Sexual Health Flashcards
1
Q
– Cluster 1: Sexual Health Overview –
What are the key symptoms presenting with STI [5]?
A
- urethral, vaginal discharge
- lower abdo pain
- genital lumps, ulceration
- genital itching
- rectal symptoms
2
Q
What are the four ‘core’ STIs tested for at sexual health clinics, and how are they tested for in men and women?
A
- Chlamydia trachomatis (CT)
- Neisseria gonorrhoeae (GC; gonococcus)
- HIV
- Syphilis
- GC/CT NAAT: vulvovaginal swab (VVS) in women, and first void urine (FVU) in men. consider throat and rectum swabs in MSM
- high vaginal swab (HVS, Amies swab) in recurrent/persistent discharge, postpartum or post gynae surgery, PID etc.
- HIV and syphilis via serology
3
Q
Name the partner notification (PN) periods for CT, GC, NGU, TV, PID, HIV, and syphilis.
A
- CT: 4w (male urethral), 6m
- GC: 2w (male urethral), 3m
- NGU/TV: 4w
- PID: 6m
- HIV: 4w before last negative result, or 4w before most likely infection
- syphilis: primary 90 days, secondary 2yr
4
Q
For which sexual infections is partner notification (PN) not required?
A
- warts, herpes
- thrush
- bacterial vaginosis
5
Q
Name the three categories of serovar seen in CT and which infection types they may cause.
A
- A-B: ocular infection
- D-K: urethritis, epididymo-orchitis, neonatal pneumonia and conjunctivitis
- L1-3: LGV (lymphogranuloma venereum), mainly MSM with rectal symptoms
6
Q
Name the clinical features of CT.
A
- milky urethral discharge, irregular bleeding, abdominal pain, dysuria
- inflammation of urethra, cervix, epididymis, rectum
- [neonatal pnuemonia, conjunctivitis]
7
Q
What is Fitz Hugh-Curtis Syndrome?
A
A very rare presentation of CT, with perihepatitis and piano-string adhesions
8
Q
Describe the management of CT.
A
- doxycycline 100mg BD/wk
- azithromycin 1g stat + 500mg OD/2days; this is second line and should only be used when tetracyclines genuinely cannot be taken (e.g., during pregnancy) due to antibiotic resistance
9
Q
What are the complications of CT?
A
- ectopic pregnancy
- PID (manage with ceftriaxone, doxycycline, metronidazole)
- reactive arthritis
- reinfection (1/5)
10
Q
Describe the symptoms of NG [4].
A
4D’s: Discharge (mucopurulent), dysuria, ‘Damn that hurts’ (anterior urethritis, lower abdominal pain), Disruption to menstrual cycle (PCB/IMB)
- rarer: proctitis, sepsis/DGI, tenosynovitis, arthritis, erythematous skin
11
Q
Describe the management of GC.
A
- 1st line: ceftriaxone, 1g IM stat
- 2nd line: ceftaime, 400mg PO + azithromycin 2g PO
- test of cure in all patients 2 weeks after completing treatment
12
Q
Describe the swab findings in a positive case of GC infection.
A
- > 5 polymorphs per high powered field indicates urethritis
- look for gonococcal cells (these are purple gonococci within cells)
- NB CT cannot be seen on gram stain
13
Q
What are the complications of GC?
A
In men (PENIS):
- P: prostatitis
- E: epididymo-orchitis
- N: nasty infection of Mullerian or Cowper glands
- I: infertility
- S: strictures (of the urethra)
In women (3P’s):
- PID (in ~33%), resulting in chronic pelvic pain, tubal infertility, ectopic pregnancy
- Peritoneal spread (Fitz-Hugh-Curtis syndrome)
- Pregnancy complications (spontaneous abortion, premature labour, PROM, perinatal mortality, gonococcal conjunctivitis in the newborn)
In both sexes, disseminated gonorrhoea (DGI) is a potentially serious complication thought to occur in 0.5-3% of untreated cases
- septic arthritis, polyarthralgia, tenosynovitis
- petechial/pustular skin lesions
- endocarditis or meningitis
14
Q
What are the most common causes of non-gonococcal urethritis (NGU)?
A
CT, mycoplasma genitalium, ureaplasma urealyticum, TV, HSV 1/2, adenoviruses
15
Q
Describe the natural history of syphilis.
A
- a chronic systemic disease caused by Treponema pallidum, a motile spirochete
- primary: incubation 9-90 days with primary papule at site of inoculation which ulcerates to form a chancre. 25% of untreated primary cases will go on to develop into secondary syphilis
- secondary: widespread rash on palms/soles, anterior uveitis, condylomata lata (highly infectious plaques). may also include hepatitis, glomerulonephritis, and splenomegaly.
- tertiary: gummatous syphilis. can affect cardiovascular and neurological systems
16
Q
Describe the clinical examination of suspected syphilis.
A
Primary and secondary
- genital examination
- skin examination (inc. mucosal surfaces such as eyes and mouth, scalp, palms, and soles of feet)
- neurological examination (if neurological symptoms elicited)
Late-stage disease
- skin examination
- MSK examination (congenital)
- cardiovascular (?aortic regurgitation)
- neurological examination (paresis, dysarthria, hypotonia, intention tremor, reflex abnormalities, Tabes dorsalis, pupil abnormalities, impaired vibration/joint position sense, sensory ataxia, optic atrophy)
17
Q
Describe the investigation options for syphilis.
A
- cannot be cultured
- dark field microscopy, PCR, or serology (IgM/IgG ELISA)
- dark field microscopy requires highly skilled microscopists, is less reliable in rectal and non-penile lesions, and is not suitable for oral lesions (commensal treponemes)
- therefore serology remains the main lab diagnosis
Serology
- non-treponemal tests: VDRL, RPR. titres can be used to monitor response to treatment, and NTTs revert to negative after treatment.
- treponemal tests: TPPA, ELISA, INNO-LIA, FTS antibodies. remain positive even after treatment.
TPPA: Treponenum pallidum particle agglutination; TPHA: TP haem agglutination; TP-EIA: TP enzyme immunoassay
VDRL: venereal disease research laboratory; RPR: rapid plasma reagin
18
Q
Describe the investigation algorithm used for suspected syphilis.
A
Traditional vs contemporary
- a non-treponemal test (NTT) has previously been used prior to a treponemal test (TT). However, this produces a subjective result, and there is a higher rate of false positives in low incidence settings.
- the positive predictive value (PPV) of a lab is affected by incidence. a lower incidence of syphilis worldwide now means the NTT –> TT approach is less accurate.
Current algorithm
- a TT (e.g. TP-EIA) is first used, then followed up by a NTT if positive. if both are positive, there is evidence of current syphilis.
- a positive TT and negative NTT (TT+, NTT-) is open to interpretation (e.g. past, successfully treated syphilis; early or late/latent syphilis; false positive). in these situations, a second, different TT is performed (e.g. TPPA).
19
Q
Describe the management of syphilis.
A
- single dose of 2.4 MU benzthine penicillin G IM stat
- doxycycline 100mg BD 2/52
- late syphilis: penicillin G IM weekly for 3 wk
- followup until RPR -ve or serofast. Titres should decrease fourfold by 3-6m
20
Q
Describe the main adverse effect observed with treatment of syphilis.
A
- Jarisch-Herxheimer reaction (JHR)
- caused by a release of inflammatory cytokines, most commonly associated in spirochete infection (e.g. also associated with Lyme disease, leptospirosis)
- occurs within 24 hours of treatment
- usually consists of mild fever, malaise, headache, and flu-like symptoms lasting several hours
- treatment is with reassurance and antipyretics (e.g. paracetamol)
21
Q
– Cluster 2a: Urethritis –
Describe the presentation and classification of urethritis.
A
- the term ‘urethritis’ is usually reserved for men to describe urethral discharge and dysuria, although it is asymptomatic in up to 30% of men
- it is typically divided into gonococcal or non-gonococcal urethritis (NGU)
- infectious causes include GC, CT, MG, UU, TV, HSV, UTI, and adenoviruses
- non-infective causes include physical and chemical trauma and urethral stricture
22
Q
Describe the investigations used for urethritis.
A
- microscopy of urethral discharge or urethral swab; NAAT and culture for GC; NAAT for CT and MG; serology for syphilis and HIV
- tests for TV and HSV are not usually performed routinely; there is no commercial test available for Ureaplasma urealyticum
- midstream specimen of urine (MSSU) if symptoms are suggestive of UTI
23
Q
– Cluster 2b: Vaginal discharge –
Describe the aetiology of vaginal discharge as a presenting complaint.
A
Vaginal discharge is a common presenting symptom and is not always pathological.
- infective: vaginal (BV, candida, TV) or cervical (CT, NG, HSV)
- physiological discharge
- non-infective: cervical ectropion, cervical polyps, neoplasms, retained products of conception, retained products (e.g. tampons), chemical irritation etc.
24
Q
Describe the aetiology of physiologic vaginal discharge.
A
- regulated by hormone levels in the body
- around ovulation, discharge is thin and clear to allow sperm to swim easier, and occurs with high levels of oestrogen in the body
- as the cycle progresses, cervical mucus becomes thicker and more hostile to sperm
25
Describe the investigation of vaginal discharge.
- microscopy for BV, candida, and TV
- culture for candida
- NAAT for TV, CT, GC
- serology for syphilis, HIV
26
Describe the pathology of most cases of bacterial vaginosis (BV).
A lack of lactobacilli allows overgrowth of pathogenic bacteria (including Gardnerella vaginalis, anaerobes, mycoplasmas, and Mobiluncus spp.)
An increased pH can lead to prolonged/heavy periods
27
Describe the diagnostic criteria for bacterial vaginosis.
3/4 of the Amsel's criteria
- creamy-white homogenous discharge
- clue cells (stippled vaginal epithelial cells) on microscopy
- vaginal pH >4.5
- positive whiff test (characteristic fishy odour released by mixing vaginal discharge with potassium hydroxide)
28
Describe the clinical features and management of BV.
- increased vaginal discharge, offensive fishy odour, creamy-white homogenous discharge which may be frothy
- amine production causes offensive odour and froth
- metronidazole 400mg BD 5-7/7
- alternatives: intravaginal metronidazole, intravaginal clindamycin
29
Describe the microscopy and presentation of trichomonas vaginalis (TV).
- highly motile, flagellated protozoan
- nearly all men are asymptomatic, as are 10-50% of women
- in women, the most common symptoms are increased purulent vaginal discharge (grey-green) and malodour, pruritis, dysuria, dyspareunia, and strawberry cervix (vulvar erythema)
30
Describe the management of TV.
- metronidazole 2g orally as a single dose, or 400mg BD for 7/7
- TV infects areas beyond the vagina (e.g. the urethra) and as such intravaginal metronidazole gel has poor cure rates
31
Describe the complications associated with BV and TV in pregnancy.
- BV: increased risk of miscarriage, preterm birth
- TV: increased risk of preterm birth and low birth weight
- increases risk of acquisition and transmission of HIV
32
-- Cluster 3: Anogenital ulcers --
What is the wider differential diagnosis for genital ulceration?
vIndIcATe
- infectious (HSV, VZV, EBV, HIV)
- iatrogenic (drug eruption, SJS)
- autoimmune (Crohn's, Behcet's, lichen sclerosus)
- trauma (self-harm, artefacta)
33
Describe the investigation of anogenital ulceration.
- ulcer swab for HSV PCR, +/- syphilis (condylomata lata is a differential)
- NAAT for CT, NG
- in MSM, consider genotyping for LGV
34
Describe the timeline of HSV infections.
- primary: virus ascends peripheral sensory nerves to DRG, establishing latency.
- - symptoms: ulcers, inguinal lymphadenopathy, viraemia, dysuria, vulval pain
- non-primary genital infection: those with previous HSV1/2 who acquire the other type.
- - cross-protection from other type means a milder illness
- recurrent infection: 4x more common in HSV2 than 1
- - tingling, itching, pain, unilateral ulcer, can be asymptomatic
- - usually resolves 5-7days, although all episodes potentially infectious
35
Describe the management of HSV-caused genital ulceration.
- primary infection: saltwater bathing, topical anaesthetic (5% lidocaine), and acyclovir (400mg TDS 6/7 days).
- avoid sharing towels, etc. to prevent autoinoculation
- suppressive therapy offered with >6 recurrences/yr. This is acyclovir 400mg OD
36
Describe the management of HSV in pregnancy.
The main risk of HSV in pregnancy is vertical transmission, with risk highest within the first 6 weeks of infection.
- first trimester: women who acquire primary HSV in the first trimester are not at increased risk of miscarriage
- women with recurrent genital herpes in the first and second trimesters are advised to take acyclovir from 36 weeks
- tertiary infection, primary: manage with C/S
- tertiary, recurrent: suppressive acyclovir from 36 weeks and vaginal delivery
37
Describe the aetiology, presentation, investigation and management of chancroid.
- chancroid is caused by Haemophilus ducreyi
- a tender papule develops at site of inoculation, with a short incubation of 4-7 days. the papule breaks into a painful, ragged-edged ulcer with a necrotic base that bleeds easily. there is often tender inguinal lymphadenopathy.
- diagnosis is most sensitive with PCR
- azithromycin 1g PO or ceftriaxone 250mg IM
- other options: ciprofloxacin 500mg BD 3/7; erythromycin 500mg QDS 7/7
38
Describe the microbiology and presentation of Donovanosis.
- also known as granuloma inguinale; caused by Klebsiella granulomatis
- K granulomatis are gram-negative rods that develop into Donovan bodies
- exceedingly rare, confined to southeast Asia, south America, and the Caribbean
- nodules at the site of inoculation develop into friable, non-painful ulcers or hypertrophic lesions that increase in size
39
Which HPV subtypes are covered by the quadrivalent vaccine, and what pathologies do these cause?
- HPV 6/11: viral warts
- HPV 16/18: oncogenic
40
Describe the pathology of HPV infection and the main management options.
- warts appear at sites of trauma during sex (prepuce/glans, fourchette, vulva, perineum)
- non-hair-bearing skin: soft and non-keratinised
- hair-bearing skin: firm and keratinised
- topical podophyllotoxin, imiquimod, ablation (cryotherapy, electrocautery)
41
-- Cluster 4a: Proctitis --
Describe the aetiologies of proctitis/proctocolitis.
- rectal infection: CT, NG, LGV, HSV, syphilis
- enteric infection: Shigella, campylobacter, protozoa, salmonella, E coli, cryptosporidium
- non-infectious: IBD, neoplasms
42
Describe the investigations used for proctitis/proctocolitis.
- rectal smear microscopy, culture, and NAAT for CT, GC
- if CT positive, genotype for LGV
- serology for syphilis, HIV
- cultures for enteric pathogens if symptoms of enteritis present
43
-- Cluster 4b: Abdominopelvic pain --
Describe the aetiology of PID.
- an infection that begins in the endocervix and ascends upward to involve most of the structures in the female genital system, encompassing endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis
- the most common cause is chlamydia trachomatis
- additional causes include GC, MG, and polymicrobial after spontaneous/induced abortion or ab/normal deliveries (e.g. staph, strep, coliforms, Clostridium perfringes)
44
Name the risk factors and describe the presentation of PID.
Risk factors
- age <25
- multiple sexual partners, unprotected sexual intercourse
- recent change to sexual partner
- recent insertion of an IUD
Presentation
- lower abdominal, pelvic pain
- fever
- abnormal vaginal bleeding
- offensive discharge
- deep dyspareunia
- dysuria
- cervical motion tenderness (excitation), adnexial tenderness
45
Describe the investigation and differential diagnosis of PID.
Investigations
- pregnancy test (?ectopic pregnancy)
- HVS and NAAT for CT, GC, BV
- MSSU if UTI probable
Differential diagnosis
- ectopic pregnancy
- acute appendicitis
- endometriosis
- UTI
- IBD
46
Describe the treatment regimens for PID.
- ceftriaxone, doxycycline, and metronidazole; 500mg IM single dose, 100mg BD and 400mg BD for 14/52
- ofloxacin and metronidazole, both 400mg BD for 14/52
- abstinence from sex for at least 14 days with partner notification
47
Describe the complications associated with PID.
- perihepatitis (Fitz-Hugh-Curtis); spread of bacteria into the peritoneum, which attack Glisson's capsule and cause violin-string adhesions
- infertility and tubal obstruction (may be as high as 10-20% from a single episode)
- ectopic pregnancy
- chronic pelvic pain
- intestinal obstruction (adhesions between bowel and pelvic organs)
48
-- Cluster 5: Genital itching --
Describe the causes and investigations of genital itching.
Causes
- infective: candida, TV, pubic lice, and scabies
- dermatologic: irritant dermatitis, genital eczema, lichen sclerosus, lichen planus
Investigations
- microscopy for candida
- NAAT/culture for TV, CT, GC
- serology for syphilis and HIV
49
Describe the risk factors and presentation for genital candidiasis.
Risk factors
- pregnancy
- diabetes mellitus
- broad spec antibiotics
- corticosteroids
- immunosuppression
Presentation
- vulval itching
- thick white vaginal discharge
- vulval burning, external dysuria, superficial dyspareunia
- transient penile irritation and rash
- erythema of foreskin and glans penis, with accumulation of white discharge under the foreskin
- in severe cases, there may be fissuring and phimosis of the foreskin
50
Describe the management of genital candidiasis.
- diabetes should be excluded in men with severe balanoposthitis
- fluconazole 150mg PO single dose, itraconazole 200mg BD 1/7
- intravaginal cotrimazole pessary 500mg single dose etc.
- intravaginal treatment is safe in pregnancy, but oral therapies should not be used
51
Describe the management of pubic lice.
- treatment should be applied to all areas on the body, including facial hair if present
- malathion 0.5% left on ~2hr
- permethrin 1% left on ~10min
- a second application is usually advised after 3-7 days
- permethrin is safe for use in pregnancy
52
-- Cluster 6: HIV & AIDS --
Name the key viral proteins expressed on the HIV particle.
- p10 (protease - processes viral genome RNA)
- p17, p24, gp120 (transcribes viral mRNA)
- p32 (integrase - integrates viral DNA into CD4 cells)
- gp41 - binds CD4 cells, inc. CCR5 receptors
53
Describe the main types of HIV, and how their epidemiology varies.
- HIV-1: accounts for most cases worldwide. subgroups include
- - M (major, 98%)
- - N (new)
- - O (outlier)
- - P (single patient in Cameroon)
- HIV-2: localised mainly to sub-Saharan Africa
54
Describe the viral lifecycle of HIV.
1. binding (gp41)
2. fusion
3. reverse transcription
4. integration (p32)
5. replication
6. transcription (p10, gp160, p24, p17)
7. viral budding
55
Describe the changes HIV infection causes on CD4 and CD8 cells.
- decreasing circulating CD4 cells and proliferation
- increased proliferation of CD8, but decreased activation (dysregulated cytokines)
- reduced cross-switching of antibodies and subsequent affinity
56
There are three main stages of HIV infection. Name these and describe how CD4 cell count and viral RNA copies change during these times.
1. acute HIV syndrome: rapid reduction of CD4, rapid increase in viral RNA over weeks (0-9wk)
2. clinical latency: reduction in viral load and increased number of CD4 cells; these gradually increase/decrease respectively over years
3. AIDS: viral load rapidly increases. CD4 count rapidly decreases.
57
Describe the clinical features of the acute HIV syndrome (stage 1/3).
fever, maculopapular rash, myalgia, pharyngitis, aseptic meningitis, headache
very high risk of transmission
58
Describe the clinical features of clinically latent HIV infection (stage 2/3).
- neuro: distal sensory polyneuropathy, mononeuritis multiplex, vascular myopathy, aseptic meningitis, GBS, neurosyphilis
- CVS: dec. HDL, increased IHD, cardiomyopathy, CHF, and myocarditis
- GI: weight loss, diarrhoea, encephalopathy, hypochlorrhydria
- endocrine: reduced testosterone, abnormal adrenal function
- renal: HIVAN, nephrotic syndrome
- haem: lymphopenia, anaemia, neutropenia, isolated thrombocytopaenia
59
Name the main AIDS-defining syndromes (stage 3/3).
- pulmonary (pneumocystis jiroveci, TB)
- neurological (toxoplasma gondii, PML by JC virus
- CMV (retinitis, colitis, and/or encephalopathy)
- viral (VZV, HSV; more extensive and recurrent)
- neoplasia: HHV8 (Kaposi sarcoma), EBV (non-Hodgkin, Burkitt lymphoma)
60
Name the main methods of transmission of HIV.
- sex (raised in MSM, trauma, ulceration, concurrent STI)
- parenteral (PWIDs, contaminated blood and blood products)
- mother-to-child (transplacental, perinatal, breastfeeding)
61
Who do we screen for HIV?
- universal, where prevalence >0.2% (NHS Lothian)
- GUM clinics, antenatal services, TOP services, drug dependency programmes, care for TB/HBV/HCV/lymphoma
- high-risk: those with STI, partners of those with HIV, MSM and their F contacts, PWIDs, those from countries of high prevalence
- those with indicator conditions
62
Name the drug classes used in the treatment of HIV.
- NRTIs (nucleoside reverse transcriptase inhibitors)
- NNRTIs (non-NRTIs)
- integrase inhibitors
- protease inhibitors
- coreceptor (CCR5) inhibitors
- fusion inhibitors (very expensive, S/C, last option)
- [in development: capsid, monoclonal antibodies, maturation-based drugs]
63
Describe the makeup and purpose of HAART.
- combination of 3 drugs, from which at least 2 are classes to which the virus is susceptible.
- 2 NRTIs + 1 other agent
- reduce viral load, restore immunocompetence, reduce morbidity, mortality, and transmission.
64
Describe and give examples of primary and secondary prevention of HIV.
- primary prevention: acquiring HIV. condoms, regular tests, behaviour change, PEP/PrEP, PMTCT, circumcision, needle exchange
- secondary prevention: onward transmission. condoms, regular tests, behaviour change, disclosure, PMTCT, needle exchange
65
What are the criteria for PrEP?
- MSM condomless anal sex, 2+ partners in the last year, sex likely in the next 3m
- rectal bacterial STI in last year
- partner of someone with HIV who does not have suppressed viral load.
66
When is PEP initiated?
<72h after possible exposure to HIV (occupational, sexual). Taken for 4 weeks.
67
Describe PMTCT.
- prevention of mother to child transmission
- achieved with HAART during pregnancy
- vaginal delivery undertaken with an undetectable viral load
- C/S done with a detectable viral load.
68
-- Cluster 7: Contraception --
Describe the benefits of family planning.
- planned pregnancies help protect women at higher risk of pregnancy-related complications due to age and associated health problems
- can ensure pregnancies are not too close together; a short interpregnancy interval (<12mo) is associated with increased risk of preterm labour, FGR, stillbirth, and overall neonatal mortality
- decreases vertical transmission of HIV
- allows women to continue with education, paid employment, and public life
- reduces adolescent pregnancy; women who become pregnant in their adolescent years are less likely to continue into higher education
- slowing unsustainable population growth, preventing negative impacts on the economy, environment, and reducing maternal mortality
69
Name the methods of long-acting reversible contraception (LARC).
- progestogen-only implant (Nexplanon): 0.05% experience an unintended pregnancy within the first year of use, meaning this is the most successful method of contraception. useful if cannot take oestrogen, reduces menorrhagia and dysmenorrhoea
- levonorgestrel IUS (Mirena, 52mg): 0.2%. effective after 7/7 insertion; immediate effect if <5 days of cycle, <21/365 postpartum, <5 days abortion or miscarriage. Mirena lasts for ~5yr; additional systems include Kyleena (19.5mg, 5yr) and Jaydess (13.5mg, 3yr)
- copper IUD: reduces sperm motility and survival. 0.8% (typical use), 0.6% (perfect use). 99% effective for 5/10 years. can make periods longer, heavier, and more painful.
- progestogen-only injectable (Depo-Provera): 6%, 0.2%. administered IM every 13/52. useful if cannot take oestrogen; can lead to amenorrhoea and used in HMB, dysmenorrhoea, and endometriosis
70
Describe the methods and use of fertility awareness methods (FAM).
- relies on physiologic indications of ovulation to identify when women are most fertile to avoid otherwise unprotected intercourse
- calendar method
- temperature: an increase in body temperature 3 days in a row indicates fertility has decreased
- Billings method: start of fertile period indicated by sticky, white, creamy mucus; nearer ovulation this becomes watery and clear, indicating peak fertility
- mobile apps, supporting the above methods (which can take up to 6 months to learn reliably)
71
Describe the use of the combined transdermal patch (CTP).
- worn for 7 days and changed on day 8; this continues for 3 weeks and week 4 is patch-free to allow for a withdrawal bleed
- if started <5 days of menstrual cycle onset, contraceptive effect is immediate
- if started >5 days, condoms should be used for 7 days
- if patch falls off <48hr, stick back on ASAP or use a new patch; protection remains as long as the patch was used correctly for 7 days prior
- if patch falls off >48hr, a new patch should be started immediately and additional contraception for 7/7
72
Describe the use of the combined vaginal ring (CVR).
- inserted into vagina for 21 days before removal for 7 days (to allow withdrawal bleed)
- expelled <3hr: rinse and reinsert. no additional contraception needed
- expelled >3hr: additional protection if weeks 1-2; new ring/withdrawal bleed week if week 3
- can be used immediately after miscarriage or abortion
- insert 21 days postpartum for immediate contraception; after 21 days, condoms should also be used 7/7
73
Describe the use of the progestogen-only injectable (Depo-Provera) in a non-emergency context.
- administered IM every 13/52
- can be used for immediate effect after miscarriage/abortion; if taken >5/7 condoms should be used for 7/7
- can be used any time postpartum if not breastfeeding; effect immediate if <21/365, condoms for 7/7 if >21/365
74
Describe the use of barrier methods of contraception.
- methods include male condom, female condom, and diaphragm. benefits include protection against STIs and avoids use of hormones
- typical use failure rate is high and these are highly user-dependent
- female condoms are less widely available and may be more difficult to use than male
- diaphragm does not protect against STIs and increases risk of cystitis. new diaphragm required with weight change >3kg, pregnancy, miscarriage, or abortion
75
Describe the use of the progestogen-only pill (POP, Desogestrel).
- pill should be taken at the same time every day without a pill-free break
- if started <5 days of cycle, effect is immediate
- if started >5 days, condoms should be used for 2/7
- if missed <12hr, take pill as normal
- if missed >13hr, take missed pill ASAP and continue with rest of pack; use condoms until pills taken for 48hr
76
Describe the risks and side effects associated with use of the COCP.
Risks
- cervical cancer
- breast cancer
- VTE, stroke, ischaemic heart disease
S/E
- hormonal (headache, nausea, mastalgia, mood/libido changes)
- irregular bleeding (common in first 3/12)
77
Name the contraindications of oestrogen.
- oestrogen-sensitive malignancy, including breast, ovarian, and endometrial
- ischaemic heart disease, history of VTE or stroke
- migraine with aura
- liver disease
- pregnancy or breastfeeding <6/52 postpartum
- age 35+ and smoking 15+/day
- positive antiphospholipid antibodies
- thrombogenic mutations
78
Describe the use of the COCP.
- taken for 21 days and stopped for 7 (to allow withdrawal bleed)
- <5 days of menstrual cycle, contraceptive effect is immediate; after 5 days, additional contraception required for 7/7
- the pill can be started up to 5 days after miscarriage or abortion
79
Describe what to do if the COCP is missed (1 pill and 2 pills).
- 1 pill missed: take the last pill, even if 2 pills are taken in 1 day. no additional contraception needed
- 2 pills missed: take the last pill, even if 2 pills are taken in 1 day, and omit any earlier missed pills. use condoms or abstain until the pill has been taken 7/7 in a row
- 2 missed in week 1: emergency contraception
- 2 missed in week 2: if pill taken consecutively 7/7, no additional contraception needed
- 2 missed in week 3: pills in current pack should be finished and new pack started the next day after, omitting the pill-free interval
80
Describe the use of emergency contraception.
- three methods: oral levonorgestrel, oral ulipristal (EllaOne), and copper IUD
- levonorgestrel: 1.5mg, doubled if BMI >26/over 70kg or taking enzyme inducers. effective <72hr (3 days)
- ulipristal (EllaOne): 30mg, effective <5 days
- copper IUD: effective <5 days
81
Describe the methods of postnatal contraception.
- lactational amenorrhoea method (LAM): effective up to 6/12, must be exclusively breastfeeding (at least every 4hr day, 6hr night), and fully amenorrhoeic
- methods that can be used immediately include Nexplanon (progestogen-only implant), Desogestrel (progestogen-only pill), or Depo-Provera (progestogen-only injectable) (not if breastfeeding)
- if inserted >48hr birth, IUC insertion should be delayed until at least 4 weeks
- COCP should be delayed until at least 3 weeks postnatally, due to the risk of VTE
82
Define and describe the Fraser guidelines.
- the Fraser guidelines are a form of Gillick competence - a task specific ability of children (<16 years) to consent to medical procedures - relating to contraception to <16yrs without parental consent
1. the child must show a sufficient maturity and intelligence to understand the nature and implications of management being offered
2. the child cannot be persuaded to tell their parents, or allow the doctor to do so
3. the child is likely to begin or continue sexual intercourse without contraception
4. physical and/or mental health is likely to suffer without intervention
5. management is in the patient's best interest
83
-- Cluster 8: Termination of Pregnancy (TOP) --
Describe the risks of unplanned pregnancies.
Unplanned pregnancies are more likely to result in
- preterm birth
- postpartum depression
- substance misuse
- child neglect or abuse
- reduced interaction with antenatal care
- reduced birthweight
- reduced breastfeeding and child-mother bonding
- increased incidence of developmental anomalies
84
Describe the role of conscientious objection in relation to abortion.
Doctors can conscientiously object to participate in outpatient abortion, **but** will always have a duty to provide emergency care. It is important that a woman's access to abortion is not delayed or prevented by individual conscientious objection. This also mandates direction to a doctor who does not object, **and does not apply** to indirect tasks (such as paperwork) or emergencies.
85
Name the documents governing clinical use of TOP in the UK, and describe their use.
- in the UK, abortion is governed by the Abortion Act 1967, updated by the Human Fertilisation and Embryology Act 1990
- in a non-emergency situation, 2 doctors must sign (typically a HSA4 form), utilising clauses (A-E)
- clause C is by far the most commonly used (>98%), and mandates that *the pregnancy has not exceeded its 24th week, and that pregnancy would involve risk of physical or mental health injury to the woman or any existing children of her family*
- the next most common is clause E, which states *there is a substantial risk that if the child was born, it would suffer from such physical or mental abnormalities as to be seriously handicapped*
- in an emergency situation, only one doctor needs to sign
86
Describe the regimens used for medical termination of pregnancy (MTOP).
- mifepristone (anti-progestogen) is combined with misoprostol (a prostaglandin, which stimulates uterine contraction). timing is unpredictable.
- remember that abortion is legal up until 24 weeks gestation.
- <10/52: mifepristone 200mg PO, followed by misoprostol 800ug PV/SL. if bleeding has not been induced within 4hr, an additional 400ug misoprostol may be used
- 10 - 11+6: as for <10/52, with 3 additional misoprostol doses. Misoprostol can be given up to a max of 5 doses/24hr
- 12 - 19+6: undertaken as an inpatient procedure. misoprostol 800ug PV, followed by 400ug 3 hourly up to 4 doses.
- 20 - 23+6: potassium chloride, a feticide, is injected into the foetal heart with USS guidance.
- a pregnancy test is required in 2 weeks to confirm the pregnancy has ended, which should quantify (rather than qualify) level of HCG (termed a multi-level pregnancy test)
87
Describe the options for surgical termination of pregnancy (STOP).
STOP is a surgical procedure performed under anaesthetic (local or general). In all cases, the cervix is primed with misoprostol or osmotic dilators to reduce risk of cervical injury.
- <10/52: manual vacuum aspiration (MVA) under local
- 10 - 13+6: electrical vacuum aspiration (EVA) under general
- 14 - 23+6: dilatation and evacuation (**performed in England only**)
Rhesus-D negative patients should be given anti-D prophylaxis, and doxycycline is provided to cover post-surgical infection.
88
-- Cluster 9: Infertility --
Give an overview of infertility.
- 'failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse, in the absence of a known reason'
- infertility affects ~1/6 couples, of which ~50% will conceive spontaneously or with treatment
- investigations are not generally advised until after 12mo for this reason, unless the woman is >35, in which case investigations may begin early
- causes of infertility are roughly divided into thirds: 1/3 male factor, 1/3 female factor, and 1/3 other causes
- primary infertility: the couple has never conceived
- secondary infertility: the couple has conceived previously, whether that did/not result in a live birth (e.g. includes miscarriage and ectopic pregnancies)
89
Give an overview of male factor infertility.
May be roughly divided into obstructive, congenital, infective, endocrine, and pathologic causes
- obstructive: cystic fibrosis (lack of vas deferens), vasectomy
- congenital: cryptorchidism, Klinefelter's (47XXY), Y chromosome microdeletions, Robertsonian translocations (of acrocentric chromosomes)
- infective: mumps, STIs
- endocrine: pituitary, hypothalamic, thyroid, diabetes, CAH
- pathologic: testicular tumours, globozoospermia (sperm have rounded heads and lack an acrosome, so unable to undergo capacitation)
90
Give an overview of female factor infertility.
- congenital: malformation of genital tract, Mullerian agenesis, imperforate hymen, Turner's syndrome, Kallmann's syndrome
- POI (premature ovarian insufficiency)
- endocrine: hypothalamic, pituitary, CAH, hyperprolactinaemia, thyroid
- Sheehan's syndrome
- Asherman's syndrome
91
Describe the investigation of infertility in a couple.
Male
- sperm sample, count, and morphology
- hormone levels (FSH, LH, testosterone, PRL)
- genetic testing if suspected (CF, Klinefelter's)
Female
- assess ovarian reserve with FSH, USS
- assess if ovulation is occurring (day 21 progesterone; >30nmol/l indicates ovulation is occurring)
-- <16nmol/l: repeat. if consistently low, refer to specialist
-- 16-30nmol/l: repeat
-- >30nmol/l: ovulation is occurring
- assess for endocrine dysfunction (PRL, FSH, LH, testosterone + SHBG for FAI, TFTs)
- assess for structural abnormalities (pelvic USS, hysterosalpingogram, hysteroscopy)
-- laparoscopy preferred if probable tubal disease/PID, or known previous pathology (e.g. ectopic)
-- hysterosalpingogram: no known risk factors for pelvic disease, or if laparoscopy C/I (e.g. obesity, Crohn's)
92
Name the general counselling advice for a couple with infertility.
- lifestyle advice: smoking cessation, BMI to <30, limit alcohol and caffeine
- intercourse: every 2-8 days, considering psychosexual issues and counselling, and infection (especially rubella immunity)
- folic acid 400ug, 5mg for neural tube defects, and vitamin D 10ug
93
-- Cluster 10: Assisted Reproductive Technology (ART) --
Name the criteria for ART.
- cohabiting stable relationship >2 years
- female <40 years, BMI 18.5-30
- both non-smokers >3mo
- teetotal prior to and during treatment
- the woman must not already have a biological child
- neither may be on drugs, including methadone (>1yr)
- neither may be sterilised, even if reversal has been self-funded
- infertility unexplained >2 years
- fresh cycles of treatment must be initiated by the female partner's 40th birthday, and all subsequent frozen transfers by her 41st
- the woman must be up to date with cervical smears, immunised against rubella, screened for BBVs, and take the folic acid
94
Name the indications for ART.
- infertility in a heterosexual couple >2 years
- same-sex couple in the absence of a diagnosis of infertility
- preservation of fertility in patients undergoing cancer treatment
- patients undergoing gender reassignment surgery
- to avoid transmission of BBVs, such as HIV
- to allow pre-implantation diagnosis of certain inherited disorders
95
Describe the use and mechanisms of intrauterine insemination (IUI).
- sperm is placed directly inside the uterus to facilitate fertilisation
- this is only possible where the sperm and semen are healthy, ovulation is occurring, and there is no tubal disease
- indications include sexual dysfunction (e.g. ejaculation disorders, erectile dysfunction), and same-sex relationships (donor sperm or surrogacy)
