Use of tampons is associated with both microscopic and macroscopic ulcerations. Healing of the macroscopic ulcerations occurs within several weeks without specific therapy if tampon use is suspended. A follow-up examination to demonstrate healing is appropriate, with biopsy of any persistent ulcerations to rule out other lesions.
Toxic shock syndrome (TSS) is associated with tampon use and vaginal exotoxins produced by Staphylococcus aureus. This syndrome consists of fever, hypotension, a diffuse erythroderma with desquamation of the palms and soles, plus involvement of at least three major organ systems (136). Vaginal involvement includes mucous membrane inﬂammation. The frequency of TSS appears to be declining, and an increasing percentage of cases are not associated with menses. Approximately one-half of all cases of TSS are menstrual related (137). Epidemiologic studies suggest that adolescents are at greater risk of menstrual TSS than older women; however, this finding does not appear to be explained by differences in the detection of antibodies to the TSST-1 toxin-producing strain of S. aureus or in S. aureus vaginal colonization rates (138).
Abscesses of Bartholin and Skene’s glands are related to both aerobic and anaerobic organisms, with mixed infections accounting for approximately 60% of these and other vulvar and labial abscesses, although the possibility of methicillin-resistant S. aureus (MRSA) infections must be kept in mind (139,140). Therapy consists of surgical drainage, with use of antibiotics as a secondary measure. In younger adolescents, incision and drainage with insertion of a Word indwelling catheter may require general anesthesia (140).
Normal Menses After adolescence, menstrual cycles generally conform to a cycle length of 21 to 38 days, with menstrual ﬂow duration of fewer than 7 days (Table 14.9). As a woman approaches menopause, cycle length becomes more irregular as fewer cycles are ovulatory (51,141). The most frequent cause of irregular bleeding in the reproductive age group is hormonal, although other causes such as pregnancy-related bleeding (spontaneous abortion, ectopic pregnancy) should always be considered (Table 14.4). A variety of terms are used to describe abnormal menses; it is strongly recommended by an international panel of experts that the confusing terms noted in Table 14.10 be abandoned in favor of a much simpler system with description of cycle
Table 14.9 Parameters for Normal Menstrual Cycles in Women of Reproductive Age
Data from Fraser IS, Critchley HO, Munro MG. Abnormal uterine bleeding: getting our terminology straight. Curr Opin Obstet Gynecol 2007;19:591–595.
regularity (irregular, regular, or absent), frequency (frequent, normal, or infrequent), duration (prolonged, normal, or shortened), and heaviness of bleeding episodes (heavy, normal, or light) (Table 14.11) (141). Prospective charting of bleeding can be helpful in characterizing abnormal bleeding. The mean duration of menses is 4.7 days; 89% of cycles last 7 days or longer. The average blood loss per cycle is 35 mL (56). Menses is a suspension of blood-and tissue-derived solids within a mixture of serum and cervicovaginal ﬂuid; the blood content of menses varies over the days of bleeding, but on average is close to 50% (142). Recurrent bleeding in excess of 80 mL/cycle results in anemia.
Differential Diagnosis of Abnormal Bleeding in Reproductive-Age Women