• If there is obvious cutaneous or mucosal disease present 

• Treat the disease! Ie. infections, dermatoses 

• We talk about this here on previous podcasts: 

• Vulvar itching

• Benign vulvar dermatoses

• If there is not, do the cotton swab test 

• If no areas of tenderness then consider alternative diagnosis 

• If there is tenderness or burning with cotton swab test, do a yeast culture 

• Positive yeast culture: antifungal 

• If negative, or if antifungal does not provide adequate relief, move to:

• Vulvar care measures

• Cotton underwear and no underwear at night 

• Avoid vulvar irritants and douching 

• Mild soaps for bathing, or anti-allergenic soaps, do not apply directly to vulva 

• Apply preservative free emollient (ie. coconut oil) 

• Switch to 100% cotton menstrual pads 

• Use water based lube for intercourse 

• Cool gel to vulvar area for relief 

• Topical medications - ie. estrogen cream, tricyclic antidepressants can be compounded 

• Oral medications - TCAs and anticonvulsants; use one drug at a time 

• TCAs should be used for up to 3 weeks to assess adequate pain control 

• Injections (ie. botox for trigger point injections, can also use steroids for trigger point injections ) 

• Biofeedback/physical therapy - assess for pelvic floor dysfunction 

• Dietary modification 

• CBT 

• Sexual counseling 

• If still no adequate relief and localized pain → can consider surgery with vestibulectomy 

• Should only be done if other treatments have failed 

• Success rate is 60-90% compared to 40-80% for nonsurgical interventions 

• If generalized pain - consider increasing the dose of medication, combining meds, etc. 

An Update on Pelvic Inflammatory Disease

We last covered PID and TOA on the podcast in February 2019 — and since then, as with our gonorrhea and chlamydia update, have some new updates to reflect the 2021 CDC Treatment Guidelines.

What is PID/TOA? 

• PID: pelvic inflammatory disease 

• This is a wide variety of inflammatory disorders of the upper female genital tract, including: 

• Endometritis

• Salpingitis

• TOA: tubo-ovarian abscess

• Pelvic peritonitis 

• Caused by many infectious diseases. 

• Most common: N. gonorrhoeae and C. trachomatis (gonorrhea and chlamydia)

• 50% of PID diagnoses test positive for GC/CT, though this proportion is decreasing.

• Other organisms that can be implicated:

• Anaerobes, 

• G. vaginalis 

• H. influenzae

• Enteric GNRs

• Strep agalactiae

• Cytomegalovirus 

• Trichomonas (Trichomonas vaginalis)

• Mycoplasima hominis and M. genitalium

• Ureaplasma urealyticum

Diagnosis of PID

• Can be difficult because of many vague symptoms, and some are asymptomatic 

• Differential diagnosis is broad for abdominopelvic pain: 

• Appendicitis 

• Ectopic pregnancy

• Ovarian torsion or ovarian cysts

• Diverticulitis

• Functional GI pain, IBS, IBD

• Etc. etc. etc. 

• A presumptive dx should be made, and treatment started,

  • In sexually active women and those at risk for STIs experiencing pelvic/lower abdominal pain, if no other cause for illness can be identified,

  • and if they have 1 or more of these minimum clinical criteria: 

• Cervical motion tenderness 

• Uterine tenderness 

• Adnexal tenderness  

• One or more of the following can be used to enhance specificity of the minimal clinical criteria: 

• Oral temp > 101 F (38.3) 

• Abnormal cervical mucopurulent discharge or friability 

• Presence of abundant WBC on saline microscopy of vaginal fluid 

• Elevated erythrocyte sedimentation rate 

• Elevated C-reactive protein 

• Laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis 

• Even more specific criteria can include:

• Endometrial biopsy with histopathologic evidence of endometritis 

• TVUS or MRI showing thickened, fluid-filled tubes with or without free fluid or tubo-ovarian complex

• Laparoscopic findings of PID (Fitz-Hugh-Curtis syndrome) 

What should I do if I think someone has PID?

• Testing:

• HIV

• Testing recommended by CDC “in all persons seeking STI testing who do not have a known diagnosis of HIV.” 

• GC/CT

• 50% will test positive, so they are high yield for PID testing.

• NAAT testing is preferred method.

• Patient self-collected swabs are just as accurate as clinician-collected.

• First void urine is most sensitive; decreases with later voids during the day.

• Urine testing may miss over 400k infections per year in USA - vaginal swab testing should be offered first, and patient-collected may help improve acceptability.

• Imaging

• Not recommended outright by CDC in PID evaluation.

• Will frequently be part of your evaluation in a differential diagnosis

• TVUS - may continue to have cervical motion tenderness, can demonstrate TOA. Can also demonstrate other GYN pathologies.

• CT/MRI - unlikely to demonstrate specific findings for PID outside of large TOAs.

• Treatment:

• Primary Considerations: 

• Choice of medication:

• Treatment is empiric, requiring broad spectrum coverage of likely pathogens

• All treatment types should be effective against gonorrhea and chlamydia 

• Need for hospitalization:

• Recommended if:

• A surgical emergency (ie. appendicitis) cannot be excluded

• Presence of tubo-ovarian abscess 

• Pregnancy

• Severe illness including nausea, vomiting, or high fever,

• Inability to tolerate or follow outpatient regimen

• Failed outpatient therapy based on follow up

• Parenteral treatments

• Ceftriaxone (1g IV q24 hrs) + doxycycline (100 mg oral or IV q12hrs) + metronidazole (500mg oral or IV q12h).

• Cefoxitin (2g IV q6hrs) + doxycycline (100mg oral or IV q12hrs) 

• Cefotetan (2g IV q12h) + doxycycline (100mg oral or IV q12hrs)

• Because of pain associated with IV infusion, doxycycline should be given orally whenever possible.

• Oral and IV doxycycline and metronidazole have similar bioavailability

• Alternative regimens pending allergies and antibiotic availability:

• Clindamycin (900 mg IV q8hrs) + gentamicin (2mg/kg loading dose IV or IM, then maintenance of 1.5mg/kg every 8 hrs, or single daily dosing of 3-5mg/kg) 

• Ampicillin-sulbactam (Unasyn) 3g IV q6hrs + doxycycline 100mg q12hrs  

• Goal of parenteral therapy will be to transition to oral antibiotics within 24-48 hours if clinical improvement.

• Those with TOA should have at least 24 hours of inpatient observation

• IM/Oral treatment - For continuation of inpatient treatment, or start here in those with mild-to-moderate symptoms of acute PID. 

• Clinical outcomes are similar to those treated with IV therapy, but if women don’t respond in 72 hours, should be re-evaluated and treated with IV

• Ceftriaxone 500mg IM x1 + doxycycline 100mg BID x14 days + metronidazole 500 mg BID x14 days 

• Cefoxitin 2g IM + Probenecid 1g orally + doxycyline 100mg BID x14 days + metronidazole 500mg BID x14 days 

• Some other 3rd generation cephalosporin + doxy + metronidazole 

• If starting with outpatient treatment, improvement should be documented by follow up within 72 hours.

• If no improvement has occurred, then hospitalization, assessment of the antimicrobial regimen, and considering potential additional diagnostics (imaging, laparoscopy) are indicated.

• Retesting should occur at 3 months after treatment, regardless of treatment of sex partners, to assess for reinfection.

• Patients should refrain from sex until treatment is completed, symptoms resolved, and sex partners have been treated.

• Sex partners within previous 60 days of patients with PID should also be treated presumptively for gonorrhea and chlamydia

• This is regardless of PID etiology or pathogens isolated 

• Consider expedited partner therapy (EPT).

Managing TOAs 

• Surgical drainage indicated if:

• Failure to respond to treatment within 48-72 hours 

• Clinical decline (ie. becoming septic) 

• Likelihood of need for surgical intervention is related to the size of TOA: 

• 60% of those with abscess >10cm 

• 30% in 7-9cm 

• 15% in those of 4-6 cm

Special considerations for treatment in certain populations:

• Pregnancy

• Pregnant patients with PID are at high risk of morbidity, pregnancy loss, preterm delivery.

• Hospitalization and consultation with ID are recommended.

• Persons with HIV

• Patients with HIV may be more likely to have TOA, though symptoms are similar overall to those without HIV.

• No data currently to suggest more aggressive therapy is needed in patients with HIV.

• If patient has an IUD:

• IUD is not required to be removed with a diagnosis of PID.

• However, if there is no clinical improvement in 48-72 hours, then should consider removing the IUD.

Primary Ovarian Insufficiency

Reading: Committee Opinion 604

What is Primary Ovarian Insufficiency? 

1. Definition 

1. Depletion or dysfunction of ovarian follicles with cessation of menses before age 40 

2. Used to be caused premature menopause or primary ovarian failure 

3. Note: should not be confused with menopause because 5-10% of women with POI can still experience spontaneous conception and delivery 

What Causes POI? 

1. Causes of POI 

1. There are many, but usually caused by chromosomal abnormalities or damage from chemotherapy or radiation therapy  

2. Common cause: chemo and radiation 

1. Immediate loss of ovarian function after chemo/radiation is called acute ovarian failure 

2. Highest incidence occurs after use of alkylating agents or procarbazine 

3. Younger the patient at time of receiving chemo, the more likely some follicles will survive  

3. Common cause: premutation of the FMR1 gene for fragile X 

1. As a reminder, Fragile X is an X-linked dominant condition

2. Caused by an increase in the repeats of CGG, typically >200 

3. In fragile X, there is genetic anticipation, meaning that the number of repeats can increase as they get passed onto future generations 

4. A pre-mutation is when there is between 55-200 repeats, and those with Fragile X or a pre-mutation have a 20% chance of developing POI in their lifetime 

5. 1% of pre mutation carriers will experience final menses before age 18 

4. Another common cause: Turner Syndrome 

1. Chromosomal abnormality with XO instead of XX 

2. Certain people can also have Turner mosaicism, which can also lead to POI 

3. When evaluating adolescents with primary amenorrhea and no associated comorbidities, about 50% will have chromosomal abnormalities 

4. Can also lead to pubertal and growth delays 

5. Gonadal dysgenesis 

6. Less frequently can be caused by infection or infiltrative process 

7. Other cause could be iatrogenic (ie. removal of the ovaries) 

8. Can also have autoimmune component, as 4% of patients with POI will have adrenal or ovarian antibodies 

How do we diagnose primary ovarian insufficiency? 

1. Diagnosis 

1. Unfortunately, no consensus criteria to identify POI in adolescents, and so a delay in diagnosis is common 

2. Some adolescents may have hot flashes or vaginal dryness, but the most common presenting symptom is POI 

3. So in someone who is presenting with amenorrhea or menstrual irregularity for 3 or more months, important to evaluate for all etiologies (ie. pregnancy, PCOS, hypothalamic amenorrhea, thyroid abnormalities, hyperprolactinemia, and POI) 

2. Work up 

1. History and physical 

1. Ask about menstrual history, family history of early menopause, and other factors that may place patients at risk for POI (ie. above etiologies) 

2. Physical exam should include other signs of disorders of sexual development (ie. breast development, uterus present or absent) 

2. Labwork 

1. Obtain basal FSH and estradiol levels - do not obtain when patient is on OCPs or other hormonal medications 

2. Pregnancy test 

3. Thyroid function tests and prolactin 

3. If gonadotropins are elevated in menopausal range (FSH 30-40 mIU/L), a repeat FSH measure is indicated in 1 month

1. If FSH is still elevated, this is diagnosed as POI 

2. Hypoestrogenism is when estradiol levels are <50 pg/mL 

3. Once diagnosis is established 

1. Karyotype 

2. FMR1 pre mutation testing 

3. Adrenal antibodies 

4. Pelvic ultrasound  

5. Meeting with genetic counselor depending on genetic findings 

4. Other tests being studied  

1. AMH is currently being used to assess ovarian reserve, but should not be used to determine if someone is fertile or not 

2. Inhibin B is not recommended as there is significant variability between menstrual cycles 

Management 

1. Note about treatment 

1. Diagnosis can be emotionally distressing in young women 

2. Therefore, treatment should have focus on sensitivity to both physical and emotional needs 

3. Some patients may need referral to counseling/group therapy for support  

2. Goal overall physically is to replace the hormones that the ovary would be producing before age of menopause 

1. May need more than menopausal women 

2. Pubertal development 

1. Breast development 

1. Initiate estrogen and increase gradually before administering progesterone until breast development is complete to prevent tubular breast formation 

2. Consultation to REI or PAGs for further management 

3. Ongoing hormonal treatment 

1. Will be necessary to prevent comorbidities 

2. Usually, transdermal, oral, or occasionally transvaginal estradiol of doses of 100 mcg daily is the therapy of choice 

1. Remember that oral estradiol can be used, but there is a higher risk of VTE compared to transdermal estrogen 

3. Addition of progesterone for 10-12 days each month is protective against endometrial hyperplasia 

4. The instinct may be to reach for OCPs, but OCPs have a much higher dosage of estrogen than is needed, and so is not first line treatment 

3. Associated Comorbidities 

1. Bone loss 

1. We know that ovarian function loss can affect bone architecture, especially in adolescents when bone accrual is at its maximum 

2. There is no consensus regarding DEXA scan or monitoring bone density annually; some do, but the the implications of low bone mineral density result in this population is unclear given low risk of fracture 

3. Long term use of bisphophonates is not recommended because of uncertain adverse effects and safety profiles 

2. Cardiovascular Disease 

1. Those with early estrogen loss are at higher risk of CV mortality 

2. Other than supplementing estrogen, there should be monitoring 

3. Routine visits should also focus on other methods of prevent CV morbidity: smoking avoidance, appropriate diet and exercise 

4. Blood pressure measurement annually and lipid levels every 5 years 

3. Endocrine Disorders 

1. 20% of adults with idiopathic POI will experience hypothyroidism, commonly Hashimoto’s thyroiditis 

2. No formal recommendation, but appropriate to test for thyroid insufficiency every 1-2 years 

3. Test for adrenal antibodies and should undergo yearly corticotropin stimulation testing as there is a 50% chance of developing adrenal insufficiency 

4. Fertility and Contraception 

1. For patients that desire to start families, they should be referred to REI to discuss options 

1. Can have egg preservation if possible 

2. Can also discuss other ways of having offspring (ie. donor eggs, gestation carrier) 

2. Fertility can still persist as long as few follicles are present 

1. Therefore, contraception should still be a discussion 

2. OCPs can be prescribed, but other methods such as IUDs or barrier methods can also be used 

3. Even if estrogen method is not chosen, estrogen should still be supplemented for the above reasons 

4. A missed period should still warrant a pregnancy test 

Pessaries for the GYN Patient, feat. Dr. Edward Kim

What are pessaries?

• Pelvic organ prolapse (or POP) and stress urinary incontinence (or SUI) are common problems that impact millions of women in the world.

• A pessary is a support device placed vaginally that can be used to treat symptoms of POP, SUI, or both.

  • Pessaries are generally cost effective, well-tolerated, safe and can help avoid surgery.

    • For POP, up to 90% of patients report relief of symptoms like pressure and bulge.

    • For SUI, about half of patients report improvement in urinary symptoms.

History of the pessary

• Historically, the first use of pessary for reduction of pelvic organ prolapse was described by Hippocrates.

  • He put a halved pomegranate soaked in wine into the vagina.

• In 1860, Dr. Hugh Lenox Hodge, an ob/gyn faculty at the University of Pennsylvania, used newly developed vulcanized rubber to create a pessary shaped more anatomically.

  • Today, most pessaries are made of soft, flexible silicone thus considered non-allergenic.

The Modern Pessary

• The most commonly used pessaries are ring, Gellhorn and donut. 

  • Ring pessary is a go-to in practice.

    • Subtypes: Ring without support

    • Ring with support (kinda looks like a mini frisbee),
      Ring without support with a knob

    • Ring with support with a knob.

      • The knob sits under the pubic bone and helps with stress urinary incontinence. So a ring with support and a knob will address POP and SUI. Rings can be removed by patients fairly easily.

  • A Gellhorn has a stem and a concave disc (kinda looks like a baby pacifier).

    • The concave disc part sits below the vaginal apex and creates somewhat of a suction.

    • The stem sits posteriorly and prevents the pessary from flipping around.

      • Gellhorns are little more difficult to place. Patients seldom can remove them on their own.

      • For removal, a provider usually needs to grasp the stem with their fingers or a ring forceps, gently wiggle it out to break the suction allowing for removal.

      • Gellhorns are generally used for more severe prolapse.

  • A donut (as the name implies) looks like a mini donut and it achieves its function by occupying the vagina.

    • A donut works better for more severe prolapse, as well, and difficult for patients to remove on their own.

Indication and counseling:

• Patients with symptomatic POP or SUI who desire to avoid surgery, poor candidate for surgery, desire further childbearing, current pregnancy or within 12 months postpartum.

• Contraindications include:

  • active pelvic infection,

  • latex allergy (as some inflatable pessary are composed of latex),

  • non adherence to care and follow up

• Studies report a very wide range of patient acceptance of pessary: from 42 to 100%.

  • Patients who decline tend to be younger, sexually active,  nulliparous, or have severe POP or SUI and desire surgical correction.

  • But it also depends on the counseling. In our practice, we discuss pessary in the range of management options for POP and SUI. We sometimes use it as a bridge between now and surgery for patients who prefer symptom relief now.

Placement:

• Placement comes with practice and it often involves trial and error.

• There have been no identified reliable predictors of which size pessary should be tried first.

• Start with a ring with support pessary (ring with support and a knob if also trying to address SUI).

• Identifying the starting size (say, 3, 4, 5) comes with practice and pelvic exam. Wet it with warm water first.

  • You could use lubricant but if you use too much it may be too slippery for you to handle and also easier for it to be expelled.

• Fold it in half like a taco, insert, and allow it to resume its disc shape in situ. Remember, it should NOT be painful. If the patient says it’s painful once it’s placed, then it is often too big.

  • Liken it to a corrective device like glasses or contact lens. When you first start using it, you notice that it’s there. But it should not be painful and with time you often forget it’s there.

• Then have pt Valsalva.

  • It’s okay that you can see the pessary descend as long as it does not completely get expelled.

• Then have them ambulate and go to the toilet and Valsalva with a toilet hat to catch the pessary if it does get expelled.

  • If it’s still in situ after that and patient has no discomfort, we send them home with it.

• Placement of Gellhorn, donuts, and other types of pessaries are little different and may be best reserved for providers who have more experience with them. But I think ring pessaries can be something everyone can have in their toolbox.

Maintenance:

• Patients who wish to and have the dexterity to maintain the pessaries on their own are instructed to take it out and clean with warm soapy water as often as they want but usually at least once a week.

  • If they are unable to, then typically they come to the clinic every 3-4 months for maintenance.

• Patients with Gellhorn, donut, or other types of pessaries that patients cannot remove easily on their own also follow up every 3-4 months. At these visits, the pessary is removed, gently cleaned, and a speculum exam is done to assess for any excoriation or abrasion.

• For postmenopausal patients without contraindication for topical vaginal estrogen, we typically have them use it to prevent significant vaginal excoriation or abrasion since atrophy can worsen these.

Complications:

• Most common complaints are increase or change in vaginal discharge or odor. Reassurance and ruling out for vaginitis and bacterial vaginosis are reasonable next steps. Reports of vaginal bleeding long after placement warrants exam in the office.

• Spontaneous expulsion or difficulty with voiding or defecation or pain often means a different size or shape should be tried.

• Pessaries that have been left in situ and neglected for prolonged period of time should be taken seriously. Embedded pessaries may need removal under general anesthesia.

• But overall, it is generally very safe.

Gonorrhea and Chlamydia

We talked about most STIs in a series back at the beginning of 2019! This podcast is an update to the treatment guidelines and will replace our last episode on gonorrhea and chlamydia, as these two bugs had some changes in treatment with the 2021 CDC STI guidelines.

First of all, why are we doing these two STDs together? 

• Because they have a lot of common symptomatology 

• They may come together (ie. if you have one, you may have the other) 

• We usually order the two tests together (say it in one breath anyway in the clinic or the ED) 

What are gonorrhea and chlamydia and why do we care? 

• Both are sexually transmitted infections that anyone can get if they are sexually active (any kind of sex), and there is vertical transmission between mother and child 

• Gonorrhea 

• Caused by bacteria Neisseria gonorrhoeae (gram negative diplococci) 

• 1.6 million new infections annually in the US

• More than 50% occur in patients aged 15-24

• Usually symptomless but in men can cause burning with urination, penile discharge, or even testicular pain 

• In women, 50% are symptomless but can lead to burning with urination, vaginal discharge, intermenstrual bleeding/postcoital spotting, pelvic pain

• Can also affect other areas like throat or anus 

• If untreated, it can lead to pelvic inflammatory disease and infertility. Additionally, at risk for disseminated gonococcal infection 

• Skin pustules/petechiae, septic arthritis, meningitis, endocarditis 

• Very rare (0.6-3% of infected women and 0.4-0.7% of infected men 

• In pregnant patients: septic abortion, chorio, neonatal blindness 

• Chlamydia 

• Caused by bacteria Chlamydia trachomatis (gram negative bacteria that only replicates in host cells).

• 4 million new infections annually in the US

• More than 65% occur in patients aged 15-24

• Some estimates show at any given time, 1 in 20 sexually active women aged 15-24 has active chlamydia infection in the US.

• Again, usually symptomless (70-80%), but can cause vaginal discharge and burning with urination in women 

• In men, can have discharge from penis, burning with urination, pain and swelling in testicles. 

• Rectal, oral/throat infections are also possible.

• If untreated, can also cause PID and infertility in women → around 15% of women will develop.

• Also can cause chlamydia conjunctivitis or trachoma → blindness 

• Reactive arthritis → can’t see, can’t pee, can’t climb a tree = arthritis, conjunctivitis, urethral inflammation 

How do we diagnose them? 

• Usually a urine test, but can also do endocervical swab, vaginal swab, rectal swab, or pharyngeal swab 

• Nucleic acid amplification test = gold standard 

• Who should be tested? 

• CDC recommends screening:

• Of anyone with concern for symptoms;

• Annually for GC/chlamydia for all sexually active women younger than 25 years 

• Opportunistic screening for older women with identified risk factors (ie. new or multiple sexual partners or sex partner who recently had an STI) 

• For men: once a year for GC/chlamydia for all sexually active MSM, and more frequently (q3-6 months) for MSM who have HIV or if they have multiple or anonymous partners 

How do we treat gonorrhea and chlamydia? - note, this is only for adolescents and adults 

• Treating gonorrhea (NOT disseminated) 

• Gonorrhea is becoming more and more resistant to antibiotics, and we are down to one class of antibiotic that really treats it: cephalosporins 

• CDC recommends: ceftriaxone 500mg IM x1

• This is an update to the previous recommendations, which used 250mg. This reflects the changing state of antibiotic resistance of gonorrhea.

• Test of cure is recommended for throat infections and for pregnant patients, but not necessarily for genital or rectal infections.

• If cephalosporin allergic:

• Gentamicin 240mg IM in single dose, AND Azithromycin 2g orally in single dose.

• Treating chlamydia 

• Recommended regimen by the CDC: Doxycycline 100mg PO twice daily for 7 days.

• Alternative regimens include:

• Azithromycin 2g orally, single dose

• Levofloxacin 500 mg orally for 7 days 

• Azithromycin has lower efficacy amongst persons with concomitant rectal infection, which is why the doxycycline regimen is preferred.

• Repeat screening may be needed to ensure efficacy of the single-dose azithro regimen.

• Expedited partner treatment - treat the sexual partner of the patient diagnosed with chlamydia or gonorrhea without first examining the sexual partner 

• CDC says: EPT is a useful option to facilitate partner management in states where it is permissible, and reduces re-infection risk for the patient while treating the partner.

• Should always counsel the patient that partner and patient should refrain from having intercourse for at least 7 days after all partners have been treated.

GC/chlamydia in pregnancy 

• Screen in first trimester and if positive, should be treated

• Exception: for chlamydia, Azithromycin 1g orally x1 is the recommended regimen.

• These medications are safe during pregnancy, and risks outweigh the benefits of not treating

• Expedited partner treatment is recommended where permissible.

• Test of cure is recommended in three weeks (and should also screen in 3rd trimester again)

• Pregnancy-specific risks of non-treatment

• Vertical transmission to newborn 

• Chlamydia: conjunctivitis (5-14 days after birth), and pneumonia (4-12 weeks of age) 

• Gonorrhea: conjunctivitis (more purulent compared to watery discharge of chlamydia… both can lead to blindness!) 

• Gentamicin/erythomycin eye gel helps to prevent these and why we use it!

• Otherwise: septic abortions, intact chorio, etc. 

A final “fun fact” we had dug out in the original GC/CT episode…

• There is no consensus as to why gonorrhea is called the clap… but some theories: 

• Old English word “clappan” means throbbing or beating -- could mean the burning during urination with gonorrhea 

• Proposed treatment during medieval times of “clapping” the penis or slamming the penis between both hands on a hard surface to get rid of the discharge/pus