ILA- sexual health Flashcards
1
Q
What is the difference between normal and abnormal PV discharge?
A
- PV discharge normally white/ clear and used to keep vag clean and moist
- pathology: offensive smell eg fishy; colour (yellow, brown, green, clumpy); blood; itchy; swollen; dyspareunia; change consistency (thick or heavy)
2
Q
What are the physiological causes of normal PV discharge?
A
-physiological - hormone related, puberty, pregnancy, OCP, intercourse
3
Q
What are the pathological causes of abnormal PV discharge?
A
Causes:
-non-infective: polyps; foreign body; fistula; cancer; atrophic vaginitis (menopause)
Infective:
-non-STI - BV (green-white, fishy) - more sexually active
-candida (cottage cheese white, thick)
-STI: chlamydia (purulent); gonorrhoea (purulent); trichomoniasis (offensive, yellow, profuse, frothy, associated other sx eg pain, itch)
-children: with birth; otherwise suspect possible abuse
4
Q
What causes chlamydia?
A
Chlamydia trachomatis
5
Q
What are the vaginal sx for chlamydia?
A
70% asx; abnormal discharge (as cervix inflammed); dysuria; IMB or PCB; pelvic pain; deep dyspareunia
6
Q
Out of chlamydia and gonorrhoea which is more likely to be asx?
A
CHLAMYDIA
7
Q
What are the vaginal signs of chlamydia?
A
cervix sometimes has a ‘cobblestone’ appearance, with contact bleeding and mucopurulent discharge; Pelvic adnexal tenderness on bimanual palpation.
8
Q
Penile sx of chlamydia?
A
50% asx; dysuria, discharge, pain
9
Q
ix for chlamydia?
A
triple swab
10
Q
What is a triple swab?
A
endocervical NAAT for chlamydia and gonorrhoea; endocervical charcoal swab for gonorrhoea and high vaginal swab in posterior fornix for Bacterial vaginosis; Trichomonas vaginalis; Candida; Group B streptococcus
11
Q
What is the treatment of chlamydia?
A
doxycycline (BD for 7 days) or single azithromycin stat
12
Q
What are the potential complications of chlamydia and gonorrhoea?
A
infertility; PID; epididymo-orchitis; reactive arthritis; prostatitis
13
Q
What causes gonorrhoea?
A
Neisseria gonorrhoeae
14
Q
What are the vaginal sx of gonorrhoea?
A
asx 50%; abnormal discharge (most common); pelvic pain; dysuria
15
Q
What are the penile sx of gonorrhoea?
A
asx 5%; discharge (most common); dysuria; rectal and pharngeal infection usually asx but can have pain or discharge
16
Q
mx of gonorrhoea - confirmed or suspected
A
Ceftriaxone 1 g intramuscular (IM) injection as a single dose
17
Q
What is trichomonas vaginalis?
A
T. vaginalis is a flagellated protozoan.
18
Q
What are the vaginal sx of T. vaginalis?
A
vaginal discharge (normally yellow and frothy); vulvar itching; dysuria; offensive odour
19
Q
What may be seen O/E of a woman with trichomamonas vaginalis?
A
Vaginal signs: strawberry cervix
20
Q
penile sx of t. vag?
A
usually asx; dysuria, discharge
21
Q
ix for t. vaginalis?
A
triple swab; vaginal pH >4.5
22
Q
mx of trichomamonas vaginalis?
A
metronidazole
23
Q
main complication of trichomamonas vaginalis?
A
Complications: pregnancy complications eg preterm delivery
24
Q
Difference between HSV type 1 and 2?
A
Type 1 associated with cold sores, but in UK has now become most common genital cause, rather than type 2.
25
How does HSV present?
Primary infection: commonly asx, sometimes systemic sx.
Recurrent infection: lesions unilateral; incubation 2-7 days, genital redness, swelling, pain pruritus, sometimes discharge, painful lymphadenopathy in groin area, after days punched out lesions that can ulcerate (single or many red bumps or white vesicles)
26
ix for HSV?
microscopy of Tznack smear (from surface of ulcer), viral culture, PCR, test for other STIs
27
mx of HSV?
acyclovir during outbreaks to decrease severity and duration; topical lidocaine
28
Most common types of HPV that cause warts?
6 and 11
29
How does HPV present?
Incubation period from infection to warts can be 3wks-years, small fleshy growths, skin changes, usually painless, warts can be inside urethra or anus.
Warts on moist, non-hairy skin are usually soft and non-keratinised, whereas those on dry hairy skin are more likely to be firm and keratinised.
30
mx of HPV?
multiple non-keratinised - topical podophyllum
keratinised - crytoptherapy
topical imiquimod is second line
31
How does scabies present?
infected contacts may be asymptomatic for up to a month; then present with itching, lesion which may be papules (elevated), vesicles (blister), pustules (pus filled vesicle), and nodules. May be excoriation marks from scratching
Can also cause burrows- A thread-like linear or serpiginous (wavy, serpent-like) tunnel in the epidermis
Papules are small and erythematous. They can be sparse, or numerous and close-set.
32
What causes syphilis?
treponema pallidum
33
What is primary syphilis?
Primary syphilis- at site of infection solitary macule that develops to painless ulcer aka chancre. Persists for 4-6 wks before healing. Sometimes local lymphadenopathy otherwise asymptomatic but infectious
34
What is secondary syphilis?
Secondary syphilis- 25% of patients have fever and poylmorphic rash - typically trunk, face, palms, soles, remaining 75% of untreated patients have latent asymptomatic phase. Most infectious
35
What is tertiary syphilis?
Tertiary/ late syphilis- gumma nodule (non-cancerous granuloma can occur in any tissue in body), cardiovascular aortic aneurysms, neurosyphilis (dementia, strokes, psychosis)
36
Ix of syphilis?
treponemal tests – which do an immunoessay for antibodies and anitgens
37
mx of syphilis?
IM benzathine penicillin
38
presentation of hepatitis B?
jaundice, anorexia, nausea, RUQ pain, fever, malaise, darkening urine, lightening faeces, decompensated liver disease include ascites, encephalopathy and gastrointestinal haemorrhage.
39
ix for hep b?
serum HBsAg, LFTs, FBC
40
Describe the progression of HIV
Acute primary infection: 2-4 weeks to 10 months post-infection. Fever, rash, weight loss, lethargy
Asymptomatic phase (clinical latency): After 3-6 months from initial exposure. Lymphadenopathy.
Early symptomatic HIV aka constitutional symptoms: Oral/vaginal candida, Shigella >2 episodes/ dermatomes, cervical dysplasia, periphery neuropathy, PID, fever or diarrhoea >1M
AIDS acquired immune deficiency syndrome: CD4<200, occurs after 5-10yrs from initial infection
AIDS defining conditions: candidiasis, TB, toxoplasmosis, recurrent bacteria pneumonia, invasive cervical carcinoma, Kaposi’s carcinoma, primary CNS lymphoma, non-Hodgkin’s lymphoma, Pneumocystis jeroveci
41
What is bacterial vaginosis?
Overgrowth of bacteria often gardnerella vaginalis, no STI. Increased risk w douching, vaginal deadorants
42
WHat are the sx of BV?
can be asymptomatic, offensive "fishy" discharge, white/grey, vaginal itch
43
ix for BV?
Whiff test (potassium hydroxide added); Triple swab
44
mx for BV?
metronidazole (one off dose) or clindamycin cream
45
mx of candida?
fluconazole – second line pessary and cream
46
What test must be done before an IUD is fitted?
sti screen needs to be done TWO WEEKS before otherwise make much worse
47
What has higher hormones dose OCP or IUS?
mirena - lower hormonal dose than OCP as is local
48
What are CI to the coil?
STI, PID, pregnancy, structural abnormalities, cancer, allergy copper, DVT/PE, breast cancer for IUS
49
What are the pros of the coil?
99% effective, normal fertility when removed, can used any stsage cycle, good for CI COCP
50
What are the cons of the coil?
no protection STI, insertion painful
IUDs make periods heavier, longer and more painful
IUS associated initial frequent uterine bleeding and spotting
uterine perforation
First 20 days increased risk of PID
Expulsion risk 1st 3 months
51
What is tier 1 vs tier 2 contraceptives?
tier 1 = most effective: coil and sterilisation
| tier 2= less effective, other hormonal mx
52
What is the mechanism of action for the COCP?
inhibits ovulation via stopping negative feedback loop of oestrogen and prog to hypothalamus so no LH surge and no ovulation and: endometrium thinned so blastocyst can implant, mucus thicker so harder for sperm to enter
53
monophasic vs biphasic pills?
Monophasic: These pills deliver the same amount of estrogen and progestin each day for 21 days. In the final week, you either take no pills or placebo pills.
Biphasic: These pills deliver one strength for 7-10 days and a second strength for 11-14 days.
54
How does the transdermic patch contraceptive work?
changed every 7 days, works same as COCP - ortho evra
55
How does the nuva ring work?
springs open around cervix - stays in for 21 days and comes out 7 days later for withdrawal bleeding. Can be removed for sex and replaced and still work.
Uses same mechanism as COCP
56
What are the pros of COCP?
Pros: Reduced risk cancer ovary, uterus (endometrial) and colon, doesnt interrupt sex, better thn barrier
57
What are the cons of COCP?
Cons: hard take same time every day, forget pill, BP increase, VTE increase, small increase MI and stroke risk, small increased risk breast and cervical cancer
58
CI for COCP?
CI: >BMI over 35 (clinical judgement advised); breast feed (up to 6 weeks post-partum- ABSOLUTE); migraines; htn; smoking over 35 yrs; diabetes, VTE (if first degree relative with hx of it <45 yrs)
59
Give examples of COCP?
levonorgestrel, norgestimate, norethisterone, desogestrel, gestodene and drospirenone.
60
How does POP work?
Desogestrel POP works mainly by inhibiting ovulation. It also works by thickening cervical mucus and thinning the endometrium.
Norethisterone and levonorgestrel POPs work mainly by thickening cervical mucus and thinning the endometrium. These POPs are taken much less commonly as they should be taken within the same 3 hours every day to be effective.
61
What is a pro of POP?
less endometrial cancer risk, lower risk than COCP for certain things
62
Cons of POP?
Missed pills can have 12 hr window but some are 3 hr window
back to back, no bleeds so harder to tell if pregnant, increased risk ovarian cysts and breast cancer, random bleeding, same as above
63
CI to POP?
CI: breast cancer, liver problems, higher weight, CVD
64
is the implant combined or progesterone only?
progesterone only
65
pros of impant?
-pros: can be used breastfeeding, good all BMIs, reduce risk endometrial cancer
66
cons of impant?
Cons: pain at start, slight increased risk breast cancer, infection when put in
67
CI of implant?
CI: pregnant, liver tumour, breast cancer
68
How does DMPA injection work?
eg depot provera : inhibits ovulation and thicken mucus
69
What are the pros of the injection?
Pros: v effective, no known interactions, reduce risk endometrial cancer
70
What are the cons of injection?
Conns: CAN TAKE A YEAR for fertility to return to normal when finish, breast cancer risk, risk of bone loss, random patterns of bleeding, weat gain
71
CI to injection?
CI: breast cancer, pregnant, DM, if want child soonish
72
How does morning after pill work?
-levonorgestrel or ulipristal acetate → delay ovulation by enough time for sperm to die and be non-viable
73
emergency contracpetive alternative to morning after pill?
Copper coil - 5 days after kills the sperm
74
Difference between fraser and gillick competence?
Fraser are for contraception and sexual health
| Gillick - wider context <16 yrs
75
Describe fraser guidelines
Encourage them to tell their parents or carers if poss and say you can do that for them if they don't want to talk to them
Child can understand drs advice
Cant persuade to tell parents
Is likely to have sex with or without contraceptive
liekly to suffer mentally or physically without contraceptive
Best interests indicate contraceptive
Consent invalid if they're being pressured, affected by stress, mental health, they may be competent for some decisions but not for more serious things - if incompetent need to conent parents
76
How long after taking contraceptives does it take for them to effective? (think IUD, POP, COCP, depot, IUS, implant)
Contraceptives - time until effective (if not first day period):
instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS
77
Up to what point can the IUD be inserted as an emergency contraceptive
The copper intrauterine device can be inserted for emergency contraception within 5 days after the first unprotected sexual intercourse in a cycle, or within 5 days of the earliest estimated date of ovulation, whichever is later
78
At what point can you become pregnant postpartum?
After 21 days - is thought women will ovulate at earliest 28 days post-partum and sperm can survive up to 7 days
79
list some ABSOLUTE CI to the COCP
```
Migraine with aura
Breastfeeding <6 weeks post-partum
Age 35 or over smoking 15 or more cigarettes/day
Systolic 160mmHg or diastolic 95mmHg
Vascular disease
History of VTE
Current VTE (on anticoagulants)
Major surgery with prolonged immobilisation
Known thrombogenic mutations
Current and history of ischaemic heart disease
Stroke (including TIA)
Complicated valvular and congenital heart disease
Current breast cancer
Nephropathy/retinopathy/neuropathy
Other vascular disease
Severe (decompensated) cirrhosis
Hepatocellular adenoma
Hepatoma
Raynaud's disease with lupus anticoagulant
Positive antiphospholipid antibodies
```
80
What action should be done if one COCP is missed? what about two?
If 1 pill is missed
take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
no additional contraceptive protection needed
If 2 or more pills missed
take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
the women should use condoms or abstain from sex until she has taken pills for 7 days in a row. FSRH: 'This advice may be overcautious in the second and third weeks, but the advice is a backup in the event that further pills are missed'
if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception
if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval
81
What action should be taken if the POP is missed?
```
traditional - if more than 3 hrs later take the missed pill as soon as possible (if desogestrel is 12 hrs). If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day
continue with rest of pack
extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
```
82
mechanism of action for contraceptives
COCP - Inhibits ovulation
POP- (excluding desogestrel) Thickens cervical mucus
Desogestrel-only pill Primary: Inhibits ovulation
Also: thickens cervical mucus
Injectable contraceptive (medroxyprogesterone acetate) Primary: Inhibits ovulation
Also: thickens cervical mucus
Implantable contraceptive
(etonogestrel) Primary: Inhibits ovulation
Also: thickens cervical mucus
IUD -Decreases sperm motility and survival
IUS - Primary: Prevents endometrial proliferation
Also: Thickens cervical mucus
