Revision 2 Flashcards
Can COCP be used in breastfeeding?
NO
UKMEC4 if breastfeeding and <6 weeks portpartum
UKMEC2 if breastfeeding and >6 weeks postpartum
When can a copper coil or intrauterine system (e.g. Mirena) be inserted after birth?
Either within 48 hours after birth OR 4 weeks after birth (not in between - UKMEC 3)
What type of condoms can be used in latex allergy?
Polyurethane condoms
How long must diaphragms/cervical caps be in place following intercourse?
6 hours
COCPs containing what are considered first-line for premenstrual syndrome?
Why?
Drospirenone –> antimineralocorticoid effects help with bloating, water retention, mood changes etc
COCPs containing what are considered in the treatment of acne and hirsutism?
Cyproterone acetate (i.e. co-cyprindiol) –> anti-androgen effects
What is potential risk in COCPs with co-cyprindiol?
Greater risk of VTE - only use for 3 months
Risk of which cancers are REDUCED with the COCP?
Ovarian, endometrial & colon
Risk of which cancers are INCREASED with the COCP?
Breast and cervical
What UKMEC is a BMI > 35 for the COCP?
UKMEC 3
Starting the COCP on what day of the cycle offers protection straight away?
Day 1-5
COCP and major operations?
Should be stopped 4 weeks before
What is the only UKMEC 4 criteria for POP?
Active breast cancer
What must be excluded where irregular bleeding is persistent >3 months after starting the POP?
STIs, pregnancy or cancer.
How often is the contraceptive injection given?
Every 12w (3m)
Why is the progesterone only injection less suitable for women wishing to great pregnant in the near term?
Can take up to 12m for fertility to return
What is a potential long term complication of DMPA?
Osteoporosis
What is the main mechanism of action of the progesterone injection?
Inhibits ovulation
What 2 side effects are unique to the progesterone only injection?
1) weight gain
2) osteoporosis
Between what ages is Nexpanon (implant) licensed for use?
18 and 40 y/o
What is the most effective form of contraception available?
Implant
What guidelines are used for providing contraception to patients under 16 years without having parental input and consent?
Fraser guidelines
To follow the Frazer guidelines, what 5 critiera must the patient meet?
1) Mature and intelligent enough to understand treatment
2) Can’t be persuaded to discuss with their parents, or let the health professional discuss it
3) Likely to have intercourse regardless of treatment
4) Their physical or mental health is likely to suffer without treatment
5) Treatment is in best interest
What hormone does the intrauterine system (IUS) contain?
Levonorgestrel (form of progesterone)
How long is the Mirena coil licensed for in
a) HRT
b) contraception
a) 5 years
b) 6 years
When the coil threads cannot be seen or palpated, what 1st line investigation is required?
US
After female sterilisation, how long is alternative contraception required?
Until the next menstrual period - as an ovum may have already reached the uterus during that cycle, ready for fertilisation.
What is involved in a vasectomy?
This involves cutting the vas deferens, preventing sperm travelling from the testes to join the ejaculated fluid. This prevents sperm from being released into the vagina, preventing pregnancy.
After male sterilisation, how long is alternative contraception required?
What is required before a vasectomy can be relied upon for contraception?
2 months after
Testing of the semen to confirm the absence of sperm is necessary before it can be relied upon for contraception.
Semen testing is usually carried out around 12 weeks after the procedure, as it takes time for sperm that are still in the tubes to be cleared. A second semen analysis may be required for confirmation.
How long after taking EllaOne (ulipristal acetate) must you wait before taking COCP/POP?
5 days
What are the 2 major contraindications with ulipristal acetate?
1) breastfeeding
2) severe asthma
How long should breastfeeding be avoided after taking ulipristal acetate?
1 week - milk should be expressed and discarded
How soon after unprotected sex should the copper coil be inserted?
5 days within UPSI or up to 5 days after estimated date of ovulation
What dose of levonorgestrel is given as emergency contraception?
1.5mg single dose (3mg if BMI >26)
Mx of all patients with 2ary dysmenorrhoea?
Refer to gynae for further investigations
What is offered 1st line in the mx of dysmenorrhoea?
NSAIDs - inhibit prostaglandin synthesis (one of the main causes of dysmenorrhoea)
When is cervical ectropion more common?
- during pregnancy
- on COCP
How long after fitting a Mirena coil does it take to become effective?
7 days
Stepwise mx of PMS?
1) Lifestyle e.g. sleep, exercise, smoking, alcohol, regular, frequent (2-3 hourly), small, balanced meals rich in complex carbohydrates
2) COCP (w/ drospirenone)
3) SSRI (severe symptoms) - can be taken continuously or just during luteal phase)
What contraceptive methods are indicated in transgender men (assigned female at birth) who are undergoing testosterone therapy?
IUD or barrier (no hormones as would interact with testosterone)
What type of bacteria is chlamydia trachomatis?
Gram negative obligate intracellular bacteria
How can chlamydia present in a newborn? (2)
1) Pneumonia
2) Neonatal conjunctivitis (ophthalmia neonatorum)
What 2 types of swabs are used in sexual health testing?
1) Charcoal swabs
2) Nucleic acid amplification test (NAAT) swabs
What is NAAT testing used to test specifically for?
(2)
1) Chlamydia
2) Gonorrhoea
In women, a NAAT can be performed on what 3 methods of sample collecting?
1) Vulvovaginal swab (a self-taken lower vaginal swab)
2) Endocervical swab
3) First-catch urine sample
The order of preference is endocervical, vulvovaginal, and then urine.
If gonorrhoea is suspected or demonstrated on a NAAT test, what happens next?
An endocervical charcoal swab is required for microscopy, culture and sensitivities.
1st line management for uncomplicated chlamydia?
Doxycycline (oral) 100mg 2x a day for 7 days
Contraindications for doxycycline in treatment of chlamydia?
(2)
1) Pregnancy
2) Breastfeeding
Alternatives options for doxycycline in treatment of chlamydia incases of pregnancy/breastfeeding?
Macrolides e.g. erythromycin
When is a test of cure recommended for chlamydia?
(3)
1) rectal cases
2) in pregancy
3) symptoms persist
What is Lymphogranuloma venereum (LGV)?
A condition affecting the lymphoid tissue around the site of infection with chlamydia.
Caused by a serotype of Chlamydia trachomatis.
Who does LGV most commonly present in?
MSM presenting with anal discharge and pain, or anyone presenting with rectal chlamydia.
Management of LGV?
Requires longer (21 days) course of Abx
What is a crucial differential diagnosis of Chlamydial Conjunctivitis and should always be tested?
Gonococcal conjunctivitis –> can result in severe complications such as vision loss if the bacteria penetrate further and cause corneal ulceration and scarring
What type of bacteria is Neisseria gonorrhoeae?
Gram -ve diplococcus
Why should a standard charcoal endocervical swab also be taken from the symptomatic area in all patients with symptoms of gonorrhoea?
This is to test for sensitivities and monitor patterns of antimicrobial resistance.
NAAT just tests for the presence of the bacteria.
1st line management for gonorrhoea?
IM injection 1g ceftriaxone
what class of antibiotic is ceftriaxone?
cephalosporin
what class of antibiotic is cirpofloxacin?
fluoroquinolone
Why should ALL patients with gonorrhoea have a follow up ‘test of cure’ 2 weeks after treatment?
given the high abx resistance
Causative organism of syphilis?
Treponema pallidum
What is the incubation period of syphilis (i.e. time from inital infection to symptom presentation)?
Approx 21 days
What type of bacteria is Treponema pallidum?
Spirochete
Congenital syphilis (i.e., present from birth) can be broken down into two stages.
What are these?
Early congenital –> presents in those <2 y/o
Late congential –> presents in those >2 y/o
How does PRIMARY syphilis present?
Development of an indurated painless ulcer (chancre) on the genitals.
How does secondary syphilis typically present?
Widespread non-pruritic maculopapular rash (if involving the soles and palms, is almost pathognomonic for syphilis)
Condylomata lata (grey wart-like lesions around the genitals and anus)
Low-grade fever
Lymphadenopathy
Alopecia (localised hair loss)
Oral lesions
What rash is almost pathognomonic for syphilis?
Widespread non-pruritic maculopapular rash involving palms and soles
When does tertiary syphilis occur?
occurs >2 years following infection
Features of 3ary syphilis?
- Gummatous lesions (gummas are granulomatous lesions that can affect the skin, organs and bones)
- Aortic aneurysms
- Neurosyphilis
What is Argyll-Robertson pupil? What is it found in?
A specific finding in neurosyphilis.
It is a constricted pupil that accommodates when focusing on a near object but does not react to light.
They are often irregularly shaped.
What is the mainstay of diagnosis of syphilis?
Serology
In patients with lesions, how can syphilis be diagnosed?
syphilis PCR swab of the lesion
What is the window period of syphilis?
12 weeks
Testing should be repeated at least 12 weeks after last exposure
1st line pharmacological management of syphilis?
Single deep IM dose of benzathine benzylpenicillin
What is a Jarisch-Herxheimer reaction?
A Jarisch-Herxheimer (JH) reaction can occur following the initial treatment of syphilis in some patients.
This phenomenon causes a sepsis-like picture due to the release of toxins from treponemal bacterium breakdown.
Which sensory nerve ganglia is affected in genital herpes?
Sacral nerve ganglia
How should a PCR swab of HSV lesion be taken?
The lesion should be BURST and a swab taken from the BASE of the ulcer.
Lesions must be present for HSV testing to occur.
When is the risk of neonatal HSV increased?
If mother becomes infected in 3rd trimester
What should be excluded if genital wart lesions appear atypical or suspicious?
Oncogenic HPV type
What risk factor is known to increase the risk of genital wart recurrence?
Smoking
Topical treatments for genital warts?
1) Topical podophyllotoxin (Warticon® and Condyline®)
2) Topical imiquimod (patients should be made aware that this damages condoms)
What are some physical ablation therapy options for genital warts?
1) Cryotherapy
2) Surgical excision
What is trichomoniasis?
STI caused by a parasite/protozoan - (Trichomonas vaginalis)
How is vaginal discharge typically described in trichomoniasis?
Frothy and yellow-green, although this can vary significantly. It may have a fishy smell.
What can examination of the cervix in trichomoniasis reveal?
Strawberry cervix
Vaginal pH in trichomoniasis?
Raised pH (>4.5)
Where should swabs for trichomoniasis be taken from in women?
Posterior fornix of vagina (behind cervix)
Management of trichomoniasis?
Metronidazole
How long should alcohol be avoided for following treatment with metronidazole?
72h
What bacteria can cause non-gonococcal urethritis?
Mycoplasma genitalium
what is the gold standard for diagnosis of mycoplasma genitalium?
NAAT
1st line management of uncomplicated Mycoplasma genitalium?
1) Doxycycline 100mg twice daily for 7 days
2) Followed by azithromycin 1g as a single dose then 500mg daily for 2 days
What human cells does HIV infect?
CD4+ helper cells
What are the 2 types of HIV?
HIV-1 (most common)
HIV-2 (mainly found in west africa)
What is the protein on the surface of HIV that binds to CD4+?
gp120
What CD4+ cell countis sufficient for a diagnosis of AIDS?
<200
Give some examples of AIDS-deining illnesses
1) Kaposi’s sarcoma
2) PCP
3) CMV infection
4) Candidiasis
5) Lymphomas
6) TB
7) Hairy leukplakia
What is the treatment aim of ART in HIV? (2)
1) undetectable viral load
2) normal CD4+ count
When must PEP be commenced after HIV exposure?
within 72h
What is the most common life-threatening opportunistic infection in AIDS?
Pneumonia
Which mode of delivery is used in mothers with the following HIV viral loads:
a) under 50 copies/ml
b) over 50 copies/ml
c) over 400 copies/ml
a) vaginal
b) consider a pre-labour c-section
c) pre-labour c-section is recommended
What is given as an infusion during labour and delivery if the HIV viral load is unknown or above 1000 copies/ml?
IV zidovudine
when is IV zidovudine given during labour and delivery?
if viral load is unknown or >1000
Can HIV be transmitted during breastfeeding?
Yes
ALWAYS avoid breastfeeding
Investigation window period for chlamydia?
2 weeks
When is a test of cure for gonorrhoea recommended?
Pregnancy
Discharge in men in gonorrhoea vs chlamydia?
Gonorrhoea - urethritis +/- yellow discharge
Chlamydia - urethral discharge typically clear/white
What are the 2 most common causes of non-gonococcal urethritis?
1) Chlamydia trachomatis
2) Mycoplasma genitalium
Does urethral discharge always need investigation?
Yes
What symptom typically accompanies a chancre?
Local lymphadenopathy
Management of late latent, CVS and gummatous syphilis?
Benzathine penicillin IM for 3 weeks
Length of aciclovir treatment in herpes in primary vs recurrent infection?
Primary - 10 days
Recurrent - 3 days
What systemic symptoms can initial infection with herpes cause?
- dysuria
- myalgia
- flu like
- fever
- malaise
What triad is seen in disseminated gonococcal infection?
1) tenosynovitis
2) migratory polyarthritis
3) dermatitis
What investigation is standard for diagnosis and screening of HIV?
Combination HIV p24 antigen and HIV antibody test
What is acute epididymo-orchitis in sexually active younger adults most commonly caused by?
Chlamydia
Investigation of choice in genital herpes?
NAAT tests
What determines the risk of HIV transmission following a needle stick injury?
Viral load (higher load = higher risk)
mx of genital warts:
1) multiple, non-keratinised warts
2) solitary, keratinised warts
1) topical podophyllum
2) cryotherapy
What is the most common and important viral infection in solid organ transplant recipients?
CMV
Most common cause of epididymo-orchitis in individuals with a low STI risk (e.g. married male in 50s, wife only partner)?
E. coli (enteric organisms)
Mx of herpes if contracted during 3rd term?
Oral aciclovir 400 mg TDS (three times daily) until delivery
IV aciclovir for the mother or for the infant is only recommended if there has been a PPROM or a spontaneous vaginal delivery in the presence of a 1ary herpes infection.
Which type of pneumonia typically causes desaturation on exertion and a normal CXR?
PCP
What is the component of the healthy vaginal bacterial flora?
Lactobacilli (produce lactic acid –> keep pH low)
What is the ideal pH of the vaginal canal?
3.8 - 4.5
What anaerobic bacteria causes BV?
Gardnerella vaginalis
At what vaginal pH does BV occur?
> 4.5
What is the most likely cause of discharge changes in post-menopausal women?
Atrophic vaginitis (reduction in oestrogen causes irritation)
Describe discharge & odour in
a) BV
b) Candida
c) Trichomonias vaginalis
a) thin & watery, fishy
b) thick & white, no odour
c) green & frothy, fishy
Describe vulval irritation in
a) BV
b) Candida
c) Trichomonias vaginalis
a) nil
b) itching, irritation & pain
c) itching, soreness & dysuria
Describe vaginal pH in
a) BV
b) Candida
c) Trichomonias vaginalis
d) Physiological
a) >4.5
b) <4.5
c) >4.5
d) <4.5
What is seen on microscopy in BV?
‘Clue cells’ - epithelial cells from the cervix that have bacteria stuck inside them, usually Gardnerella vaginalis.
A diagnosis of BV can be made based on bedside investigations using what 2 criteria?
1) Amsel criteria
2) Hay/Ison criteria
What are the Amsel criteria?
1) Homogeneous discharge on clinical examination
2) Microscopy showing clue cells
3) Fishy odour on adding 10% potassium hydroxide to vaginal fluid
4) Vaginal pH >4.5
What is the Abx of choice in treating BV?
Metronidazole (specifically targets anaerobic bacteria)
Complications of BV?
Higher risk of STIs
what hormonal changes can increase risk of candidiasis?
Increased oestrogen e.g. pregnancy
What antifungal agent is present in topical antifungal creams & vaginal pessaries for candidiasis?
Clotrimazole
What antifungal agent is present in oral medications for candidiasis?
Fluconazole
Contraindications of oral antifungal tablets for candidiasis?
pregnant women, women at risk of pregnancy, and breastfeeding women.
What is Fitz-Hugh-Curtis Syndrome?
A complication of PID (10%).
Caused by inflammation and infection of the liver capsule (Glisson’s capsule), leading to adhesions between the liver and peritoneum.
Presentation –> RUQ pain that can be referred to the right shoulder tip if there is diaphragmatic irritation.
What may Fitz-Hugh-Curtis Syndrome be confused with?
Cholecystitis
When are antibiotics started in PID?
Empirically
A typical outpatient regime for PID:
Combination of:
1) Doxycycline
2) Metronidazole
3) Ceftriaxone
What should you always look for signs of in PID?
Sepsis !
In which cases of PID require admission for IV Abx?
1) sepsis
2) pregnancy
1st line for mx of non-pregnant women with thrush?
Single dose of oral fluconazole
Mx of BV in pregnant women?
Oral metronidazole (low dose) for 7 days
What is chancroid?
A tropical disease caused by Haemophilus ducreyi.
It causes painful genital ulcers associated with unilateral, painful inguinal lymph node enlargement.
Features of chancroid?
- painful genital ulcers
- unilateral inguinal lymph node enlargement
- ulcers have sharply defined, ragged, undermined border
When should a positive HIV test be repeated?
Around 12 weeks time
Start antiretroviral therapy in the meantime
