GP Reproductive Health and Urology

Question 1

Define pre-menopause, peri-menopause, menopause and post menopause?

Answer 1

• Menopause is the cessation of periods
• Pre-menopause a woman is having regular periods
• During the peri-menopause a woman is having irregular periods
• Post-menopause the woman has had no periods for over 12 months

Question 2

What is the average age of menopause in the UK?

Answer 2

51

Question 3

What is premature ovarian insufficiency?

Answer 3

menopause before age 40

Question 4

What is early menopause?

Answer 4

occurs between the ages 40-44 and this occurs in 5% of women

Question 5

What stage in menopause are symptoms most severe? Do symptoms improve?

Answer 5

late peri and early post menopause

most symptoms improve in time as body adjusts, genito-urinary symptoms may not improve

Question 6

Symptoms of menopause?

Answer 6

• The top 3 symptoms are hot flushes, night sweats and mood swings
• Others include: brain fog, period problems, anxiety, dizziness, memory loss, dry skin and hair, aches and pains, weight gain, tiredness, lack of energy, palpitations, recurrent UTI symptoms, pins and needles, insomnia, decreased libido, headaches, painful sex and irritability

Question 7

Diagnosis of menopause?

Answer 7

• Don’t need laboratory tests in healthy women over 45 years with menopausal symptoms
• Can use FSH tests in women aged 40 to 45 with menopausal symptoms or women aged under 40 with suspected menopause

Question 8

Management of menopause?

Answer 8

• Lifestyle changes
• CBT for hot flushes
• Environment changes
• Non hormonal treatment: herbal medicine, SSRIs/ SNRIs, complementary medicine
• HRT

Question 9

What are the advantages, disadvantages and contraindications of HRT?

Answer 9

Advantages: better quality of life, improved symptoms, better mental health, better sexual health, decreased osteoporosis, decreased CVD disease until age 60

Disadvantages: increased breast cancer risk, increased VTE risk if taken orally, increased CVD risk if > 60

Contraindications to HRT: history of breast cancer, coronary heart disease, TIA or previous stroke, unexplained vaginal bleeding, active liver disease

Question 10

How should you give HRT?

Answer 10

• If a person has had a hysterectomy or they have a Mirena in situ they only need oestrogen
• If a person has a uterus and no Mirena then they need oestrogen and progesterone
• If they are perimenopausal then oestrogen and progesterone should be given as sequential therapy
• If they are postmenopausal then oestrogen and progesterone should be given as continuous combined therapy
• There is no time limit on HRT, it can either be gradually reduced or stopped immediately
• In those with early menopause or primary ovarian insufficiency strongly advise giving HRT until at least age 51

Question 11

Why do you need to give progesterone as well as oestrogen to those with a uterus?

Answer 11

unopposed oestrogen can cause endometrial hyperplasia which can progress to cancer

Question 12

Describe perimenopausal contraception?

Answer 12

• Age < 40: POI may be transitional, continue contraception
• Age 40-49: stop 2 years after last natural period or if on contraception that is hormonal stop 2 years after 2 results of FSH 30 or more taken 4-6 weeks apart
• Age 50 or more: same as above but 1 year
• Age over 55: can stop even if still having periods

Question 13

What is vulvo-vaginal atrophy and how can it be treated?

Answer 13

• Thinning, drying and inflammation of the vaginal walls due to less oestrogen
• Can cause dryness, soreness, irritation, dyspareunia and urge incontinence
• Can be effectively treated with topical oestrogen which carries very little risk and can be used for as long as needed

Question 14

Describe gonorrhoea bacteria?

Answer 14

• Gram negative intracellular diplococcus which infects the urethra, endocervix, rectum and pharynx
• It is a fastidious organism which means it doesn’t survive well when it is not in ideal growth conditions

Question 15

Is gonorrhoea more common in men or women?

Answer 15

• It is more common in men than women
• Males are more likely to pass it to a partner vs females passing it to a partner

Question 16

Presentation of gonorrhoea?

Answer 16

• In Men: mucopurulent or purulent discharge and dysuria
• In women: increased, vaginal discharge, dysuria, postcoital or intermenstrual bleeding and lower abdo pain

Question 17

Investigations for gonorrhoea?

Answer 17

• NAATs (nucleic acid amplification tests) are test of choice as these have better sensitivity than culture
• However antimicrobial resistance is increasing and culture on selective media should be performed prior to any treatment being given
- NAAT is done with FVU in men and VVS in women, then endocervical for culture in women or urethral for culture in men
• MSM may need rectal and pharyngeal swabs

Question 18

Management for gonorrhoea?

Answer 18

• Patients with confirmed gonorrhoea must be referred to sexual and reproductive health because antimicrobial resistance is high and treatment should not be prescribed without sensitivity testing
• Often it is IM ceftriaxone that is given and azithromycin may also be given
• Follow up of patients and test of cure is necessary

Question 19

Is a test of cure required with gonorrhoea?

Answer 19

yes

Question 20

Is a test of cure required with chlamydia?

Answer 20

no

Question 21

What is the commonest STI in the UK?

Answer 21

chlamydia

Question 22

Describe the chlamydia serovars?

Answer 22

• Serovars D-K cause genital infection, A-C cause eye infection and L1-L3 cause lymphogranuloma venereum

Question 23

Is chlamydia more common in women or men?

Answer 23

women

Question 24

Presentation of chlamydia?

Answer 24

• Up to 80% of women and 50% of men may be asymptomatic
• Symptoms in women include increased vaginal discharge, dysuria, postcoital or intermenstrual bleeding and lower abdo pain, examination of cervix may reveal mucopurulent cervicitis and/ or contact bleeding
• Symptoms in men include urethritis with milky discharge and dysuria

Question 25

Investigations for chlamydia?

Answer 25

• NAATs (nucleic acid amplification tests) are test of choice as these have better sensitivity than culture
- in men FVU for NAAT and in women VVS

Question 26

Management of chlamydia?

Answer 26

• Treatment is 7 days doxycycline, azithromycin can be used if doxycycline intolerant
• Recommend no sex for one week after treatment to prevent re-infection (from partner if also being treated) or infecting others
• A test of cure is not routinely required for chlamydia

Question 27

What is the difference between UTI and bacteruria?

Answer 27

• Bacteruria = presence of bacteria in the urine, some people have chronic bacteruria, bacteruria does not equal infection (you have to interpret results with clinical symptoms)
• UTI = presence of microorganisms in the urinary tract that are causing clinical infection

Question 28

Groups/ risk factors for UTIs?

Answer 28

• UTIs overall are very common
• They are more common in women due their shorter, wider urethra and the proximity of opening to the anus
• Tends to peak in child bearing ages and generally a woman of child bearing age with a single UTI needs no further investigations, recurrent UTIs need investigation
• There is increased risk with sexual activity as bacteria can be massaged up the urethra (voiding before and after sex decreases risk)
• Pregnancy increases risk
• Catheterised patients are at increased risk
• Patients with abnormalities of urinary tract are at increased risk

Question 29

What is the most common causative organism for UTI?

Answer 29

E.coli

Question 30

List some causative organisms for UTIs?

Answer 30

Mainly the coliforms (gram negative bacilli):
• E. coli is most common
• Klebsiella
• Proteus – associated with the formation of stones and is foul smelling, swarming cultures, smells like burnt chocolate

Others:
• Pseudomonas Aeruginosa – associated with catheters and instrumentation, resistant to most oral antibiotics except ciprofloxacin
• Enterococci – more common in hospital acquired infections
• Staph Saprophyticus – usually only in women of childbearing age

Question 31

Presentation of UTI?

Answer 31

• Dysuria (pain passing urine)
• Frequency
• Nocturia
• Haematuria
• Fever
• Loin Pain
• Rigors

(last three suggest involvement of upper urinary tract)

Question 32

Investigations for UTI?

Answer 32

urine culture (midstream sample if possible as first pass is usually contaminated by urethral flora) and lab testing of this
dipstick testing

Question 33

What might you see on dipstick in a UTI? Explain?

Answer 33

• Must be interpreted with clinical signs – do they have symptoms of a UTI?
• Leukocyte esterases – suggests there are white blood cells in urine which is sign of inflammation
• Nitrites – this suggests presence of coliforms as these metabolise nitrates to nitrites
• Protein – can be sign of infection
• Blood – can be sign of infection

Question 34

What is Kass’s criteria?

Answer 34

Kass’s criteria describes the likelihood of a urinary tract infection from a mid stream urine sample:
• If > 105 organisms/ ml = significant and probable UTI
• If < 103 organisms/ ml = not significant

Question 35

Management of uncomplicated lower UTI?

Answer 35

Uncomplicated Lower UTI (female or male, un-catheterised and non-recurrent)
• 1st line = Nitrofurantoin 100 mg MR bd (3 days)
• 2nd line= trimethoprim 200 mg bd (3 days)

Question 36

UTI treatment in pregnancy?

Answer 36

should be treated with antibiotics but bear in mind trimethoprim should be avoided as teratogenic, nitrofurantoin is safe generally but should be avoided at term

Question 37

Pyelonephritis/ urosepsis/ complicated uti treatment?

Answer 37

• Primary care – co-trimoxazole or co-amoxiclav
• Secondary care – amoxicillin IV (if pen allergic give co-trimoxazole instead) and gentamicin IV

Question 38

What is pelvic inflammatory disease?

Answer 38

• General term for inflammation of the upper female genital tract including the uterus, fallopian tubes and ovaries
• PID usually results from ascending infection from the cervix
• It is a common and serious complication of some sexually transmitted infections especially chlamydia and gonorrhoea

Question 39

Symptoms and signs of pelvic inflammatory disease?

Answer 39

Symptoms:
• Bilateral lower abdominal pain
• Deep dyspareunia (pain with deep vaginal penetration, superficial dyspareunia is pain on initial penetration of the vaginal introitus)
• Abnormal vaginal bleeding (postcoital, intermenstrual or menorrhagia)
• Vaginal or cervical discharge that is purulent

Signs:
• Lower abdominal tenderness
• Mucopurulent cervical discharge and cervicitis seen on speculum examination
• Cervical motion tenderness and adnexal tenderness on bimanual vaginal examination
• Fever above 38 degrees C but may be apyrexial

Question 40

Investigations for pelvic inflammatory disease?

Answer 40

• Diagnosis should be made on clinical grounds – negative swabs do not rule out diagnosis
• Pregnancy test – need to exclude ectopic pregnancy
• Cervical swabs for chlamydia and gonorrhoea
• Nonspecific but helpful tests include bloods for ESR, CRP and leucocyte count
• Offer bloods for HIV and Syphilis

Question 41

Management of pelvic inflammatory disease?

Answer 41

• Need to admit urgently if cannot rule out ectopic pregnancy, symptoms and signs are severe, surgical emergency cannot be ruled out

In other women:
• Ensure they are referred to GUM clinic to facilitate screening for infections and contact tracing
• Ensure sexual partners within the last 6 months are traced appropriately
• Provide pain relief with ibuprofen or paracetamol
• Start empirical antibiotics
• Outpatient: ofloxacin plus metronidazole
• Inpatient: ceftriaxone plus metronidazole plus doxycycline

Question 42

Complications of pelvic inflammatory disease?

Answer 42

• Infertility
• Ectopic pregnancy
• Abscess formation
• Chronic pelvic pain

Question 43

What is bacterial vaginosis, what causes it, is it an STI?

Answer 43

• This is the most frequent cause of vaginal discharge among women of child bearing age
• It is not a STI
• It is more of an imbalance of biota vs infection
• It occurs when normal lactobacilli – dominant vaginal flora are replaced by an overgrowth of other bacteria
• Usually overgrowth of anaerobic organisms
• It is not an STI but it is more common in women who are sexually active

Question 44

Presentation of bacterial vaginosis?

Answer 44

• Symptoms are increased vaginal discharge with offensive fishy odour, discharge is creamy, homogenous and may be frothy
• No visible inflammation should be seen

Question 45

Vaginal discharge with a fishy odour?

Answer 45

bacterial vaginosis

Question 46

Investigations for bacterial vaginosis?

Answer 46

Can generally be diagnosed clinically based on:
- Thin white/ grey homogenous coating of the vaginal walls and vulva that has a fishy odour
- Not associated with soreness or itching
- Test of vaginal pH- a pH greater than 4.5 is suggestive of BV (BV raises vaginal pH)
Most accurate diagnosis is by microscopy – clue cells on gram-stained slide of vaginal fluid

Question 47

Management of bacterial vaginosis?

Answer 47

Metronidazole for 5 days

Question 48

What is trichomonas vaginalis?

Answer 48

• Trichomonas vaginalis is a single cell protozoa parasite
• Sexually transmitted infection
• Common worldwide but less common in UK

Question 49

Presentation of trichomonas vaginalis?

Answer 49

• Most infected men are asymptomatic
• Symptoms in women include increased purulent vaginal discharge and malodour, discharge is usually yellow or grey and frothy and can be profuse, can also cause vulval pruritis, external dysuria and dyspareunia
• “strawberry cervix” – red spots on cervix from inflammation make it look like a strawberry

Question 50

Trichomonas and BV often confused but what is a key difference?

Answer 50

BV should not cause inflammation as is not a true infection, trichomonas will cause inflammation

Question 51

Investigations for trichomonas vaginalis?

Answer 51

• Diagnosis is with a high vaginal swab for microscopy in women
• For men a urethral swab and/ or urine sampling

Question 52

Management for trichomonas vaginalis?

Answer 52

• Treatment should generally be started with a sexual health specialist
• Treatment is with metronidazole