Sexual and reproductive health Flashcards
What is the treatment of candida (thrush)?
Topical imidazoles e.g. clotrimazole (Canesten) or oral fluconazole.
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.
What causes bacterial vaginosis?
When normal lactobacilli are overgrown by a mixed flora containing anaerobes, Gardnerlla or Mycoplasma hominis.
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
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.
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
How does gonorrhoea normally present in women?
Commonly asymptomatic Vaginal discharge Urethritis Bartholinitis Cervicitis Pelvis commonly affected
What are systemic complications of gonorrhoea?
Bacteraemia
Acute, usually monoarticular, septic arthritis
What investigations should be done for suspected gonorrhoea?
Culture of endocervical swabs
NAAT test, followed by cultures for abx sensitivities
What is the treatment of gonorrhoea?
IM ceftriaxone (or oral cefixime) Partner notification and treatment
How are genital warts (HPV) treated?
Topical podophyllin and imiquimod cream
Cryotherapy or electrocautery
HPV vaccine may be protective
What are the complications of herpes infection?
Secondary bacterial infection
Aseptic meningitis
Acute urinary retention
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.
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.
What are the symptoms of Trichomoniasis (TV)?
Offensive grey-green discharge Vulval irritation Superficial dyspareunia Cervicitis (punctate erythematous, strawberry like appearance) Can be asymptomatic
How is TV diagnosed?
Wet film microscopy
Staining or culture of vaginal swabs
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.
