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Anna and louise > Sexual health > Flashcards

Sexual health Flashcards

1
Q

Contact tracing

- conditions required for

A 
Required for:
	- Chlamydia
	- Gonorrhoea
	- Trichomonas
	- Syphilis
	- Urethritis
	- PID (including pathogen unidentified)
	- Epididymo-orchitis (if STI related)
Not required for genital warts or herpes

Automatic lab-notifiable infections:

- HIV
- Syphilis
- Gonorrhoea
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2
Q

Clinical features of herpes

A

Signs tend to develop within 3-7 days of skin-to-skin contact with an infected person (range 2-20 days)

First outbreak is usually the most painful, may last longer than later outbreaks

Other signs:
- Fever
- Muscle aches
- Headaches, which may be severe
- Vaginal discharge or painful urination
- Swollen and tender lymph nodes in the groin
Women are more severely affected than men

Virus is shed from the infected area for a median of 11 days
Systemic and local symptoms last 2-3 weeks if untreated
- Oral Rx reduces the duration and intensity of symptoms

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3
Q

HSV incidence

A

Up to 23% of adults have HSV-2 antibodies

Prior HSV-1 means HSV-2 is less likely to be symptomatic

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4
Q

Treatment of HSV non-pregnant

A

Valaciclovir 500mg BD for 7 days
Aciclovir 400mg TDS for 7 days

All first episodes should be treated regardless of timing of onset of symptoms
Treat before waiting for HSV PCR results

Episodic treatment: Valaciclovir 500mg BD for 3 days
Suppressive: Valaciclovir 500mg OD
- Reduces recurrences by 70-80%

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5
Q

Chlamydia - what is it?

and clinical features

A

Chlamydia trachomatis
Obligate intracellular bacterium infects columnar and transitional epithelium

70% of females asymptomatic
- c.f. 50% of males

Reiters syndrome

  • Urethritis, arthritis and conjunctivitis
  • Triggered by chlamydia

Risk of ectopic pregnancy

  • No increased risk after single episode
  • RR 11 after three episodes of chlamydia
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6
Q

Treatment of chlamydia

A

Treat immediately if high index of suspicion
Azithromycin 1g po stat for asymptomatic urogenital infection
Doxycycline 100mg po BD for 7 days
- Not in pregnancy

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7
Q

Pregnancy and chlamydia

A

Conflicting results in prospective studies looking at impact on pregnancy

Neonates born to women with untreated chlamydia:

  • 50-60% will become colonised
  • up to 50% will develop conjunctivitis or chlamydia pneumonitis

Test of cure recommended in 3 weeks following completion of antibiotics

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8
Q

gonorrhoea

- what is it?

A

Neisseria gonorrhoeae
Gram negative diplococci

Infects the epithelium of the genitourinary tract, rectum, pharynx and eye
Acute infection can –> bacteraemia and disseminated disease (~1% of cases)
Bacteria can invade bloodstream and infects the skin, synovia and joints

Almost 40% are co-infected with chlamydia

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9
Q

Clinical features of gonorrhoea

A

Frequently asymptomatic In >50% of women
In males, usually symptomatic with urethritis >95%

Diagnose with NAAT swab
- High sensitivity
Endocervical swab useful for anti-microbial susceptibility testing

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10
Q

Treatment of gonorrhoea

A

Ceftriaxone 500mg IM stat PLUS azithromycin 1g po stat

Dual therapy is recommended to delay anti-microbial resistance to gonorrhoea

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11
Q

Pregnancy and gonorrhoea

A

Increased risk of:

- Preterm ROM
- Preterm birth
- Low birthweight

Increased risk of PP fever

Risk of postpartum infection which can be severe

  • Gonococcal ophthalmia neonatorum occurs in ~30% of exposed babies
  • Pharyngeal infection carries a higher risk of disseminated gonococcal infection
  • Disseminated infection - rare (<1%)
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12
Q

Trichomoniasis

- what is it?

A

Trichomonas vaginalis
Flagellated Protozoal infection
Co-infection with other STIs common
- 60-80% have co-existent BV

Incubation period: 4-28 days
10-15% of females asymptomatic

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13
Q

Treatment of trichomonas

A

> 90% effective
Metronidazole 2g po STAT

Treatment in pregnancy and breastfeeding: metronidazole 400mg BD for 7 days

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14
Q

Complications of trich

A

Increased risk of PP or post-STOP infections
Increases the risk of HIV acquisition and transmission
Increases the risk of PID in women with HIV

Associated with:

  • Preterm birth
  • Low birthweight
  • Premature ROM

Little neonatal morbidity is associated with maternal T. vaginalis

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15
Q

Risk factors of PID

A 
Age <30
Recent change in sexual contact
Multiple sexual contacts 
Previous STI
Vaginal 'douching' - 'Cleaning' the vagina by squirting water or vinegar >3x in 1 month --> 300% increase risk in PID
Smoking
Low SES
Recent IUCD insertion (within 4 weeks)
Lack of barrier contraception
Sex during or just after menstruation 
Recent uterine instrumentation or unplanned pregnancy
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16
Q

Complications of PID

A

TOA
Chronic pelvic pain
Ectopic pregnancy and tubal factor infertility
- Risk of ectopic pregnancy and infertility increases 6x after episode of PID, and further 17x after 2 episodes
Perihepatitis (Fitz-Hugh Curtis syndrome)
- RUQ pain
- Aminotransferases are usually normal or only slightly elevated
- 10% of women with acute PID

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17
Q

PID severe if:

A 
Acute abdomen
Pregnant - Rare in the absence of septic miscarriage 
Fever, vomiting, or systemically unwell
Intolerant of oral therapy
Clinical failure at review
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18
Q

Treatment of PID

  • IUD
  • Antibiotics
  • Pregnancy
A

High index of suspicion and low threshold for treatment

  • Short delays can markedly increase the risk of subsequent complications
  • Negative swabs do not exclude PID

Evidence suggests PID treatment outcomes are not affected by the presence of an IUD
Consider removal if:
- No improvement after 48-72h
- Removal requested by patient
- Actinomyces-like organisms on smear and has pelvic pain
Delay removal until ~24h into antibiotic therapy and consider ECP if unprotected sex in previous 7 days

Ceftriaxone 500mg IM stat + doxycycline 100mg po BD for 2 weeks + metronidazole 400mg po BD for 2 weeks

Alternative:
Ceftriaxone 500mg IM stat + azithromycin 1g po stat and repeat in 1 week if poor compliance likely
Pregnancy:
Ceftriaxone 500mg IM stat + azithromycin 1g stat and 1 week later + metronidazole 400mg po BD for 2 weeks

Severe:
- Cefoxitin 2g IV q6h or Cefuroxime 1.5g IV q8h
+ metronidazole + doxycycline

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19
Q

Follow up of PID

A

Review 1 week after completion of treatment to ensure resolution (GP)
No sex for 1 week following treatment
Outpatient management
- If no significant improvement in 72h, refer to hospital
- Further f/u at 2-4 weeks to assess:
○ Response to treatment
○ Reiterate importance of screening for STIs
○ Check compliance

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20
Q

pH of physiological discharge

what’s in a healthy vagina?

A

Fluctuating and dynamic
pH 3.8-4.5

lactobacilli predominant organisms

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21
Q

Signs of BV

and typical organisms

A

Often asymptomatic
Thin watery discharge
Symptoms more noticeable following menstruation or intercourse

No lactobacilli present - Normally an acid producing bacteria
Typical organisms:
- Gardnerella
- Mobiluncus species (present in 50-70%)
- Mycoplasma hominus (present in 60-70%)
-Prevotella species
- pretostreptococcus

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22
Q

Amsel’s criteria

A

3 out of 4 to diagnose BV:

- Offensive vaginal discharge
- Vaginal pH >4.5 (alkaline)
- Positive amine ("whiff") test with KOH
- Clue cells on microscopy of wet film
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23
Q

Recurrent BV treatment

A

Longer term Metronidazole gel twice weekly for 16 weeks after initial 10 days of treatment
Treat partner
Suppressive clindamycin cream - can lead to secondary fungal infections
Identify triggers - E.g. douching

Attempts to colonise with exogenous Lactobacillus crispatus

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24
Q

Pregnancy

and BV

A 
15% of pregnant women have BV
	- Most are asymptomatic 
Associated with:
	- Preterm rupture of membranes
	- Preterm birth
	- Low birthweight 
	- Postpartum infection
Increased risk of complications the earlier in pregnancy the condition occurs 
Cochrane review found overall treatment does not reduce complications compared to no treatment or placebo
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25
Candida incidence
Vaginal candida colonisation 10-20% asymptomatic women Pregnancy 20-40% 90% Candida albicans
26
Recurrent vulvovaginal candida
4+ episodes in 12 months (proven microbiologically on 2+ episodes) <5% of women Fluconazole 150mg for 3 doses at 3 day intervals - Follow with 100-150mg weekly for 6 months Review contraception - linked to increased oestrogen Exclude underlying medical comorbidity
27
LARC use
14.3% of women of reproductive age globally use IUC | LARC uptake in Au and NZ lags behind other similar countries
28
Advantages to LARC
Less chance of unintended pregnancy compared to user-dependent methods Most effective, reversible methods available High rates of user satisfaction High continuation rates Few contraindications 'Fit and forget' methods that do not require daily adherence Require fewer visits to health care providers Cost effective Suitable for women of all ages including young nulliparous women Safe for nulliparous or parous women and adolescents Do not affect fertility after removal Some methods have non-contraceptive benefits, e.g. reduced HMB and pain for Mirena
29
Barriers to use of LARC
Lack of accurate knowledge among providers and women about LARC methods Insufficient training in insertion and removal, and management of complications Lack of appropriate remuneration for these procedures in GP (Au) Misperceptions about the risks of infection and infertility, concerns about potential side effects Lack of information designed for specific audiences - E.g. low literacy, low income, culturally and linguistically diverse backgrounds
30
Pearl index
the number of contraceptive failures per 100 women-years of exposure
31
typical and perfect use failure rate - Mirena - Cu IUD
LNG-IUS: 0.20% for both CuIUD: 0.8%
32
Hormone and dose of Mirena | Mechanism of action
52mg levonorgesterel Releases daily intrauterine dose of 20 mcg/24h Causes endometrial changes, including atrophy Thickens cervical mucus preventing sperm penetration Prevents or delays ovulation in some users Inhibits sperm migration to the upper genital tract Inhibits ovum transport Prevents implantation
33
Mirena Contraindications
``` UKMEC4 Current breast cancer PP sepsis GTD persistently elevated HCG levels or malignant disease PID current ``` ``` UKMEC3 ischaemia heart disease Stroke Cirrhosis Known long QT syndrome (initiate) Uterine fibroids with distortion of the uterine cavity ```
34
Timing of insertion and when becomes effective Mirena
Any time that pregnancy can be confidently excluded Becomes effective Up to 7 days after insertion
35
Side effects of mirena
``` Bleeding changes - May be a/w unscheduled bleeding particularly in the first 5 months Moods changes / depression Acne Hirsutism Breast pain ``` Pelvic infection - 1 in 300 in first 20 days - Often due to unrecognised STI Uterine perforation : 1.4 per 1000 insertions - Breastfeeding (6x increased risk) - First 6 months PP - Previous CS delivery
36
IUD and actinomyces
If asymptomatic, don't need to remove If pelvic pain present with ALO on smear, consider other infective causes and do formal culture for Actinomyces - Israeli = bad, needs removal - If confirms Actinomyces, remove IUD - D/w ID
37
Pregnancy with IUD in situ
Determine gestation Exclude ectopic with USS IUD should where possible be removed immediately - A/w small increased risk of miscarriage but higher if IUD left in situ - 50% risk of spontaneous miscarriage and an increased incidence of placenta problems (e.g. APH, TPTL, adherent placenta) If >12/40 refer to specialist for management
38
Evidence for analgesia for IUD insertion
Evidence supporting benefit of: - Naproxen - 10% lidocaine spray - EMLA 5% - Tramadol 1h pre insertion has been shown to be more effective at pain reduction than naproxen or placebo No evidence supporting benefit of: - Lignocaine 2% gel - Ibuprofen - Misoprostol No RCT evidence to suggest that cervical cleansing prior to IUD insertion reduces subsequent pelvic infection
39
Outcomes of Mirena
In Australia, continuation rates at 3y - 77% After 1y - 71-95% reduction in menstrual blood loss ~50% of women have amenorrhoea - 65% have amenorrhoea or light bleeding after the first year of use Return to fertility - Pregnancy rate at 1y is similar to those who do not use contraception
40
Copper IUD - mechanism of action
Copper ions adversely affect sperm motility Inhibits sperm migration to the upper genital tract Inhibits ovum transport Prevents implantation Becomes effective immediately
41
Disadvantages / side effects of copper IUD
heavier and more prolonged menses - Increases the duration and amount of menstrual bleeding, resulting in ~50% greater blood loss acute or recurrent vulvovaginal candida Can be associated with BV Early menstruation cycle following insertion Continuation at 3y 61.3%
42
Jadelle mechanism of action
Two silicone rods, each containing 75mg of levonorgestrel Prevents or interferes with ovulation Thickens the cervical mucus Prevents sperm penetration
43
Contraindications for jadelle
Only absolute contraindication is current breast cancer Risks of use outweigh benefits with: - Severe cirrhosis - Unexplained vaginal bleeding - PMHx of breast cancer
44
Side effects of jadelle
``` Change in normal menstrual bleeding pattern Other frequent side effects: - Mood swings - Weight gain - Headache - Acne - Mood changes - Loss of libido ``` Pregnancy that does occur may be more likely to be ectopic Implant migration
45
Outcomes for jadelle
1 in 5 women experience amenorrhoea 1 in 4 experience frequent or prolonged bleeding At 3y - continuation 53%
46
Typical and perfect use of jadelle
0.05% for both
47
Depo provera mechanism of action
Depot medroxyprogesterone acetate (DMPA) 150mg IM injection Inhibits ovulation Alters cervical mucous to limit sperm penetration Causes changes to the endometrium which are unfavourable for implantation
48
Contraindications for depo provera
Women who wish to become pregnant in the near future Women >50y Women at particular risk of osteoporosis Don't use as first-line option in women <18y (yet to reach peak bone mass) (UK MEC 2) UKMEC4 - current breast cancer
49
Side effects of depo provera
Weight gain - Particularly in adolescents with BMI >30 - Women who gain >5% of baseline body weight in first 6 months are likely to continue to experience weight gain Irregular bleeding Small decrease of bone mineral density which is usually recovered on discontinuation Return to fertility - Unpredictable but temporary delay - Up to 1 year
50
Failure rate of depo provera
Perfect use - 0.2% | Typical use 6%
51
Hormones in COCP
``` Contain ethinylestradiol (EE), oestradiol valerate, or oestradiol and one of a range of progestogens - In NZ, all contain EE ``` Older progestogens - Levonorgestrel or norethisterone New progestogens - have less androgenic side effects - cyproterone acetate, drosperidone, etonogestrel Monophasic - all active tablets have an identical formulation Multiphasic - there are two or more formulations within the active pills First line (RANZCOG) - monophasic COCP with LNG or norethisterone
52
Mechanism of action of COCP
Primary mechanism: prevention of ovulation Thickens cervical mucus, preventing sperm penetration Alters the endometrium, making it atrophic and unreceptive to implantation
53
Efficacy | of COCP
One year (RANZCOG): Perfect use 99.7% Typical use 91% failure rate 9% typical 0.3% perfect
54
Contraindications to COCP
``` UKMEC4 Smoking 15+/day and >35y HTN >160/100 Impaired cardiac function / AF IHD Stroke Current breast cancer Positive antiphospholipid antibodies Migraine with aura Severe cirrhosis PP 0-6 weeks and BF ``` ``` UKMEC3 Carrier of known gene mutations a/w breast Ca (e.g. BRCA) Past breast cancer Complicated diabetes BMI >35 ```
55
Advantages of COCP
Very effective with correct use Readily accessible to most women Easily reversible Ability to manipulate cycles Can be used to manage menstrual problems Can improve acne Can reduce the risk of endometrial and ovarian cancer Can reduce the risk of bowel cancer Can be used to manage PMS and PMDDn Can reduce the incidence of functional ovarian cysts and benign ovarian tumours Can be useful in managing PCOS symptoms Can assist with management of perimenopausal symptoms
56
Side effects
Minor hormonal side effects, e.g. nausea, fluid retention, weight gain, breast tenderness VTE risk - due to oestrogen-induced effect on clotting factors - Absolute risk is low - Increased with 30-35 ug EE pills with desogestrel, gestogene, CPA and drosperinone (compared to LNG or norethisterone) Increased risk of arterial disease - in the presence of other risk factors Interactions with some drugs causes reduction of efficacy Concomitant illness - e.g. vomiting and diarrhoea can affect absorption and reduce efficacy Small increase in risk of cervical cancer
57
Newer progestogens in COCP + VTE risk
oestrogen-induced effect on clotting factors (increased FVIII and X, and fibrinogen) desogestrel, gestogene, CPA and drosperinone - diuretic effect causes haemoconcentration
58
Drosperidone beneficial effects
4th generation progestogen Diuretic effect - Weight loss - Drop in BP - Useful in premenstrual bloating Anti-androgenic effect by increasing SHBG - Reduces acne, hirsutism
59
Mechanism of action of POP
Alteration of the cervical mucous --> thicker and less penetrable to sperm Also effect on tubal motility and endometrium - Making fertilisation and implantation less likely Cerazette (desogestrel-based pill) prevents ovulation in 97%
60
Contraindications for POP
Sensitivity or side effects to progestogens Pregnancy Undiagnosed vaginal bleeding Breast cancer
61
Failure rate of POP
typical use: 9% | perfect use: 0.3%
62
Failure rate of male condom
Typical use: 18% Perfect use: 2%
63
What are the natural family planning methods
The calendar method - rhythm method - Based solely on the length of the menstrual cycle and the lifespan of sperm in the female genital tract (5-7 days) Basal body temperature method - body temperature rises after ovulation Billings method - Ovulatory mucus - Cervical mucous becomes clear and elastic 6 days prior to ovulation - After ovulation, mucous becomes thick, sticky and opaque Cervical palpation method
64
Natural family planning | - pros and cons
ADVANTAGES May be the only option for couples with certain religious or cultural beliefs Not medical - no need to visit clinics Makes women aware of their ovulation cycle and natural fertility Can enhance communication and cooperation within a relationship DISADVANTAGES Removes spontaneity There is variation in length of the follicular phase of the menstrual cycle which can introduce inaccuracies in ovulation prediction The reliability of fertility awareness methods is likely to be reduced during breastfeeding, when discontinuing hormonal methods or during the perimenopause
65
Criteria for lactational amenorrhoea (LAM)
<6 months postpartum Amenorrhoeic (no bleeding after 56 days PP) Fully breastfeeding
66
Outcomes of LAM
Increased risk of pregnancy if: - Frequency decreases (e.g. through stopping night feeds, supplementary feeding, pacifier use, expressing milk) - >6 months - Menstruation returns Pregnancy rates at 6 months: - Range from 0.45-7.5%
67
Physiology of LAM
Infant suckling --> reduction of pulsatile secretion of GnRH and LH --> suppresses ovarian activity High levels of prolactin inhibit oestrogen secretion and ovulation at the level of the hypothalamic-pituitary axis and LAM is 98% effective if all criteria area met
68
IUD insertion post-partum
Do within first 48h After 48h, delay until 28 days Contraindications: increased risk of bleeding or infection Does not seem to increase the risk of infection Perforation risk seems to be low - Possibly due to the thickened myometrium at delivery Overall continuation rate at 6 months is not affected by timing of insertion It is also cost-effective compared to interval insertion which is associated with high rates of non-attendance There is an increase in the expulsion rate following vaginal PPIUC insertion compared to delayed insertion (approximately 1 in 7 compared to 1 in 20)
69
COCP and breastfeeding
Don't use within first 6 weeks if risk factors for VTE Individual papers suggest risk of slow infant weight gain if COCP initiated prior to 6/52 but not after Cochrane review 2015 - no difference in duration of breastfeeding, composition of breast milk or infant growth and development If not breastfeeding and no additional risk factors for VTE, wait until 21 days before starting
70
Hormones in ECP | - timing
Hormone and dose LNG - Levonorgestrel - icensed up to 72h (3d), may have some efficacy up to 96h (4d) UPA - Ulipristal acetate 30mg - greatest efficacy within 24h of UPSI - effective for up to 120h (5d)
71
Pregnancy rate if taken within 120h for ECP
LNG 2.2% UPA 1.4%
72
Disadvantages of ECP
Liver enzyme inducing medications reduce efficacy - CuIUD recommended instead - If patient declines, double LNG dose (3mg) LNG reduced efficacy if obese
73
Timing and efficacy for CuIUD as emergency contraception
Can be inserted for EC within 5 days of UPSI (or within 5d of ovulation) Screen for STIs if high risk but should not prevent use of IUD for EC Failure rate <1%
74
Incidence of sexual assault
Estimate 1 in 5 Australian women have experienced sexual violence, 1 in 22 men 10% reported - Only 15% reported will result in conviction
75
WHO definition of sexual assault
Sexual assault is an act of a sexual nature carried out against a persons will through the use of physical force, intimidation or coercion
76
High risk groups for sexual assault
Young people - Females 15-19y - highest victimisation rate for sexual assault Within a setting of domestic violence / intimate partner - 65% occurs in private dwellings Childhood sexual assault - Usually not in caregiver role Impaired physical or intellectual disability - 90% of women with intellectual disabilities have been abused Indigenous people - Rate 2-5x higher Women of non-English speaking backgrounds
77
Long term health consequences of sexual assault
Physical - CPP - abdo pain - sexual dysfunction Mental health - anxiety - depression - ptsd health risk behaviours - early sexual debut - smoking - alcohol - obesity - avoidance of presentation health care - smears, breast exams
78
Management of sexual assault
``` Involve DSAC/ local forensic team STI prevention and emergency contraception - Consider HIV PEP Counselling initiated early Explain confidentiality Preserve forensics where possible ``` Police involvement and/or Women's refuge Confirm that they have safe place to go Make follow up plan
79
Causative agents of PID
Chlamydia tracheomatis Neisseria gonorrhoea Mycoplasma Mixed anerobes
80
Components of normal vaginal discharge
Vaginal flora Epithelial cell sloughing from cervical columnar and vaginal and vulval squamous epithelium Mucous secretions from vaginal glands and cervix - Serum transudate from vaginal mucosa - Cervical mucosa - Small amount of fluid from Bartholin’s gland, cervix, endometrium and fallopian tubes Sweat

Anna and louise (28 decks)

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