Genito-urinary Medicine and Contraception

Question 1

Define Bacterial Vaginosis? What bacteria cause it?

Answer 1

Overgrowth of anaerobic bacteria in the vagina due to a loss of commensal lactobacilli (recent antibiotics or excessive vaginal cleaning)

Lactobacilli produce lactic acid which maintains a low vaginal pH (below 4.5) and prevents other bacteria from overgrowing. When there are reduced numbers of lactobacilli in the vagina, the pH rises and allows anaerobic bacteria to grow:

• Gardnerella vaginalis (most common)
• Mycoplasma hominis
• Prevotella species

Question 2

Presentation of Bacterial vaginosis

Answer 2

The standard presenting feature of bacterial vaginosis is a fishy-smelling watery grey or white vaginal discharge. Half of women with BV are asymptomatic.

Itching, irritation and pain are not typically associated with BV and suggest an alternative cause or co-occurring infection.

Question 3

Microscopy of a high vaginal swab (speculum) shows clue cells. What is the diagnosis?

Answer 3

Bacterial vaginosis gives “clue cells” on microscopy. Clue cells are epithelial cells from the cervix that have bacteria stuck inside them, usually Gardnerella vaginalis.

Can also test for higher vaginal pH

Question 4

Rx for BV

Answer 4

Metronidazole is the antibiotic of choice for treating bacterial vaginosis. Metronidazole specifically targets anaerobic bacteria. This is given orally, or by vaginal gel.

Asymptomatic BV does not usually require treatment.

Tom Tip: Avoid alcohol with metronidazole - Alcohol and metronidazole can cause a “disulfiram-like reaction”, with nausea and vomiting, flushing and sometimes severe symptoms of shock and angioedema.

Question 5

Complications of BV and chlamydia in pregnancy are almost indentical, name them? (6)

Which complication is chlamydia specific?

Answer 5

All:
- miscarriage
- preterm delivery
- PROM
- chorioamnionitis
- low birth weight
- post-partum endometritis

• chlamydia specific - neonatal pneumonia.conjuctivitis

Question 6

What causes vaginal thrush? (inc risk factors)

Answer 6

Vaginal infection with candida yeast (most commonly candida albicans). Cadndida may asymptomatically colonise the vagina but then progress to infection when the right environment occours:
- increased oestrogen (pregnancy)
- broadspectrum antibiotics (like BV)
- immunosupression/diabetes

Question 7

A female presents with:
- Thick, white discharge that does not typically smell
- Vulval and vaginal itching, irritation or discomfort

Diagnosis?
How would you confirm the diagnosis?

Answer 7

Thrush - Vaginal Candidiasis
A charcoal swab with microscopy can confirm the diagnosis.

Question 8

Managment of vaginal candiasis

Answer 8

Treatement is with antifungal medications. Inital management can be given in one of three ways

• intravaginal clotrimazole cream at night
• **clotrimazole pessary **
• a signle dose of oral fluconazole

Canesten Duo is a standard over-the-counter treatment worth knowing. It contains a single fluconazole tablet and clotrimazole cream to use externally for vulval symptoms.

Question 9

Ix for chlamydia

Answer 9

Nucleic acid amplification tests (NAAT) are used to diagnose chlamydia and gonorrhoea. Rather than using microscopy these are checked directly for the DNA and RNA of the organism.

In women
- Vulvovaginal swab or Endocervical swab (speculum)
- First-catch urine sample is an alternative (urine held in bladder for at least one hour)

In Men:
- first catch urine sample
- Urethral swab is an alternative

Also
- Rectal swab (after anal sex)
- Pharyngeal swab (after oral sex)

NOTE - NAAT is also used to screen for chlamydia in asymptomatic people at high risk of chlamydia infection. Everyone at GUM clinics, all women under 25, 2 secual partners in the last year….

Question 10

A women presents with abnormal vaginal discharge, pelvic pain, dyspareunia, dysuria and post-coital bleeding. Diagnosis? How does the presentation differ from another key differential?

Answer 10

Answer - Chlamydia

Presentation of Chlamydia ans Gonorrhea in women is similar:
Abnormal vaginal discharge
Pelvic pain
Abnormal vaginal bleeding (intermenstrual or postcoital)
Painful sex (dyspareunia)
Painful urination (dysuria)

The way to distinguish - discharge from chlamydia is usually clear or milky, while discharge from gonorrhoea tends to be thicker and can be yellow, white, or green.

Also Chlamydia is more likely to cause abnormal bleeding - more likely to cause cervicitis

In men (these are the same for both chlamydia and gonorrhoea)
- urethral discharge
- dysuria
- epidydymo-orchitis

A large number of chlamydia cases are asymptomatic (50% in men and 75% in woman). Infection with gonorrhoea is more likely to be symptomatic than infection with chlamydia. Only 10% of men and 50% of women are asymptomatic.

Question 11

Rx for chlamydia?

In pregnancy?

Answer 11

First-line for uncomplicated chlamydia infection is Doxycycline 100mg twice a day for 7 days.

Pregnancy:
- Doxycycline is contra-indicated in pregnancy and breastfeeding. Alternatives include Azithromycin and erythromycin - KEY
- a test of cure should be used in pregnancy

Question 12

What is chlamydial conjuctivitis

Answer 12

Chlamydia can infect the conjunctiva of the eye. Conjunctival infection is usually as a result of sexual activity, when genital fluid comes in contact with the eye, for example, through hand-to-eye spread. It presents with chronic erythema, irritation and discharge lasting more than two weeks. Most cases are unilateral.

Chlamydial conjunctivitis occurs more frequently in young adults. It can also affect neonates with mothers infected with chlamydia.

Gonococcal conjunctivitis is a crucial differential diagnosis and should be tested. In neonatas, gonococaal conjuntivitis (contracted during birth) is a medical emergency associated with sepsis and blindness.

Question 13

What is lyphogranuloma venereum?

What is the Rx?

Answer 13

Usually occours in MSM, lymphogranuloma venereum is a condition affecting the lyphoid tissues around the site of a chlamydia infection.

It occours in three stages:
1. A painless ulcer in the rectum, vagina or penis
2. Inguinal/femoral lymphadenitis (painful inflammation of lymph nodes)
3. Proctitis - anal pain, change in bowel habit

Rx is with Docycycline (just like uncomplicated chlamydia) but for 21 days (uncomplicated is 7 days).

Me - key differential will be syphillis because similar to the painless chancre. However, syphillis then leads to a rash and painLESS lyphadenopathy.

Question 14

Ix for Gonorrhoea

Answer 14

Like chlamydia, NAAT testing is used to test for gonorrhoea:
- vulvovaginal swab in women
- first catch urine in men
- rectal and pharyngeal swabs

ALSO a charcoal swab for microscopy, culture and antibiotic sensaitivities.

NAAT test do not provide any information about the specific bacteria and their antibiotic sensitivities and resistance. This is why a standard charcoal swab for microscopy, culture and sensitivities is so essential, to guide the choice of antibiotics to use in treatment.

Question 15

Rx for Gonorrhoea

Answer 15

• A single dose of intramuscular ceftriaxone 1g if the sensitivities are NOT known
• A single dose of oral ciprofloxacin 500mg if the sensitivities ARE known

Unlike chlamydia, because of high antibitoic resistance, a test of cure is performed.

Key - Ceftriaxone is also safe in pregnancy, cipro isnt though!!

Question 16

What is pelvic inflammatory disease?

Causes - 6?

Answer 16

Pelvic inflammatory disease (PID) is inflammation and infection of the organs of the pelvis, caused by infection spreading up through the cervix. It is a significant cause of tubular infertility and chronic pelvic pain. It includes endometritis, salpingitis, oophoritis, parametritis.

Most cases are caused by STI accending:
- Neisseria gonorrhoeae tends to produce more severe PID
- Chlamydia trachomatis
- Mycoplasma genitalium

Less commonly caused by non-STIs:
- Gardnerella vaginalis (associated with bacterial vaginosis)
- Haemophilus influenzae (acceding through the cervix)
- Escherichia coli (an enteric bacteria commonly associated with urinary tract infections)

Question 17

Microscopy on a high vaginal swab shows pus cells, what is the diagnosis

What are the other Ix for this condition?

Answer 17

PID

Ix for PID
- NAAT swabs
- high vaginal charcoal swab
- HIV and syohilis blood test
- pregnancy test- exclude ectopic in young women with pelvic pain
- inflammatory markers- usually raised.

Question 18

KEY - PID management

Answer 18

Complex and started empirically to avoid complications.

• IM ceftriazone (to cover gonorrhoea)
• Doxycycline twice daily for 14 days (to cover chlamydia and mycoplasma genitalium)
• metranidazole (to cover anaerobes such a gardnerella vaginalis (BV))

Ceftriazone and Doxyclycine will also cover over bacteria such as E.coli and H.influenza

NOTE - This is a great card because it has BV, Chlamdyia and Gonorrhoea management as they are indivudally.

Question 19

Complications of PID

Answer 19

• sepsis
• absess
• infertility
• chornic pelvic pain
• ectopic pregnancy
• Fitz-Hugh-Curtis syndrome - PID causing inflammation and infeciton of the liver capsule leading to peritoneal adhesions.

Question 20

What are the two main strains of herpes simplex virus?

Answer 20

HSV-1 is most associated with cold sores. It is often contracted initially in childhood (before five years), remains dormant in the trigeminal nerve ganglion and reactivates as cold sores, particularly in times of stress. Genital herpes caused by HSV-1 is usually contracted through oro-genital sex, where the virus spreads from a person with an oral infection to the person that develops a genital infection.

HSV-2 typically causes genital herpes and is mostly a sexually transmitted infection. The virus becomes latent in the sacral nerve ganglion.

Question 21

A patient presents with a painful blistering lesion in the genital area and flu-like symptoms. What is the most likely diagnosis?

Ix?

Answer 21

Genital Herpes

A viral PCR swab from the legion can confirm the diagnosis.

Me- The key here is the blisters, pain and the flu-like symptoms. Syphillis isnt usually vesicular and isn’t usually painful.

Background…
Signs and symptoms include:

Ulcers or blistering lesions affecting the genital area
Neuropathic type pain (tingling, burning or shooting)
Flu-like symptoms (e.g. fatigue and headaches)
Dysuria (painful urination)
Inguinal lymphadenopathy

Symptoms can last three weeks in a primary infection. Recurrent episodes are usually milder and resolve more quickly.

Question 22

Compare Syphillis and Herpes presentation

Answer 22

Syphilis: A patient may present with painless ulcers, rashes, or swollen lymph nodes, depending on the stage of infection. Local (often painless, but not always) lyphadenompathy

Herpes: The patient often presents with painful vesicles (genital sores), itching, burning, or flu-like symptoms and dysuria/

Question 23

Management of genital herpes

Answer 23

Aciclovir is used to treat genital herpes.

Symptomatic measures - paractamol, topical lidocaine, avoiding intercourse

There is a no cure, often recurrent outbreaks will resolve without treatment and are less severe than the initial. Some people never have recurrent outbreaks.

Question 24

What is the main prenancy-related complication of genital herpes? What is the managment?

Answer 24

The main issue with genital herpes during pregnancy is the risk of neonatal herpes simplex infection (rash and high fever) contracted during labour and delivery. Neonatal herpes simplex infection has high morbidity and mortality.

3 presentations:
1. Skin, eyes and mouth vesicles
2. encephalitis
3. dissemintated - lungs, brain, liver, adrenals

HSV rarelt causes congenital abnormalities!

Management:
Management of genital herpes in pregnancy depends on whether it is the first episode of genital herpes (primary infection) or recurrent genital herpes.

Primary gential herpes contracted before 28 weeks:
- aciclovir during the inital infection
- prophalactic aciclovir from 36 weeks
- if asymptomatic they can have a normal delivery, if symptomatic then caesarean section.

Primary genital herpes contracted after 28 weeks gestation
- the same as above (inital and prophalactic aciclovir) however, Caesarean section is recommended in all cases to reduce the risk of neonatal infection.

Recurrent gential herpes (infected before pregnancy -> antibodies cross the placenta)
- low risk of neonatal infeciton even if symptomatic during delivery, so vaginal delivery is possible
- prophalactic aciclovir is considered from 36 weeks

Question 25

Not on the list, what is mycoplasma genitalium

Answer 25

A bacterial sexually transmitted infection that causes non-gonococal urethritis.

Not culturable Ix is NAAT testing

Rx- Doxycycyline AND Azithromycin

Me - kinda like super clamydia, remeber bacteria because mycoplasma pnaeumoniae causes atypical pneumonia

Question 26

What is trichomononiasis?

How does it present? - 2 key things for the exam?

Answer 26

Trichomonas vaginalis is protozoan parasite that is spread through sexual intercourse.

2 key features in the presentation:
- frothy yellow-green discharge, that may have a fishy smell
- Speculum examination reveals a characteristic strawberry cervix (colpitis macularis)
- There is also usually itching, dysuria, dysparueunia, balantis

Sidenote
If you get confused with mycoplasma genitalium (bacteria) remember that trichomonias is similar to trypanosmiasis (african sleeping sickness). Mypoplasma also doesnt cause symptoms typically.

Question 27

Diangosis and treatment of trichomoniasis

Answer 27

Charocal swab for miscroscopy:
- high vaginal or low vaginal swab in women
- urethral swab or first catch urine in men

Rx is with metronidazole (just like BV)

Question 28

Syphillis causative orgnaism?

Answer 28

Syphilis is caused by bacteria called Treponema pallidum. This bacteria is a spirochete, a type of spiral-shaped bacteria. The bacteria gets in through skin or mucous membranes, replicates and then disseminates throughout the body. It is mainly a sexually transmitted infection, but can also be spread vertically during pregnancy or from IV drug use. The incubation period between the initial infection and symptoms is 21 days on average.

Question 29

Stages of Syphillis infection?

Pupil defect?

Answer 29

Primary syphilis can present with:
- A painless genital ulcer (chancre). This tends to resolve over 3–8 weeks.
- Local lymphadenopathy

Secondary syphilis typically starts after the chancre has healed, with symptoms of:
- Maculopapular rash - typically n palms and feet, dont confuse with Lyme disease
- Condylomata lata (grey wart-like lesions around the genitals and anus)
- Low-grade fever
- Lymphadenopathy
- Alopecia (localised hair loss)
- Oral lesions

Tertiary syphilis can present with several symptoms depending on the affected organs. Key features to be aware of are:

• Gummatous lesions (gummas are granulomatous lesions that can affect the skin, organs and bones)
• Aortic aneurysms
• Neurosyphilis

Neurosyphilis can occur at any stage if the infection reaches the central nervous system, and present with symptoms of:

• Headache
• Altered behaviour
• Argyll-robinson pupil - explaination below
• Dementia
• Tabes dorsalis (demyelination affecting the spinal cord posterior columns)
• Ocular syphilis (affecting the eyes)
• Paralysis
• Sensory impairment

Argyll-Robertson pupil is a specific finding in neurosyphilis. It is a constricted pupil that accommodates when focusing on a near object but does not react to light. They are often irregularly shaped. It is commonly called a “prostitutes pupil” due to the relation to neurosyphilis and because “it accommodates but does not react“.

Question 30

Ix for syphilis

Answer 30

Screening test - test the blood for antibodies to T.pallidum

Samples from the infeciton site (chancres) - test with PCR or darkfield microscopy

Be award of the nonspecific RPR (rapid plasma reagin test) that test for the quantity of antibodies in order to determine the chances of active disease - can confirm have has it with antibody screening test but doesnt tell you how active it is.

Question 31

Rx for Syphilis

Answer 31

A single dose of IM benzathine benzylpenicillin/ PEN G is the standard treatmnet for syphilis.

Late and neurosyphilis are treated with alternative regimes (e.g. ceftriaxone)

NOTE - Pen G is also used for GBS (Pen V is the one for GA strept)

Question 32

Types of HIV virus?

DNA or RNA virus?

Answer 32

HIV is an RNA retrovirus (hence antiretrovirals). HIV-1 is the most common type. HIV-2 is mainly found in West Africa.

The virus enters and destroys the CD4 T-helper cells of the immune system.

Question 33

What is HIV seroconversion

Answer 33

A flu-like illness that occours within weeks of infection. The infection is then asymptomatic for years until it progresses to immunodeficiency (AIDs) if left untreated.

It caused by the immune repsonse developing antibodies to the virus - hence the name (sero - serology)

Question 34

Examples of AIDs-Defining Illnesses

Answer 34

There is a long list of AIDS-defining illnesses associated with end-stage HIV infection. These occur where the CD4 count has dropped to a level that allows for unusual opportunistic infections and malignancies to appear.

Examples of AIDS-defining illnesses include:

• Kaposi’s sarcoma (HHV 8 causing multiple purple patches/tumours on the skin and mucous membranes )
• Pneumocystis jirovecii pneumonia (PCP)
• Cytomegalovirus infection
• Candidiasis (oesophageal or bronchial)
• Lymphomas
• Tuberculosis

Question 35

HIV screening tests vs monitoring test, 2 and 2.

Answer 35

SCREENING - to diagnose
Self-test kit - tests for antibodies to HIV and the p24 antigen - window period of 45 days after exposure.

The immediate point of care-test only check for antibodies so has a 90 day window

MONITORING
CD4 count - >500 is normal, <200 is classed as AIDs (oppotunistic infections)
HIV RNA copies per ml - Viral Load

Question 36

HIV Treatment

Answer 36

Antiretroviral therapy is offered to everyone diagnosed with HIV, irrespective of viral load or CD4 count.

There are several classes of antiretroviral therapy medications:

Protease inhibitors (PI)
Integrase inhibitors (II)
Nucleoside reverse transcriptase inhibitors (NRTI)
Non-nucleoside reverse transcriptase inhibitors (NNRTI)
Entry inhibitors (EI)

The usual starting regime is two NRTIs (e.g., tenofovir plus emtricitabine) plus a third agent (e.g., bictegravir).

Treatment aims to achieve a normal CD4 count and undetectable viral load. Generally, when a patient has a normal CD4 and an undetectable viral load on ART, physical health problems (e.g., routine chest infections) are treated the same as those without HIV.

Question 37

Additional HIV management (in addition to ARVT)

Answer 37

Prophylactic co-trimoxazole is given to all HIV positive patients with a CD4 count under 200/mm3 to protect against pneumocystis jirovecii pneumonia (PCP).

HIV infection increases the risk of developing cardiovascular disease. Patients with HIV have close monitoring of cardiovascular risk factors, such as blood lipids. Interventions to reduce the risk (e.g., statins) may be recommended.

Yearly cervical smears are recommended in HIV as it increases the risk of human papillomavirus (HPV) infection and cervical cancer.

Vaccinations should be up to date, including against influenza (yearly), pneumococcal, HPV and hepatitis A and B. Live vaccines (e.g., BCG and typhoid) are avoided.

Question 38

HIV prevention

Answer 38

Reproductive health for infected indivduals:
Correct use of condoms protects against spreading HIV. Effective treatment combined with an undetectable viral load appears to prevent the spread of HIV, even during unprotected sex (although there is still a risk of other STIs).

Breastfeeding - HIV can be tranmitted through breastmilk so breastfeeding is best avoided.

Prophalaxis:
Post-exposure prophylaxis (PEP) can be used after exposure to reduce the risk of transmission. PEP involves a combination of ART therapy. The current regime is emtricitabine/tenofovir (Truvada) and raltegravir for 28 days.

Pre-exposure prophylaxis (PrEP) is also available to take before exposure to reduce the risk of transmission. The usual choice is emtricitabine/tenofovir (Truvada).

Question 39

HIV management in pregnancy

Answer 39

The mother’s viral load will determine the mode of delivery:

• <50 - normal vedilvery
• > 50 - consider a pre-labour caesarean section
• > 400 - pre-labour caesarean section is recommended

Zidovudine:
IV zidovudine is given during labour and delivery if the viral load is >1000 or unknown

All babies should be given zidovudine for 4 weeks

High risk babies, where mums viral load is > 50 copies / ml, should be given zidovudine, lamivudine and nevirapine for 4 weeks

Breast feeding:
HIV can be trasnmitted through breastfeeding so it is avoided. It can be attempted with monitoring if the viral load is undetectable.

Question 40

What is chancroid?

Causative organism?

How can it be distinguished from differentials such as primary syphillis, Lyphogranuloma and Herpes?

Answer 40

Chancroid is a bacterial STI caused by infection with Haemophilus ducreyi. It is characterized by painful necrotizing genital ulcers that may be accompanied by inguinal lymphadenopathy.

Key point for idnetifying it in the exam: Painful - distinguishes it from primary syphillis and lyphogranuloma venerium. It is an ulcer not a vesicle (herpes).

Question 41

What is Balanitis

Answer 41

Inflammation of the glans penis (sore, dysuria, discharge udner the foreskin) caused by improper hygeine, thrush, STI, washing with soap.

Rx:
- steroid cream
- antifungal cream
- antibiotics (STI)

Question 42

What causes genital warts?

management?

Answer 42

Genital warts are small, rough lumps that can appear around the vagina, penis or anus. They’re a common sexually transmitted infection (STI).

Gential warts are caused by the human papilloma virus - the most common are HPV types 6 and 11 (remeber 16 and 18 is cervical cancer).

mnemonic 16, 17 (6+11), 18 - in between the two cerival cancer types

Treatment isn’t always needed (30% resolve within 6 months) but can include ointment (imiquimod), cryotherapy or surgery.

Abstenance is advised unitl the warts are gone

Question 43

Rx for pubic lice

Answer 43

Pubic lice are tiny insects that can live on body hair, especially the pubic hair around the penis or vagina. They’re spread through close body contact, most commonly through sexual contact.

The usual treatment for pubic lice is:

permethrin cream (Lyclear) - mnemonic - perm for pubes
aqueous malathion (Derbac-M)

Question 44

Define erectile dysfunction?

Up to of 50% of erectile dysfunction is caused by what?

Anatomy of the penis:
- which artery supplies the erectile tissue with blood during arousal?
- Which two nerves innervate the penis and what is their spinal original?
- which receptor classes do these two nerves activate?

Answer 44

Erectile dysfunction (ED): inability to obtain/maintain an erection sufficient for penetration and sexual satisfaction. Risk increases with age

Cardiovascular link: 50% of ED patients have atherosclerosis; ED may signal undiagnosed cardiovascular disease. Timely intervention can prevent future health consequences.

Anatomy: penis structured into root, body, and glans. Erectile tissues (corpus cavernosa x2, 1xcorpus spongiosum around the urethra) fill with blood during arousal.

• The internal pudendal artery supplies the eretile tissues and branches into: the dorsal penile artery, the deep penile artery and the bulbourethral artery.
• Supplied by internal pudendal artery, drained by superficial/deep dorsal veins. Innervation from
• S2-S4 (Pee, poop and penis off the ground)
• Sympathetic innervation (Shoot = ejaculation) - provided by the pudendal nerve -> dorsal nerve of the penis - mnemonic ejeculate from the base- Alpha-1 Adrenergic receptors
• Parasympathetic innervation (Point = erection) - provided by the prostatic nerve plexus -> carvenous nerves Mnemonic is cavernosa make are eretion tissues. M3 receptors

Question 45

Causes of erectile dysfunction?

How is the severity of ED assessed?

Investigations? 3 key bloods in primary care? Specialist Ix - 2?

Answer 45

Multifactorial Causes:

2 main classes
Primary Organic:
- vascular (hypertension, atherosclerosis) - MOST COMMON
- neurological (Parkinson’s, MS)
- hormonal (hypogonadism)
- drug-induced (antihypertensives, antidepressants)
- systemic (diabetes)
- structural (trauma, Peyronie’s)

Primary Psychogenic (depression, anxiety, relationship stress!)

Note: Ascertaining whether a patient is having normal or impaired nocturnal erections will help to distinguish between organic vs. psychogenic causes of ED.

Use International** Index of Erectile Function (IIEF-5) questionnaire** to assess severity.

Investigations:
Blood tests for an underlying cause and cardiovascular risk:
- lipids
- HbA1c
- fasting serum testosterone - hypogonadism

Others - LFTs, U+E, TFTs, PSA for prostate

Specialist Ix - complex or refractory ED
specialised tests:
- Nocturnal penile tumescence testing (NPT): used to distinguish between organic vs. psychogenic ED.
- Duplex doppler imaging/angiography: if a vascular cause of ED is suspected.

Question 46

Management of Erectile Dysfunction - 5 categories?

Answer 46

DEPENDS ON THE CAUSE

Management:
- Lifestyle modification: smoking cessation, minimal alcohol intake, weight loss.
- Psychosexual counselling for psychogenic components.
- PDE-5 inhibitors: sildenafil, vardenafil, avanafil. Take on empty stomach, avoid alcohol/fatty meals. Follow-up at 6-8 weeks. Contraindications: nitrates, recent cardiovascular events. Side effects: headache, flushing, dizziness.
- Hormone treatments: endocrine referral for hormone replacement if needed.
- Penile prosthesis: for refractory cases. Options include inflatable implants and semirigid rods. Risks: infection, malfunction, erosion/adhesion.

Question 47

Female Sexual Dysfuntion:
- 3 types?
- Management? 4 things

Answer 47

3 types:
Female Sexual Arousal Disorder: Difficulty in becoming aroused during sexual activity, often leading to insufficient lubrication and discomfort.
Female Orgasmic Disorder (FOD): Inability to achieve orgasm despite adequate sexual stimulation.
Dyspareunia (Penetration disorder): Pain during or after sexual intercourse. Vagninimsus is involuntary contraction on the vaginal wall muscles preventing penetration and causing pain.

There are three criteria for diagnosing a sexual disorder:
- Sx for a minimum of 6 months
- affecting 75% to 100% of sexual encounters
- causing clinically significant distress

Diagnosis:
- Pain - rule out underlying causes such as infections, tumors, or conditions like endometriosis.
- Examination if suspecting prolapse, scarring, or vaginismus.
- Lab tests like FBC, lipids, and hormone levels (FSH, LH, estrogen, testosterone) evaluate the hypothalamic-pituitary-gonadal axis.
- Female Sexual Function Index is used to assess FSD.

Management:
- CBT/psycho-sexual therapy - first line for all three types

Also:
- Oestrogen - for post-meanuapsal women with sexual arousal disorder
- Vibrostimulation for orgasmic disrorder. Also testosterone and fribanserin are somtimes used
- Pelvic floor exercises

Question 48

Management of premature ejaculation

Answer 48

Definition: Ejaculation that occurs sooner than desired, either before or shortly after penetration.

Management:
- Behavioral therapy: Techniques such as the “start-stop” method or “squeeze” technique.
- Dapoxetine - SSRI short acting
- Regular SSRIs
- Topical anesthetics (e.g., lidocaine).

Question 49

Contraception Basics Starts Here…

Question 50

The key contraceptive methods available are:

Natural family planning (“rhythm method”)
Barrier methods (i.e. condoms)
Combined contraceptive pills
Progestogen-only pills
Coils (i.e. copper coil or Mirena)
Progestogen injection
Progestogen implant
Surgery (i.e. sterilisation or vasectomy)

Which of these are the most effective?

Answer 50

It is essential to distinguish between the effectiveness of perfect use and typical use. This is especially important with methods such as natural family planning, barrier contraception and the pill, where the effectiveness is very user-dependent. If used perfectly these are all 99% (even family planning is only slightly less)

Long-acting methods such as the implant, coil and surgery are the most effective with typical use, as they are not dependent on the user to take regular action.

Question 51

Emergency contraception is also available after unprotected intercourse. However, emergency contraception should not be relied upon as a regular method of contraception.

Name three options for EC?

Answer 51

There are three options for emergency contraception:

• Levonorgestrel should be taken within 72 hours of UPSI (start hormonal contraception immediately but not effective for one week on COPC or 2 days on POP) - only one available over the counter
• Ulipristal (similar to mifepristone - progesterone antagonist) should be taken within 120 hours of UPSI (have to wait five days after to take hormonal contraception, contraindicated in asthma) - so 5 days and 5 days before contraception
• Copper coil can be inserted within 5 days of UPSI, or within 5 days of the estimated date of ovulation (14 days before menstruation)

Question 52

Contraception: what are the UKMEC criteria?

Answer 52

There are four levels, from least risk of most risk:

UKMEC 1: No restriction in use (minimal risk)
UKMEC 2: Benefits generally outweigh the risks
UKMEC 3: Risks generally outweigh the benefits
UKMEC 4: Unacceptable risk (typically this means the method is contraindicated)

Question 53

Risk factors affecting contraception choice:

• contraceptive options to be avoided in breast cancer?
• cervical and endometrial cancer?
• Wilson’s disease

Key - there are several risk factors that make the COCP UKMEC 4 - list them 6/9?

Answer 53

Exam questions frequently present an individual with specific risk factors and ask for the most suitable form of contraception for that person. It helps to remember key risk factors and their contraindications:

Breast cancer: avoid any hormonal contraception and go for the copper coil or barrier methods
Cervical or endometrial cancer: avoid the intrauterine system (i.e. Mirena coil) Me - wierd because IUS used to treat Endometrial hyperplasia and prevent ECa
Wilson’s disease: avoid the copper coil

////

There are specific risk factors that should make you avoid the combined contraceptive pill (UKMEC 4):

Uncontrolled hypertension (particularly ≥160 / ≥100)
Migraine with aura
History of VTE
Aged over 35 smoking more than 15 cigarettes per day
Major surgery with prolonged immobility
Vascular disease or stroke
Ischaemic heart disease, cardiomyopathy or atrial fibrillation
Liver cirrhosis and liver tumours
Systemic lupus erythematosus and antiphospholipid syndrome

Question 54

Contraception in older women:
- how long after the last period (menaupause) should women continue to use contraception for? 2
- does HRT prevent pregnancy?
- why must the progesterone depot be stopped before 50?
- if women are amoenorrhoeic on the POP how long should they continue using it for contraception? 2

Answer 54

There are some additional considerations in older and perimenopausal women:

After the last period, contraception is required for 2 years in women under 50 and 1 year in women over 50
Hormone replacement therapy does not prevent pregnancy, and added contraception is required
The combined contraceptive pill can be used up to age 50 years, and can treat perimenopausal symptoms
The progestogen injection (i.e. Depo-Provera) should be stopped before 50 years due to the risk of osteoporosis

Women that are amenorrhoeic (no periods) when taking progestogen-only contraception should continue until either:

FSH blood test results are above 30 IU/L on two tests taken six weeks apart (continue contraception for 1 more year)
55 years of age

Question 55

Contraception for under 20s:
- Which 3 options are UKMEC 1
- Which 2 options are UKMEC2

Answer 55

When prescribing contraception to women under 20 years:

UKMEC 1
- Combined + progestogen-only pills are unaffected by younger age
- The progestogen-only implant is a good choice of long-acting reversible contraception

UKMEC 2
- The progestogen-only injection is UK MEC 2 due to concerns about reduced bone mineral density
- Coils are UKMEC 2, as they may have a higher rate of expulsion

Question 56

Contraception after childbirth:
- lactational amenorrhea is effective for how long and on what conditions
- when can the POP or Implant be used?
- who cannot use the COCP?
- when should coilds be inserted?

Answer 56

Fertility is not considered to return until 21 days after giving birth, and contraception is not required up to this point. The risk of pregnancy is very low before 21 days. After 21 days women are considered fertile, and will need contraception (including condoms for 7 days when starting the combined pill or 2 days for the progestogen-only pill).

Lactational amenorrhea is over 98% effective as contraception for up to 6 months after birth. Women must be fully breastfeeding and amenorrhoeic (no periods).

The progestogen-only pill and implant are considered safe in breastfeeding and can be started at any time after birth.

The combined contraceptive pill should be avoided in breastfeeding (UKMEC 4 before 6 weeks postpartum, UKMEC 2 after 6 weeks) - oestrogen reduced breast milk production and increases VTE risk

A copper coil or intrauterine system (e.g. Mirena) can be inserted either within 48 hours of birth or more than 4 weeks after birth (UKMEC 1), but not inserted between 48 hours and 4 weeks of birth (UKMEC 3).

TOM TIP: Remember that the combined pill should not be started before 6 weeks after childbirth in women that are breastfeeding. The progestogen-only pill or implant can be started any time after birth.

Question 57

How does the COCP affect PV bleeding?

How does the POP affect bleeding?

Management of problematic bleedign whilst on contraception

Answer 57

THE COCP
The lining of the endometrium is maintained in a stable state while taking the combined pill. When the pill is stopped the lining of the uterus breaks down and sheds. This leads to a “withdrawal bleed“. This is not classed as a menstrual period as it is not part of the natural menstrual cycle. “Breakthrough bleeding” can occur with extended use without a pill-free period.

Often there is an improvement in premenstrual symptoms, menorrhagia (heavy periods) and dysmenorrhoea (painful periods). However, unscheduled bleeding is common in the first three months and should then settle with time.

THE POP
The bleeding pattern that a woman will experience with progestogen-only contraception (the pill, implant or injection) is unpredictable. To make it simple to remember I round the risks into thirds, with a third having lighter, less regular or no bleeding, a third having normal bleeding and a third having unscheduled, heavier or more prolonged bleeding. It is not possible to predict how individuals will respond. Irregular or troublesome bleeding often settles after three months, so it may be worth persisting.

Management:
Excluded underlying pathology including STI!
- COCP shouldnt be causing ireggular bleeding - check compliance - i think after the first 3 months
- POP - Reassure, if 3 months have passed NSAIDs or swap to COCP (unless contraindications)
- implant or depot - The FSRH guidance typically recommends Progestogen-only options (like the PoP or IUS) as a first-line intervention for managing bleeding irregularities associated with progestogen-only contraception methods such as the implant - THEY TESTED THIS IN THE EXAM

Question 58

COCP

What are the missed pill rules?

When are condoms also required?

When is emergency contraception required?

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POP what are the missed pill rules?

Answer 58

Missed pill rules are commonly tested in exams, either in MCQs or by having to council a patient in an OCSE scenario. It is worth understanding the theory as this makes it easier to work out what to do. In reality, always double-check the rules with guidelines or product literature to make sure you get it right.

The best way to understand the rules is to consider that theoretically women will be protected if they perfectly take the pill in a cycle of 7 days on, 7 days off. This will prevent ovulation.

Missing one pill is when the pill is more than 24 hours late (48 hours since the last pill was taken).

Missing one pill (48 - 72 hours since the last pill was taken):

• Take the missed pill as soon as possible (even if this means taking two pills on the same day)
• No extra protection is required provided other pills before and after are taken correctly

Missing more than one pill (more than 72 hours since the last pill was taken):

• Take the most recent missed pill as soon as possible (even if this means taking two pills on the same day)
  - Additional contraception (i.e. condoms) is needed until they have taken the pill regularly for 7 days straight

SO CONDOMS ARE REQUIRED IF MISS MORE THAN ONE PILL!

Requiring emergency contraction:
- If day 1 – 7 of the packet they need emergency contraception if they have had unprotected sex (ABOVE need 7 days to protect)
- If day 8 – 14 of the pack (and day 1 – 7 was fully compliant) then no emergency contraception is required, condoms advised for 7 days (above)
- If day 15 – 21 of the pack (and day 1 – 14 was fully compliant) then no emergency contraception is needed. They should go back-to-back with their next pack of pills and skip the pill-free period, condoms for 7 days.

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POP

A pill is classed as “missed” if it is:

More than 3 hours late for a traditional POP (more than 26 hours after the last pill)
More than 12 hours late for the desogestrel-POP (more than 36 hours after the last pill)

The instructions are to take a pill as soon as possible, continue with the next pill at the usual time (even if this means taking two in 24 hours) and use extra contraception for the next 48 hours of regular use. Emergency contraception is required if they have had sex since missing the pill or within 48 hours of restarting the regular pills.

Episodes of diarrhoea or vomiting are managed as “missed pills”, and extra contraception (i.e. condoms) is required until 48 hours after the diarrhoea and vomiting settle.