GUM Flashcards
What are the RF in a sexual health history for HIV?
- MSM
- Those diagnosed w an STI
- Having multiple sexual partners
- High risk sexual practices - group sex, chemsex
- Female sexual contacts of MSM
- Current of former sexual partner known to be HIV affected
- Current or former sexual partner w IVDU hx
- Individuals who have paid or have been paid for sex
- Rape/sexual assault from those w HIV
What are non sexual related RF of HIV?
- IVDU
- Individuals from a country w high HIV prevalence
- Received a blood transfusion or other risk prone procedures in countries that don’t screen for HIV
- Babies w mothers who have untreated HIV
- Dodgy piercing and tattoo shop
Who is recommended a HIV test?
- MSM
- Female sexual contacts of MSM
- Individuals diagnosed w STI
- Those w hx of IVDU
- Black African men and women
- Born or partner from a country of high HIV prevalence
- Where HIV enters the differential diagnosis
- W HIV positive sexual partner
What are the different methods of testing HIV?
- Lab testing - venepuncture sample
- Self sampling and rapid point of care tests - POCTs
- CD4 count
- HIV viral load
- General bloods to see how patient is
- Screen for other STIs and blood borne viruses
What is the window period for HIV testing?
45-90 days for most tests. Is the window between exposure to HIV and when a test gives and accurate result.
For HIV ab detection and HIV p24 antigen detection tests you have to wait 45 days from potential exposure for the result to be accurate.
Positive tests are confirmed w HIV-1/HIV-2 differentiation immunoassay.
What are the routes of transmission of HIV?
- Sexual transmission
- Vertical transmission - in utero, peri-natal period or breast feeding
- Contaminated needles
- Contaminated blood products and organs
What increases risk of transmission and what decreases risk?
- Anal intercourse is more common to transmit HIV
- More likely to transmit HIV if you are receiving
- Female to male transmission is less efficient
- Transmission less common w oral sex
- Concomitant STIs increase risk of transmission
What is the natural history of HIV?
- Acute infection
- Chronic infection
- Late stage HIV/AIDs
What is involved in acute infection of HIV?
- Initial infection = flu or mononucleosis type infection
- Non specific sx, mild and often dismissed
- 1-6 weeks after infection
- Due to seroconversion = development of Ab to HIV
- Lots of pt are asymptomatic during early phases
- Fever, lymphadenopathy, myalgia, malaise
- Diarrhoea, sore throat, oral ulcers
- Rash, headache
What happen in the chronic infection stage of HIV infection?
- Around 6 months viraemia reaches a steady state
- Viral load is steady but CD4 lymphocyte count slowly falls
- Pt tend to be asymptomatic, in the absence of treatment the length of this phase varies but on avg it is 8-10 years
What is involved in AIDs/late stage HIV?
- CD4 count <200cells/mm3
- Increase in risk of developing AIDs defining illnesses
- Fatigue, malaise, weight loss, opportunistic infections and malignancies
- Untreated pt w late stage HIV have a median survival of 12-20 months
- If diagnosed at this stage pt need detailed exam and ix
- After treatment initiation they are at risk of IRIS
What are the AIDs defining illnesses?
Neoplasms - Non Hodgkin lymphoma, Kaposi’s sarcoma, cervical cancer
Bacterial infection - M.tuberculosis, MAC, recurrent pneumonia
Viral infection - cytomegalovirus, herpes simplex, progressive multifocal leukoencephalopathy
Fungal infection - PCP, Candidiasis, Cryptococcosis, histoplasmosis
Parasitic infection - cerebral toxoplasmosis, cryptosporidiosis, atypical disseminated leishmaniasis
What is IRIS?
Immune reconstitution inflam syndrome - elevated inflam response as the immune system recovers against pre existing opportunistic infections
What are the baseline ix into HIV?
Confirm diagnosis, assess degree of immunosuppression, co existing conditions and drug resistance:
- HIV-1/HIV-2 differentiation immunoassay
- HIV-1 viral load
- Genotypic resistance
- CD4 T cell count
- Viral hepatitis serology
- Full STI screen
- Bloods - FBC, renal func, LFT, bone profile
- Urine dip
- Cervical cytology
What is the management of HIV?
- Psychological support and counselling
- ART - reduced morbidity and mortality and minimises treatment SEs
- PREP and PEP
- ARTs have many complex interactions w other meds, pt and clinicians must be aware
What is a typical ART regime?
- Two nucleoside reverse transcriptase inhib NRTIs
- Third agent - PI/r (protease inhib), NNRTI, INI (integrase inhib)
Eg. tenofovir-DF and emtricitabine + atazanavir boosted w ritonavir
What is involved in the monitoring of HIV?
- Viral load, aim to achieve and undetectable viral load, testing will be repeated every 6-12 months
- CD4 count, once established on treatment w suppressed viral load and 2 readings >350 a year apart routine testing is not needed
What is PrEP and PEP?
PrEP - pre exposure prophylaxis, for those at risk of getting HIV, if have a HIV positive partner or take part in risky sexual behaviours, reduces risk of getting HIV from sex by 90%+ and 70% for IVDU but need to take every day, test every 3 months
PEP - post exposure prophylaxis, only for emergency situations, must be started w/i 72 hours after possible exposure - truvada and raltegravir 28 days and will have HIV screening tests
What are the CFs of gonorrhoea?
Neisseria gonorrhoea
- Women - discharge, dysuria, abnormal bleeding
- O/E - discharge from os, Skene’s gland or Bartholin’s gland
- Extra genital complications - pharyngitis, rectal pain and discharge, disseminated infection
What are Skene’s and Bartholin’s glands?
Skene’s - x2 glands either side of the urethra, help w lubrication during intercourse and potentially antimicrobial
Bartholin’s - lubricant during sex, near to the vaginal opening
What are the ix into gonorrhoea and what is the management?
- Vulvovaginal swab
- Microscopy - gram negative diplococci w polymorphonuclear leukocytes
- NAATs and culture
Treat - 1g ceftriaxone IM injection then test of cure
What are the CFs of chlamydia?
Chlamydia trachomatis
- Women usually asymptomatic
- Dysuria, intermenstrual bleeding, vaginal discharge
- Neonates - pneumonia and conjunctivitis
What are the ix of chlamydia and how is it managed?
Vulvovaginal swab or endocervical swab - NAAT
Treat - oral doxycycline BD for 7 days.
What are the CFs of bacterial vaginosis?
Caused by overgrowth of anaerobic bacteria and loss of lactobacilli.
Increased vaginal discharge. Is grey white watery and fishy smelling.
What is the management of BV?
Metronidazole or clindamycin - orally or intravaginally.
Different types of discharge
- Fishy, grey and watery - BV
- Thick and white, clumpy - thrush
- Green, yellow, frothy - trichomoniasis
- W pelvic pain or bleeding - chlamydia or gonorrhoea
- W blisters or sores - genital herpes
What is involved in STI screening in asymptomatic patients?
- Vuvlo vaginal swabs - microscopy, NAAT
- Endo cervical swab - speculum needed and can’t be done w/o clinician
- First catch urine
- Urethral swabs
- Extra genital swabs
- High vaginal swab - gram stain
- Blood test - syphylis and HIV
- Charcoal swab - BV and thrush
What are the available contraceptive methods?
- Barrier contraception - diaphragm, condoms
- COCP
- Implant
- Depo injection
- Patch
- Female condoms
- IUD
- IUS
- Fertility awareness
- POP
How do the contraceptive pills work? How effective are they?
COCP - over 99% effective when taken properly, prevents ovulation mainly but also thickens cervical mucus and things the endometrial lining
POP - over 99% effective when taken properly, must be taken at the same time every do, if more than 3 hours late it might not be effective, thickens cervical mucus
What are the missed pill rules?
- Vomit w/i 3 hours of taking the pill needs to take another pill straight away, if continue to be sick/have diarrhoea need to use another form of contraception until you’ve taken the pill for 7 days
- If you miss one pill, can take two the next day
- If you miss two pills need to use alt contraception until have taken the pill consecutively for 7 days
How do the contraceptive injection and patch work?
Injection - depop provera = releases progestogen into bloodsream, lasts for 13 weeks, is 99% effective when used properly, can take 1 year for fertility to return to normal, thickens cervical mucus and thins the endometrium
Patch - more than 99% effective when used properly, change the patch every week or 3 weeks and then have a week off, releases O+P to prevent ovulation, thicken mucus and thin endometrium
How do the implant, IUS and IUD work?
Implant - releases progestogen, thickens mucus and thins endometrium, lasts for 3 years
IUS - releases progestogen, lasts for 5 years
IUD - is made of copper which is a natural spermicide, lasts for 5-10 years
How does fertility awareness work?
- Temperature method - small rise in body temp after ovulation, needs to be a super active specialist thermometer, 3 days in a row w a higher temperature, likely not fertile
- Cervical secretion monitoring - first few days after period = dry vagina, sticky creamy white mucus = preparing for ovulation and is the fertile period, clear slippery mucus = most fertile, immediately after ovulation, then 3 days of stick mucus = no longer fertile
- Can be up to 99% effective but have to follow instructions very carefully, takes practice and commitment
What are the different methods of emergency contraception? How long are they effective?
- Levonelle ( 3days after) or ellaOne (5 days after) = emergency contraceptive pill
- IUD (5 days after)
What do you need to tell a patient taking the emergency contraceptive pills?
- SEs - headache, abdo pain, nausea and vomiting
- If sick w/i2 hours of taking levonelle or 3 hours of taking ella one = need another dose or IUD fitted
How do the emergency contraceptive pills work?
- Levonelle - levonorgestrel = synthetic progesterone, stop or delay the release of an egg
- ellaOne - ulipristal acetate, stops or delays the release of an egg
- They don’t continue to protect against pregnancy, need another contraceptive method
What is the transmission of Hep C?
- Parenteral - sharing needles
- Vertical
- Sexual transmission v low
What are the CF of Hep C?
- > 60% asymptomatic
- Acute hepatitis picture - jaundice, RUQ pain, generally unwell
- Most people get chronic hepatitis C (80%) - cirrhosis leading to hepatocellular carcinoma
What are the testing options for Hep C?
- Anti HCV ab - can have infection or have had infection
- HCV RNA - distinguishes current from past infection, if +ve are infectious
What is the transmission of Hep B?
- Parenteral
- Vertical
- Sexual
- Sporadic infections w no RF
What are the CF of Hep B?
- Infants and children = asymptomatic acute infection - more likely to become chronic
- Chronic carriers have no sx
- Acute infection in adults mainly asymptomatic
- Sx - flu like illness then RUQ pain and jaundice for about a week
- Can lead to cirrhosis if chronic
What are the 3 components of hep B serology?
- Surface antigen - do they have hep B?
- Core ab - have they been exposed to hep B?
- Surface ab - is the person immune to hep B - had hep B and clearing it naturally or had the vaccine
What is the management of Hep B?
- Notifiable disease
- Acute infection is usually self limiting
- Screen for other STIs or BBV and other hep variants
- Vaccinate against hep A if not already done
- Are treatments - antivirals
How do you treat a needlestick injury?
- Wash and bleed wound
- Inform senior
- Risk assessment - occupational heatlh, may need HIV PEP or HBV vaccine/booster w/i 48 hours
What are the different causes of genital ulceration?
- Infectious - herpes, Varicella, syphilis, fungal, CMV, EBV, chancroid
- Inflam - aphthous, Crohns, Behcets
- Drug related - topical reaction, IVDU
- Traumatic
- Malignant
How can u tell between recurrent and primary herpes infection?
Primary - ulcers on both labia
Recurrent - single labia has ulcer
What is the management of herpes warts?
- Sx - rest, analgesia, saline washing - once a day until lesions resolved
- Antiviral if are systemic - cyclovir 3 times a day to reduce ulcer duration
- 5% lidocaine ointment to help w pain
What are the complications of genital herpes?
- Urinary retention
- Adhesions
- Meningism
- Emotional distress
- Recurrence
What are the different stages of syphilis?
Primary - chancre lesion ulcer, can be on penis, labia, anus, oral mucosa
Secondary - systemic effects - rash, lymphadenopathy, blurred vision, hearing problems and meningism, derranged LFTs
Latent - no symptoms
Tertiary - dementia, cardiovascular probs, balance issues
What are the CFs of monkeypox?
Fever, headache, muscle aches, swollen LN, chills, fatigue, joint pain
Rash 1-5 days after fever
More skin to skin contact than sexually transmitted
Self limiting disease
Who is a RF of monkeypox?
- MSM
- Recent foreign travel
What is the treatment of bacterial vaginosis?
Metronidazole 400 mg BD for 5 days
How is tricomonas vaginalis treated?
Metronidazole 400mg BD 7 days and treat partners
What do you give for Chlamydia in pregnancy?
Azithromycin - doxy is teratogenic
What are some contraindications to COCP?
> 35 smoking
Prev breast cancer
Migraine w aura
Prev VTE
