Genito-urinary med Flashcards
1
Q
CONTRACEPTION
What are certain cancers you need to be aware of in relation to the contraceptives you need to avoid?
A
- Breast cancer = avoid any hormonal contraception > IUD or barrier methods
- Cervical or endometrial cancer = avoid IUS
2
Q
CONTRACEPTION
When is contraception needed after birth?
What natural method might be trialled?
What contraceptives can be used at any time?
A
- Fertility not considered to return until 21d after birth
- Lactational amenorrhoea very effective for up to 6m after birth but must be fully breastfeeding + amenorrhoeic
- POP + implant safe
3
Q
COCP
What is the COCP?
How can it be taken?
A
- Pill containing supraphysiological level of oestrogen AND progesterone (of varying types).
- 21d on then 7d off (withdrawal bleed), tricycle or B2B packs
4
Q
COCP
What are the benefits of using the COCP?
A
- Very effective
- Improves acne
- Decreased risk of endometrial, ovarian + colorectal cancer
5
Q
COCP
What are some risks of using the COCP?
A
- Small risk of heart attacks + strokes
- Small risk of blood clots
- Increased risk of breast + cervical cancer
6
Q
COCP
What are some side effects with the COCP?
A
- Headaches
- Nausea
- Breast tenderness
- Abnormal bleeding
7
Q
COCP
What are the UKMEC4 criteria for the COCP?
A
- Active breast cancer
- Migraine with aura
- Hx of VTE, stroke or IHD
- > 35 smoking >15/d
- Antiphospholipid syndrome + SLE
- Breastfeeding <6w postpartum
8
Q
COCP
What are the important starting instructions for the COCP?
Rules for switching from POP to COCP?
A
- Start within first 5 days of cycle = immediate protection.
- Start after day 5 = extra contraception for first 7d.
- Can switch from traditional POP at any time but 7d extra contraception unless desogestrel then no additional
9
Q
COCP
What is classified as a missed pill for the COCP?
What are the missed pill rules for…
i) 1 pill?
ii) 2 pills?
A
- Taken >24h late
i) Take missed pill and normal, even if 2 pills > continue
ii) Take missed pill and normal, even if 2 pills > 7d extra protection
10
Q
COCP
If someone has missed 2 pills and had unprotected sexual intercourse, what action is required?
A
- Day 1–7 packet = emergency contraception
- Day 8–14 packet = no action
- Day 15–21 = next pack B2B (skip pill-free period)
11
Q
POP
What is the POP?
What is the only UKMEC4 contraindication?
A
- Pill containing only progesterone, taken continuously
- Active breast cancer
12
Q
POP
What different types of POP are there and what are their mechanisms?
A
- Traditional POP (norgeston) = thickens cervical mucus
- Desogestrel POP (Cerazette) = inhibits ovulation and thickens cervical mucus
13
Q
POP
What are the benefits of the POP?
What are the risks/side effects of the POP?
A
- Very effective, role in menorrhagia Mx
- Irregular vaginal bleeding #1 in first 3m, acne, headaches, ovarian cysts
14
Q
POP
What are the important starting instructions for the POP?
Rules for switching from COCP to POP?
A
- Start within first 5 days of cycle = immediate protection
- Start after day 5 = extra contraception for 48h
- Best time is days 22–28 (hormone-free period) as no extra protection, if not 48h
15
Q
POP
What is classified as a missed pill for the POP?
What are the missed pill rules for POP?
What are the rules about UPSI?
A
- > 3h in traditional POP, >12h late for desogestrel POP
- Take pill ASAP, continue with next pill as usual and extra contraception for 48h
- UPSI since missing pill or within 48h restarting = emergency contraception
16
Q
PROGESTERONE INJECTION
What is the progesterone only injection, how often is it given and what is the mechanism?
What is the only UKMEC4 contraindication?
A
- Depo-Provera = depot medroxyprogesterone acetate every 12w to inhibit ovulation
- Active breast cancer
17
Q
PROGESTERONE INJECTION
What are some adverse effects of the progesterone injection?
A
- Irregular bleeding
- Weight gain
- Osteoporosis (stopped before 50 due to this risk)
- Can take 12m for fertility to return after stopping injections
18
Q
PROGESTERONE INJECTION
What are the important starting instructions for the progesterone injection?
A
- Day 1–5 = immediate protection.
- Beyond day 5 = extra contraception for 7d
19
Q
PROGESTERONE IMPLANT
What is the progesterone implant and the ages it’s used for?
What is the mechanism of action?
What is the only UKMEC4 contraindication?
A
- Nexplanon used in UK, 68mg of etonogestrel, licensed 18–40y/o.
- Inhibits ovulation + thickens cervical mucus
- Active breast cancer
20
Q
PROGESTERONE IMPLANT
What are the important starting instructions for the progesterone implant?
How long do they last for?
A
- Day 1–5 = immediate protection.
- Beyond day 5 = 7d contraception.
- Lasts 3y then needs replacing.
21
Q
PROGESTERONE IMPLANT
What are the benefits of the progesterone implant?
A
- Effective
- Can improve menorrhagia
- Don’t have to remember taking a pill
22
Q
PROGESTERONE IMPLANT
What are the drawbacks of the progesterone implant?
A
- Irregular bleeding
- Pain on insertion
23
Q
PROGESTERONE IMPLANT
What are the risks with the progesterone implant?
A
- Can be bent/fractured or impalpable/deeply implanted needing extra contraception until located (USS/XR), may need specialist removal.
- Very rarely can enter vessels + migrate through body to lungs.
24
Q
PROGESTERONE IMPLANT
What is the UKMEC4 criteria for the progesterone implant?
A
- Active breast cancer.
25
COILS
What are the 2 types of coils?
What are the contraindications to insertion?
- Copper IUD or levonorgestrel intrauterine system (IUS)
- PID, immunosuppression, unexplained bleeding, uterine cavity distortion (fibroids), UKMEC3 48h–4w after birth (before or after is okay)
26
COILS
What is the copper coil licensed for?
What is the mechanism of action?
Is extra contraception required?
- 5–10y after insertion device dependent, emergency contraception as well as long-term
- Inhibits implantation
- No it's effective immediately
27
COILS
What are the benefits of the copper IUD?
What are the drawbacks?
- Reliable, no hormones so safe in cancer
| - Pain on insertion, irregular bleeding
28
COILS
What is the IUS licensed for?
What is the mechanism of action?
Is extra contraception required?
- Main type Mirena effective for 5y for contraception, 4y for HRT
- Thickens cervical mucus + inhibits implantation
- No if inserted up to day 7 if not yes
29
COILS
What are the benefits of the IUS?
What are the drawbacks?
- Treats menorrhagia, reliable, can improve dysmenorrhoea
| - Pain on insertion, irregular bleeding
30
COILS
What must you do prior to and after insertion of a coil?
What happens if there's an infection?
What should you advise patients before removal?
- Screen for STIs prior and at 3–6w check threads visible
- Treat with coil in place
- Abstain from sex or use extra contraception for 7d before coil removed
31
EMERGENCY CONTRACEPTION
| What 3 types of contraception can be used as emergency contraception?
- Copper IUD
- PO Ulipristal acetate (ellaOne)
- PO levonorgestrel (levonelle)
32
EMERGENCY CONTRACEPTION
What is the time frame after UPSI that you can use the various emergency contraceptives and their relative effectiveness?
- Levonorgestrel = <72h, 84% + decreases with time
- Ulipristal acetate = <120h, in between the two
- Copper IUD = <120h or up to 5d after likely ovulation date, 99%
33
EMERGENCY CONTRACEPTION
| What is the mechanism of action of the various emergency contraceptives?
- Levonorgestrel = stops ovulation + inhibits implantation
- Ulipristal acetate = inhibits ovulation
- Copper IUD = inhibits implantation + fertilisation
34
EMERGENCY CONTRACEPTION
| What is important cautions should be remembered for the various emergency contraceptives?
- Levonorgestrel = 1.5mg single dose, 3mg if BMI >26 or >70kg
- Ulipristal acetate = avoid in severe asthma and avoid breastfeeding for 1w after use
- Copper IUD = keep in until at least next period
35
EMERGENCY CONTRACEPTION
| Can the various emergency contraceptives be used more than once in the same cycle?
- Yes for levonorgestrel and ulipristal
| - Copper IUD N/A
36
EMERGENCY CONTRACEPTION
| In terms of long-term contraception after the use of emergency contraception, what is the information to tell patients?
- Levonorgestrel = hormonal contraception starts immediately after
- Ulipristal acetate = wait 5d before starting contraception
- Copper IUD = offers long term contraception
37
STERILISATION
What is female sterilisation?
How effective is it?
- Tubal occlusion by laparoscopy under GA
| - Less effective than male sterilisation
38
STERILISATION
What is male sterilisation?
What are the benefits?
What follow up is required?
- Vasectomy performed under LA = vas deferens ligated + excised
- Relatively quick, less invasive + more effective
- Contraception until semen analysis at 16w + 20w
39
INFERTILITY
What is primary and secondary infertility?
What is the epidemiology?
- Primary = no pregnancy after at least 1 year of regular intercourse
- Secondary = couples who have been pregnant ≥1 before but now cannot
- Very common, 1 in 6 of whom most will conceive after 2y
40
INFERTILITY
| When would you consider referring to a specialist before 1 year?
- Female >35y
- Previous STI
- Abnormal examination
- Previous pelvic or uro-genital surgery
41
INFERTILITY
| What are some causes of female infertility?
- Ovulatory = PCOS, age, hyperprolactinaemia, Turner's syndrome
- Tubal/uterine/cervical = PID, Asherman's, endometriosis, fibroids
42
INFERTILITY
| What are some causes of male infertility?
- Testicular = cryptorchidism, testicular cancer, Klinefelter's, mumps
- Post-testicular = retrograde ejaculation, CF
- Azoospermia = steroid abuse, hypogonadotropic hypogonadism
43
INFERTILITY
| What are some risk factors of infertility?
- Obesity
- Smoking
- Excessive alcohol/drugs
- Occupational risks
44
INFERTILITY
| What are some first line investigations for infertility?
- STI screens (particularly chlamydia).
- Ovulatory tests (mid-luteal progesterone levels)
- Semen analysis (>15million/ml)
- FSH (high in testicular/premature ovarian failure), LH
- TFTs + prolactin if clinical suspicion
45
INFERTILITY
When do you perform mid-luteal progesterone levels?
What results would you expect?
- 7d before end of cycle (usually day 21)
| - <16 = anovulation, 16–30 repeat, >30 is ovular
46
INFERTILITY
| What are the ovarian reserve tests?
- Pelvic USS, CF screen, Karyotyping
| - Tubal patency = hysterosalpinogram if no risk factors, laparoscopy + dye test gold standard in high risk
47
INFERTILITY
What pre-conception advice would you give to couples?
To females?
To males?
- Intercourse 2–3 a week, regular smear tests
- Healthy BMI, smoking + drinking advice
- F = take 0.4mg folic acid (or 5mg if high risk).
- M = looser underwear, avoid extreme heat near genitals, zinc
48
INFERTILITY
| How would you manage anovulation?
- Weight loss
- Clomifene days 2–6 to inhibit oestrogen > more GnRH > more FSH/LH
- GnRH if clomifene resistant
49
INFERTILITY
| How would you manage tubal disease?
- Tubal surgery e.g., catheterization or cannulation
50
INFERTILITY
| How do you manage male infertility?
- Depends on abnormality
- Intrauterine insemination (IUI), IVF, intracytoplasmic sperm injection (ICSI), donor insemination if no sperm
- Surgical sperm retrieval if obstructive azoospermia (epididymal obstruction)
- Gonadotropins if hypogonadotropic hypogonadism
51
INFERTILITY
| How does IVF work?
- Suppression of natural menstrual cycle with GnRH agonist
- Ovarian stimulation + oocyte collection
- Insemination then embryo culture + transfer
52
INFERTILITY
| What is a key complication of IVD and what is the pathophysiology?
- Ovarian hyperstimulation syndrome
- Occurs after iatrogenic induction of ovulation (HCG) due to mass maturation of follicles becoming corpus luteum + so lots of vascular endothelial growth factors > increased vascular permeability
53
INFERTILITY
| What are the various severities of ovarian hyperstimulation syndrome?
- Abdo pain + vomiting = mild
- N+V + USS showing ascites = moderate
- Ascites, oliguria = severe
- Anuria, VTE, ARDS = critical
54
INFERTILITY
| What is the management of ovarian hyperstimulation syndrome?
- USS + serum oestrogen (high) may be monitored
| - Supportive = IV crystalloids, monitor urine output, LMWH, paracentesis
55
CHLAMYDIA
What is chlamydia?
What is it caused by?
What is the incubation period?
- Most common STI in UK (approx 1 in 10 young women have it)
- Chlamydia trachomatis – obligate intracellular gram -ve cocci
- 7–21d
56
CHLAMYDIA
| What are the risk factors for chlamydia, and STIs in general?
- Age <25
- Multiple sexual partners
- Lack of barrier methods
- Poor socioeconomic status
- Other STIs
57
CHLAMYDIA
| What is the clinical presentation of chlamydia?
- No symptoms in 70% F, 50% M
- Women = cervicitis (discharge, bleeding), dysuria, dyspareunia
- Men = urethral discharge, dysuria
58
CHLAMYDIA
What is the investigation of choice for chlamydia?
Who is screening offered to?
- Nucleic acid amplification tests (NAAT) = M first void urine sample, F vulvo-vaginal swab, MSM pharyngeal and rectal swab too
- Screening 15–24y but relies heavily on opportunistic testing
59
CHLAMYDIA
| What are some complications with chlamydia?
- Reactive arthritis
- Epididymitis
- PID
- Ectopic pregnancies
- #1 preventable cause of infertility
60
CHLAMYDIA
What is the conservative management of chlamydia?
What is the medical management?
- Partner notification (treat too), contact tracing, contraceptive advice, ?child protection services
- Test for other STIs, test 3m after treatment if <25y to ensure not re-contracted
61
CHLAMYDIA
| What is the medical management of chlamydia?
- First line = doxycyline 100mg BD for 7d (C/I pregnancy + breastfeeding)
- Second line = azithromycin (1g stat, 500mg OD for 2d), erythromycin or amoxicillin
62
GONORRHOEA
What is gonorrhoea caused by?
What is the incubation period?
- Neisseria gonorrhoea – gram -ve diplococcus
| - 2–5d
63
GONORRHOEA
| What is the clinical presentation of gonorrhoea?
- Males = urethral discharge (purulent green/yellow), dysuria
- Females = cervicitis with discharge (purulent green yellow)
- Rectal + pharyngeal usually asymptomatic
64
GONORRHOEA
| How would you investigate for gonorrhoea?
- Nucleic acid amplification tests (NAAT) = M first void urine sample, F vulvo-vaginal swab, MSM pharyngeal and rectal swab too
65
GONORRHOEA
| What are the local complications of gonorrhoea?
- Urethral strictures
- Epididymo-orchitis
- Salpingitis
- Subfertility
66
GONORRHOEA
| What are the systemic complications of gonorrhoea?
- PID
- Septic arthritis
- Disseminated gonococcal infection as triad of tenosynovitis, migratory polyarthritis, dermatitis lesions (can be maculopapular or vesicular)
67
GONORRHOEA
| What complication of gonorrhoea may present in neonates?
- Ophthalmia neonatorum (gonococcal conjunctivitis)
68
GONORRHOEA
What is the management of gonorrhoea?
What if that first line management is refused?
- 1g single dose IM ceftriaxone (add PO ciprofloxacin 500mg but only if sensitive as high antibiotic resistance)
- PO cefixime + PO azithromycin if refuses IM
- Follow-up test of cure with NAAT testing or cultures
69
PID
| What is pelvic inflammatory disease?
- Inflammation + infection of the pelvic organs (upper genital tract), caused by ascending infection through the cervix.
70
PID
| What are the causes of PID?
- Chlamydia trachomatis = most common cause
- Neisseria gonorrhoea, Mycoplasma genitalium
- Less commonly non-STI like Gardnerella vaginalis, E. coli
71
PID
| What are some risk factors for PID?
- Younger age
- Existing STIs
- Multiple sexual partners
- Copper IUD
- Previous PID
72
PID
| What is the clinical presentation of PID?
- Pelvic/lower abdo pain (chronic)
- Abnormal PV discharge (purulent), dysuria
- Abnormal bleeding
- Deep dyspareunia
- Exam = fever, bimanual (Adnexal tenderness, cervical motion tenderness/excitation)
73
PID
| What investigations would you do in PID?
- Urinary pregnancy test to exclude ectopic
- NAAT swabs for gonorrhoea + chlamydia
- HVS for BV, candidiasis + trichomoniasis
- HIV + syphilis bloods
- FBC, blood cultures + CRP/ESR if acutely unwell/septic
- TV USS if abscess suspected
74
PID
What might you look for on microscopy in PID?
What is the relevance?
- Pus cells on swabs from vagina or endocervix
| - Absence is useful to exclude PID
75
PID
| What are the complications of PID?
- Chronic pelvic pain
- Ectopic pregnancy
- Infertility
- Fitz-Hugh-Curtis syndrome
76
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PID
What is Fitz-Hugh-Curtis syndrome?
What does it cause?
How does it present?
How is it managed?
```
- Inflammation + infection of liver (Glisson's) capsule leading to adhesions between liver + peritoneum
- RUQ pain ± referred R shoulder pain if diaphragmatic irritation
- LFTs + USS to exclude stones, laparoscopy for Dx + adhesiolysis
77
PID
| What is the management of PID?
- STAT IM ceftriaxone 1g then doxycycline 100mg BD + metronidazole 400mg BD for 14d
- OR ofloxacin 400mg + metronidazole 400mg BD for 14d
78
BACTERIAL VAGINOSIS
| What is the pathophysiology of BV?
- Overgrowth of mostly anaerobic organisms (#1 = Gardnerella vaginalis) leading to consequent drop in lactic acid producing aerobic lactobacilli > raised vaginal pH
79
BACTERIAL VAGINOSIS
What are the risk factors of bacterial vaginosis?
What causes BV to occur less frequently?
- Multiple sexual partners
- Excessive vaginal cleaning (douching)
- Recent Abx
80
BACTERIAL VAGINOSIS
| What is the clinical presentation of BV?
Amsel's diagnostic criteria (3/4) –
- Thin, white homogenous discharge
- Vaginal pH using swab + pH paper >4.5
- Clue cells on charcoal MC&S
- Positive whiff test = add potassium hydroxide > strong fishy odour
81
BACTERIAL VAGINOSIS
| What is the management of BV?
- PO metronidazole 5–7d to target anaerobic bacteria, even in pregnancy
- Topical metronidazole or clindamycin alternatives
82
TRICHOMONAS VAGINALIS
What is TV caused by?
What can it increase the risk of?
- Trichomonas vaginalis = highly motile, flagellated protozoan parasite
83
TRICHOMONAS VAGINALIS
| What is the clinical presentation of TV?
- Vaginal discharge = offensive, yellow/green, frothy
- Vulvovaginitis = itchy, dyspareunia
- Cervix = "strawberry cervix" due to cervicitis + haemorrhages on surface
84
TRICHOMONAS VAGINALIS
| What investigations would you do for TV?
- Vaginal pH >4.5
| - Charcoal swab for MC&S = wet microscopy showing motile trophozoites
85
TRICHOMONAS VAGINALIS
| What is the management of TV?
- PO metronidazole 5–7d (or stat 2g dose)
86
SYPHILIS
What causes syphilis?
What are the modes of transmission?
- Treponema pallidum – spirochete (spiral-shaped) bacteria
| - Sexual contact (esp. MSM), vertical transmission, IVDU
87
SYPHILIS
What are the three stages of syphilis?
How does the first stage present?
- Primary, secondary + tertiary
- Painless genital ulcer (chancre) at site of sexual contact)
- Non-tender local lymphadenopathy
88
SYPHILIS
What indicates secondary syphilis?
What is the clinical presentation?
- Chancre healed
- Systemic = fever, lymphadenopathy
- Rash (trunk, soles + palms)
- Condylomata lata (painless, warty lesions on genitalia)
- Buccal 'snail track ulcers'
89
SYPHILIS
When does tertiary syphilis develop?
What is the clinical presentation?
- >2y
- Gummas = granulomatous lesions of skin + bones
- Ascending aortic aneurysms
- Neurosyphilis = tabes dorsalis (gait issues), paralysis, dementia, Argyll-Robertson pupil
90
SYPHILIS
| What is an Argyll-Robertson pupil?
"Accommodates but does not react"
- Constricted pupil that accommodates when focusing on near object but does not react to light, often irregularly (small) shaped
91
SYPHILIS
| What investigations would you do for syphilis?
Non-treponemal + treponemal tests –
- +ve non, +ve treponemal = active syphilis
- +ve non, -ve treponemal = false positive (pregnancy, SLE, TB, HIV)
- -ve non, -ve treponemal = successfully treated syphilis
92
SYPHILIS
| How would you manage syphilis?
- Single dose IM benzathine benzylpenicillin or PO doxycycline if allergic
93
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SYPHILIS
What is a potential adverse effect of treating syphilis?
How does it present?
What is an important differential?
How is it managed?
```
- Jarisch-Herxheimer reaction within a few hours of treatment
- Fever, rash + tachycardia after dose, thought to be due to release of endotoxins following bacterial death
- DDx = anaphylaxis but no wheeze or hypotension
- Mx = antipyretics
94
GENITAL HERPES
| What causes genital herpes?
- Herpes simplex virus (HSV) causes both cold sores (HSV-1) + genital herpes (HSV-2) but considerable overlap
95
GENITAL HERPES
| What is the clinical presentation of genital herpes?
- Painful genital ulcers (neuropathic type pain)
- Flu like Sx (headache, fever) + inguinal lymphadenopathy
- Herpetic whitlow = painful skin lesion on finger/thumb
96
GENITAL HERPES
What is the investigation for genital herpes?
How is it managed?
- NAAT swab from lesion can confirm
- PO anti-viral aciclovir within 5d of start of episode
- Conservative = paracetamol, lidocaine 2% gel, warm saltwater clean, vaseline
97
GENITAL HERPES
| What time can genital herpes be dangerous and what is the main risk?
- During pregnancy as risk of neonatal herpes simplex infection
98
GENITAL HERPES
| What is the management of primary genital herpes contracted before 28w gestation?
- Aciclovir during initial infection + prophylaxis from 36w
- No Sx at delivery = vaginal delivery (if >6w from initial infection)
- Sx at delivery or <6w = c-section
99
GENITAL HERPES
| What is the management of primary genital herpes contracted after 28w gestation?
- Aciclovir during initial infection + immediate prophylactic aciclovir
- C-section in all cases
100
GENITAL HERPES
| What is the management of recurrent genital herpes in pregnancy?
- Prophylactic aciclovir from 36w gestation but transmission risk low
101
GENITAL WARTS
| What causes genital warts?
- Human papilloma virus 6 + 11
102
GENITAL WARTS
| What is the clinical presentation of genital warts?
- Asymptomatic fleshy, slightly pigmented warts around genitals
- Itching or bleeding, abnormal urinary stream
103
GENITAL WARTS
| What are the investigations for genital warts?
- Clinical diagnosis (may use magnifying glass or colposcope)
- Biopsy if atypical
104
GENITAL WARTS
| How is genital warts managed?
- Prophylaxis with HPV vaccine for 12–13y (may be given to MSM + sex workers)
- First line = topical podophyllum (multiple non-keratinised) or or cryotherapy (solitary keratinised)
- Second line = topical imiquimod
105
CANDIDIASIS
What is candidiasis?
What are some risk factors?
- Thrush secondary to Candida yeast infection (#1 albicans)
| - Increased oestrogen (pregnancy), poorly controlled DM, immunosuppression, broad spectrum Abx
106
CANDIDIASIS
| What is the clinical presentation of candidiasis?
- Thick, white, non-offensive discharge (cottage cheese)
- Superficial dyspareunia, dysuria, itching
- Erythema, fissuring, "satellite" lesions
107
CANDIDIASIS
| What are the investigations for candidiasis?
- Clinical Dx
| - Vaginal pH <4.5
108
CANDIDIASIS
What is the management of candidiasis?
What treatment should be used in pregnancy?
- Recurrent candidiasis = ≥4 episodes a year
- Confirm diagnosis with high vaginal charcoal swab MC&S
- Consider blood glucose for ?DM
- Induction-maintenance regime of PO fluconazole
109
CANDIDIASIS
What is the management of candidiasis?
How does this differ in pregnancy?
- Local = clotrimazole pessary, PO = itraconazole, fluconazole
- Pregnancy = local only (clotrimazole)
110
LICHEN SCLEROSUS
| What is lichen sclerosus?
- Chronic inflammatory condition which usually affects the genitalia in elderly females causing epidermis atrophy + formation of white plaques
111
LICHEN SCLEROSUS
| What is the suspected cause of lichen sclerosus?
- Thought to be autoimmune as associated with other autoimmune conditions
112
LICHEN SCLEROSUS
| What is the clinical presentation of lichen sclerosus in women?
- White patches which might scar, Koebner phenomenon
- Prominent itch
- Dyspareunia + dysuria
- Often affects vulva + perianal areas but not perineum = hourglass/'8' shape
113
LICHEN SCLEROSUS
| What are the investigations for lichen sclerosus?
- Clinical Dx but biopsy if atypical = failure to respond to treatment or ?VIN/cancer (SCC of vulva)
114
LICHEN SCLEROSUS
| What is the management of lichen sclerosus?
- Topical steroids + emollients
115
HIV
What is HIV?
What is the pathophysiology of HIV?
- RNA retrovirus that encodes reverse transcriptase
- Binds to GP120 envelope on CD4 T helper cells
- Virus enters + reverse transcriptase makes single stranded RNA > DNA
- DNA integrated into host DNA via integrase enzyme + then core viral proteins are synthesised and cleaved by viral protease enzyme
116
HIV
What is the aetiology of HIV?
What are high risk groups for HIV?
- HIV-1 is most common type
- HIV-2 is rare outside West Africa
- MSM, IVDU, commercial sex workers
117
HIV
| How is HIV transmitted?
- Unprotected sex (co-existing STIs can enhance transmission)
- Vertical transmission (pregnancy, breastfeeding)
- IVDU
- Blood exposure
118
HIV
| What is the initial clinical presentation of HIV?
- Initial seroconversion 3–12w post infection = fever, maculopapular rash, flu symptoms, lymphadenopathy, diarrhoea
- Clinical latency with progressive loss of CD4 count = poor immunity but no symptoms
119
HIV
After a period of clinical latency, what happens in terms of clinical presentation of HIV?
What is AIDS?
- Early symptomatic HIV = rise in viral load + fall in CD4 count > fever, night sweats, diarrhoea, opportunistic infections (AIDS-related complex)
- AIDS = Sx of immune deficiency + CD4 count <200
120
HIV
| What tests can be used to investigation HIV?
- Combination tests (HIV p24 antigen and HIV antibody) for diagnosis and screening
- CD4 count
- PCR for HIV RNA (viral load)
121
HIV
Explain the management of the results from combination tests?
What are self-testing kits and how are they used?
- Combined test +ve = repeat to confirm
- Test 4w after possible exposure = repeat at 12w if negative
- Self-testing kits are antibody tests and can be -ve for 3m
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HIV
| How can HIV infection be monitored?
- Monitoring CD4 count
| - Monitoring viral load
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HIV
What would you monitor with CD4 count?
What does viral load measure?
- 500–1200cells/mm^3 = normal range, <200 risk of AIDS
| - Measure of viral replication + indicator of prognosis (undetectable <50copies/ml)
124
HIV
| What are the considerations with HIV and pregnancy?
- Normal vaginal delivery if viral load <50 copies/ml
- Consider c-section if >50, but mandatory in >400 with IV zidovudine 4h before c-section
- Neonatal PO zidovudine if maternal viral load <50 if not triple ART both for 4–6w
- No breastfeeding AT ALL, even undetectable
125
HIV
| What are AIDS defining illnesses?
- All associated with end-stage HIV infection where CD4 count dropped to level that allows unusual opportunistic infections + malignancies to occur
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HIV
| What opportunistic infections can occur with a CD4 count of 200–500?
- Oral thrush (Candida), shingles, hairy leukoplakia (EBV)
| - Kaposi's sarcoma = vascular tumour 2º to HHV-8, purple papules on skin, conjunctiva + GI/resp tract
127
HIV
| What opportunistic infections can occur with a CD4 count of 100–200?
- Cryptosporidium #1 cause of diarrhoea
- Cerebral toxoplasmosis = MULTIPLE lesions with ring or nodular enhancement
- Progressive multifocal leukoencephalopathy = neuro Sx, widespread demyelination
- Pneumocystis jirovecci pneumonia, HIV dementia
128
HIV
| What opportunistic infections can occur with a CD4 count of 50–100?
- Aspergillosis, oesophageal candidiasis
- Cryptococcal meningitis = #1 CNS fungal infection, ring enhanced lesion
- Primary CNS lymphoma 2º to EBV = SINGLE homogenous enhancing lesion
129
HIV
| What opportunistic infections can occur with a CD4 count <50?
- Cytomegalovirus retinitis
| - Mycobacterium avium-intracellulare
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HIV
| What is the management of HIV and give some classes of drugs?
- Highly active antiretroviral therapy (HAART) = 2 NRTIs + third agent
- Nucleoside reverse transcriptase inhibitors (NRTIs)
- Protease inhibitors
- Integrase inhibitors
- Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
131
HIV
Give some examples of and explain the mechanism of action of...
i) NRTIs?
ii) protease inhibitors?
i) Tenofovir, zidovudine = inhibits synthesis of DNA by reverse transcriptase
ii) Indinavir (–navir) = acts comptetitively on HIV enzyme involved in production of functional viral proteins
132
HIV
Give some examples of and explain the mechanism of action of...
i) integrase inhibitors?
ii) NNRTIs?
i) Raltegravir (–gravir) = inhibits insertion of HIV DNA to the genome
ii) Nevirapine = binds directly to + inhibits reverse transcriptase
133
HIV
| What is the management of potential exposure to HIV?
- Combination anti-retrovirals within 72h of exposure for 4w (post-exposure prophylaxis/PEP)
- HIV test done immediately + after 3m of exposure (abstain for 3m)
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HIV
| What is the general management of HIV?
- Education (safe sex, sexual partners, regular testing)
- Prophylactic co-trimoxazole if CD4 <200 (PCP)
- Pre-exposure prophylaxis (PrEP) + PEP
- Yearly cervical smears for women
- Vaccinations up to date but avoid live ones
- Conceive safely if undetectable or via sperm washing or IVF
