Sexual Health Flashcards
HIV exposure mx
- risk of transmission of HIV
- risk of transmission of other STI
- STI/Bloodborne virus screen
- Baseline bloods (FBE/UEC/LFT/CRP)
- Ref Tertiary
- MDI - Sexual health/ID/Psych/Counsel
- Treatment:
1. empirical PID (ceft/doxy/metro)
2. HIV PEP - Follow-up for results
- Retest for seroconversion 6/52
- Advice: safe sex/barrier/etoh/smoke
- Contraception advice
- written information
- follow-up appointment
SA - non-consensual IC
- risk of preg/STI/PID
- bHCG/FBE/UEC/LFT/CRP
- HIV/HBV/HCV/Syphilis
- Chlam/Gono/MG/Trich PCR
- admit for observation & rx
- MDI - gyn/ID/SW/Psych/CASA
- Physical ax - injuries - rx e.g. peri
- MH ax - psych rv - PTSD
- EC options - Ulipristal/LNG
- Empiric PID rx - Ceft/Doxy/Metro
- HIV PEP/HBIG
- Police - statement
- Follow-Up
1. 1/52 physical/emotional recovery
2. check sx of STI
3. bHCG in 3-4/52
4. rp bloodborne serol 6/52 then 3/12
Mirena pre/post insertion spiel
- urine bHCG
- STI risks +/- screen
- near end of menses
- sx - cramp/irregular bleeding 1-2mo
- risk - perf/expulsion/PID/ectopic if fail
- risk - migration - no contra/axr/retriev
- risk of fainting during insertion
- not effective to suppres ovulation
- not effective w PMS or cysts
- avoid IC for 48/24
- immediate effective if inserted D1-5 menses, otherwise 7d required
- monitor sx - fever/offensive DC/pain
- 6/52 check, expires in 5yrs
- can remove anytime
Mirena insertion cervical shock management
- cervical shock = vasovagal syncope
- stop procedure/remove all instrument
- call for help - ABC
- assess vitals +/- O2
- supine - elevate legs
- +/- 500-600mcg of IV atropine
- rest
- consider re-insertion under GA
LARC options & counselling
Depo
- 0.2%, 6% typical
- systemic - mood/weight gain
- slow return of fertility
- compliance issue
- osteo, not long term
- alternative to implant/IUD
Implant
- implanon, 0.5%
- 3yr, arm, local, systemic, stop ovulate
- pros - most effective, min mense delay
- cons - removal/irreg PVB 20%/migrat
IUD
Hormonal
5yr, intrauterine,
mirena 0.2% vs kyleena
pros - localized, effective HMB/contrace, smaller size -> easier insertion
cons - infection/migrate/malposition
Non-hormonal
copper 0.8% 5 & 10 yr
pros - localized, effective contracept
cons - HMB, infection/migra/malpos
Sexual hx/Mx of sexual dysfunction
Scenario 1 - aparunia post cervical ca RT with previous hx of SA/sexual difficulties
DDx - post RT
- vaginal stenosis
- vaginal atrophy
- risk - psych impact/relationship
- clarify Hx -
1. new vs chronic
2. personal stress
3. previous partner
4. interpersonal difficulties - MDI - gynae/MH/sex therapist/PT
- behavior based therapy
- sexual health counselling
- vaginal dilators
- pelvic floor physical therapy
Vulvodynia
Initial Encounter
- severity of sx/impact on relationship
- menstrual hx/CST/contraception/STI
- med/surg/fhx/shx
- vulval appearance/architecture/ulcer
- rash or abnormality
- cotton tip - pressure test of vulva
- HVS, endocervical - STI, pelvic USS
+/- precon bloods/advice LS/Supp
- F/U rv with partner
- Refer to services
- Review results next visit
Second encounter
- revisit sx & impact
- examine again
- rv with partner
- look at Ix result
- Inflammatory response
- Proliferation of nerve fibers
- Lower pain threshold
- Central sensitization
- Treatable, mo-yrs
- Physio - pelvic floor therapy
- Psych support, sexual health counsel
- SSRI/SNRI/TCA/gabapentin/lignocaine
- Levator ani botulin injections
- fertility options - IUI or ET under GA
Mx of incidental dx of Chlamydia
- risk of other STIs
- risk of PID- infertility/hydrosalpinx/CPP
- full STI testing (include serology)
- contact tracing - testing - rx
- avoid IC till rx complete 7d post or sx resolve whichever is later
- treat - Azithro stat or Doxy
- test for re-infection in 3 months
- +/- sexual health referral if other infections
Mx of PID
Scenario 1 - 22yo unplanned preg, febrile, PVB - MC + Chlamydia -> initially mx for MC, subsequently admitted for PID - testing for decision re: surgical mx
Scenario 2 - 15yo chlam/TOA fails to respond to medical therapy -> lap confirms bilat TOA w extensive adhesion
Scenario 3 - 28yo chlam/PID from SA, also HSV PCR
- Risk of PID…
- Risk of other STI…
- Full bloods + STI screen (include serol
- Pelvic USS
- Admit - Observe & Rx
- MDI - Gynae + ID
- IV Abx/antipyretic/analgesia
- VTE prophylaxis
- Monitor clinical/biochem resp to abx
- Advise - safe sex/contraception
(OCP/Depo/Implanon, not IUD if PID) - chase MCS
+/- home with PO if stable
+/- F/U with pelvic USS 6/52
+/- contact tracing + rx + TOC
+/- NBM -> for OT if meeting criteria for OT for diagnostic lap +/- washout +/- cystectomy/USO+/-salpingectomy…
Criteria for operative mx of PID/TOA
- hemodynamically unstable
- fail to abx (clinical/biochem)
- postmeno - high risk of malignancy
- TOA >9cm
Risks of surgery
- extensive adhesion
- no surgical plane
- injuries to organs
- bleeding
Risks of no surgery
- further deterioration
- no source control
- peritonitis -> adhesion
- fertility implications
Mx vulval ulcer
DDx
- syphilis
- herpes
- chlamydia
- confirm with PCR
- screen for other STIs
- risk pain/sacral nerve/urine retention
- risk to future preg - recurrence/VT
- admission if severe pain/urinary
- MDI - gyn/ID
- acyclovir/analgesia/SITZ bath
- +/- IDC
- +/- long term suppression
- advise - contraception/barrier/CST
- F/U in 1/52 with GP
PMD management
- risk - psychosocial impact
- to confirm dx
- Sx diary for 2 cycles before rx
1. occur during luteal phase
2. abate @menses
3. sx free btw menses & ovulation - +/-GnRH analogue to check resolution
- exclude thyroid dysfunction
Treatment options
- pharm vs non-pharm
- hormonal vs non-hormonal
Treatment options depends on
- ? contraception
- ? mood sx
1st line - CBT + COCP vs SSRI
2nd line - E2 patch + LNG - IUD
3rd line - GnRH
4th line - Hyster/BSO
