1 What is the average age at menarche? Describe the normal menstrual cycle

The average age at menarche is 12.7 years, with a normal range of 11–14 years. Typically, it occurs approximately 2 years after thelarche and 1 year after peak height velocity.

One menstrual cycle is the time between the onset of one menses to the onset of another. Normal cycle length varies (21–45 days in teens), lasts from 2–8 days, and results in an average blood loss of 30–40 mL. Clinically, the menstrual cycle is usually defined by the ovarian cycle, which includes the follicular, ovulatory, and luteal phases.

During the follicular phase (7–22 days), low levels of estradiol and progesterone result in elevated gonadotropin-releasing hormone levels and, thus, rises in both follicle-stimulating hormone (FSH) and luteinizing hormone (LH). FSH stimulates the maturation of one follicle, while LH stimulates the theca cells to produce androgens, which are converted to estrogens that stimulate proliferation of the endothelium. As estradiol levels rise, FSH levels begin to fall. During the ovulatory phase, a preovulatory estradiol surge causes an LH surge, resulting in release of the ovum. During the luteal phase, the corpus luteum produces large amounts of progesterone and estrogen, resulting in development of the secretory endometrium. If fertilization does not occur, involution of the corpus luteum occurs, and there is loss of estrogen and progesterone. Sloughing of the endometrium follows, and increased levels of FSH lead to a new cycle.

Adams Hillard PJ, Dietch HR: Menstrual disorders in the college age female. Pediatr Clin North Am 52:179–198, 2005.

Gordon CM, Neinstein LS: Normal menstrual physiology. In Neinstein LS (ed). Adolescent Health Care: A Practical Guide, 4th ed. Baltimore, Williams & Wilkins, 2002, pp 947–952.

2 What is dysfunctional uterine bleeding (DUB)?

DUB is excessive menstrual bleeding occurring during the menses or outside the normal intervals in the absence of underlying structural abnormalities. An orderly sequence of hormonal and endometrial events is responsible for the regular and limited bleeding that occurs in adult women. In adolescents, the most common cause of DUB results from anovulatory menstrual cycles due to “immaturity” of the hypothalamic–pituitary–ovary axis, with lack of normal negative feedback. During anovulatory cycles, estrogen levels are increased without increasing FSH responsible for subsequent fall in the estrogen level. Lack of progesterone normally produced by the corpus luteum, which stabilizes the endometrium, results in sporadic growth and slough of the endometrium. In adolescents, it may be more useful to think of this as anovulatory uterine bleeding because this term reflects the most common etiology in adolescents.

Adams Hillard PJ, Dietch HR: Menstrual disorders in the college age female. Pediatr Clin North Am 52:179–198, 2005.

Mitan LA, Slap GB: Dysfunctional uterine bleeding. In Neinstein LS (ed). Adolescent Health Care: A Practical Guide, 4th ed. Baltimore, Williams & Wilkins, Baltimore, 2002, pp 966–972.

3 List the causes of abnormal vaginal bleeding in the adolescent female

Although anovulation is the most common cause of dysfunctional vaginal bleeding in the adolescent, it remains a diagnosis of exclusion. The diseases listed in Table 28-1 must be considered when excessive vaginal bleeding is present.

Table 28-1 Causes of Abnormal Bleeding in the Adolescent Female

4 How should a clinician evaluate a patient to determine a source of vaginal bleeding?

After a careful physical examination, include a pelvic examination to evaluate the source of the bleeding and any pathology. Screens for sexually transmitted diseases (STDs), a pregnancy test, and a serum hemoglobin are useful. In the young teenager who is not sexually active and has mild symptoms, a pelvic examination may be deferred. As always, follow-up is an important part of patient care.

Adams Hillard PJ, Dietch HR: Menstrual disorders in the college age female. Pediatr Clin North Am 52:179–198, 2005.

Mitan LA, Slap GB: Dysfunctional uterine bleeding. In Neinstein LS (ed): Adolescent Health Care: A Practical Guide, 4th ed. Baltimore, Williams & Wilkins, 2002, pp 966–972.

5 What are the recommended therapies for dysfunctional uterine bleeding?

Patients with DUB present with a wide spectrum of severity of illness. Therapy is aimed at stopping the bleeding by converting the endometrium to the secretory state so that sloughing can occur under controlled conditions, correcting the anemia, restoring normal cyclic bleeding, and preventing recurrence and long-term sequelae of anovulation.

A combination of estrogen and progesterone is needed in patients with active bleeding. Any pill combining 35 or 50 μg of ethinyl estradiol or mestranol and a progestin can be used. Progestin only may be used in patients who are not actively bleeding (Table 28-2).

Table 28-2 Therapies for Dysfunctional Uterine Bleeding

OCP = oral contraceptive pill (combination of estrogen, progesterone, and suggested minimum of 30 μg ethinyl estradiol). Antiemetics are usually needed when higher dose of estrogen is given.

In patients with severe bleeding, attention to the ABCs is necessary with IV access and fluid/blood resuscitation. All patients with active bleeding, low hemoglobin, and change in vital signs require admission for treatment. Evaluation should include coagulation studies. Bleeding usually stops after 24 hours of treatment. Combination pills with a higher dose of estrogen (50 μg of ethinyl estradiol) are the first-line therapy. IV estrogen is reserved for use in unstable patients; pulmonary embolism is associated with this therapy. In patients for whom estrogen is contraindicated, progesterone regimens can be tried. If this fails, other therapies include aminocaproic acid, desmopressin, or surgical curettage.

Mitan LA, Slap GB: Dysfunctional uterine bleeding. In Neinstein LS (ed). Adolescent Health Care: A Practical Guide, 4th ed. Baltimore, Williams & Wilkins, 2002, pp 966–972.

Slap BG: Menstrual disorders in adolescence. Best Prac Res Clin Obstet Gynaecol 17:75–92, 2003.

Strickland JL, Wall JW: Abnormal uterine bleeding in adolescents. Obstet Gynecol Clin North Am 30:321–335, 2003.

6 What is primary dysmenorrhea?

Primary dysmenorrhea is painful menses without associated pelvic disease that typically appears 6–24 months following menarche. Dysmenorrhea typically occurs with ovulatory cycles, which become more frequent as the hypothalamic–pituitary–ovarian axis matures. Two years after menarche, 20–50% of teens have ovulatory cycles. Typical symptoms include crampy, lower abdominal pain beginning a few days before or at the start of the menstrual cycle and last for 1–3 days. Associated symptoms include fatigue, back pain, headache, nausea, vomiting, and diarrhea.

7 What causes dysmenorrhea, and how frequently does it occur?

Dysmenorrhea is caused by prostaglandin E₂ and F_2α. These are produced in higher concentrations in ovulatory cycles during the secretory phase. Locally, prostaglandins cause myometrial contraction; however, when they enter the systemic circulation they can cause fatigue, headache, dizziness, nausea, vomiting, diarrhea, and back pain. Prostaglandin F_2α causes uterine contractions, vasoconstriction, and ischemia. Prostaglandin E₂ causes platelet disaggregation and vasodilation.

8 How common is dysmenorrhea?

It occurs very commonly during adolescence. Half to three-quarters of teens experience dysmenorrhea that affects their daily activities. Fifteen percent of teens describe severe symptoms that incapacitate them for 1–3 days during each menstrual cycle. However, only 15% of teens seek medical care for menstrual pain.

Banikarim C, Middleman AB: Primary dysmenorrhea in adolescents. UpToDate, version 13.3, 2005. www.utdol.com.

Braverman PK, Neinstein LS: Dysmenorrhea and premenstrual syndrome. In Neinstein LS (ed): Adolescent Health Care: A Practical Guide, 4th ed, Baltimore, Williams & Wilkins, 2002, pp 952–963.

9 What is the treatment for primary dysmenorrhea?

Nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line therapy for dysmenorrhea; a majority (70–80%) of patients experience relief with their use. Ibuprofen, naproxen, and naproxen sodium have all been used successfully. The patient should begin the medication at the onset of the premenstrual symptoms or at the onset of menses and continue this for 1–3 days as needed to control symptoms. The patient should use the chosen NSAID for four cycles until treatment failure is considered. A second NSAID can be tried at that time. Mefenamic acid competes with prostaglandin-binding sites, antagonizes existing prostaglandin, and inhibits prostaglandin synthesis and thus may be more effective than other NSAIDs.

If the patient continues with symptoms despite NSAID use, a 3- to 6-month course of oral contraceptive therapy may alleviate dysmenorrhea. Ovulation is suppressed, as are prostaglandin production and menstrual flow.

Patients should be followed closely. If they do not respond to the described therapies, a re-evaluation seeking secondary causes is indicated.

Banikarim C, Middleman AB: Primary dysmenorrhea in adolescents. UpToDate, version 13.3, 2005. Available at www.utdol.com.

Braverman PK, Neinstein LS: Dysmenorrhea and premenstrual syndrome. In Neinstein LS (ed): Adolescent Health Care: A Practical Guide, 4th ed. Baltimore, Williams & Wilkins, pp 952–963.

10 What are the causes of secondary dysmenorrhea?

11 What is the approach to a patient with secondary dysmenorrhea?

Teens who present 6–12 months after menarche, who are <20 years of age, and who describe pain with menses can be treated and followed for resolution of symptoms. A pelvic examination is not necessary in young teens who are not sexually active. Pelvic examination, laboratory testing, and imaging are reserved for patients who have atypical symptoms; have signs, symptoms, or risk factors for other diseases; or do not respond to therapy.

Banikarim C, Middleman AB: Primary dysmenorrhea in adolescents. UpToDate, version 13.3, 2005. Available at www.utdol.com.

Braverman PK, Neinstein LS. Dysmenorrhea and premenstrual syndrome. In Neinstein LS (ed): Adolescent Health Care: A Practical Guide, 4th ed. Baltimore, Williams & Wilkins, 2002, pp 952–963.

12 When should the pregnancy test be included in a workup?

Unfortunately, teenage pregnancy continues to be a common occurrence; thus, physicians caring for teens should always include pregnancy in the differential diagnosis of many chief complaints, and they should have a low threshold for performing a pregnancy test. Fortunately, these tests have become very sensitive and specific and are quick and relatively inexpensive.

The most commonly used tests rely on enzyme-linked immunosorbent assay (ELISA) for the detection of the β–human chorionic gonadotropin (hCG) subunit. The level of β-hCG secreted by the trophoblast doubles every other day during the first 6 weeks of pregnancy. By the time it reaches 1000–2000 mIU/mL, a gestational sac can be seen via vaginal ultrasound. Urine ELISA detects β-hCG levels of 30–50 mIU/ml and is typically positive within 7 days of implantation. Thus, the result of this test is positive at the time of the missed menses. Practically, if the teen is concerned about pregnancy, and the urine test result is negative, she should return the following week for a repeat test.

Neinstein LS, Farmer M: Teenage pregnancy. In Neinstein LS (eds): Adolescent Health Care: A Practical Guide, 4th ed. Baltimore, Williams & Wilkins, Baltimore, 2002, pp 809–833.

13 What is the differential diagnosis of vaginitis in young women?

Vaginal discharge, foul odor, itching and irritation of the vulva, and dyspareunia characterize vaginitis. The most common causes include infections due to Trichomonas vaginalis, Candida albicans, and Gardnerella vaginalis. Vaginal discharge can also occur with cervicitis due to Neisseria gonorrhoeae or Chlamydia trachomatis. Noninfectious causes include foreign body (tampon), trauma, allergies, chemical irritants, and poor hygiene. Etiology of vaginitis is determined by physical examination, the vaginal pH, the whiff test, saline, and potassium hydroxide (KOH) microscopy, and cervical cultures for gonorrhea and chlamydia.

Centers for Disease Control and Prevention: Sexually transmitted diseases treatment guidelines 2002. MMWR Morb Mortal Wkly Rep 51:1–80, 2002.

14 How is the diagnosis of cervicitis made?

Most young women with cervicitis are asymptomatic. Some, however, may present with abnormal vaginal discharge or bleeding, dysuria, frequency, dyspareunia, or bleeding with intercourse. On pelvic examination, the cervix appears inflamed, and mucopurulent discharge is visible. Often, increased friability leads to bleeding. Causes of cervicitis include Chlamydia trachomatis, N. gonorrhoeae, T. vaginalis, Candida albicans, and herpes simplex virus. Thus, evaluation should include a wet mount, a KOH prep, and diagnostic tests for Chlamydia trachomatis and N. gonorrhoeae. A significant number of patients do not have laboratory evidence of Chlamydia trachomatis and N. gonorrhoeae infection.

15 What are the recommended treatment and follow-up for cervicitis?

Treatment at the time of the examination depends on the level of clinical suspicion, as well as reliability of follow-up of the patient. Currently, unless cervicitis is known to be caused by one of the organisms above, therapy should cover both Chlamydia trachomatis and N. gonorrhoeae. Recently, quinolone-resistant N. gonorrhoeae has increased; ceftriaxone and cefixime are excellent alternatives.

The following are acceptable treatments for Chlamydia trachomatis:

The following are acceptable treatments for N. gonorrhoeae:

Because these treatment regimens are so successful, “test of cure” or reculture is not routinely recommended. Some adolescent specialists consider screening at 2–3 months, as the rate of reinfection is high. As always, the patient’s sexual partners within the preceding 2 months should be evaluated and treated.

Centers for Disease Control and Prevention: Sexually transmitted diseases treatment guidelines 2002. MMWR Morb Mortal Wkly Rep 51:1–80, 2002.

16 What is pelvic inflammatory disease (PID)?

PID is a polymicrobial infection of the upper genital tract in postpubertal women caused by a sexually transmitted disease. This disease presents with a broad spectrum of clinical manifestations, making an accurate diagnosis challenging. Further, many teens have mild or subtle symptoms. Clinical diagnosis is imprecise; in symptomatic patients salpingitis can be demonstrated by laparoscopy 65–95% of cases. There is no single historical finding, physical examination finding, or laboratory test that is sensitive and specific for the diagnosis. Many cases of PID are missed. Common symptoms include crampy, lower abdominal pain; abnormal vaginal discharge/bleeding; anorexia/vomiting; fever; diarrhea; dysuria; and dyspareunia. Important parts of the differential diagnosis include ectopic pregnancy, ovarian torsion, appendicitis, threatened abortion, and endometriosis.

17 How is the diagnosis of PID made?

In 2002, the Centers for Disease Control and Prevention guidelines changed the criteria for the diagnosis of PID in an effort to capture and treat more patients with mild disease in order to reduce long-term sequelae. The minimum criteria for diagnosis are uterine/adnexal tenderness and/or cervical motion tenderness. All patients who have minimum criteria should be empirically treated unless another diagnosis is present. Additional criteria include oral temperature > 38.3°C, abnormal cervical or vaginal mucopurulent discharge, presence of white blood cells on saline microscopy of vaginal secretions, elevated erythrocyte sedimentation rate, elevated C-reactive protein level, and laboratory evidence of Chlamydia trachomatis or N. gonorrhoeae infection.

Centers for Disease Control and Prevention: Sexually transmitted diseases treatment guidelines 2002. MMWR Morb Mortal Wkly Rep 51:1–80, 2002.

Pletcher JR, Slap GB: Pelvic inflammatory disease. In Neinstein LS (ed): Adolescent Health Care: A Practical Guide, 4th ed. Baltimore, Williams & Wilkins, 2002, pp 1161–1170.

18 What is the treatment for PID? When is hospitalization necessary?

Regimens for the treatment of PID have been developed to cover the polymicrobial nature of the disease. Thus, therapy must be effective against N. gonorrhoeae and Chlamydia trachomatis as well as anaerobes, Streptococcus sp., gram-negative enterics, and Mycoplasma sp. Consider hospitalization in the following instances: pregnancy, unclear diagnosis, vomiting, peritoneal signs, the young teenager (age < 15 years), tubo-ovarian abscess present or suspected, failed outpatient treatment, or patient’s inability to follow the outpatient regimen. Ideally, patients should take their medications, rest, and avoid intercourse. Treatment of all sexual partners within the preceding 2 months is indicated. Follow-up is needed at 48–72 hours.

The following represent acceptable treatment regimens for PID:

Parenteral Therapy

Oral Therapy

Centers for Disease Control and Prevention: Sexually transmitted diseases treatment guidelines 2002. MMWR Morb Mortal Wkly Rep 51:1–80, 2002.

Pletcher JR, Slap GB: Pelvic inflammatory disease. In Neinstein LS (ed): Adolescent Health Care: A Practical Guide, 4th ed. Baltimore, Williams & Wilkins, Baltimore, 2002, pp 1161–1170.

19 What diagnostic tests should be considered when evaluating an adolescent with a suspected sexually transmitted infection?

The development of Food and Drug Administration–approved nucleic acid amplification tests (NAATs) for N. gonorrhoeae and Chlamydia trachomatis has revolutionized the ability to screen at-risk populations as well as to identify infection in symptomatic patients. The sensitivity of these tests range from 85% to 100%. The specificity is 99%. Because these tests can be done by using urine, NAAT offers the most noninvasive method for screening and diagnosing sexually transmitted infections. These tests can be used on cervical, urethral, or vaginal swab specimens and can be incorporated into the annual evaluation of adolescents. In many circumstances, a careful sexual history and physical examination, review of symptoms, along with the NAATs, can replace routine pelvic examinations. In the teen with suspected PID, the pelvic examination can be limited to the bimanual examination.

The following laboratory tests may be helpful in the evaluation of postpubertal females with vaginal discharge/discomfort or suspected PID:

Centers for Disease Control and Prevention: Sexually transmitted diseases treatment guidelines 2002. MMWR Morb Mortal Wkly Rep 51:1–80, 2002.

Pletcher JR, Slap GB: Pelvic inflammatory disease. In Neinstein LS (ed): Adolescent Health Care: A Practical Guide, 4th ed. Baltimore, Williams & Wilkins, 2002, pp 1161–1170.

20 What is Fitz-Hugh-Curtis syndrome?

Fitz-Hugh-Curtis syndrome, or perihepatitis, results from salpingitis in 5–20% of patients. Inflammatory exudate travels up the paracolic gutter of the abdominal cavity and settles around the liver capsule. The hallmark of this disease is acute right-upper-quadrant pain and tenderness. The patient may also have splinting, anorexia, vomiting, or fever. Other important diagnoses to consider include pneumonia, pulmonary embolus, hepatitis, and gall bladder disease. It is not unusual for the patient to have silent pelvic infection. Liver function test results should be minimally elevated. The treatment regimens for PID are appropriate for these patients.

Pletcher JR, Slap GB: Pelvic inflammatory disease. In Neinstein LS (ed): Adolescent Health Care: A Practical Guide, 4th ed. Baltimore, Williams & Wilkins, Baltimore, 2002, pp 1161–1170.

21 List the causes of vaginal discharge in the prepubertal girl

The complaint of vaginal discharge in young girls presenting to the ED is not uncommon. Remember that a very small number of these children are victims of sexual abuse, and that in most a variety of infectious and noninfectious causes is possible. The most common etiology is “nonspecific vaginitis,” which is vaginitis without an identifiable cause. This is attributed to poor hygiene, tight-fitting clothes, soaps, creams, and bubble baths. Pathogens include group A β-hemolytic streptococcus, Haemophilus influenzae, Staphylococcus aureus, Moraxella catarrhalis, Streptococcus pneumoniae, Neisseria meningitidis, Shigella sp., and Yersinia enterolitica. Respiratory pathogens (Streptococcus pneumoniae and Streptococcus pyogenes), enteric organisms (Shigella sp.), and sexually transmitted diseases can also be associated with vaginitis. The most common cause of bloody vaginal discharge is a foreign body. Other causes to consider include pinworms, trauma, urethral prolapse, atopic dermatitis, lichen sclerosis, and scabies.

Emans SJ: Vulvovaginal problems in the prepubertal child. In Emans SJ, Laufer MR, Goldstein DP (eds): Pediatric and Adolescent Gynecology, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2005, pp 83–119.

22 What treatment is recommended for vaginal discharge in a prepubertal girl?

Therapy includes sitz baths, good hygiene, and removal of any irritants.

23 When should you consider vaginal cultures in the prepubertal girl?

It is helpful to culture patients with vaginal symptoms when an abnormal discharge is present upon physical examination. Routine cultures in the evaluation of children who are potential victims of sexual abuse are not indicated. The rate of STDs in prepubertal children as a result of sexual abuse is only 1–3%. Additionally, children with an STD can usually be identified by the presence of abnormal genital findings, such as discharge and inflammation. Therefore, although the decision to obtain vaginal cultures for N. gonorrhoeae and Chlamydia trachomatis in the evaluation of children suspected of being sexually abused must be made on an individual case basis, general recommendations include the following: in the presence of vaginal discharge, genital symptoms, evidence of acute injury, or history of stranger abduction. Currently, culture techniques are the only acceptable method to identify and document an STD in prepubertal children. Rapid tests, such as ligase chain reaction or direct fluorescent antibody, should not be used solely.

Emans SJ: Vulvovaginal problems in the prepubertal child. In Emans SJ, Laufer MR, Goldstein DP (eds): Pediatric and Adolescent Gynecology, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2005, pp 83–119.

Leder MR, Emans SJ: Sexual abuse in the child and adolescent. In Emans SJ, Laufer MR, Goldstein DP (eds): Pediatric and Adolescent Gynecology, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2005, pp 939–975.

24 What are the symptoms and signs of ectopic pregnancy?

This diagnosis must be entertained in any postpubertal female with abdominal pain, especially when vaginal bleeding is present. Classically, patients present with abdominal pain, with or without vaginal bleeding in the face of either missed menses or irregular vaginal bleeding. As the pregnancy progresses, pain becomes more severe, and signs of peritoneal irritation develop with rupture, vaginal bleeding and hemodynamic compromise. More commonly, however, patients present with abnormal vaginal bleeding and a smaller than expected uterus. Importantly, remember that 50% of patients are asymptomatic. The differential diagnosis includes PID, spontaneous/threatened abortion, ovarian torsion, ovarian or corpus luteal cyst, and appendicitis. A negative urine pregnancy test result rules out the presence of an ectopic pregnancy.

25 What is the initial approach to a patient with suspected ectopic pregnancy?

Attention to the ABCs is important in these patients because they are at risk for severe hemorrhage. Immediate gynecologic consultation is mandatory. Stable patients with positive results on a β-hCG and a closed cervical os can be followed with serial quantitative β-hCG determination and transvaginal ultrasound. Several protocols for the care of these patients exist in the literature.

Sowter MC, Farquhar CM: Ectopic pregnancy: An update. Curr Opin Obstet Gynecol 16:289–293, 2004.

26 What is bacterial vaginosis?

Bacterial vaginosis is the most common cause of vaginitis. This condition results from replacement of the normal Lactobacillus spp. with overgrowth of facultative anaerobes, including Gardnerella vaginalis, Prevotella sp., Mobiluncus spp., and Mycoplasma hominis Sexual transmission of this infection has not been substantiated, but the condition is more common in women who have had multiple partners and rare in women who are not sexually active. Partner treatment does not affect recurrence of infection. Bacterial vaginosis is associated with an increased risk for premature labor, premature rupture of membranes, and postpartum or postprocedure endometritis or PID. It remains unproven whether treatment reduces these risks.

The clinical diagnosis is made when patients have three of the four following criteria: (1) presence of a homogenous, gray-white discharge; (2) vaginal pH > 4.5; (3) clue cells present on Gram stain of vaginal fluid (epithelial cells studded with many small bacteria, producing a fuzzy border; offers a “clue” to the diagnosis); and (4) malodorous, fishy smell before or after exposure to 10% KOH. Culture for Gardnerella vaginalis has very poor specificity because it is present in many women who do not have bacterial vaginosis.

27 What is the treatment for bacterial vaginosis?

All symptomatic women should be treated. Treatment options include metronidazole, 500 mg twice daily for 7 days; clindamycin cream 2%, one full applicator once a day at bedtime for 7 days; metronidazole gel 0.75%, one full applicator twice daily for 5 days; or clindamycin, 300 mg twice daily for 7 days. The recurrence rate 1 month after therapy is 20%; accordingly, patients should be instructed to return if symptoms reappear. The addition of vaginal lactobacilli suppositories to metronidazole regimens is currently under investigation.

Centers for Disease Control and Prevention: Sexually transmitted diseases treatment guidelines 2002. MMWR Morb Mortal Wkly Rep 51:1–80, 2002.

Okun N, Gronau KA, Hannah ME: Antibiotics for bacterial vaginosis or Trichomonas vaginalis in pregnancy: A systematic review. Obstet Gynecol 105:857–868, 2005.

28 What are genital ulcers? What causes them?

Genital ulcers are lesions characterized by disruption of the epithelium/mucosa with associated inflammation. Infections associated with ulcers include herpes simplex virus (HSV), syphilis, and chancroid. HSV is, by far, the most common cause of genital ulcers. Grouped vesicles on an erythematous base that rupture and leave a shallow, painful ulcer are typical in HSV infection. Patients often have pain and paresthesias preceding the appearance of the ulcers. During primary infection, 16–24 lesions are present and systemic symptoms may be present for 2–3 days. Lesions resolve in 2–4 weeks.

Noninfectious causes of genital ulcers include inflammatory bowel disease, Behçet’s disease, fixed drug eruptions, trauma, and neoplasms.

Centers for Disease Control and Prevention: Sexually transmitted diseases treatment guidelines 2002. MMWR Morb Mortal Wkly Rep 51:1–80, 2002.

29 How are genital ulcers caused by HSV treated?

In addition to analgesia and hygiene, one of the following therapies should be given: acyclovir, 400 mg three times daily; famciclovir, 250 mg three times daily; or valacyclovir, 1 gm twice daily for 7–10 days. For recurrent infection, treatment must be initiated within 1 day of the onset of lesions, so patients should be given a prescription with instructions to begin treatment when symptoms and lesions appear. Recommended regimens include acyclovir, 400 mg three times daily; acyclovir, 500 mg twice daily; famciclovir, 125 mg twice daily; or valacyclovir, 500 mg twice daily for 5 days. Daily suppression, with acyclovir, 400 mg twice daily, or famciclovir, 250 mg twice daily, is indicated in patients with more than six recurrences in 1 year. Patients who are immunocompromised, or who have severe or disseminated infection, such as hepatitis, pneumonia, encephalitis, or meningitis, require systemic acyclovir therapy.

Centers for Disease Control and Prevention: Sexually transmitted diseases treatment guidelines 2002. MMWR Morb Mortal Wkly Rep 51:1–80, 2002.

30 Describe the genital ulcers caused by syphilis and chancroid. How are they treated?

The ulcer or chancre of primary syphilis is typically painless and solitary, with smooth margins and a clean indurated base with a serous exudate. The diagnosis of syphilis is confirmed by a positive result on a rapid plasma reagin test. Treatment for primary syphilis is one intramuscular 2.5-μU dose of benzathine penicillin G. Patients should be re-evaluated at 6 and 12 months.

Chancroid, a much less common etiology, results in one or several painful ulcers with irregular margins and deep undermined edges. These ulcers can become quite large. If evaluation for HSV and syphilis is negative, the patient should be treated for chancroid with one 1-gm dose of azithromycin; one 250-mg intramuscular dose of ceftriaxone; ciprofloxacin, 500 mg twice daily for 3 days; or erythromycin base, 500 mg four times daily for 7 days.

Centers for Disease Control and Prevention: Sexually transmitted diseases treatment guidelines 2002. MMWR Morb Mortal Wkly Rep 51:1–80, 2002.

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