Gynaecology Flashcards
Organic causes of Menorrhagia
• Extremes of reproductive age
• Fibroids
• Adenomyosis
• Endometriosis
• Pelvic inflammatory disease (infection)
• Contraceptives, particularly the copper coil
• Connective tissue disorders
• Endometrial hyperplasia or cancer (uterus and cervix)
• Polycystic ovarian syndrome
• Cervical eversion: Cervical ectropion
• Trauma e.g. sex
• Others e.g. arteriovenous malformations on endometrium
• Systemic causes
o Endocrine disorders e.g. Hyper/ hypothyroidism, Diabetes mellitus, Adrenal disease and Prolactin disorders: can cause amenorrhea if very high
o Disorders of haemostasis e.g. Von Willebrand’s disease, ITP (autoimmune thrombocytopenia) and Factor II, V, VII and XI def
o Liver disorders
o Renal disease
o Anticoagulants e.g. artificial heart valves, AF, past stroke
• Pregnancy: Miscarriage, Ectopic pregnancy, Gestational trophoblastic disease & postpartum haemorrhage
Non-organic Menorrhagia
• DUB: Dysfunctional uterine bleeding (no identifiable organic cause)
• Anovulatory: no eggs is released (85% of all DUB)
o Occurs at extremes of reproductive life
o Irregular cycle
o More common in obese women
• Ovulatory
o More common in women aged 35-45 years
o Regular heavy periods
o Due to inadequate progesterone production by corpus luteum
Menorrhagia Ix
Pelvic examination with a speculum and bimanual: fibroids, ascites and cancers
- Full blood count: iron deficiency anaemia
• Cervical smear, TSH, coagulation screen, U&Es and LFTS
- Hysteroscopy
o Suspected submucosal fibroids
o Suspected endometrial pathology
o Persistent intermenstrual bleeding
• Pelvic and transvaginal ultrasound should be arranged if the is:
o Endometrial thickness for screening for endometrial carcinoma
o Possible large fibroids (palpable pelvic mass)
o Possible adenomyosis
- Swabs if there is evidence of infection
• Endometrial sampling
o Pipelle biopsies
o Hysteroscopic directed
o Dilatation & curettage (D & C)
Menorrhagia Mx (without contraception)
- Tranexamic acid when no associated pain (antifibrinolytic – reduces bleeding)
- Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain)
Menorrhagia Mx (with contraception)
- Mirena Coil
- COCP
- Cyclical oral progesterones e.g. norethisterone
- Progesterone only contraception
- Danazol (androgenic hormones):
GnRH Analogues: e.g. Goserelin, Decapeptyl, Buserelin
Menorrhagia surgical Mx
- Endometrial ablation (combined HRT required)
- Hysterectomy (oestrogen only HRT)
Intermenstrual bleeding causes
o Cervical ectropion
o Pelvic inflammatory disease (PID) and sexually transmitted disease
o Endometrial or cervical polyps
o Cervical cancer
o Endometrial cancer
o Undiagnosed pregnancy/ pregnancy complications
o Hyatidiform molar disease.
Premenstrual syndrome
Cyclical somatic, psychological and emotional symptoms that occur in the luteal (premenstrual) phase of the menstrual cycle and resolve by the time menstruation
ceases.
Contributing factors are decreased progesterone synthesis and increased prolactin, oestrogen, aldosterone and prostaglandin synthesis during the luteal phase.
Premenstrual syndrome signs/symptoms
depression, irritability and emotional lability.
physical manifestations include fluid retention, weight gain and breast tenderness. • Bloating • Cyclical weight gain • Mastalgia • Abdominal cramps • Fatigue • Headache • Depression • Changes in appetite and increased craving • Irritability
Premenstrual syndrome Mx
Severe symptoms: - SSRIs e.g. fluoxetine or SNRI daily or during luteal phase
- CBT
Mild
- Medical treatment includes combined oral contraceptive pill, transdermal oestrogen, short-term GnRH analogues (to reduce risk of osteoporosis).
Refractory
- last resort of hysterectomy with bilateral salpingo-oophorectomy
Post coital bleeding
Bleeding from sex
Cervical ectropion • Cervical carcinoma • Trauma • Atrophic vaginitis • Cervicitis secondary to sexual transmitted diseases. • Polyps • Idiopathic
Endometritis
barrier to ascending infection (acid, vaginal pH and cervical mucus) is broken e.g. after miscarriage, TOP and childbirth, IUCD insertion or surgery
Endometritis causes
• Micro-organisms: Neisseria, Chlamydia, TB, CMV, Actinomyces and HSV o Intra-uterine contraceptive device o Postpartum o Post-abortal o Post curettage o Chronic endometritis NOS o Granulomatous (TB, sarcoid, foreign body post ablation) o Associated with leiomyomata or polyps
Endometritis signs/symptoms
- Lower abdominal pain and fever/sepsis
- Uterine tenderness on bimanual palpation
- Offensive vaginal discharge
- Bleeding that gets heavier or does not improve with time
Endometritis Ix
High vaginal swabs
Blood cultures
Urine culture
USS: retained products of contraception
Endometritis Mx
- Antibiotics e.g. cefalexin 500mg/8h PO with metronidazole 400mg/8h for 7 days
- Septic patients will require hospital admission and the septic six, including blood cultures and broad-spectrum IV antibiotics Blood tests will show signs of infection (e.g. raised WBC and CRP).
- IV Amoxicillin + Metronidazole + Gentamicin
Endometrial polyps
occur around and after menopause
Transvaginal USS
Adenomyosis
Endometrial tissue inside the myometrium (muscle layer of the uterus).
Later reproductive years and several pregnancies (tend to resolve after menopause due to being hormone dependent)
Adenomyosis signs/symptoms
- Painful periods (dysmenorrhoea)
- Heavy periods (menorrhagia)
- Pain during intercourse (dyspareunia)
- It may also present with infertility or pregnancy-related complications
- enlarged and tender uterus. It will feel more soft than a uterus containing fibroids.
Adenomyosis Ix and
Transvaginal USS
Adenomyosis Mx
No contraception
o Tranexamic acid when there is no associated pain (antifibrinolytic – reduces bleeding)
o Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain)
Contraception
- Mirena coil
- Combined oral contraceptive pill
- Cyclical oral progestogens
- Progesterone only medications such as the pill, implant or depot injection may also be helpful.
- GnRH analogues
- endometrial ablation
- uterine artery embolisation
- hysterectomy
PCOS diagnosis
• Endocrine features: high free androgens (↑testosterone, ↓SHBG, ↑prolactin), high LH, impaired glucose tolerance
• Diagnosis: score 2 out of 3:
o chronic anovulation: Oligio/amenorrhoea
o polycystic ovaries – ultrasound
12/more 2-9mm follicles (tiny cysts at periphery of ovary)
Increased ovarian volume >10ml
Unilateral / bilateral
o hyperandrogenism (clinical or biochemical) e.g. acne, hirsutism
• Insulin resistance: Insulin lowers SHBG levels: increased free testosterone leads to hyperandrogenism.
PCOS Mx
- ) Clomifene citrate
- ) Metformin
- ) Gonadotrophin therapy (daily injections)
- ) Laparoscopic ovarian diathermy
Post menopausal bleeding week aim
NICE guidelines state that women over the age of 55 with PMB should be investigated within 2 weeks by ultrasound for endometrial cancer. (2)
PMB causes
atrophic vaginitis endometrial hyperplasia endometrial carcinoma cervical cancer cervical ectropion endometrial polyps Ovarian cancer (theca cell) Vaginal - rare
PMB Ix
Transvaginal USS
- <3mm - reassured
>4mm - endometrial biopsy
if HRT - 5mm cut off
CT/MRI - further imaging
PMB Mx
Atrophic vaginitis
topical oestrogen and vaginal lubricants
Endometrial hyperplasia: dilatation and curettage, progestogen treatment e.g. Mirena coil
Primary dysmenorrhoea
no underlying pelvic pathology. It affects up to 50% of menstruating women and usually appears within 1-2 years of the menarche.
Excessive endometrial prostaglandin production
- pain typically starts just before or within a few hours of the period starting
- suprapubic cramping pains which may radiate to the back or down the thigh
Secondary dysmenorrhoea
develops many years after the menarche and is the result of an underlying pathology.
In contrast to primary dysmenorrhoea the pain usually starts 3-4 days before the onset of the period.
Dysmenorrhea Mx
NSAIDs such as mefenamic acid and ibuprofen
inhibiting prostaglandin production
- Combined oral contraceptive pills
- Levonogestrel intrauterine system (LNG-IUS) – when dysmenorrhea occurs with menorrhagia
- GnRH analogues
Urinary incontinence
loss of control of urination
o Urethral sphincter incompetence (urinary stress incontinence)
o Detrusor instability (overactive bladder: bladder contracts)
o Retention with overflow (prolapse)
o Mixed
o Functional
Urge incontinence
overactivity of the detrusor muscle of the bladder
increased urgency and frequency. may experience nocturia
OAB wet or dry
Causes: idiopathic, pelvic surgery, MS and spina bifida
Stress incontinence
Involuntary leakage of urine when there is increased intra-abdominal pressure, with the absence of detrusor muscle contraction. Weakness in pelvic floor and sphincter muscles
Causes: Commonly seen after childbirth, pelvic surgery and oestrogen deficiency
o Triggers: Coughing, sneezing, exercise
Overflow incontinence
- occur when there is chronic urinary retention due to an obstruction to the outflow of urine.
- anticholinergic medications, fibroids, pelvic tumours and neurological conditions such as multiple sclerosis, diabetic neuropathy and spinal cord injuries.
Incontinence Ix
Bladder diary - 3 days
Urine dipstick: UTI, microscopic haematuria
Post void residual
Urodynamic testing
Mx of stress incontinence
- Lifestyle: wt loss etc
- Supervised pelvic floor exercises for at least three months
- Medical: Duloxetine (increase inraurethral closure pressure)
Surgery - Tension-free vaginal tape (TVT): mesh sling looped under the urethra and up behind the pubic symphysis to the abdominal wall
- Autologous sling procedures
- Laparoscopic or open Colposuspension: stitches connecting the anterior vaginal wall and the pubic symphysis, around the urethra
- Intramural urethral bulking
- artificial urinary sphincter
Urge Mx
Lifestyle
Bladder retraining 6 weeks
Anticholinergic medication e.g. oxybutynin, tolterodine and solifenacin (oral/patch)
- reduce intra-vesical pressure, increase compliance, raise volume threshold for micturition and reduce uninhibited contractions
- Mirabegron
- Surgery
- Botulinum toxin A injection
- Percutaneous sacral nerve stimulation -Augmentation cystoplasty
- ## urinary diversion
Pelvic organ prolapse
descent of pelvic organs into the vagina
Uterine prolapse
Uterus itself prolapses into vagina
Vault Prolapse (middle/apical)
- Vault prolapse occurs in women that have had a hysterectomy, and no longer have a uterus. The top of the vagina (the vault) descends into the vagina.
- Symptoms: bulging, pressure, “mass”, difficulty voiding, incomplete emptying, splinting vaginal wall, difficulty inserting tampon, pain with intercourse.
Rectocele
defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina.
• Loading of faeces results in significant constipation, urinary retention (due to compression on the urethra) and a palpable lump in the vagina.
Cystocele
defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina.
• Prolapse of the urethra is also possible (urethrocele).
• Prolapse of both the bladder and the urethra is called a cystourethrocele.
Risk factors for pelvic organ prolapse
o Multiple vaginal deliveries
o Instrumental, prolonged or traumatic delivery
o Advanced age and postmenopausal status
o Obesity
o Chronic respiratory disease causing coughing
o Chronic constipation causing straining
Pelvic organ prolapse signs/symptoms
- A feeling of “something coming down” in the vagina
- A dragging or heavy sensation in the pelvis
- Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention
- Bowel symptoms, such as constipation, incontinence and urgency
- Sexual dysfunction, such as pain, altered sensation and reduced enjoyment
mass
Grades of uterine prolapse
1st degree: mild protrusion on examination (-1cm of introitus)
2nd degree: prolapse present at introitus of vagina/anus/urethra (between -1 cm and +1cm of introitus)
3rd degree: prolapse protruding outside of the introitus (beyond +1cm introitus)
4th degree: procidentia (complete prolapse)
above hymen: -ve
below hymen: +ve
Pelvic organ prolapse Mx
Physiotherapy (pelvic floor exercises): minimum 4-6 months supervised
o Weight loss
o Lifestyle changes
Vaginal pessaries
Surgery
- Cystocele/cystourethrocele: anterior colporrhaphy
- Rectocele: posterior colporrhaphy
- Repair of Uterine Prolapse/Vault prolapse
- Vaginal hysterectomy (remove uterus via vagina)
- Manchester repair (cervix amputated, uterosacral ligaments shortened)
- Sacrospinous Fixation
- Others: Abdominal/laparoscopic sacrocolpopexy, mesh techniques, colpocleisis
Breast cancer: avoid what contraception?
avoid any hormonal contraception and go for the copper coil or barrier methods
Cervical or endometrial cancer: avoid
intrauterine system (i.e. Mirena coil)
Wilson’s disease
avoid the copper coil
Over 50 and under 50 women contraception
After the last period, contraception is required for 2 years in women under 50 and 1 year in women over 50
contraception after childbirth
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 progesterone 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).
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).
Natural family planning
o Length of menstrual cycle varies & should be measured for at least 3 consecutive months
o As sperm can live for up to 7 days in female genital tract, sex should be restricted 7 days before ovulation and at least 2 days after ovulation.
• Temperature: A record of body temperature is also done as an increase in temperature 3 days in a row could indicate that fertility has decreased.
Diaphragms and Cervical Caps
• The woman fits them before having sex, and leaves them in place for at least 6 hours after sex.
• If they want sex again, just reapply spermicide gel within 6 hours
- No protection against STIs
Combined oral contraceptive pill
licensed up to 50 years old
- Preventing ovulation (this is the primary mechanism of action)
o Progesterone thickens the cervical mucus
o Progesterone inhibits proliferation of the endometrium, reducing the chance of successful implantation
Yasmin and other COCPs containing drospirenone are considered first-line for
premenstrual syndrome.
continuous use. Drospirenone has anti-mineralocorticoid and anti-androgen activity, and may help with symptoms of bloating, water retention and mood changes.
COCP regimes
o 21 days on and 7 days off
o 63 days on (three packs) and 7 days off (“tricycling“)
o Continuous use without a pill-free period
COCP side effects
- Unscheduled bleeding (breakthrough): first three months and should settle with time
- Can interact with other medicines – liver enzyme inducing drugs e.g. anti-epileptic
- Hormonal side effects: Breast pain, tenderness, Mood changes, depression & Headaches
- Hypertension
- Venous & arterial thromboembolism
- Small increased risk of breast and cervical cancer, returning to normal ten years after stopping
- Small increased risk of myocardial infarction and stroke esp in smokers
COCP benefits
contracpetion
improved premenstrual symptoms, meorrhagia and dysmenorrhoea
reduced risk of endometrial, ovarian and colon cancer
reduced risk of ovarian cysts
COCP contradictions
o Uncontrolled hypertension (particularly ≥160 / ≥100): <140/90
o Migraine with aura (risk of stroke)
o History of VTE
o Aged over 35 and smoking more than 15 cigarettes per day
o Major surgery with prolonged immobility
o Vascular disease or stroke
o Ischaemic heart disease, cardiomyopathy or atrial fibrillation
o Liver cirrhosis and liver tumours
o Systemic lupus erythematosus (SLE) and antiphospholipid syndrome
o It is worth noting that a BMI above 35 is UKMEC 3 for the combined pill (risks generally outweigh the benefits).
Starting pill
day 5 of cycle - fine
after day 5 - extra contraception for 7 days
COCP pill - missed pills
• Missing one pill (less than 72 hours since the last pill was taken):
o Take the missed pill as soon as possible (even if this means taking two pills on the same day)
o 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):
o Take the most recent missed pill as soon as possible (even if this means taking two pills on the same day)
o Additional contraception (i.e. condoms) is needed until they have taken the pill regularly for 7 days straight
o If day 1 – 7 of the packet they need emergency contraception if they have had unprotected sex
o If day 8 – 14 of the pack (and day 1 – 7 was fully compliant) then no emergency contraception is required
o 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.
Combined Transdermal Patch (CTP)
releases a daily dose of oestrogen and progesterone through the skin into the blood to prevent ovulation. It also thickens cervical mucus.
worn for 7 days and changed on day 8. This is to be continued for 3 weeks and a patch-free week should happen in week 4, to allow a withdrawal bleed.
CTP - missed patch
- If patch falls off for less than 48 hours, stick it back as soon as possible or use a new patch. Protection against pregnancy remains as long as patch was used correctly for 7 days before it was removed.
- If patch was removed for more than 48 hours, a new patch should be started immediately, and additional contraception used for the next 7 days.
Combined Vaginal Ring (CVR)
- Continuous release of oestrogen and progesterone into the bloodstream, preventing ovulation.
- The ring should be in the vagina for 21 days before it is removed for 7 days to allow a withdrawal bleed
CVR - Missed
• If the ring is expelled for <3 hours, rinse the ring with cool water and reinserted immediately, no additional contraception is needed.
• If the ring remains out of the vagina for >3 hours, contraceptive protection may be reduced.
o If this occurs during week 1 or 2 of the menstrual cycle, additional protection should be used for the next 7 days after the ring is re-inserted.
o If expulsion occurs during week 3, a new ring can be inserted to start a new cycle or a withdrawal bleed can be allowed. A new ring should be inserted no later than 7 days after the ring was expelled.
Progesterone Only Pill (POP): mini pill
only contains progesterone and taken continuously
o Traditional progestogen-only pill (e.g. Norgeston or Noriday)
o Desogestrel-only pill (e.g. Cerazette)
POP mechanism?
• Traditional progestogen-only pills work mainly by:
o Thickening the cervical mucus
o Altering the endometrium and making it less accepting of implantation
o Reducing ciliary action in the fallopian tubes
• Desogestrel works mainly by:
o Inhibiting ovulation
o Thickening the cervical mucus and altering the endometrium
o Reducing ciliary action in the fallopian tubes
POP missed pills
• 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)
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.
Progestogen only injection
- depot medroxyprogesterone acetate (DMPA).
- 12 to 13 week intervals as an intramuscular or subcutaneous injection
- Depo-Provera: given by intramuscular injection (healthcare administers)
- Sayana Press: a subcutaneous injection device that can be self-injected
• Noristerat is an alternative to the DMPA that contains norethisterone and works for eight weeks
Progesterone injection side effects
weight gain
osteoporosis
small risk of breast and cervical cancer
Progesterone injection mechanism
inhibit ovulation. It does this by inhibiting FSH secretion by the pituitary gland, preventing the development of follicles in the ovaries.
Progestogen Only Implant
releases progestogen into the systemic circulation (3 years)
• Nexplanon: contains 68mg of etonogestrel.
- Inhibiting ovulation
- Thickening cervical mucus
- Altering the endometrium and making it less accepting of implantation
Contradictions for coil
- Pelvic inflammatory disease or infection
- Immunosuppression
- Pregnancy
- Unexplained bleeding
- Pelvic cancer
- Uterine cavity distortion (e.g. by fibroids)
Risks relating to insertion of the coil
o Bleeding
o Pain on insertion
o Vasovagal reactions (dizziness, bradycardia and arrhythmias)
o Uterine perforation (1 in 1000, higher in breastfeeding women)
o Pelvic inflammatory disease (particularly in the first 20 days)
o The expulsion rate is highest in the first three months
if coil threads are not seen: what to worry about
uterine perforation
pregnancy
expulsion
Copper coil
3 – 10 years after insertion (depending on the device).
• It can also be used as emergency contraception, inserted up to 5 days after an episode of unprotected intercourse.
• It is notably contraindicated in Wilson’s disease and submucosal fibroids and uterine malformation
toxic to ovum and sperm
copper coil benefits
reduce risk of VTE
risk of endometrial and cervical cancer
copper coil drawbacks
heavy bleeding
pelvic pain
risk of ectopic pregnancies
Mirena coil mechanism
releasing levonorgestrel (progestogen) into the local area:
o Thickening cervical mucus
o Prevents endometrium proliferation and making it less accepting of implantation
o Inhibiting ovulation in a small number of women
Mirena coil benefits
- periods lighter or stop altogether: licensed for heavy periods
- It may improve dysmenorrhoea or pelvic pain related to endometriosis
- No restrictions for use in obese patients (unlike the COCP)
- Safe: breastfeeding and postpartum. Fewer hormonal S/E than systemic hormones
Mirena coil drawbacks
irregualr bleeding
• Increased risk of ectopic pregnancies
• Increased incidence of ovarian cysts
• systemic absorption causing side effects of acne, headaches, or breast tenderness
• Intrauterine devices can occasionally fall out (around 5%)
female sterilisation methods
removal, band, clip, essure
elective or c section
female sterilisation risks
ectopic pregnancy
irreversible
Vasectomy
cutting vans deferens
requires 2 months of contracpetion after
semen testing at 12 weeks after procedure
Emergency contraception types and duration
o Levonorgestrel should be taken within 72 hours of UPSI
o Ulipristal should be taken within 120 hours of UPSI
o Copper coil can be inserted within 5 days of UPSI, or within 5 days of the estimated date of ovulation (most effective - not affected by BMI, enzyme inducing drugs or malabsoption)
Levonorgestrel (EC)
preventing or delaying ovulation
Extra contraception (i.e. condoms) is required for the first 7 days of the combined pill or the first 2 days of the progestogen-only pill
Dose
o 1.5mg as a single dose
o 3mg as a single dose in women above 70kg or BMI above 26
Can be used more than once in a menstrual cycle and breastfeeding allowed
Ulipristal
selective progesterone receptor modulator (SERM) that works by delaying ovulation. The common brand name is EllaOne
Wait 5 days before starting the combined pill or progestogen-only pill after taking ulipristal and don’t take more than once during menstrual cycle
There are several notably restrictions with ulipristal:
o Breastfeeding should be avoided for 1 week after taking ulipristal (milk should be expressed and discarded)
o Ulipristal should be avoided in patients with severe asthma
o Don’t take with levonorgestrel
STI causes
•Bacterial o Chlamydia trachomatis (chlamydia) o Neisseria gonorrhoeae (gonorrhoea) o Mycoplasma genitalium o Treponema pallidum (syphilis)
Viral
o Human papilloma virus (genital warts)
o Herpes simplex (genital herpes)
o Hepatitis and HIV
Parasites
o Trichomonas vaginalis
o Phthirus pubis (pubic lice or “crabs”)
o Scabies (not covered in this lecture)
Charcoal swabs
microscopy, culture and senstivities
endocervical swabs and high vaginal swabs (HVS).
Can confirm:
• Bacterial vaginosis
• Candidiasis
• Gonorrhoeae (specifically endocervical swab)
• Trichomonas vaginalis (specifically a swab from the posterior fornix)
• Other bacteria, such as group B streptococcus (GBS)
Nucleic acid amplification tests (NAAT) check directly for the DNA or RNA of the organism.
chlamydia and gonorrhoea
In women, a NAAT test can be performed on a vulvovaginal swab (a self-taken lower vaginal swab), an endocervical swab or a first-catch urine sample
In men, a NAAT test can be performed on a first-catch urine sample or a urethral swab.
Chlamydia
gram negative bacteria
Infects columnar epithelium at mucosal sites at urethra, rectum, throat and eyes
Obligate intracellular bacteria
Chlamydia types
o Serovars A-C = Trachoma (eye infection) (NOT an STI)
o Serovars D-K = Genital infection
o Serovars L1-L3 = Lymphogranuloma venereum: men who have sex with men. Presents with proctitis
Chlamydia female signs/symptoms
mostly asymptomatic o Abnormal vaginal discharge o Pelvic pain or abdominal tenderness o Abnormal vaginal bleeding (intermenstrual or postcoital) o Painful sex (dyspareunia) o Painful urination (dysuria) o Cervical motion tenderness (cervical excitation) o Inflamed cervix (cervicitis)
Males chlamydia signs/symptoms
o Urethral discharge or discomfort (milky) o Painful urination (dysuria) o Epididymo-orchitis o Reactive arthritis o Abdominal pain o Urethritis o Proctitis
Chlamydia Ix
NAAT - 14 days - first catch urine sample (male and female) o Vulvovaginal swab o Endocervical swab o Urethral swab in men o Rectal swab (after anal sex) o Pharyngeal swab (after oral sex) o Eye swabs (babies and adults)
Chlamydia Mx
Doxycycline 100mg bd 7 days (not in preg or breastfeeding)
o Azithromycin 1g stat then 500mg once a day for 2 days (removed as 1st line due to mycoplasma genitalium resistance to azithromycin)
o Erythromycin 500mg four times daily for 7 days
o Erythromycin 500mg twice daily for 14 days
o Amoxicillin 500mg three times daily for 7 days
PID Mx
Ceftriaxone 1G IM (GN), Doxycycline 100mg BD (CL) x 2 weeks and metronidazole 400 mg BD x 2 weeks (anaerobes)
Lymphogranuloma Venereum
condition affecting the lymphoid tissue around the site of infection with chlamydia.
• Serovars of Chlamydia trachomatis (L1-3)
• It most commonly occurs in men who have sex with men (MSM).
