Scenario A: Polycystic Ovarian Syndrome (PCOS)
A 29-year-old female presents to the clinic with a complaint of hirsutism and irregular menses. She describes irregular and infrequent menses (five or six per year) since menarche at 11 years of age. She began to develop dark, coarse facial hair when she was 13 years of age, but her parents did not seek treatment or medical opinion at that time. The symptoms worsened after she gained weight in college. She got married 3 years ago and has been trying to get pregnant for the last 2 years without success. Height 66 inches and weight 198. BMI 32 kg/m2. Moderate hirsutism without virilization noted. Laboratory data reveal CMP within normal limits (WNL), CBC with manual differential (WNL), TSH 0.9 IU/L SI units (normal 0.4-4.0 IU/L SI units), a total testosterone of 65 ng/dl (normal 2.4-47 ng/dl), and glycated hemoglobin level of 6.1% (normal value ≤5.6%). Based on this information, the APRN diagnoses the patient with polycystic ovarian syndrome (PCOS) and refers her to the Women’s Health APRN for further workup and management.
Question 1
What is the pathogenesis of PCOS?
Scenario B: Polycystic Ovarian Syndrome (PCOS)
A 29-year-old female presents to the clinic with a complaint of hirsutism and irregular menses. She describes irregular and infrequent menses (five or six per year) since menarche at 11 years of age. She began to develop dark, coarse facial hair when she was 13 years of age, but her parents did not seek treatment or medical opinion at that time. The symptoms worsened after she gained weight in college. She got married 3 years ago and has been trying to get pregnant for the last 2 years without success. Height 66 inches and weight 198. BMI 32 kg/m2. Moderate hirsutism without virilization noted. Laboratory data reveal CMP within normal limits (WNL), CBC with manual differential (WNL), TSH 0.9 IU/L SI units (normal 0.4-4.0 IU/L SI units), a total testosterone of 65 ng/dl (normal 2.4-47 ng/dl), and glycated hemoglobin level of 6.1% (normal value ≤5.6%). Based on this information, the APRN diagnoses the patient with polycystic ovarian syndrome (PCOS) and refers her to the Women’s Health APRN for further workup and management.
Question 2
How does PCOS affect a woman’s fertility or infertility?
Scenario C: Pelvic Inflammatory Disease (PID)
A 30-year-old female comes to the clinic with a complaint of abdominal pain, foul-smelling vaginal discharge, and fever and chills for the past 5 days. She denies nausea, vomiting, or difficulties with bowels. Last bowel movement this morning and was normal for her. Nothing has helped with the pain despite taking ibuprofen 200 mg orally several times a day. She describes the pain as sharp and localizes the pain to her lower abdomen. Past medical history noncontributory. GYN/Social history positive for having had unprotected sex while at a fraternity party. Physical exam: thin, ill-appearing, anxious-looking white female who is moving around on the exam table and unable to find a comfortable position. Temperature 101.6°F orally, pulse 120, respirations 22 and regular. Review of systems negative except for chief complaint. Focused assessment of abdomen demonstrated moderate pain to palpation in the left and right lower quadrants. Upper quadrants soft and non-tender. Bowel sounds diminished in bilateral lower quadrants. Pelvic exam demonstrated positive adnexal tenderness, positive cervical motion tenderness, and copious amounts of greenish thick secretions. The APRN diagnoses the patient as having pelvic inflammatory disease (PID).
Question 3
What is the pathophysiology of PID?
Scenario D: Syphilis
A 37-year-old male comes to the clinic with a complaint of a “sore on my penis” that has been there for 5 days. He says it burns and leaked a little fluid. He denies any other symptoms. Past medical history noncontributory.
SH: Bartender and he states he often “hooks up” with some of the patrons, both male and female, after work. He does not always use condoms.
PE: WNL except for a lesion on the lateral side of the penis adjacent to the glans. The area is indurated with a small round raised lesion. The APRN orders laboratory tests, but feels the patient has syphilis.
Question 4
What are the 4 stages of syphilis?
Please provide reference(s) for each answer.
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What is the pathogenesis of PCOS?
The exact pathogenesis of polycystic ovary syndrome (PCOS) is still unclear, but it involves multiple factors, including the interplay of genetic, environmental, and hormonal factors. Genetics plays a role in the development of PCOS. According to Shaaban et al. (2019), up to 30% of women with PCOS have a family history of the condition, suggesting a possible genetic predisposition to the disorder. In addition, studies have identified several genetic variants associated with PCOS, including variants in genes related to sex hormone and insulin production and genes involved in ovarian development and androgen metabolism (Shaaban et al., 2019).
Hormonal imbalances are believed to be a significant factor in the pathogenesis of PCOS. Women with PCOS typically have elevated levels of androgens, such as testosterone, which can interfere with the normal development of the follicles in the ovaries (Shaaban et al., 2019). This can disrupt the normal menstrual cycle and may contribute to the development of cysts in the ovaries (Shaaban et al., 2019). In addition, women with PCOS typically have elevated levels of luteinizing hormone (LH), which can further stimulate the ovaries to produce androgens. Insulin resistance is also believed to be a significant factor in PCOS. According to Xu & Qiao (2022), 70% of women with PCOS have insulin resistance, which is thought to be caused by elevated levels of androgens that interfere with the body’s ability to respond to insulin. This can lead to an increase in insulin levels, which can further contribute to the development of cysts in the ovaries (Xu & Qiao, 2022).
How does PCOS affect a woman’s fertility or infertility?
Polycystic Ovarian Syndrome (PCOS) is a complex disorder that affects a woman’s fertility and can lead to infertility. PCOS is caused by an hormone imbalance, which can cause the ovaries to produce too many androgens, such as testosterone. This hormonal imbalance can disrupt a woman’s menstrual cycle and ovulation, making it difficult for her to get pregnant. PCOS can cause other fertility issues (Shaaban et al., 2019). For example, it can cause the ovaries to develop multiple small cysts, leading to difficulty ovulating or releasing an egg. PCOS can also cause the lining of the uterus to become too thick, preventing a fertilized egg from implanting (Gaba et al., 2020). Additionally, PCOS can lead to an increased risk of miscarriage due to the increased risk of chromosomal abnormalities in the egg (Cena et al., 2020).
What is the pathophysiology of PID?
Pelvic Inflammatory Disease (PID) is an infection of the female reproductive organs and is the most common lower genital tract infection. It is caused by bacteria that travel from the vagina and cervix to the uterus, fallopian tubes, and ovaries (Mitchell et al., 2021). The most common bacteria responsible for PID are Neisseria gonorrhoeae and Chlamydia trachomatis, but other bacteria such as Mycoplasma genitalium, Staphylococcus aureus, and Streptococcus can also cause the infection (Hillier et al., 2021). When the bacteria enter the reproductive organs, they cause inflammation, which leads to the development of PID. The symptoms of PID usually include pelvic pain, lower abdominal pain, fever, chills, fatigue, vaginal discharge, irregular menstrual bleeding, and pain during intercourse (Mitchell et al., 2021). The inflammation caused by PID can lead to scarring of the fallopian tubes and damage to the ovaries and uterus. This can lead to infertility, ectopic pregnancy, and chronic pelvic pain. The pathophysiology of PID is complex. It is believed that the bacteria travel from the vagina and cervix and attach to the endometrium of the uterus. They spread to the fallopian tubes and ovaries, resulting in inflammation and infection (Hillier et al., 2021). The bacteria can also spread to the lymph nodes and other pelvic organs. There is also evidence that the bacteria can spread through the bloodstream, leading to a systemic infection. The inflammation caused by PID can block the fallopian tubes, which can prevent the sperm from reaching the egg and fertilization from occurring (Hillier et al., 2021). The inflammation can also cause damage to the ovaries and uterus, leading to infertility and chronic pelvic pain. The bacteria can sometimes enter the bloodstream, leading to sepsis and other systemic complications.
What are the four stages of syphilis?
Syphilis is a sexually transmitted infection caused by the bacterium Treponema pallidum (Koundanya & Tripathy, 2022). It has four distinct stages: primary, secondary, latent, and tertiary. The primary stage of syphilis usually begins with a single, painless, round ulcer on the genitals, rectum, or mouth. This ulcer is usually firm, round, and painless and often appears three to four weeks after exposure (Koundanya & Tripathy, 2022). Other symptoms may include swollen lymph nodes, fever, and body aches. The secondary stage of syphilis usually begins two to eight weeks after the initial infection. Symptoms may include a rash on the palms and soles and sores inside the mouth, vagina, or rectum. Other signs and symptoms may include fever, swollen lymph nodes, sore throat, hair loss, headaches, weight loss, and fatigue (Koundanya & Tripathy, 2022). The latent stage of syphilis is when there are no symptoms, but the infection remains in the body. This stage can last for years, even if left untreated. The tertiary stage of syphilis is the most severe and can occur up to 30 years after the initial infection with patients experiencing difficulty coordinating muscle movements, blindness, paralysis, numbness, dementia, and death.
References
Cena, H., Chiovato, L., & Nappi, R. E. (2020). Obesity, polycystic ovary syndrome, and infertility: a new avenue for GLP-1 receptor agonists. The Journal of Clinical Endocrinology & Metabolism, 105(8), e2695-e2709. https://doi.org/10.1210/clinem/dgaa285
Gaba, A., Hörath, S., Hager, M., Marculescu, R., & Ott, J. (2019). Basal Anti Mullerian hormone levels and endometrial thickness at midcycle can predict the outcome after clomiphene citrate stimulation in anovulatory women with PCOS, a retrospective study. Archives of Gynecology and Obstetrics, 300, 1751-1757. https://doi.org/10.1007/s00404-019-05359-7
Hillier, S. L., Bernstein, K. T., & Aral, S. (2021). Review the challenges and complexities in pelvic inflammatory disease’s diagnosis, etiology, epidemiology, and pathogenesis. The Journal of Infectious Diseases, 224(Supplement_2), S23-S28. https://doi.org/10.1093/infdis/jiab116
Koundanya, V. V., & Tripathy, K. (2022). Syphilis ocular manifestations. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK558957/
Mitchell, C. M., Anyalechi, G. E., Cohen, C. R., Haggerty, C. L., Manhart, L. E., & Hillier, S. L. (2021). Etiology and diagnosis of pelvic inflammatory disease: looking beyond gonorrhea and chlamydia. The Journal of Infectious Diseases, 224(Supplement_2), S29-S35. https://doi.org/10.1093/infdis/jiab067
Shaaban, Z., Khoradmehr, A., Shirazi, M. R. J., & Tamadon, A. (2019). Pathophysiological mechanisms of gonadotropins–and steroid hormones–related genes in etiology of polycystic ovary syndrome. Iranian journal of basic medical sciences, 22(1), 3.
Xu, Y., & Qiao, J. (2022). Association of insulin resistance and elevated androgen levels with Polycystic Ovarian Syndrome (PCOS): a literature review. Journal of healthcare engineering, 2022. https://doi.org/10.1155/2022/9240569