Sexual and reproductive health Flashcards by Shirley Yick

What is the treatment of candida (thrush)?

Topical imidazoles e.g. clotrimazole (Canesten) or oral fluconazole.

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What are the typical symptoms of thrush?

A cottage cheese discharge with vulval irritation and itching. There may be superficial dyspareunia and dysuria. The vagina and vulva are inflamed and red.

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What causes bacterial vaginosis?

When normal lactobacilli are overgrown by a mixed flora containing anaerobes, Gardnerlla or Mycoplasma hominis.

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How is BV diagnosed?

Raised vaginal pH.
Positive “whiff” test - fishy odour when 10% KOH is added to the secretions
Presence of “clue cells” - epithelial cells studded with Gram-variable coccobacilli on microscopy

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What are the possible complications of BV and how can it be treated?

Can cause PID or preterm labour.

Treat with metronidazole or clindamycin cream.

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What are the complications of chlamydia infection?

Pelvic infection leading to tubal damage, subfertility and chronic pelvic pain.
Reiter’s syndrome - uveitis, conjunctivitis and arthritis

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How does gonorrhoea normally present in women?

Commonly asymptomatic
Vaginal discharge
Urethritis
Bartholinitis
Cervicitis
Pelvis commonly affected

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What are systemic complications of gonorrhoea?

Bacteraemia

Acute, usually monoarticular, septic arthritis

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What investigations should be done for suspected gonorrhoea?

Culture of endocervical swabs

NAAT test, followed by cultures for abx sensitivities

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What is the treatment of gonorrhoea?

IM ceftriaxone (or oral cefixime)
Partner notification and treatment

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How are genital warts (HPV) treated?

Topical podophyllin and imiquimod cream
Cryotherapy or electrocautery
HPV vaccine may be protective

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What are the complications of herpes infection?

Secondary bacterial infection
Aseptic meningitis
Acute urinary retention

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How does primary or secondary syphilis present?

Primary syphilis - a solitary painless vulval ulcer (chancre).
If untreated, secondary syphilis may develop weeks later, often with a rash, influenza-like symptoms and genital/peri-oral growth. This may be followed by latent syphilis.

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What investigations should be done for suspected syphilis and how is it treated?

Enzyme immunoassay and VDRL tests.

Treatment at all stages is IM penicillin.

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What are the symptoms of Trichomoniasis (TV)?

Offensive grey-green discharge
Vulval irritation
Superficial dyspareunia
Cervicitis (punctate erythematous, strawberry like appearance)
Can be asymptomatic

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How is TV diagnosed?

Wet film microscopy

Staining or culture of vaginal swabs

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What are the risk factors for HIV infection?

Multiple sexual partners
Migration from high prevalence countries (esp. Sub-Saharan Africa)
Failure to use barrier contraception
Presence of other STIs
IV drug use
Sexual contact with high risk males
Blood product transfusion

What does sexual health screening for women involve?

Swabs taken from vagina - endocervical for chlamydia and gonorrhoea, posterior fornix for TB & BV, group B strep, and candida.
A fresh urine sample is also requested.
For both men and women, blood tests will be offered for syphilis and HIV.

What does sexual health screening for men involve?

Fine swabs from urethra for gonorrhea and non-specific urethritis. Fresh urine sample for chlamydia.
Some people may be offered a test for HepB and HepC. Gay and bisexual men will be offered HepB vaccination.

What methods of emergency contraception are available?

The morning after pill. There are two varieties. Levonell contains a single 1.5mg dose of levonorgestrel and is best taken within 24 hours and no later than 72 hours after intercourse. It affects sperm function, endometrial receptivity and may prevent follicular rupture. Vomiting and menstrual disturbances may occur in following cycle.

Ullipristol (ellaOne) - selective progesterone receptor modulator which prevents ovulation and may affect implantation. It can be used up to 120 hours afterwards. It reduces the effectiveness of progesterone containing contraceptives.

Mirena coil if inserted within 5 days of ovulation.

What routine tests should be done before termination of pregnancy?

FBC, blood group and rhesus status
If clinically indicated, HIV, HBV, HCV and haemoglobinopathies and cervical smear
Screening for chlamydia

What is the preferred method of termination <7 weeks gestation?

Medical - using mifepristone plus a prostaglandin e.g. misoprostol is the most effective method of abortion and can also be used for gestations 7-9 weeks.

What methods of termination are available at 7-13 weeks gestation?

Surgical - suction termination

Medical - mifepristone and prostaglandin

What methods of termination are available >15 weeks?

Medical TOP is the most usual and effective method at 13-24 weeks. Beyond 21 weeks, feticide via injection of KCI should be considered.
Surgical dilatation and evacuation is also possible >15 weeks with skilled practitioners. Cervical preparation may be beneficial.

What re the complications of TOP?

``` Haemorrhage Infection Uterine perforation Cervical trauma Failure of TOP Multiple surgical abortions are associated with an increased risk of subsequent preterm delivery Psychological sequelae are common ```

What is the differential diagnosis for IMB and irregular menstruation?

Anovulatory cycles in early and late reproductive years Pelvic pathology e.g. fibroids, uterine and cervical polyps, chronic pelvic infection, adenomyosis and ovarian cysts. In older women, particular if there has been a recent change, malignancy should be considered.

What investigations should be done for IMB?

Speculum and bimanual, cervical smear Bloods - Hb, clotting, TFTs TVUS for endometrial thickness, uterine fibroids, ovarian masses and large intrauterine polyp.

When should an endometrial biopsy be taken for IMB?

If endometrial thickness >10mm or a polyp is suspected, or if a woman is >40 with recent onset menorrhagia or IMB or has not responded to treatment.

What is the differential for PCB?

Cervical carcinoma Ectropion Cervical polyps Cervicitis, vaginitis

What is the clinical definition of menorrhagia?

Excessive menstrual loss that interferes with the woman's physical, emotional, social and material quality of life. Objectively, it's a blood loss of >80ml.

What are the causes of menorrhagia?

The majority of women with menorrhagia have no histological abnormality that can be implicated. Uterine fibroids Polyps Chronic pelvic infection Ovarian tumours Endometrial and cervical malignancy Rare: thyroid disease, haemostatic disorders

What treatments are available for menorrhagia?

First line medical treatment: Mirena coil - reduces menstrual flow by >90%. Second line: tranexamic acid (antifibrinolytics) and NSAIDs Third line: Progestogens and GnRH antagonists Surgical options include polyp removal, endometrial ablation, myomectomy, hysterectomy and uterine artery embolisation.

What is the average age of menopause in the UK?

50.5 years

What risk factors are there for premature ovarian failure?

Autoimmune disease Down's syndrome Turner's syndrome

How is menopause diagnosed biochemically?

Age >50 with FSH >30 IU/dl | Age <50 - 2 readings required

What are common problems of menopause?

Vasomotor symptoms - hot flushes ad night sweats Cardiovascular disease Urogenital problems - oestrogen deficency can cause vaginal atrophy, urinary problems (frequency, nocturia, urgency, incontinence) Sexual problems including loss of libido and dyspareunia Osteoporosis

What is the differential for PMB?

``` Endometrial carcinoma Endometrial hyperplasia, atypia and polyps Cervical carcinoma Atrophic vaginitis Cervicitis ovarian carcinoma Ovarian polyps ```

How should PMB be investigated?

Bimanual and speculum Cervical smear Transvaginal US If endometrium is equal to or greater than 4mm, or if there have been recurrent bleeds, endometrial biopsy and hysteroscopy may be required.

What is endometriosis?

The presence of endometrium outside the uterine cavity.

What are common features of endometriosis?

``` Pelvic pain and dysmenorrhoea Pain preceding menstruation which eases during bleeding Deep dyspareunia Subfertility Alterations in bowel habit (if in bowel) Haematuria (if in urinary tract) ```

How may endometriosis be managed?

Conservatively - simple analgesia, support groups Medical - to cause atrophy of the ectopic endometrium - COCP, progestogens, GnRH agonists combined with add back HRT Surgical - laparoscopic ablation and excision, TAH and BSO.