Menopause is the climacteric or climax, change of life. Between the ages of forty-five and fifty the average woman undergoes gradual changes in the sex glands that bring on certain symptoms. These symptoms are definitely related to the breaking down of the glands. Most common is the appearance of what are called hot flashes, during which the entire body becomes warm and there is excessive perspiration, followed by chilliness. Changes in the circulation bring on palpitation, headache and dizziness; frequently are associated with irritability and also with sleeplessness. Fortunately, new discoveries have developed substitutes for the glandular materials which are effective in stopping the most serious symptoms. These are mostly estrogenic hormones, and synthetic forms are known, called stilbesterol. These drugs, when suitably prescribed by the doctor, have been of the greatest importance in freeing women from the fears associated with the menopause and in overcoming the disagreeable symptoms.


In the primary care setting, vaginitis is the most common gynecologic diagnosis. Vaginitis is an inflammatory condition of the vagina characterized by vaginal discomfort, pruritis, and discharge. Infection causes 90% of cases and the offending organisms include bacteria, fungi, and parasites, and most of these infections are not sexually transmitted. Bacterial vaginosis (40-50% of cases) is the most common cause of vaginitis, followed by vulvovaginal candidiasis (20-25% of cases) and trichomoniasis (15-20% of cases).

Bacterial vaginosis is typically caused by an overgrowth of Gardnerella vaginalis, although other bacteria, especially anaerobes, may play a role. G. vaginalis is sometimes sexually transmitted. Up to 50% of women colonized with G. vaginalis are asymptomatic. Candida albicans causes 80% to 90% of vaginal yeast infections. Another cause of vaginitis is Trichomonas vaginalis, a parasite that is almost always sexually transmitted. Noninfectious causes of vaginitis include atrophic vaginitis, allergy, chemical irritation, desquamative inflammatory vaginitis, lichen planus, and collagen vascular disease.

The symptoms of vaginitis are nonspecific and include vaginal discharge and pain or pruritis that may be exacerbated by urination. The dysuria of vaginitis is described as external, occurring when urine touches the vulva. The dysuria of cystitis is usually described as a more internal pain that begins before urine leaves the urethra. About 25% of women with T. vaginalis and 50% with G. vaginalis are asymptomatic. The history in women with vaginitis should also include questions regarding menstrual history, sexual history, abdominal or pelvic pain, and fever.

Although not diagnostic, the physical examination is important in localizing the site of involvement to the vagina, vulva, or cervix. In cases of candidal infection, the vulva and vagina are erythematous and edematous, with fissures and a thick, white, adherent discharge. In cases of trichomoniasis, the vulva and vagina are also erythematous and edematous, but the discharge tends to be frothy and purulent. Up to 25% of women with trichomoniasis will also have “strawberry cervix. In cases of bacterial vaginosis, the vulvar and vaginal tissues appear normal but have a gray, adherent, malodorous discharge.



Early treatment is imperative to prevent the long-term sequelae of PID (Pelvic Inflammatory Disease). Most patients can be treated on an outpatient basis, and only 10% to 25% of patients with PID are now hospitalized for treatment.
Factors that might warrant hospitalization include the following:
– Pregnancy
– Severe illness with vomiting or high fever
– Tubo-ovarian abscess
– Intolerance to oral antibiotic regimen
– Poor response to oral antibiotics
– Surgical abdomen not excluded
Empiric treatment needs to cover a wide range of bacteria, including N. gonorrhoeae, C. trachomatis, anaerobes, gram-negative facultative bacteria, and streptococci. There are no efficacy data that compare parenteral and oral regimens, but the efficacy of each has been demonstrated in many clinical trials. If treatment is initiated with parenteral drugs, the transition to oral medications can be made within 24 hours of clinical improvement. The total duration of antibiotic treatment should be 14 days.

Parenteral Regimens
The decision to use parenteral therapy can be guided by the criteria for hospitalization. The CDC recommends two parenteral regimens: doxycycline plus cefotetan (Cefotan) or cefoxitan (Mefoxin); and clindamycin (Cleocin) plus gentamicin. If possible, doxycycline should be administered orally because of the pain associated with intravenous infusion.
Once a clinical improvement occurs, patients can be switched to an oral regimen of doxycycline (100 mg every 12 hours) or clindamycin (450 mg every 6 hours) for a total of 14 days of therapy. Clindamycin for anaerobic coverage may be more appropriate if a tubo-ovarian abscess is present.
There are limited data to support the use of other parenteral regimens, but the three alternative regimens listed by the CDC are (1) ofloxacin (Floxin) with or without metronidazole (Flagyl); (2) levofloxacin (Levaquin) with or without metronidazole; and (3) ampicillin/sulbactam (Unasyn) plus doxycycline. Although some clinicians treat PID with fluoroquinolones alone, the addition of metronidazole offers better coverage of anaerobes.

Oral Regimens
Two CDC-recommended oral regimens for PID are ofloxacin with or without metronidazole and levofloxacin with or without metronidazole. Each regimen is administered for 14 days. As with parenteral regimens, the addition of metronidazole offers better coverage of anaerobes.

Combined Oral and Parenteral Regimens
Another set of CDC-recommended regimens combine single-dose intramuscular medications with oral medications.

Patients receiving outpatient therapy should be seen within 3 days for re-evaluation. If there has been no substantial improvement, hospitalization for intravenous antibiotics and further evaluation is warranted. If N. gonorrhoeae or C. trachomatis is detected, many clinicians recommend testing for cure 4 to 6 weeks after therapy is completed. Recent (60 days) sexual partners should also be evaluated. During follow-up evaluations, consideration should be given to testing for other sexually transmitted infections such as human immunodeficiency virus, human papillomavirus, syphilis, and hepatitis В virus.


The diagnosis of PID can often be challenging, since a wide variety of symptoms, which may be mild, are often seen. Although only 50% sensitive and specific, the diagnosis is usually made clinically.
In women at risk for PID who have no apparent alternative diagnosis, the CDC has suggested several findings on physical examination that are suggestive of PID:
–    Uterine tenderness
–    Adnexal tenderness
–    Cervical motion tenderness
Use of these criteria makes it very unlikely that a case of PID will go undetected.
Additional criteria that support the diagnosis of PID are the following:
–    Temperature greater than 101°F
–    Abnormal mucopurulent cervical or vaginal discharge (Most women with PID will have visible mucopurulent discharge or vaginal secretions with white blood cells. If neither of these finding is present, serious consideration should be given to an alternate diagnosis.1)
–    White blood cells in vaginal secretions
–    Elevated erythrocyte sedimentation rate
–    Elevated C-reactive protein
–    Positive tests for N. gonorrhoeae or C. trachomatis (However, negative endocervical N. gonorrhoeae or C. trachomatis tests do not rule out infection of the upper genital tract.)
Several other tests may be helpful in supporting a diagnosis of PID, and these include laparoscopy, endometrial biopsy, transvaginal ultrasonography, and magnetic resonance imaging. Laparoscopy is very useful, but it is not always readily available, and it is difficult to justify in mild cases. Imaging studies such as ultrasonography or magnetic resonance imaging may be used to look for distinct abnormalities: fallopian tubes that are thickened or fluid-filled; free pelvic fluid; or a tubo-ovarian complex. Power Doppler ultrasonography to detect fallopian tube hyperemia is a newer technology that may prove useful.