GUM Flashcards
How do barrier contraceptives work?
They prevent the sperm from coming into contact with the ovum
What is one of the big benefits of most barrier contraceptives?
Decreased transmission of STIs
What are the types of barrier contraception?
Male condom
Female condom
Diaphragms
Cervical caps
Describe how female condoms work.
Tubular shape with inner ring that sits in vagina, and outer ring that sits just outside the vulva.
Describe how a diaphragm works?
Rigid metal inner frame spanning the posterior fornix and covering the cervix.
Describe how cervical caps work?
Sit directly over the cervix, held on by suction and vaginal tone. Spermicide often added to increase efficacy.
What are the advantages to the male condom?
No contraindications (unless latex allergic, but alternate materials can be used)
Responsibility shared between both people.
Widely available, simple to use.
Protect against STIs.
What are the benefits of female condom?
No contraindications
Less likely to tear than male condom
Protects against some STIs
Can be inserted up to 8 hours before intercourse
What are the benefits of the diaphragm and the cervical cap?
Can be inserted up to 3 hours before intercourse.
What are the disadvantages of the male condom?
User dependant, and perfect use is rarely achieved.
Can reduce sensitivity/arousal.
What are the disadvantages of the female condom?
Perfect use is rarely achieved
Penis can be inserted outside of the condom
Can be noisy or uncomfortable
What are the disadvantages of diaphragms and cervical caps?
Perfect use is rarely achieved Require planning and careful insertion Require measuring and fitting to find the correct size High rate of UTIs STI transmission is not reduced
With perfect use, what are the efficacy rates of barrier contraceptions?
Male condom 98%
Female condom 95%
Diaphragm 94%
Cervical cap 80-91% depending on parity.
Considering the failure rates of barrier contraception, what should we counsel patients to do if the barrier fails or is omitted?
Seek emergency contraception from a pharmacy ASAP
What is the primary action of combined hormonal contraception?
Inhibits ovulation by preventing LH surge by negative feedback.
In addition to the primary action of combined hormone contraception, how else does it work?
Progesterone inhibits endometrial proliferation and thickens cervical mucus
What forms does combined hormonal contraception come in?
COCPs
Transdermal patch
Contraceptive vaginal ring
What kind of COCPs are there, and how do they work?
Monophasic pills - same amount of hormones in each pill. 21 day cycle with a 7 day break.
Phasic pills - varying amounts of hormone throughout the cycle. May be biphasic, triphasic, or quadraphasic. Important to take them in the correct order.
Give 2 examples of brands of monophasic COCP.
Microgynon 30
Brevinor
Give 2 examples of phasic COCP brands.
QIaira
BiNovum
How does the transdermal patch work?
Apply and change every 7 days over 3 weeks, with a one week break. Withdrawal bleed usually occurs.
Very sticky, can stay on while bathing or swimming.
How does the contraceptive vaginal ring work?
120 micrograms etonogestrel and 15 micrograms ethinyl estradiol per day deposited into vagina.
Sits in place for 21 days, rest for 7 days.
What are the advantages of combined hormonal contraceptives?
Non invasive.
If taken correctly, more effective than barrier.
Menses can be regulated and lighter/less painful.
Reduce risk of ovarian, uterine, and colon cancer, and ovarian cysts.
Return to normal fertility immediately after stopping use.
What are the disadvantages of combined hormonal contraception?
User dependant
Side effects (headaches, breast tenderness, mood wings)
BP may increase
Breakthrough bleeding may occur
Small risk of VTE, MI/stroke, breast and cervical cancer
What are the contraindications to combined hormonal contraception?
BMI over 35 Breast feeding Smoking over age 35 HTN Personal or FHx of VTE Prolonged immobility Diabetes mellitus with complications Migraine with aura Breast cancer or primary liver tumours
How effective are combined hormonal contraceptives when used perfectly?
99.7% effective
91% with typical use
What is something key to consider with hormonal contraceptives?
There is no protection against STIs.
It is also important to counsel them on what to do if they miss a pill.
What is the mechanism of action of the POP?
Thicken cervical mucus primarily.
Suppresses ovulation to varying degrees also, depending on the type of pill.
What are the 5 POPs licensed in the UK?
Femulen Norgeston Noriday Micronor Cerazette
What are the advantages of the POP?
More effective than barrier when taken correctly.
No need to interrupt intercourse.
Used when COCP is contraindicated.
May reduce risk of endometrial cancer.
What are the disadvantages of the POP?
User dependant Have to be taken at the same time every day Can deregulate menses Some adverse effects 30% increased risk in ovarian cysts Small increased risk of breast cancer
When is the POP contraindicated?
Current or PMHx of breast cancer
Liver cirrhosis or tumours
Weight over 70kg lowers efficacy
Stroke or coronary heart disease
What is the UK licensed progesterone only implant? How does it work?
Nexplanon - 40mm long plastic tube inserted into upper arm.
Releases 68mg of etonogestrel over 3 years.
How does the progesterone implant work?
Primarily inhibits ovulation and thickens cervical mucus, and thins endometrium.
What are the advantages of the progesterone implant?
Extremely effective - one of the smallest failure rates.
Can be used where COCP contraindicated.
In situ for 3 years
Can use during breast feeding
Normal fertility returns quickly after removal
Effective in women of all BMIs
What are the disadvantages of the progesterone implant?
50% of women experience change to menstrual cycle, irregular patterns common.
Fitting/removal can be painful, bleed, and cause irritation.
Small risk increase for breast cancer.
Can bend or break in situ.
When is the progesterone implant contraindicated?
Pregnancy Unexplained vaginal bleeding Liver cirrhosis or tumours Hx of breast cancer Stroke or TIA with implant in situ
How many injectable progesterone contraceptives are there available in the UK?
3:
Depo-Provera
SAYANA PRESS
Noristerat
How frequently are the injectable contraceptives given?
Every 8-13 weeks depending on brand.
Depo-Provera = most common = given every 12 weeks IM.
How does the progesterone injection work?
Inhibits ovulation
Thickens cervical mucus
What are the advantages of the progesterone injection?
Very effective.
Long term - don’t have to worry about contraception.
No known drug interactions.
Can be used when COCP is contraindicated.
Can be used in women BMI over 35
What are the disadvantages of the progesterone injection?
Not rapidly reversible - can take up to a year to return to normal fertility.
Altered bleeding patterns inc. persistent bleeding
Weight gain
Slight increase in breast cancer
Loss of bone mineral density if used over a year
What are the contraindications to the progesterone injection?
Current breast cancer Hx of severe arterial disease Pregnancy Diabetes with complications Those who want quick return to fertility
How effective is the progesterone injection with perfect use?
99.8% effective
How long does an IUD/IUS stay in situ?
It can stay in for up to 5 years
What is the IUD?
Copper coil which is toxic to sperm and inhibits implantation
What is the IUS?
Levonorgestrel-releasing coil which thins endometrium and thickens cervical mucus.
How effective is the IUD/IUS?
Over 99% effective but do not offer any protection against STIs
When can an IUD/IUS be inserted?
At any point in the menstrual cycle
What would you tell a patient who wants an IUD/IUS inserting about the procedure?
Takes about 20 minutes.
Bimanual examination then speculum examination to visualise cervix.
Insertion of a cervical dilator or sizer.
Small plastic T shaped device is inserted into uterus via cervix and remains there. Strings are cut to suit patient so the coil can be removed.
Should an STI screen be performed before insertion of a coil?
It is usually performed 2 weeks before insertion as recent STI exposure is an absolute contraindication for the coil.
Which coil can be used as emergency contraception?
The copper coil if inserted within 5 days of UPSI
What are the indications for the IUS other than contraception?
First line for treatment of heavy menstrual bleeding.
Second line for dysmenorrhoeaa
When are coils contraindicated?
Infection -hx of PID, STI, or infection of the uterus. Pregnancy/up to 4 weeks post partum Abnormal structure of uterus Gynae malignancy Current unexplained vaginal bleeding Copper allergy
What specific contraindications are there for the IUS?
Current DVT or PE
Current liver disease
History of breast cancer
What are the advantages of the coil?
Over 99% successful
Quick return to normal fertility after removal
Can be fitted at any time of cycle and during breastfeeding
Good when COCP contraindicated
Mirena helps with heavy/painful periods
Copper coil has no hormones
What are the disadvantages of the coil?
No protection against STIs
Risk of ascending or iatrogenic infection
Risk of uterine perforation when inserted
Risk of body expelling the coil
Irregular bleeding for up to 6 months after insertion
Can be painful
Higher risk of ectopic pregnancy
Cervical dilation increases risk of seizures in epileptics
What can be used as emergency contraception?
IUD/Copper coil
Levonorgestrel morning after pill (Levonele One Step)
Ulipristal acetate morning after pill (EllaOne)
When is emergency contraception indicated?
UPSI or contraception method has failed.
Missed pills may require emergency contraception depending on how many have been missed.
How does the levonorgestrel morning after pill work?
Synthetic progesterone that delays ovulation for 5-7 days until the sperm is no longer viable.
When can someone take the levonorgestrel pill?
Within 72 hours of unprotected sex
When can someone take the ulipristal acetate/ellaone pill?
Within 120 hours of unprotected sex
How does the ulipristal acetate pill work?
Progesterone receptor modulator that delays ovulation by 5-7 days by which time the sperm have become non-viable.
Why might someone choose the copper IUD over a pill as emergency contraception?
It can provide contraceptive cover for 5-10 years after insertion!
When would the levonorgestrel morning after pill be contraindicated?
There are no absolute contraindications.
May have reduced efficacy in diseases of malabsorption, or when they are taking enzyme-induing drugs e.g. rifampicin.
When would the ulipristal acetate morning after pill be contraindicated?
May have reduced efficacy in diseases of malabsorption Severe hepatic dysfunction Enzyme inducing drugs Breast feeding Asthma controlled by steroids Drugs increasing gastric pH
When is the copper IUD contraindicated for emergency contraception?
Uterine fibroids causing cavity distortion
PID (diagnosed or suspected)
STI (documented or suspected)
What safety-netting/aftercare advice do you need to give to someone who has taken a morning after pill?
Verbal and written.
Seek help if vomiting occurs within 2 hours (levonorgestrel) or 3 hours (ulipristal).
If UPSI occurs again, the pill only covers the original episode.
ADRs inc. nausea, dizziness, menstrual disturbance, and abdominal pain.
Can levonorgestrel be used more than once in a cycle?
Yes
Can ulipristal acetate be used more that once in a cycle?
It didn’t used to be recommended, but now it can be.
What is PID?
Pelvic inflammatory disease is an infection of the upper genital tract in females, affecting the uterus, fallopian tubes, and ovaries.
What age group is PID most common in?
Ages 15-24
Where does the infection come from in PID?
Lower genital tract e.g. vagina or cervix
What are the common causes of PID?
Chlamydia trachomatis Neisseria gonorrhoea Streptococcus Bacteriodes Anaerobes
What are the risk factors for PID?
Sexually active Age 15-24 Recent partner change Intercourse without barrier contraception Hx of STIs or PID
Can PID be iatrogenic?
Yes - can be caused by instrumentation of the cervix
What are the symptoms of PID?
May be asymptomatic Lower abdo pain Deep dyspareunia Menstrual abnormalities Post-coital bleeding Dysuria Abnormal vaginal discharge
If a woman with suspected PID has fever and nausea and vomiting, what might be the problem?
Severe PID which may go on to sepsis
What signs may a patient with PID have?
Adnexal tenderness
Cervical excitation
May have a palpable mass in lower abdomen
Abnormal vaginal discharge
What are the differentials for PID?
Ectopic pregnancy
Ruptured ovarian cyst
Endometriosis
UTI
How is suspected PID investigated?
Urine dip +/- MSU Pregnancy test Endocervical swabs and full STI screen TVUS if severe or diagnosis uncertain Laparoscopy if diagnosis uncertain
What does Neisseria gonorrhoea look like on microscopy?
Diplococci
How is PID managed?
Antibiotic therapy
What antibiotic therapy is used for PID?
14 days of broad spectrum antibiotics with good anaerobic coverage. Start immediately, before swab results are available.
What are the 2 options for broad spec abx for PID?
- Doxycycline 100mg BD 14 days + Ceftriaxone 500mg stat + Metronidazole 400mg BD 14 days
- Ofloxacin 400mg BD 14 days + Metronidazole 400mg BD 14 days
Aside from abx, what other Mx should be considered/advised in PID?
Analgesics such as paracetamol
Rest and avoid sexual intercourse
Contact tracing
Admission if severe symptoms/signs of peritonitis/unresponsive to oral meds
What are the complications of PID?
Ectopic pregnancy Infertility Tubo-ovarian abscess Chronic pelvic pain Fitz-Hugh Curtis syndrome
How does PID increase the risk of ectopic pregnancy?
Infection causing adhesions causing narrowing and scarring of fallopian tubes.
How common is infertility as a consequence of PID?
Affects 1 in 10 women with PID
What is Fitz-Hugh Curtis syndrome?
Perihepatitis that usually causes right upper quadrant pain
What is the causative organism in chlamydia?
Chlamydia trachomatis bacterium - intracellular gram negative bacterium with different serotypes
What is the most commonly reported bacterial STI in the UK?
Chlamydia - 46% of all STI diagnoses
Which Chlamydia serotypes cause GU infections
Serotypes D-K
How is a chlamydia infection transmitted?
Unprotected vaginal, anal , or oral sex, or direct skin-to-skin contact of the genitals.
Where can a chlamydia infection occur outside of the genitals?
In the eyes - chlamydial conjuncitivitis.
Rectum
Pharynx
How can chlamydial conjuncitivis occur?
Infected semen or vaginal fluid enters the eye.
Can chlamydia be passed vertically?
Yes - it can be passed from mother to baby during delivery.
How does C. trachomatis infected cells in the body?
It entters a host cell in its infectious form. It then changes into non-infective form which is capable of replication. After replication it changes back into its infectious form, causing the cell to reupture and spread the infection to other cells.
What are the risk factors of chlamydia?
- Age under 25
- Sexual partner positive for chlamydia
- Recent change of sexual partner
- Co-infection with another STI
- Use of no or non-barrier contraception
Is chlamydia always symptomatic?
No - 50% of infected men and 70% of infected women don’t know they have it.
How long is the incubation period for chlamydia?
7-21 days
When chlamydia does cause symptoms in a woman, what symptoms are common?
- Dysuria
- Abnormal PV discharge
- Intermenstrual/post-coital bleeding
- Deep dyspareunia
- Lower abdominal pain
When chlamydia does cause symptoms in a man, what symptoms are common?
- Urethritis - dysuria and urethral discharge
- Epididymo-orchtis and testicular pain
What signs of chlamydia can be seen in a woman?
- Cervicitis +/- contact bleeding
- Mucupurulent endocervical discharge
- Pelvic tenderness
- Cervical excitation
What signs of chlamydia can be seen in a man?
Epididymal tenderness
Mucupurulent discharge
If a patient has ?chlamydia, how should they be investiagted?
Do a full STI screen as the common presenting symptoms are similar for many STIs and they commonly occur alongside each other.
Which STIs are particularly hard to differentiate from each other?
Chlamydia and gonorrhoea
How does the National Chlamydia screening programme work?
Under 25s are offered chlamydia testing as part of routine primary care and sexual health consultations, as well as eductaion about testing which is available from pharmacies, universities, and contraception clinics across the UK.
What is NAAT and what does it test for?
Nucleic acid amplification test - used to investigate specimens for chlamydia as it is too small to be seen by microscopy.
What specimen is taken from women to test for chlamydia?
Vulvo-vaginal swab is first choice.
Endocervical swab or first catch urine sample can also be used.
What specimen is taken from men to test for chlamydia?
First catch urine sample if first choice.
Urethral swab can also be used.
Other than swabs, what other investiagtion needs to bedone for chlamydia?
Contact tracing and full STI screen.
How is uncomplicated chlamydia treated once it has been diagnosed?
Antibiotics -combination of:
- Doxycycline 100mg BD for 7 days
- Azithromycin 1g stat dose
If a pt with chlamydia is allergic to doxycycline or azithromycin, or it is otherwise contraindicated, how can chlamydia be treated?
Erythromycin 500mg BD 10-14 days
+
Ofloxacin 200mg BD/400mg OD for 7 days
What advice is given to patient’s on treatment for chlamydia?
Avoid sexual intercourse/other sexual contact until they +/or partner have completed treatment.
When is test of cure required for a chlamydia infection?
If the pt is pregnant, symptoms persist, or compliance has been poor.
What complications can occur in women following a chlamydia infection?
Ascending infection -> salpingitis +/or endometritis
PID
Perihepatitis
Increased risk of ectopic pregnancy
Risk of decreased fertility
What complications can occur in men following a chlamydia infection?
Epididymitis
Epididymo-orchitis
Risk of decreased fertility.
What complications of chlamydia can occur in women and men?
Sexually acquired reactive arthritis -> joint, eye, and urethral inflammation.
What effect can chlamydia have on pregnancy?
Increased risk of:
- Premature delivery
- Low birth weight
- Miscarriage
- Stillbirth
What are the drugs of choice for treating chlamydia in pregnancy? Why?
Azithromycin and erythromycin.
Doxycycline and ofloxacin are teratogenic.
How does a neonatal chlamydia infection present?
- Inflammation and discharge in eyes 5-12 days after birth
- May develop pneumonia up to 3 months after birth
How is neonatal chlamydia treated?
Oral erythromycin
What is bacterial vaginosis?
A non-sexually transmitted infection of the lower genital tract caused by disturbance of the normal vaginal flora.
How does the vaginal pH change in bacterial vaginosis?
It increases i.e. becomes less acidic.
What is the most common cause of abnormal vaginal discharge in women of childbearing age?
Bacterial vaginosis?
Which bacteria is mainly responsible for maintaining the low pH of the vagina?
Lactobacilli bacteria
Tell me about lactobacilli bacteria.
Large, rod-shaped bacteria
Produce hydrogen peroxide
Commonly found in the vagina
At what pH is the vagina normally maintained?
Under pH 4.5
Why does the vagina need to be maintained at a pH under 4.5?
To inhibit the growth of abnormal microorganisms
What organisms are normally responsible for bacterial vaginosis?
Gardnerella vaginalis
Anaerobes
Mycoplasmas
What are the risk factors associated with bacterial vaginosis?
- Sexual activity (although not an STI)
- IUD use
- Receptive oral sex
- STI presence
- Vaginal douching
- Recent abx use
- Smoking
- Ethnicity - more common in black women
What is the characteristic smell associated ith bacterial vaginosis?
Offensive fishy smelling vaginal discharge
How does bacterial vaginosis appear on examination?
Offensive fishy smelling vaginal discharge which is thin, white/grey, and homogenous.
What are the 3 elements to diagnosing bacterial vaginosis?
History
Vaginal examination
Microscopy
How is bacterial vaginosis diagnosed microscopically?
High vaginal smear
Gram stained and examined for clue cells, reduced no. lactobacilli, and absence of pus cells.
Other than microscopy, how can BV be diagnosed?
Vaginal pH over 4.5 and KOH whiff test (but this is rarely done in practice)
Do all women with BV need treating?
No - if they are asymptomatic they may opt for no treatment, and just modify risk factors and wait for resolution.
If a woman with BV dose want to take abx, what is given?
Metronidazole orally - 400mg BD for 5-7 days
OR
Metro 2g stat dose
OR
Metro gel applied directly to vagina
What lifestyle modifications can be done to treat BV?
- Stop vaginal douching
- Avoid scented shower gels, antiseptic agents, or shampoos in bath.
- Removal of IUD
Is BV in pregnancy significant?
Yes - if it is untreated and symptomatic it can increase risk of premature birth, miscarriage, and chorioamnionitis.
What is vulvovaginal candidiasis also known as?
Thrush or a yeast infection
What age group of women is thrush most common in?
Women aged 20-40
How common is thrush?
Very - most women will experience it at some point in their lives.
What is the most common cause of candidiasis?
Candida albicans, a commensal organism.
What are most cases of thrush thought to be?
Opportunistic infections
What % of women carry candida normally without any problem?
What does this mean practically?
Around 20%
A swab won’t necessarily tell us anything.
When are women at increased risk of candidiasis?
- During pregnancy
- If they have diabetes
- Use of broad spec abx
- Use of corticosteroids
- If they are immunosuppressed or have compromised immune system
What are the typical symptoms of thrush?
- Vulval pruritis
- White, curd-like non-offensive vaginal discharge
- Dysuria (superficial)
Which symptom usually dominates in a vulvovaginal candidiasis presentation?
Vulval pruritis
What signs can be found on examination of a woman with vulvovaginal candidiasis?
- Erythema and swelling of vuvla
- Satellite lesions
- Curd-like vaginal discharge
What are the common infectious differentials for candidiasis?
BV or TV
UTI is also possible
What investigations should be done for suspected candidiasis?
None - a good history is all that is really needed. A vaginal pH can be done if the pt is examined to rule out BV.
If underlying condiiton suspected e.g. in recurrent cases, can Ix for that.
How should uncomplicated vulvovaginal candidiasis be managed?
Intravaginal antifungal inserted into vagina
OR
Oral antifungal
alongside topical imidazole for vulval symptoms
What topical antifungals are used to treat candidiasis?
Clotrimazole or fenticonazole
What oral antifungals are used to treat candidiasis?
Fluconazole or itraconazole
If a simple case of vulvovaginal candidiasis dose not resolve after 7-14 days following treatment, what should be considered?
- An alternate diagnosis
- An underlying risk factor
- Patient not taking medication properly or at all
What can be recommended to help avoid candidiasis?
- Use soap substitutes
- Avoid cleaning vaginal area more than once per day
- Avoid potential irritants
- Avoid wearing tight fitting underwear/tights
Why is pregnancy is risk factor for candidiasis?
Increased oestrogen levels by increasing glycogen production and directly promoting candida growth.
How should candidiasis in pregnancy be managed?
- Treat with topical antifungals (intravaginal and vulval)
- Avoid oral antifungals
- Insert intravaginal treatment carefully
- Refer to GUM if STI suspected
How long is the treatment period for candidiasis in a pt with immune compromise?
7-14 days
What organism causes syphilis?
Treponema pallidum
Is incidence of syphilis on the rise?
Yes
How can syphilis be transmitted?
By sexual contact, vertically from mother to foetus, and through infected blood products.
What is a chancre?
An infectious hard ulcer caused by Treponema pallidum bacteria.
How long after contact with does a chancre form in syphilis?
Incubation period is 2-3 weeks.
What stage of syphilis is characterised by chancre formation?
The first stage aka Primary syphilis
How does T. pallidum cause systemic damage?
If left untreated it causes obliterating arteritis - endothelial cells of vessels proliferate causing vessels to narrow -> ischaemia.
What are the risk factors for syphilis?
- Unprotected sex
- Multiple sexual partners
- MSM
- HIV infection
How can acquired syphilis be divided?
Primary and Secondary
Early latent, late latent, and late symptomatic
What is primary syphilis?
Local infection after 2-3 weeks incubation period
What is secondary syphilis?
Generalised infection after 6-12 weeks incubation
What is early latent syphilis?
Asymptomatic syphilis of less than two years’ duration.
What is late latent syphilis?
Asymptomatic syphilis of two years’ duration or longer
What is late symptomatic syphilis?
AKA tertiary syphilis - Cardiovascular syphilis, neurosyphilis, gummatous syphilis
What comes just before a syphilis chancre?
A papule
Is a chancre a painless or painful ulcer?
Painless
What are the symptoms of secondary syphilis?
- Rash on hands and soles of feet
- Fever
- Malaise
- Arthralgia
- Weight loss
- Headaches
What are the signs of secondary syphilis?
- Condylomata lata (elevated plaques on moist areas of skin)
- Painless lymphadenopathy
- Silvery-grey mucous membrane lesions
How does gummatous syphilis present?
As syphilis in the bone, skin, mucous membranes of URT, mouth, viscera or connective tissue. Presentation depends on site.
How does neurosyphilis present?
- Dementia
- Argyll Roberston pupil
- Meningovascular complications
- Tabes dorsalis
What is Tabes dorsalis?
A form of neurosyphilis characterised by:
- ataxia
- numb legs
- absence of deep tendon reflexes
- lightning pain
- loss of pain and temperature sensation
- skin and joint damage.
How does cardiovascular syphilis present?
- Aortic regurgitation, aortic valvulitis, aortic root dilation
- Angina (stenosis of coronary arteries)
- AA dilation and calcification
How should syphilis be investigated?
- Do full STI screen
- Dark ground microscopy
- PCR swab from active lesion
- Serology
How should neurosyphilis be investigated?
Lumbar puncture for antibody testing of CSF
https://teachmeobgyn.com/sexual-health/sexually-transmitted-infections/syphilis/
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