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UCPEX > O&G Sexual Health > Flashcards

O&G Sexual Health Flashcards

1
Q

Risk factors for endometrial cancer

A

Age <35:
- chronic anovulatory bleeding
- diabetes
- FHx colon ca
- infertility
- nulliparity
- obesity
- tamoxifen use
- obese adolescents with 2-3 years untreated anovulatory bleeding
- >35 with anovulatory bleeding
- Bleeding not responsive to medical therapy

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2
Q

Causes of anovulatory bleeding

Irregular/infrequent periods
Range of flow from absent to excessive

A

Endometrial ca
PCOS
Diabetes
Hyper/hypothyroid
Hyperprolactinaemia
Antiepileptics, antipsychotics
Eating disorder
Adolescence, perimenopause, pregnancy

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3
Q

Causes of ovulatory bleeding

Regular bleeding intervals
Excessive or prolonged (>7 days) bleeding

A

Coagulopathy (von Willebrand’s, factor deficiency, leukaemia, platelet disorder)
Endometrial ca
Hypothyroid
Endometrial polyps
Uterine fibroids
Advanced liver disease

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4
Q

Causes of first trimester bleeding

A

Miscarriage (10-20%)
Ectopic pregnancy (1-2%)
Cervical/vagina lesions (malignancy, ectropion, polyps)
Infection
Gestational trophoblastic disease

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5
Q

Management of endometriosis

A

Tranexamic acid for menorrhagia
Hormone therapy
- Provera/depo-provera
- COCP
Paracetamol, NSAIDs (ibuprofen, naproxen, mefenamic acid)
Smoking cessation

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6
Q

Ectopic pregnancy:

Prevalence
Time of diagnosis
Location

A

1% pregnancies
6-10 weeks gestation
Fallopian tubes 95%
- Others in peritoneum, abdominal organs

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7
Q

Risks of ectopic pregnancy

A

Previous tubal surgery/pathology
Previous ectopic surgery
In utero diethylstilbesterol exposure
Prev STI/PID
Infertility
Current smoker
Current/prev IUD use

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8
Q

Woman with pelvic pain - conditions to rule out

A

Ectopic pregnancy
Ruptured ovarian cyst
Ovarian torsion
PID
Appendicitis

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9
Q

Management of abnormal anovulatory and ovulatory bleeding

A

Anovulatory
- COCP
- Provera

Ovulatory
- Mirena
- Provera
- TXA
- NSAIDs

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10
Q

Women with first trimester bleeding and haemodynamic instability

A

Ruptured ectopic pregnancy
Incomplete miscarriage with cervical shock (parasympathetic stimulation - hypotension, bradycardia)
Massive haemorrhage secondary to miscarriage

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11
Q

Complications of endometriosis

A

Reduced fertility
Adhesions > bowel obstruction
Risk of ovarian ca - clear cell serous endometriod
Ovarian cysts - rupture and torsion
Inflammatory bowel disease

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12
Q

Locations of endometriosis

A

Superficial peritoneal lesions <5mm deep
Deep infiltrating >5mm deep, or into muscular proper of organs
Ovarian endometrioma
Pleural, diaphragm, umbilicus lesions

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13
Q

bHCG levels in normal vs ectopic pregnancies

A

Lower level in ectopic vs intrauterine pregnancy
Normal - increases 50-66% in 48 hours
Discriminatory level = 1500-3500 - level when pregnancy visible in uterus on ultrasound

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14
Q

Prevalence of first trimester bleeding

A

20-40%

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15
Q

Types of miscarriage and management

A

RHD negative - refer to ED for Rh D immunoglobulins

Threatened - vaginal bleeding <20/40
- expectant management

Inevitable - miscarriage occurring/expected to occur
- expectant/medical/surgical

Incomplete - Some retention of POC
- expectant/medical/surgical

Missed - non-viable IUP, no bleeding
- expectant/medical/surgical

Complete - full passage POC

Septic
- Referral stat

Recurrent - >3 consecutive miscarriages

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16
Q

Risks of placenta previa

A

Chronic HTN
Multiparity
Multiple gestations
Older age
Prev C section
Smoking uterine curettage

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17
Q

Types of placenta previa

A

Complete previa - placenta overlies internal os
Marginal previa - placental edge within 2cm of os
Low-lying placenta - edge within 2-3.5cm os

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18
Q

Presentation of placenta previa bleed vs plancental abruption

A

Gestation >20 weeks
Sudden onset painless PV bleeding, often after sex.

Abruption - with pain (uterine, back), bleeding may be concealed. Foetal distress, contractions, DIC

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19
Q

Risks for placental abruption

A

Chronic HTN
Multiparity
Prev abruption
Pre-eclampsia
Short umbilical cord
Sudden decompression of extended uterus
Thrombophilia
Smoking
Drugs - cocaine, meth
Trauma
Fibroids
Raised maternal alpha fetoprotein

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20
Q

Risks for vasa previa (umbilical cord inserting in lower uterine segment, foetal vessels between cervix and presenting part)

A

IVF
Low lying placenta/second trimester placenta previa
Marginal cord insertion
Multiple gestation
Succenturiate-lobed, bilobed placentae

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21
Q

Blood volume of full term foetus

A

250mL

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22
Q

Post partum haemorrhage - levels of shock

A

Mild shock
- <20% blood loss
- diaphoresis, cool peripheries, anxiety, delayed cap refill

Moderate shock
- 20-40% blood loss
- tachycardia, tachypnoea, postural drop, oliguria

Severe shock
- >40% blood loss
- Hypotension
- Agitation
- Altered mental state, LOC

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23
Q

Causes of post partum haemorrhage

A

Uterine atony - oxytocin 10 IU + bimanual uterine massage
Trauma, vaginal/perineal laceration
Uterine inversion

24
Q

Prevalence of nausea and vomiting in pregnancy

Usual duration

A

60-70% mild nausea and vomiting
- Begins week 4-7, peaks week 9, resolves weeks 16-20

1-2% hyperemesis gravidarum

25
Q

Management of hyperemesis gravidarum

A

Small frequent fluids and food (high carb low fat), avoid hunger
Lie down if dizzy
Avoid smells and triggers
Acupressure

Mild
- No dehydration
- PO antiemetic
- oral rehydration

Moderate
- Dehydration (dizziness, dry MM, slow cap refill, postural drop, sunken eyes, slow skin turgor, tachycardia, hypotension)
- Ketones >+2
- Community IVF and antiemetics

Severe
- >5% weight loss, biochemical abnormalities
- Community +/- hospital IVF and antiemetic
- Dietician referral
- Thiamine + omeprazole

Antiemetics of choice - cyclizine, metoclopramide, prochlorperazine, promethanzine, ondansetron

26
Q

Risk factors for hyperemesis gravidarum

A

Molar pregnancy
Multiple pregnancy
Primiparous
Young
Non-smoker
Chronic H. pylori
Pasifika

27
Q

Pre-eclampsia symptoms

A

> 20 weeks gestation
New onset hypertension
Mild - 140-159 systolic, 90-109 diastolic
Severe >160 systolic, >110 diastolic

Plus one of:
- Proteinuria +/- oedema
- Organ dysfunction
- Neuro (hyperreflexia, clonus, visual scotoma)
- Haem (low platelets, haemolytic)
- Renal impairment
- Deranged LFTs
- Uteroplacental dysfunction (growth restriction, abruption)

HELLP - pre-eclampsia variant
Haemolysis
Elevated LFTs
Low platelets

28
Q

Eclampsia definition
Timing

A

Seizure in pregnant patient with or without pre-eclampsia

60-90s duration, self-limiting

53% antepartum
19% intrapartum
28% 48 hrs postpartum
Late post-partum = >2 weeks

29
Q

Risk factors for pre-eclampsia

A

Major:
- Antiphospholipid abs
- SLE
- Hx pre-eclampsia - self, mother, sister
- Pre-existing HTN
- Diabetes, renal disease

Minor:
- Oocyte donation
- African, Indian, Maori, Pacific
- Primiparous, pregnancy interval >10 years
- Multiple pregnancies
- Hx pre-eclampsia in paternal family
- Change in partner, sperm donor
- BMI >35
- Age >40

30
Q

Management of pre-eclampsia

A

Urgent obstetrics referral
Antihypertensives - labetalol, nifedipine, hydralazine
Target BP 130-150/80-100
MgSO4

Aspirin and calcium to women at high risk of pre-eclampsia

31
Q

Levonorgestrel for emergency contraception

Indications
Dose
Contraindications

A

Levonorgestrel
1.5mg stat
3mg stat BMI >26 or >70kg
Within 72 hours of UPSI (ideally 12hrs)

Contraindications: clots, breast ca, IBD, porphyria, active trophoblastic disease
Reduced efficacy within 28 days liver enzyme inducing meds - barbiturates, anti epileptics, rifampicin

32
Q

Copper IUD for emergency contraception

Indication
Timing
Side effects

A

BMI >26 more effective
Only option for BMI >30
Insert within 5 days of ovulation or within 120 hours of UPSI

May worsening heavy menstrual bleed or menorrhagia

33
Q

STI testing for males

A
  1. Urethral swab
  2. First void urine - no PU within 1 hour, do not clean first, take first 30mL
  3. Consider MSU for cystitis
  4. Consider herpes swab

Send for chlamydia + gonorrhoea NAAT

34
Q

PID risk factors

A

<30 years
Sexually active
Recent change in sexual partner
Multiple sexual partners
Prev STI

Post partum
Post TOP
Post instrumentation

35
Q

Complications of PID

A

Tubo-ovarian abscess
Chronic pain
Ectopic pregnancy
Tubal factor infertility
Fitz-Hugh-Curtis syndrome - peri hepatitis

36
Q

Management of PID

A

Usually ascending chlamydia, gonorrhoea infection

Ceftriaxone 500mg IM with 2mL lignocaine 1%
Doxycycline 100mg BD 14 days
Metronidazole 400mg BD 14 days

Leave IUD in, don’t remove until on abx for >24 hours
Contact trace and treat for chlamydia all partners of last 3/12
No sex until pain resolves
Condoms for 14 days after treatment and 7 days after treatment of sexual contacts
Repeat STI check in 3/12

37
Q

Herpes subtypes

A

HSV 1 - mostly facial lesions. 30-40% genital herpes
HSV 2 - 60-70% genital herpes
20% adults have asymptomatic HSV 2

38
Q

Herpes symptoms

First vs reactivation

A

Flu-like illness
Painful ulcers, vesicular rash in groin, perineum, genitals, mucosa
- lasts 2-3 weeks if untreated
Tender local lymphadenopathy
Dysuria and difficulty passing urine in women

Reactivation:
Smaller lesions, more closely grouped
Lasts 5-10 days
No flu-like prodrome

39
Q

Herpes transmission and causes of reactivation

A

Skin to skin transmission
Viral shedding 100-1000 times greater in active episode
Unlikely fomites - virus dies at room temperature
Lifelong infection - latent in ganglia of sensory nerves

Reactivation and recurrence
- Minor trauma
- Other infection
- UV radiation
- Menstrual
- Emotional stress

40
Q

Management of herpes

A

Valaciclovir 500mg BD 7 days
Immunocompromised: 1g BD 7-10 days
Salt wash
Lignocaine
Increase fluids, urinate in shower
Avoid sex
Refer if herpes proctitis, neonates, pregnant

Recurrence:
Valaciclovir 500mg BD 3 days

Prophylaxis for frequent recurrence:
Valaciclovir 500mg OD
or Acyclovir 400mg BD

No increased risk of ca
Not indicative of partner cheating

41
Q

Genital warts presentation

A

90% caused by HPV 6, 11
Can appear 3-6 months after skin-skin contact
Flesh coloured papule, may join together to form plaques
Pain
Bleeding
Itch

42
Q

Treatment for genital warts

A

Podophyllotoxin 5mg/mL apply BD for 3 consecutive days/week for 5 weeks

Imiquimod 3 alternate days/week for 16 weeks

Cryotherapy - only option in pregnancy
Laser
Hyfrecation
Surgical excision

Refer:
- Children if NAI concerns, cervical warts, intraurethral, extensive, pregnancy, immunosuppression, diabetes, HIV, ?malignancy

43
Q

Symptoms of primary syphilis

A

50% asymptomatic
10-90 days incubation
Solitary genital/anal/mouth ulcer, usually painless
- 30% multiple lesions
- Resolves spontaneously

44
Q

Transmission of syphilis

A

Treponema pallidum
Contact with mucocutaneous skin
Vertical transmission - congenital syphilis

45
Q

Risks for syphilis

A

Sexually active
Contact of syphilis case
MSM

Routine checks
- sexual health
- pregnancy
- immigration

46
Q

Signs of secondary syphilis

A

Incubation time 2-24 weeks
90% involving skin:
- rash on palms or soles
- generalised body rash
- Atypical mouth ulcer
- condylomata lata
- patchy alopecia

Constitutional: Fever, lethargy, lymphadenopathy

Neuro: ocular nerve palsy, unilateral deafness, meningitis

47
Q

Signs of tertiary syphilis

A

Atypical neuro - paraesthesia, ataxia, dementia, deafness, visual impairment
Cardiovascular disease - aortitis
Gummata - inflammatory nodules on skin/bone

48
Q

Management of syphilis

A

Contact tracing
Referral to sexual health - do not start treatment without advice (usually benazathine penicillin)
Abstain from sex until treatment complete
Notify MOH

49
Q

Risks for gonorrhoea

A

<30 years
sexual contact of gonorrhoea
Recent gonorrhoea
Multiple sexual contacts
MSM
Coexisting STI - HIV, chlamydia
Inconsistent condom use
Anal, oral sex
Drug use
Commercial sex work

50
Q

Gonorrhoea symptoms

A

Symptomatic in 95% men and 50% women
Purulent discharge, dysuria, abdo pain
Men: scrotal pain, anal pain/pruritis/bleeding
Women: abnormal bleeding, dyspareunia, rectal infections often asymptomatic

90% pharyngeal infections asymptomatic

51
Q

Management of gonorrhoea

A

Ceftriaxone 500mg IM
Azithromycin 1g stat

If rectal chlamydia - add doxycycline 100mg BD 7 days

Abstain or condoms for 1 week after treatment and treatment of contacts

Contact trace 2 months

Notify MOH

Follow up 7 days

52
Q

Most common STI in NZ
Most common preventable cause of infertility

A

Chlamydia

53
Q

Risk factors for chlamydia

A

Age <25
Sexual contact with chlamydia
2+ sexual partners in last year
Recent change in sexual partner
Inconsistent condom
Co-infection with another STI

54
Q

Symptoms of chlamydia

A

Asymptomatic in 50% men, 70% women

Men: urethritis (dysuria, discharge), epididymo-orchitis (unilateral testicular pain, swelling)

Women: Dysuria, vaginal discharge, intermenstrual/post coital bleeding, deep dyspareunia, lower abdo pain, fever
Cervix - friable, “cobblestone” appearance, contact bleed

Rectal chlamydia - asymptomatic in 70% MSM, 90% women. Proctitis + mucopurulent discharge

55
Q

Treatment of chlamydia

A

1st line: doxycycline 100mg BD 7 days (97% effective)
- More effective in rectal chlamydia
2nd line: azithromycin 1g stat (94% effective)
- Emerging resistance in other STIs

Abstain or condoms for 7 days post treatment of self and contacts

Contact trace 2 months

Follow up in 7 days

56
Q

Routine STI check females

A

Vulvovaginal swab for chlamydia, gonorrhoea, +/- trichomoniasis (Maori, Pacific, low SES, incarceration, contact)
HIV and syphilis serology

Consider:
Speculum + bimanual if symptomatic
High vaginal swab - BV, candida
Endocervical swab for gonorrhoea
Anorectal, pharyngeal swabs
Hep B, C serology

57
Q

Routine STI check male

A

First pass urine for chlamydia, gonorrhoea
HIV, syphilis serology

Consider:
Urethral swab for gonorrhoea if discharge
Pharyngeal/anorectal NAAT swabs if MSM
Herpes swab if ulceration
Hep B, C serology
Hep A serology if MSM

UCPEX (13 decks)

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