O&G Sexual Health Flashcards
Risk factors for endometrial cancer
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
Causes of anovulatory bleeding
Irregular/infrequent periods
Range of flow from absent to excessive
Endometrial ca
PCOS
Diabetes
Hyper/hypothyroid
Hyperprolactinaemia
Antiepileptics, antipsychotics
Eating disorder
Adolescence, perimenopause, pregnancy
Causes of ovulatory bleeding
Regular bleeding intervals
Excessive or prolonged (>7 days) bleeding
Coagulopathy (von Willebrand’s, factor deficiency, leukaemia, platelet disorder)
Endometrial ca
Hypothyroid
Endometrial polyps
Uterine fibroids
Advanced liver disease
Causes of first trimester bleeding
Miscarriage (10-20%)
Ectopic pregnancy (1-2%)
Cervical/vagina lesions (malignancy, ectropion, polyps)
Infection
Gestational trophoblastic disease
Management of endometriosis
Tranexamic acid for menorrhagia
Hormone therapy
- Provera/depo-provera
- COCP
Paracetamol, NSAIDs (ibuprofen, naproxen, mefenamic acid)
Smoking cessation
Ectopic pregnancy:
Prevalence
Time of diagnosis
Location
1% pregnancies
6-10 weeks gestation
Fallopian tubes 95%
- Others in peritoneum, abdominal organs
Risks of ectopic pregnancy
Previous tubal surgery/pathology
Previous ectopic surgery
In utero diethylstilbesterol exposure
Prev STI/PID
Infertility
Current smoker
Current/prev IUD use
Woman with pelvic pain - conditions to rule out
Ectopic pregnancy
Ruptured ovarian cyst
Ovarian torsion
PID
Appendicitis
Management of abnormal anovulatory and ovulatory bleeding
Anovulatory
- COCP
- Provera
Ovulatory
- Mirena
- Provera
- TXA
- NSAIDs
Women with first trimester bleeding and haemodynamic instability
Ruptured ectopic pregnancy
Incomplete miscarriage with cervical shock (parasympathetic stimulation - hypotension, bradycardia)
Massive haemorrhage secondary to miscarriage
Complications of endometriosis
Reduced fertility
Adhesions > bowel obstruction
Risk of ovarian ca - clear cell serous endometriod
Ovarian cysts - rupture and torsion
Inflammatory bowel disease
Locations of endometriosis
Superficial peritoneal lesions <5mm deep
Deep infiltrating >5mm deep, or into muscular proper of organs
Ovarian endometrioma
Pleural, diaphragm, umbilicus lesions
bHCG levels in normal vs ectopic pregnancies
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
Prevalence of first trimester bleeding
20-40%
Types of miscarriage and management
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
Risks of placenta previa
Chronic HTN
Multiparity
Multiple gestations
Older age
Prev C section
Smoking uterine curettage
Types of placenta previa
Complete previa - placenta overlies internal os
Marginal previa - placental edge within 2cm of os
Low-lying placenta - edge within 2-3.5cm os
Presentation of placenta previa bleed vs plancental abruption
Gestation >20 weeks
Sudden onset painless PV bleeding, often after sex.
Abruption - with pain (uterine, back), bleeding may be concealed. Foetal distress, contractions, DIC
Risks for placental abruption
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
Risks for vasa previa (umbilical cord inserting in lower uterine segment, foetal vessels between cervix and presenting part)
IVF
Low lying placenta/second trimester placenta previa
Marginal cord insertion
Multiple gestation
Succenturiate-lobed, bilobed placentae
Blood volume of full term foetus
250mL
Post partum haemorrhage - levels of shock
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
Causes of post partum haemorrhage
Uterine atony - oxytocin 10 IU + bimanual uterine massage
Trauma, vaginal/perineal laceration
Uterine inversion
Prevalence of nausea and vomiting in pregnancy
Usual duration
60-70% mild nausea and vomiting
- Begins week 4-7, peaks week 9, resolves weeks 16-20
1-2% hyperemesis gravidarum
Management of hyperemesis gravidarum
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
Risk factors for hyperemesis gravidarum
Molar pregnancy
Multiple pregnancy
Primiparous
Young
Non-smoker
Chronic H. pylori
Pasifika
Pre-eclampsia symptoms
> 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
Eclampsia definition
Timing
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
Risk factors for pre-eclampsia
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
Management of pre-eclampsia
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
Levonorgestrel for emergency contraception
Indications
Dose
Contraindications
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
Copper IUD for emergency contraception
Indication
Timing
Side effects
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
STI testing for males
- Urethral swab
- First void urine - no PU within 1 hour, do not clean first, take first 30mL
- Consider MSU for cystitis
- Consider herpes swab
Send for chlamydia + gonorrhoea NAAT
PID risk factors
<30 years
Sexually active
Recent change in sexual partner
Multiple sexual partners
Prev STI
Post partum
Post TOP
Post instrumentation
Complications of PID
Tubo-ovarian abscess
Chronic pain
Ectopic pregnancy
Tubal factor infertility
Fitz-Hugh-Curtis syndrome - peri hepatitis
Management of PID
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
Herpes subtypes
HSV 1 - mostly facial lesions. 30-40% genital herpes
HSV 2 - 60-70% genital herpes
20% adults have asymptomatic HSV 2
Herpes symptoms
First vs reactivation
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
Herpes transmission and causes of reactivation
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
Management of herpes
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
Genital warts presentation
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
Treatment for genital warts
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
Symptoms of primary syphilis
50% asymptomatic
10-90 days incubation
Solitary genital/anal/mouth ulcer, usually painless
- 30% multiple lesions
- Resolves spontaneously
Transmission of syphilis
Treponema pallidum
Contact with mucocutaneous skin
Vertical transmission - congenital syphilis
Risks for syphilis
Sexually active
Contact of syphilis case
MSM
Routine checks
- sexual health
- pregnancy
- immigration
Signs of secondary syphilis
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
Signs of tertiary syphilis
Atypical neuro - paraesthesia, ataxia, dementia, deafness, visual impairment
Cardiovascular disease - aortitis
Gummata - inflammatory nodules on skin/bone
Management of syphilis
Contact tracing
Referral to sexual health - do not start treatment without advice (usually benazathine penicillin)
Abstain from sex until treatment complete
Notify MOH
Risks for gonorrhoea
<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
Gonorrhoea symptoms
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
Management of gonorrhoea
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
Most common STI in NZ
Most common preventable cause of infertility
Chlamydia
Risk factors for chlamydia
Age <25
Sexual contact with chlamydia
2+ sexual partners in last year
Recent change in sexual partner
Inconsistent condom
Co-infection with another STI
Symptoms of chlamydia
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
Treatment of chlamydia
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
Routine STI check females
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
Routine STI check male
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
