Contraception, STIs and termination Flashcards
What is law for people under 16 having sex?
- a young child under 13 cannot consent to any sexual activity
- if you are told this by a patient, you must inform social services
- an older child (i.e. 13-15) cannot legally have intercourse or oral sex with anyone, but consensual touching, kissing and sexual conversations between older children are generally considered to be part of growing up
Describe the fraser guidelines
- he/she has a sufficient maturity and intelligence to understand the nature and implications of the proposed treatment
- he / she cannot be persuaded to tell her parents or to allow the doctor to tell them
- he / she is very likely to begin or continue having sexual intercourse with or without contraceptive treatment
- his / her physical or mental health is likely to suffer unless he / she received the advice or treatment
- the advice or treatment is in the young person best interests
How can contraception prevent ovulation?
- main mechanism of most hormonal methods (except hormone coil and traditional POPs)
- works by suppressing FSH and LH (negative feedback hypothalamus / pituitary)
- emergency hormonal contraception only temporarily delays (rather than suppresses) ovulation
How can contraception prevent fertilisation?
- condoms, diaphragm + spermicide, female and male sterilisation, intrauterine devices, hormonal methods (cervical mucous effect)
- works by creating a mechanical or surgical barrier or by direct toxicity
How can contraception prevent implantation?
- hormonal contraceptive methods
- intrauterine devices only as secondary mechanism of action but more relevant copper coil when used as emergency contraception
- works by creating a hostile endometrium or direct toxicity
Name examples of hormonal methods of contraception
- combine pill, ring and patch
- minipill
- DMPA injection and contraceptive implant (nexplanon)
Name examples of barrier methods of contraception
- male and female condoms
- diaphragm or cervical cap (plus spermicide)
Name examples of intrauterine methods of contraception
- intrauterine device (copper coil, IUD)
- intrauterine system (hormone coil IUS)
Name examples of permanent methods of contraception
- female sterilisation
- male sterilisation (vasectomy)
Name examples of fertility awareness methods of contraception
- basal temperature
- calendar
- cervical secretion monitoring methods
Name examples of emergency contraception
- emergency IUD
- emergency hormonal contraception (ulpristal acetate (ella one) or levonogestrel)
Describe the non contraceptive benefits of hormonal contraception
Decreased;
- period pain
- heavy menstrual bleeding
- irregular PV bleeding
- ovulation pain
- PMS
- cyclical breast tenderness
- ovarian cysts
- endometriosis
- ovarian cancer
- acne or hirsutism
- perimenopausal symptoms
What might be the only reliable suitable contraception method for women after breast cancer?
Intrauterine device (copper)
What is the most effective of all contraceptive methods?
Nexplanon
What is the action of combined hormonal contracpetion?
Stops ovulation
How can the COC be taken?
- starts in first 5 days of period
- or at any time in cycle when reasonably sure not pregnant plus condoms 7 days
- take daily for 21 days followed by a 7 day break
- tricycling; three months then stop for 7 days
- continuous use; bleed for 4 days or more stop for 4 days and start again
What factors may affect the effectiveness of CHC?
- impaired absorption; GI conditions
- increased metabolism; liver enzyme induction, drug interaction
- forgetting
What are some risks of using CHC?
- venous thrombosis
- arterial thrombosis
- adverse effects on some cancers
- systemic hypertension; BP checked at 3 months then annually
- migraine with aura increases the risk of ischaemic stroke so CHC use in individuals with migraine with aura is contraindicated
What is aura associated with migraine?
- a change occuring 5-20 minutes before the onset of headache
- may be visual, typical scotoma
- altered sensation
- smell or taste
- hemiparesis
Name side effects of CHC
- nausea
- bleeding
- spots
- breast tenderness
What is the mode of action of desogestrel POP?
Inhibits ovulation
How do you take / start progestogen only methods?
- POP, subdermal implant, DMPA
- day 1-5 of period
- or anytime if reasonably certain not pregnant plus condoms for 7 (2 for POP) days
Name side effects of the POP
- nausea
- irregular bleeding common
- spots
- headaches
Describe the guidance for a missed POP
- take roughly at the same time everyday
- more than 12 hours late it wont work for two days
What is the mode of action of the depo provera or syana press injections?
- lowers estradiol
- supresses FSH
Name side effects of depo rprovera and syana press
- nausea
- bleeding
- weight gain
- spots
- headaches
How are diaphragms used?
- must be held in place for 6 hours after sex
- washed out with soapy water afterwards
What legal documents are important in termination of pregnancy?
- certified on HSA1 form (certificate A), 2 doctors sign
- two emergency clauses (F and G) one doctor signs (HSA2)
- all abortions reported to CMO via abortion notification form (HSA4)
Clause C allows termination of pregnancy up to when?
- 23+6 weeks
- the pregnancy has not exceeded its 24th week and the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated , of injury to the physical or mental health of the pregnant woman
Clause E allows termination of pregnancy up to when?
- no gestational limit
- there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped
What are the two methods of abortion?
Medical or surgical
- depends on;
- gestation
- patient preference
- regional availability
How is gestation assessed before abortion?
- clinically; estimated by LMP +/- date of +ve UPT, palpable uterus (>12 weeks)
- ultrasound; abdominal or transvaginal (<6 weeks), frequently used for all pre-covid, now via risk assessment (symptoms or risk factors for ectopic, uncertainty about dates)
What two drugs are used as part of a medical abortion?
- mifepristone 200mg PO
- misoprostol 800mcg PV/SL (24-48 hours later)
- misoprostol can be taken sublingually or vaginally
Describe how medical abortion is undertaken in <12 weeks gestation
- can self administer mifepristone and misoprostol at home
- further misoprostol (400mcg) if not bleeding within 4 hours and less than 10 weeks
- 10-11+6 weeks, 3 further doses of misoprostol (400mcg) provided
Describe how medical abortion is undertaken in >12 weeks gestation
- inpatient procedure
- repeated doses of PV misoprostol; 800mcg PV then 400mcg 3 hourly PV/PO/SL (up to 4)
Medical temination of pregnancy up to 21+6 weeks is undertaken how?
- transabdominal ultrasound to visualise the heart of the foetus
- injection of potassium chloride to stop foetal heartbeat before proceeding with fetocide
What type of drug is mifepristone?
Anti-progesteron
What type of drug is misoprostol?
- prostaglandin
- provokes uterus to expel pregnancy
What is included in a medical abortion at home pack from the pharmacy?
- mifepristone 200mg
- misoprostol 800mg (PV or SL) + additional dose 400mcg
- anti-emetic
- analgesia; dihydrocodeine, paracetamol and ibuprofen
- antibiotics; 7 days doxycycline
- contraception (6 months POP)
- patient information leaflet and contact info
- low sensitivity pregnancy test
Describe the surgical abortion procedure
- removal of pregnancy via surgical procedure (under anaesthesia)
- cervical priming via misoprostol or osmotic dilators
- <14 weeks; electric vacuum aspiration, manual vacuum aspiration (up to 10weeks)
- > 14 weeks; dilatation and evacuation
Name complications of abortion
- haemorrhage +/- blood transfusion
- failed / incomplete abortion
- infection
- uterine perforation (surgical only)
- cervical trauma (surgical only)
When would VTE prophylaxis be considered at time of abortion?
- if high risk, consider LMWH for 1 week after abortion
- if very high risk, considering starting LMWH before abortion +/- continuing for longer e.g. 6 weeks
Describe what is asked during a pre-abortion consultation
- confirm ID and check alone / safe
- feelings about pregnancy
- gynae / obstetric history
- medical, drug and social history
- explore safeguarding issue e.g. under 16s
- discussion of available options
- risk of procedure and consent
- STI risk assessment +/- testing
- contraception
- further arrangements and follow up
What are the partner notification periods for different infections?
- chlamydia; male urethral = 4 weeks, any other = 6 weeks
- gonorrhoea; male urethral = 2 weeks, any other infection = 3 weeks
- non-specific urethritis; 4 weeks
- trichomonas vaginalis; 4 week
- epididymitis; 6 months unless chlamydia/ gonorrhoea
- PID; 6 months unless chlamydia / gonorrhoea
- HIV; 4 weeks before negative test; or before most likely time of infection
- primary syphilis = 90 days
- secondary syphilis = 2 years
What is the eligibility criteria for PrEP in scotland?
- MSM condomless anal sex with 2+ sexual partners in last year and likely in next 3 months
- rectal bacterial STI in last year
- partner of someone with HIV who does not have a suppressed viral load
Post exposure prophylaxis following sexual exposure is available for what infectons?
- hepatitis B; HBV vaccine up to 7 days, immunoglobulin for vaccine non-responders
- HIV; 3 antiretrovirals, start within 72 hours, 28 days total
How can gonorrhoea and chlamydia be sampled?
- vulvovaginal swab (VVS), pre speculum
- urine; first void
- throat swab
- rectal swab
What tests are done with samples from symptomatic vaginal or urethral discharge?
- cervical microscopy (gram stain)
- vaginal microscopy (gram stain and wet prep) and pH (narrow range)
- urethral microscopy (gram stain)
- amies swab (HVS culture and sensitivity) if; recurrent / persistent discharge, vaginitis of unknown cause, pregnant, postpartum, post gynae surgery / instrumentation or has symptoms or signs of PID
What is the treatment of chlamydia?
- doxycycline 100mg BD x 1 week
- azithromycin 1G stat followed by 500mg daily for 2 days
- for PID; ceftriaxone 1g IM, doxycycline 100mg BD x 2 weeks and metronidazole 400mg BD x 2 weeks
What are the 3 different serovars of chlamydia and what do they cause?
- serovars A-B; endemic trachoma, ocular infections, mostly developing countries
- serovars D-K; urethritis, epidiymo-orchitis, PID, neonatal pneumonia, neonatal conjunctivitis
- serovars L1-L3; lymphogranuloma venereum, genital ulcerative disease / proctitis
Describe the presentation of chlamydia
- urethral discharge (milky)
- irregular bleeding
- abdominal pain
- dysuria
- urethritis
- cervicitis
- epidiymo-orchitis
- proctitis
Name complications of chlamydia
- PID
- reactive arthritis
- conjunctivitis
- fitz hugh curtis
- ectopic pregnancy
What is LGV infection?
- serovars of chlamydia
- diagnosed mainly in MSM
- rectal pain, discharge and bleeding
What is the treatment of gonorrhoea?
- first line; ceftriaxone 1g IM
- second line; cefixime 400mg oral plus azithromycin 2g (only if IM injection is contraindicated or refused by patient)
- test of cure in all patients
What is gonorrhoea?
- gram negative intracellular diplococcus
- primary sites of infection are the mucous membranes of the urethra, endocervix, rectum and pharynx
Name complications of gonorrhoea
Lower genital tract - bartholinitis - tysonitis - periurethral abscess - rectal abscess - epidiymitis - urethral stricture Upper genital tract - endometritis - PID - hydrosalpinx - infertility - ectopic pregnancy - prostatitis
What is mycoplasma genitalium?
- emerging sexually transmitted pathogen
- associated with non-gonococcal urethritis
- asymptomatic carriage
- NAAT test
- high levels of macrolide resistance
Describe the management of genital ulcers
- give oral antiviral treatment (aciclovir 400mg TDS for 5/7)
- consider topical lidocaine 5% ointment if very painful
- saline bathing
- analgesia
Name symptoms of genital herpes (primary infection)
- blistering and ulceration of the external genitalia
- pain
- external dysuria
- vaginal or urethral discharge
- local lymphadenopathy
- fever and myalgia (prodrome)
How is syphilis transmitted?
- sex (acquired)
- trans-placental / during birth (congenital)
What are the different stages of syphilis?
Early infection - primary - secondary - early latent (less than 2 years) Late non-infectious - late latent (more than 2 years) - tertiary
Describe primary syphilis
- incubation period is from 9-90 days (mean of 21 days)
- lesion is traditionally known as a primary chancre (painless)
- lesions appear at the site of inoculation
- sites are genital (90%) or extra genital (10%)
- non-tender local lymphadenopathy
Describe secondary syphilis
- incubation period is 6 weeks to 6 months
- skin (macular, follicular or pustular rash on palms + soles)
- lesions of mucous membranes
- generalised lymphadenopathy, fever, sore throat
- malaise
- anterior uveitis
- cranial nerve lesions
- condylomata lata (most highly infectious lesion in syphilis, exudes a serum teeming with treponemes)
Describe the diagnosis of syphilis
- demonstration of treponema pallidum; dark field microscopy, PCR
- serological testing; detects antibody to pathogenic treponemes
Describe the treatment of syphilis
Early syphilis;
- 2.4 MU benzathine penicillin (stat)
Late syphilis;
- 2.4 MU benzathine penicillin weekly x 3 weeks
Describe the follow up of syphilis
- follow up serologically
- until RPR is negative or serofast
- titres should decrease fourfold by 3-6 months in early syphilis
- concern re serological relapse / reinfection if titres increase by fourfold
Name differentials of genital lumps
- skin tags
- molluscum contagiosum
- spots of fordyce
- pearly penile papules
Name high risk types of HPV
- 16
- 18
- 31
- 33
- 35
- 39
- 45
- 51
- 52
- 56
- 59
- 68
HPV can be associated with what symptoms?
- latent infection
- anogenital warts
- palmar and plantar warts
- cellular dysplasia / intraepithelial neoplasia
Describe HPV treatment
- podophyllotoxin (condyline); cytotoxic, no licensed for extra genital warts but widely used, not licensed in pregnancy
- imiquimod; immune modifier, can be used on all anogenital warts, not licensed in pregnancy
- cryotherapy; cytolytic can require repeat treatments
- electrocautery
What is HIV?
- RNA retrovirus
- HIV-1 and HIV-2
- HIV-1 group M responsible for global epidemic
- sub-types show geographical distribution
What does retrovirus mean?
Uses enzyme reverse transcriptase to make copies of itself
How often does HIV replicate?
- rapid replication in very early and very late infection
- new generation every 6-12 hours
Describe how HIV replicated
- two strands of single stranded RNA in an envelope of surface antigens (GP 120 and GP41)
- surface antigens helps to bind to CD4 receptor cells
- complex forms between GP120 and GP41 and CD4 receptor and co-receptor, these bind and allows the envelope to fuse with the CD4 membrane and enter the cell
- viral DNA is then incorporated into the hosts genome
- virus ‘buds’ off and then matures
- it can then go out and infect other cells
HIV usually infects which tissues / cells?
- infection of mucosal CD4+ cell (langerhans and dendritic cells)
- transport to regional lymph nodes
- disseminated to gut associated lymphoid tissue which is quickly depleted
- infection established within 3 days of entry
What is CD4?
A glycoprotein found on the surface of a range of cells including;
- t help lymphocytes
- dendritic cells
- macrophages
- microglial cells
What do CD4+ Th lymphocytes do?
- essential for induction of adaptive immune response
- recognition of MHC2 antigen presenting cell
- activation of B cells
- activation of cytotoxic T cells (CD8+)
- cytokine release
- deficiency in downstream immune reaction if no CD4 cells
What effect does HIV infection have on the immune response?
- reduced circulating CD4+ cells
- reduced proliferation of CD4+ cells
- reduction CD8+ (cytotoxic) T cell activation; dysregulated expression of cytokines
- reduction in antibody class switching; reduced affinity of antibdoies produced
- chronic immune activation
- susceptibility to; viral infections, fungal infections, mycobacterial infections, infection induced cancers
What is the normal CD4+Th cell parameters, and when is risk at its highest of opportunistic infections?
- normal; 500-1600 cell/mm3
- highest risk; <200 cells/mm3
When is the average onset of primary HIV infection?
Average 2-4 weeks after infection
Name symptoms of primary HIV infection
- fever
- rash (maculopapular) commonly on upper body
- myalgia
- pharyngitis
- headache / aseptic meningitis (if microglial cells are affected)
- very high risk of transmission
- these symptoms will resolve and move onto asymptomatic HIV infection
What occurs during asymptomatic HIV infection?
- ongoing viral replication
- ongoing CD4 count depletion
- ongoing immune activation
- risk of onward transmission if remains undiagnosed
Define opportunistic infection
An infection caused by a pathogen that does not normally produce disease in a healthy individual. It uses the ‘opportunity’ afforded by a weakened immune system to cause disease
Pneunocystis pneumonia is caused by what organism and what are the signs and symptoms?
- caused by pneumocystis jiroveci
- insidious onset of SOB and dry cough
- signs; exercise oxygen desaturation
- chest may be normal on examination
What can be seen on x-ray and how is pneumocystic pneumonia diagnosed?
- CXR: may be normal, interstitial infiltrates, reticulonodular markings
- diagnosis; BAL and immunofluorescence +/- PCR
What is the treatment of pneumocystic pneumonia?
- treatment; high dose co-trimoxazole (+/- steroid)
- prophylaxis; low dose co-trimoxazole for anyone with a reduced CD4 count <200
What causes cerebral toxoplasmosis?
- toxoplasma gondii
- CD4 threshold of <150
Describe the presentation of cerebral toxoplasmosis
- headache
- fever
- focal neurology
- seizures
- reduced consciousness
- raised ICP
- reactivation of latent infection; multiple cerebral abscess, chorioretinitis
What causes cytomegalovirus?
- CMV
- CD4 threshold; <50
Describe the presentation of cytomegalovirus
- reduced visual acuity
- floaters
- abdominal pain
- diarrhoea
- PR bleeding
- reactivation of latent infection; retinitis, colitis, oesophagitis
HIV associated neurocognitive impairment is caused by which strain of HIV and how does it present?
- HIV-1
- CD4 threshold; increased incidence with decreased CD4
- reduced short term memory
- +/- motor dysfunction
What causes progressive multifocal leukoencephalopathy (PML) and how does it present?
- JC virus (reactivation
- CD4 threshold; <100
- rapidly progressing
- focal neurology
- confusion
- personality change
- demyelination
What organism causes kaposis sarcoma and what is it?
- human herpes virus 8
- vascular tumour
- CD4 threshold; any increased incidence with increased immunosuppression
Describe the presentation and treatment of kaposis sarcoma
Presentation; - cutaneous - mucosal - visceral; pulmonary, GI Treatment; - anti-retrovirals - local therapies - systemic chemotherapy
What organism causes non-hodgkins lymphoma
- EBV
- CD4 threshold; increased incidence with increased immunosuppression
What is the presentation and treatment of non-hodgkins lymphoma?
- more advanced
- B symptoms
- bone marrow involvement
- extranodal disease
- increased CNS involvement
- diagnosis and treatment is as for HIV-ve individuals
Non-AIDS symptomatic HIV can present with what conditions?
- mucosal candidiasis
- seborrhoeic dermatitis
- diarrhoea
- fatigue
- worsening psoriasis
- lymphadenopathy
- parotitis
- epidemiologically linked conditions; STIs, hepatitis B, hepatitis C
How can HIV be transmitted?
- sexual transmission (79% of new infection in UK)
- parenteral transmission; injection drug use, infected blood products, iatrogenic
- mother to child; in utero/transplacental, delivery, breast feeding
High risk countries for HIV include where?
- sub saharan Africa
- Carribean
- South East Asia
Who should be tested for HIV?
- universal testing in high prevalence areas
- opt-out testing in certain clinical settings
- screening of high risk groups
- testing in the presence of ‘clinical indicators’
In what services is opt-out HIV testing offered?
- termination of pregnancy services
- sexual health services
- addiction and substance misuse services
- antenatal services
- assisted conception services
Which groups of people are at high risk of HIV infection so are offered screening?
- MSM
- female partners of MSM
- Black Africans
- prisoners
- trans women
- people who or have injected drugs
- partners of people living with HIV
- adults from endemic areas
- children from endemic areas
- sexual partners from endemic areas
Which markers of HIV are used by labs to detect infection?
- RNA (viral genome)
- capsule protein (p24)
What is the first marker of HIV to become positive?
- viral RNA
- then P24
- then antibody (this can take three months before detectable in blood)
For how long may an HIV test be negative even if infection is present?
Up to 45 days if 4th generation testing used
Name different targets for anti-retroviral drugs
- reverse transcriptase
- integrase
- protease
- entry; fusion, CCR5 receptor
- capsid
- monoclonal antibodies
- maturation
What is the purpose of highly active anti-retroviral therapy?
- reduce viral load to undetectable levels
- restore immunocompetence
- reduce morbidity and mortality
- prevent onward transmission
How is drug resistance prevented?
Adherence
Describe the HAART toxicity side effects
- GI side effects (protease inhibitors)
- skin; rash, hypersensitivity, stevens johnson (abacavir, nevirapine)
- CNS side effects; mood, psychosis (efavirenc, dolutegravir)
- renal toxicity; proximal renal tubulopathies, nephrolithiasis (tenofovir, disoproxil, atazanavir)
- bone; osteomalacia (tenofovir, dispoproxil)
- CVS; increased MI risk (abacavir, lopinavir, maraviroc)
- haematology; anaemia (zidovudine)
What drugs are used for PrEP?
- tenofovir
- emtricitabine
What dosing schedules are used in PrEP?
- daily
- on-demand
When is post-exposure prophylaxis taken and what drugs are used?
- start within 72 hours of high risk exposure; sexual or occupational
- combination ART taken for 4 weeks; tenofovir / emtricitabine, raltegravir
How is HIV prevented from mother to child transmission?
- HAART during pregnancy
- vaginal delivery undetected viral load
- caesarean section if detected viral load
- 2-4/52 PEP for neonate
- exclusive formula feeding
What is PMS?
- premenstrual syndrome
- any complex of symptoms experienced by some women in the days immediately before menstruation
When must symptoms be present for a diagnosis of PMS?
Must be present in luteal phase, abate during menstruation followed by a symptom free week
What is the most common oestrogen?
Estradiol e2
PMS is thought to be due to what?
- Sensitivity to progesterone
- serotonin receptors
- GABA levels
- not well understood
Describe diagnosis of PMS
- record symptoms prospectively using a symptom diary
- can use GnRH analogues to help if diagnosis from diary not conclusive
Describe management of PMS
- primary care generally until failure of treatment
- simple measures e.g. COCs, vitamin B6, SSRIs
- GnRH inhibitor / analogue; e.g. danazol
- spironolactone
- surgical managment
