Pathophysiology

Women’s Health

Case Study

Patient Profile

Name: Maryanne Connolly

Age: 19 years old

Gender: female

History of Present Illness

Lower abdominal pain and pain with intercourse.

M.C. is a 19-year-old college freshman who reports a gradual onset of dull, bilateral lower abdominal pain that has worsened over the past few days. She reports she had a telehealth visit about a month ago for vaginal discharge and was treated for a yeast infection. Mild vaginal discharge is still present with odor. She denies fever but mentions mild nausea. Reports recent dyspareunia and some spotting between periods. Denies urinary symptoms, including dysuria or urinary frequency. Denies gastrointestinal symptoms, last bowel movement was this morning and normal. Reports appetite is unchanged.

Past Medical History

  • Sexual History: Maryanne has been sexually active with one male partner in the past 6 months. She is monogamous, but her partner is not. Partner does not like condoms but reports he uses them with other partners, just not with Maryanne. Dyspareunia started approximately three weeks ago. No history of sexually transmitted infections (STIs). The last screen was 9 months ago, after she broke up with her previous boyfriend. Sexual activity is often concordant with alcohol and tetrahydrocannabinol (THC) use.
  • Menstrual History: Regular menstrual cycles, last period 2 weeks ago, lasted 4 days and was normal. Takes oral contraceptives regularly, has not missed any pills.
  • No significant medical history. Mild exercise-induced asthma.
  • Allergies: None
  • No smoking, weekly alcohol use 1-2 drinks, THC use 3-4x/month, usually when drinking.

Current Medications

Oral contraceptive pills

Physical Assessment

General Appearance: Alert and oriented, appears uncomfortable.

Vitals

  • Temperature: 99.5°F (37.5°C)
  • Heart rate: 88 bpm
  • Blood pressure: 110/70 mm Hg
  • Respiratory rate: 16 bpm

General Survey

  • Abdominal Exam: Bowel sounds x 4 quadrants. Tenderness in the lower quadrants bilaterally, with mild guarding. No umbilicus tenderness, no rebound tenderness, or palpable masses. Rovsing's sign negative, Psoas sign negative.
  • Pelvic Exam:
    • External genitalia: Normal appearance, no lesions, exudate, or ulcers noted.
    • Speculum exam: Yellow cervical discharge noted, + odor. Cervix is friable with erythema present. Cervical cultures obtained.
    • Bimanual exam: Cervical motion tenderness (positive “chandelier sign“), uterine tenderness, and adnexal tenderness bilaterally. No palpable adnexal masses.

Diagnostic Assessments

  • Nucleic Acid Amplification Test (NAAT): Positive for chlamydia trachomatis
  • Gonorrhea NAAT: Negative
  • Wet Mount Microscopy: +clue cells, +Whiff, pH 5.5, no trichomonads, no yeast buds, white blood cells (WBCs) present in vaginal discharge.
  • Urinalysis: Normal
  • Pregnancy Test (hCG): Negative
  • Complete Blood Count (CBC): Mild leukocytosis (WBC: 12,000/μL).

Diagnosis

Pelvic Inflammatory Disease (PID) related to chlamydia infection, bacterial vaginosis (BV)

Activity: Pathophysiology of PID

Fill in the blanks with the correct term: ascending, descending, chlamydia, herpes, HIV, fallopian tubes, vagina, umbilical pain, lower abdominal pain, cervical motion tenderness, Homans’ sign, ectopic pregnancy, ovarian cancer.

PID is an infection and inflammation of the upper female genital tract, including the uterus, fallopian tubes, and ovaries. It typically results from an ____________________ infection originating in the lower genital tract. The most common causative organisms are sexually transmitted pathogens, particularly ____________________ and gonorrhea. These pathogens infect the squamocolumnar epithelial cells of the cervix and ascend to the endometrium, ____________________ and adjacent pelvic structures, causing inflammation and tissue damage. PID should be suspected in sexually active women presenting with pelvic or ____________________ if no other cause is identified and if one or more of the following are present during a pelvic exam:

  • ____________________
  • uterine tenderness
  • adnexal tenderness

A single case of PID substantially increases the risk of infertility, chronic pelvic pain, and ____________________.

Activity: Pathophysiology of BV

Fill in the blanks with the correct term: Lactobacillus species, anaerobic bacteria, acidic, alkaline, Gardnerella vaginalis, trichomoniasis.

BV is a common vaginal condition characterized by an imbalance in the bacterial flora of the vagina. In a healthy vagina, ____________________ dominate, helping to maintain an ____________________ environment (pH around 3.8 to 4.5) that inhibits the growth of pathogenic organisms. In BV, this balance is disrupted, leading to a decrease in Lactobacilli and an increase in various ____________________. The overgrowth of bacteria such as ____________________, Mobiluncus, and Bacteroides contributes to the symptoms of BV. These bacteria can produce amines and other compounds that cause the characteristic fishy odor associated with the condition. The imbalance in flora also produces inflammation, which leads to vaginal epithelial irritation and discharge.

Activity: Clinical Manifestations of BV

Fill in the blanks with the correct term: below 4.5, above 4.5, sweet odor, fishy odor, epithelial cells, clue cells, columnar cells.

The pathophysiological changes in BV lead to specific clinical manifestations. If three of the four following conditions are present (Amsel’s criteria), a diagnosis of BV is made.

  1. Vaginal discharge: A thin, gray, or white discharge that is typically homogeneous and adherent to the vaginal walls.
  2. Vaginal odor: A strong, ____________________ due to the production of amines such as trimethylamine by anaerobic bacteria.
  3. pH changes: An increase in vaginal pH (____________________) due to the reduction in lactic acid-producing Lactobacilli.
  4. Presence of ____________________: Epithelial cells covered with bacteria, which are a diagnostic feature of BV

Review Questions

Click the arrow to expand the section and view the correct answers.

  1. What is the most likely causative organism of Maryanne’s pelvic inflammatory disease?
    1. Escherichia coli
    2. Chlamydia trachomatis
    3. Neisseria gonorrhoeae
    4. Mycoplasma genitalium
Answer:

B) Chlamydia trachomatis

Feedback: Chlamydia trachomatis is the most common cause of PID, particularly in young, sexually active women.

  1. Which physical exam finding is most indicative of PID?
    1. Rebound tenderness.
    2. Cervical motion tenderness.
    3. Palpable adnexal mass.
    4. Vaginal discharge.
Answer:

B) Cervical motion tenderness.

Feedback: Cervical motion tenderness, also known as the “chandelier sign,” is a hallmark finding in PID.

  1. What is the primary diagnostic test for chlamydia trachomatis?
    1. Wet mount microscopy.
    2. NAAT.
    3. Gram stain.
    4. Culture.
Answer:

B) NAAT.

Feedback: NAAT is the gold standard for diagnosing chlamydia trachomatis due to its high sensitivity and specificity.

  1. Which of the following is NOT a common complication of PID?
    1. Infertility
    2. Ectopic pregnancy
    3. Chronic pelvic pain
    4. Ovarian cancer
Answer:

D) Ovarian cancer

Feedback: Ovarian cancer is not a complication of PID. Common complications include infertility, ectopic pregnancy, and chronic pelvic pain.

  1. What is the first-line treatment for a patient with PID?
    1. Azithromycin alone.
    2. Ceftriaxone and doxycycline.
    3. Doxycycline and metronidazole.
    4. Ceftriaxone, doxycycline, and metronidazole.
Answer:

D) Ceftriaxone, doxycycline, and metronidazole.

Feedback: This combination covers chlamydia trachomatis, Neisseria gonorrhoeae, and anaerobic organisms.

  1. What is the primary mechanism by which chlamydia trachomatis causes PID?
    1. Direct invasion of the bloodstream.
    2. Ascending infection from the lower genital tract.
    3. Hematogenous spread from other organs.
    4. Reactivation of latent infection.
Answer:

B) Ascending infection from the lower genital tract.

Feedback: PID typically results from an ascending infection that spreads from the cervix to the upper genital tract.

  1. Which of the following is a risk factor for PID?
    1. Consistent condom use.
    2. Multiple sexual partners.
    3. Postmenopausal status.
    4. Use of progesterone-only oral contraceptives.
Answer:

B) Multiple sexual partners.

Feedback: Multiple sexual partners increase the risk of STIs, which are the primary cause of PID.

  1. When educating a patient about the importance of partner treatment for chlamydia, which statement should the nurse practitioner emphasize?
    1. “Only you need treatment; your partner does not.”
    2. “Your partner should be treated to prevent reinfection and further spread of the infection.”
    3. “It is not necessary to inform your partner if they are asymptomatic.”
    4. “You can wait until your symptoms resolve before informing your partner.”
Answer:

B) “Your partner should be treated to prevent reinfection and further spread of the infection.”

  1. What is the most common long-term complication of untreated PID?
    1. Tubo-ovarian abscess
    2. Infertility
    3. Fitz Hugh−Curtis syndrome
    4. Chronic urinary tract infections
Answer:

B) Infertility

Feedback: Infertility is the most common long-term complication due to scarring of the fallopian tubes.

  1. Which of the following symptoms is least likely to be associated with PID?
    1. Lower abdominal pain
    2. Vaginal discharge
    3. Dyspareunia
    4. Hematuria
Answer:

D) Hematuria

Feedback: Hematuria is not typically associated with PID. Common symptoms include abdominal pain, vaginal discharge, and dyspareunia.

  1. What is the purpose of adding metronidazole to the treatment regimen for PID?
    1. To treat Chlamydia trachomatis.
    2. To cover anaerobic bacteria.
    3. To prevent ectopic pregnancy.
    4. To reduce inflammation.
Answer:

B) To cover anaerobic bacteria.

Feedback: Metronidazole is added to cover anaerobic organisms that may contribute to PID.

  1. A nurse practitioner is assessing a patient who presents with increased vaginal discharge. Which of the following characteristics of the discharge is most indicative of bacterial vaginosis?
    1. Thick, white, curd-like discharge.
    2. Thin, grayish-white discharge with a fishy odor.
    3. Yellow, purulent discharge.
    4. Green frothy discharge.
Answer:

B) Thin, grayish-white discharge with a fishy odor.

  1. What is the first-line treatment that a nurse practitioner would likely prescribe for a patient diagnosed with bacterial vaginosis?
    1. Clotrimazole
    2. Metronidazole
    3. Azithromycin
    4. Doxycycline
Answer:

B) Metronidazole

  1. A patient with bacterial vaginosis is concerned about the implications of her condition on her sexual health. What should the nurse practitioner inform her regarding bacterial vaginosis?
    1. It is a sexually transmitted infection she must have gotten from a male partner.
    2. It is a sexually transmitted infection that causes PID.
    3. It is an overgrowth of normal vaginal bacteria.
    4. It is only transmitted through vaginal intercourse.
Answer:

C) It is an overgrowth of normal vaginal bacteria.

  1. During the assessment of a female patient with chlamydia, which of the following findings is most commonly associated with this infection?
    1. Severe abdominal pain.
    2. Purulent vaginal discharge.
    3. Asymptomatic presentation.
    4. Fever and chills.
Answer:

C) Asymptomatic presentation.

References

Centers for Disease Control and Prevention (2023). Pelvic Inflammatory Disease. Available at: https://www.cdc.gov/pid/about/index.html. Accessed 1/31/25.

Centers for Disease Control and Prevention. (2024). Sexually Transmitted Infections (STIs). Available at: https://www.cdc.gov/sti/hcp/clinical guidance/index.html. Accessed 1/31/25.

Heavey, E. (2024). Lecture on the pathophysiology of Infectious Diseases. [Transcript].

Kairys N, Carlson K, Garg M. Bacterial Vaginosis. [Updated 2024 May 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459216/

Tkacs, N. (Ed.). (2020). Advanced physiology and pathophysiology: Essentials for clinical practice. Springer Publishing Company.

You.com. (n.d.). Homepage. You.com. Retrieved February 22, 2025, from https://www.you.com

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Be Prepared for Your Nurse Practitioner Clinical Readiness Exam Copyright © 2026 by Elizabeth Heavey, Renee Biedlingmaier, Colleen Burgoyne and Carnel C. Jackson is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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