Sexual health Flashcards
Conditions and Presentations
1
Q
Syphilis
A
sexually transmitted infection caused by the spirochaete Treponema pallidum.
Infection is characterised by primary, secondary and tertiary stages.
The incubation period is between 9-90 days
2
Q
Primary features Syphilis
A
chancre - painless ulcer at the site of sexual contact
local non-tender lymphadenopathy
often not seen in women (the lesion may be on the cervix)
3
Q
secondary features Syphilis
A
- occurs 6-10 weeks after primary infection
systemic symptoms: fevers, lymphadenopathy
rash on trunk, palms and soles
buccal ‘snail track’ ulcers (30%)
condylomata lata (painless, warty lesions on the genitalia )
4
Q
Tertiary features of Syphilis
A
gummas (granulomatous lesions of the skin and bones)
ascending aortic aneurysms
general paralysis of the insane
tabes dorsalis
Argyll-Robertson pupil
5
Q
Features of congenital syphilis (6)
A
- blunted upper incisor teeth (Hutchinson’s teeth), ‘mulberry’ molars
- rhagades (linear scars at the angle of the mouth)
- keratitis
- saber shins
- saddle nose
- deafness
6
Q
Investigations of syphilis
A
Treponema pallidum is a very sensitive organism and cannot be grown on artificial media.
The diagnosis is therefore usually based on clinical features, serology and microscopic examination of infected tissue.
7
Q
Non-treponemal tests
A
- not specific for syphilis, therefore may result in false positives
- based upon the reactivity of serum from infected patients to a cardiolipin-cholesterol-lecithin antigen
- assesses the quantity of antibodies being produced
- becomes negative after treatment
- examples include: rapid plasma reagin (RPR) and Venereal Disease Research Laboratory (VDRL)
8
Q
treponemal-specific tests
A
generally more complex and expensive but specific for syphilis
qualitative only and are reported as ‘reactive’ or ‘non-reactive’
examples include: TP-EIA (T. pallidum enzyme immunoassay), TPHA (T. pallidum HaemAgglutination test)
the TP-EIA test has become increasingly popular in recent years
9
Q
Reasons for false positives on non-treponemal tests
A
pregnancy
SLE, anti-phospholipid syndrome
tuberculosis
leprosy
malaria
HIV
10
Q
Interpretating test results for syphilis
A
Positive non-treponemal test + positive treponemal test
consistent with active syphilis infection
Positive non-treponemal test + negative treponemal test
consistent with a false-positive syphilis result e.g. due to pregnancy or SLE (see list above)
Negative non-treponemal test + positive treponemal test :
consistent with successfully treated syphilis
11
Q
Managment of syphilis
A
intramuscular benzathine penicillin is the first-line management
alternatives: doxycycline
12
Q
Jarisch-Herxheimer reaction
A
fever, rash, tachycardia after the first dose of antibiotic
in contrast to anaphylaxis, there is no wheeze or hypotension
it is thought to be due to the release of endotoxins following bacterial death and typically occurs within a few hours of treatment
no treatment is needed other than antipyretics if required
13
Q
Gonorrhea
A
Gonorrhea is a sexually transmitted infection (STI) caused by the bacterium Neisseria gonorrhoeae. It primarily affects the mucous membranes of the genital tract, but it can also infect the rectum, throat, and eyes
gram positive diplococci
14
Q
Transmission of gonorrhea
A
Gonorrhea is spread through sexual contact with an infected person, including vaginal, anal, or oral sex. It can also be transmitted from mother to baby during childbirth.
15
Q
Male symptoms of gonnorhea
A
Urethral discharge (pus-like or milky discharge from the penis)
Pain or burning sensation during urination
Testicular pain or swelling
16
Q
Female symtpoms of gonorrhea
A
Vaginal discharge (often greenish or yellowish)
Pain or burning sensation during urination
Pelvic pain
Abnormal vaginal bleeding
asymptomatic causes
17
Q
complications of gonorrhea
A
Pelvic inflammatory disease (PID) in women, leading to infertility or ectopic pregnancy
Epididymitis (inflammation of the epididymis) in men, leading to infertility
Disseminated gonococcal infection (DGI), causing joint pain, skin rash, and fever
Increased risk of HIV transmission
Conjunctivitis (eye infection) in newborns born to infected mothers
18
Q
Diagnosis of gonorrhea
A
Nucleic acid amplification tests (NAATs) on urine, vaginal, cervical, rectal, or throat swabs
Gram stain or culture of urethral, cervical, or rectal specimens
Examination of discharge or lesions under a microscope
19
Q
Treatment of gonorrhea
A
Antibiotic therapy with dual therapy (typically ceftriaxone plus azithromycin) to reduce the risk of antibiotic resistance
Treatment of sexual partners to prevent reinfection and further transmission
Follow-up testing to ensure successful treatment and to detect reinfection
20
Q
Prevention of gonorrhea
A
Abstinence or mutual monogamy with an uninfected partner
Correct and consistent use of condoms during sexual activity
Routine screening for gonorrhea and other STIs, especially in high-risk populations
Vaccination (if available in the future)
21
Q
Prognosis of Gonorrhea
A
Gonorrhea is curable with appropriate antibiotic treatment, but reinfection is common without behavioral changes or partner treatment.
Early detection and treatment are essential to prevent complications and reduce the risk of transmission.
22
Q
Chlamydia
A
most prevalent sexually transmitted infection in the UK and is caused by Chlamydia trachomatis, an obligate intracellular pathogen
1 in 10 young women in the UK have Chlamydia. The incubation period is around 7-21 days, although it should be remembered a large percentage of cases are asymptomatic
23
Q
Features of Chlamydia
A
asymptomatic in around 70% of women and 50% of men
women: cervicitis (discharge, bleeding), dysuria
men: urethral discharge, dysuria
24
Q
complications of Chlamydia
A
epididymitis
pelvic inflammatory disease
endometritis
increased incidence of ectopic pregnancies
infertility
reactive arthritis
perihepatitis (Fitz-Hugh-Curtis syndrome)
25
Investigations of Chlamydia
traditional cell culture is no longer widely used
nuclear acid amplification tests (NAATs) are now the investigation of choice
urine (first void urine sample), vulvovaginal swab or cervical swab may be tested using the NAAT technique
for women: the vulvovaginal swab is first-line
for men: the urine test is first-line
Chlamydiatesting should be carried out two weeks after a possible exposure
26
Screening of Chalmydia
in England the National Chlamydia Screening Programme is open to all men and women aged 15-24 years
the 2009 SIGN guidelines support this approach, suggesting screening all sexually active patients aged 15-24 years
relies heavily on opportunistic testing
27
Managment of Chlamydia
-doxycycline (7 day course) if first-line
-if doxycycline is contraindicated / not tolerated then either azithromycin (1g od for one day, then 500mg od for two days) should be used
if pregnant then azithromycin, erythromycin or amoxicillin may be used.
28
contact tracing chlamidya
offered a choice of provider for initial partner notification - either trained practice nurses with support from GUM, or referral to GUM
for men with urethral symptoms: all contacts since, and in the four weeks prior to, the onset of symptoms
for women and asymptomatic men all partners from the last six months or the most recent sexual partner should be contacted
contacts of confirmed Chlamydia cases should be offered treatment prior to the results of their investigations being known (treat then test
29
risk factors for ED
- ageing
-cardiovascular disease
-risk factors: obesity, diabetes mellitus, dyslipidaemia, metabolic syndrome, hypertension, -smoking
-alcohol use
-drugs: SSRIs, beta-blockers
30
treatment of ED
PDE-5 inhibitors (such as sildenafil, 'Viagra') have revolutionised the management of ED
they should be prescribed (in the absence of contraindications) to all patients regardless of aetiology
sildenafil can be purchased over-the-counter without a prescription.
-Vacuum erection devices are recommended as first-line treatment in those who can't/won't take a PDE-5 inhibitor.
31
ED referrals and exercise
for a young man who has always had difficulty achieving an erection, referral to urology is appropriate
people with erectile dysfunction who cycle for more than three hours per week should be advised to stop
32
sildenafil (Viagra)
this was the first phosphodiesterase type V inhibitor
short-acting - usually taken 1 hour before sexual activity
33
tadalafil (Cialis)
longer acting than sildenafil, may be taken on a regular basis (e.g. once daily)
34
contradictions to taking Phosphodiesterase type V inhibitors
patients taking nitrates and related drugs such as nicorandil
hypotension
recent stroke or myocardial infarction (NICE recommend waiting 6 months)
35
side effects of Phosphodiesterase type V inhibitors
visual disturbances
blue discolouration
non-arteritic anterior ischaemic neuropathy
nasal congestion
flushing
gastrointestinal side-effects
headache
priapism
36
Atrophic vaginitis
-Atrophic vaginitis often occurs in women who are post-menopausal women.
- It presents with vaginal dryness, dyspareunia and occasional spotting.
-On examination, the vagina may appear pale and dry.
-Treatment is with vaginal lubricants and moisturisers - if these do not help then topical oestrogen cream can be used.
37
Pelvic inflammatory disease
Pelvic inflammatory disease (PID) is a term used to describe infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries and the surrounding peritoneum. It is usually the result of ascending infection from the endocervix.
38
causative agents of PID
Chlamydia trachomatis
+ the most common cause
Neisseria gonorrhoeae
Mycoplasma genitalium
Mycoplasma hominis
39
Features of PID
lower abdominal pain
fever
deep dyspareunia
dysuria and menstrual irregularities may occur
vaginal or cervical discharge
cervical excitation
40
Investigations for PID
a pregnancy test should be done to exclude an ectopic pregnancy
high vaginal swab
these are often negative
screen for Chlamydia and Gonorrhoea
41
Managment of PID
oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole
Removal of the IUD should be considered and may be associated with better short term clinical outcomes'
42
Complications of PID
perihepatitis (Fitz-Hugh Curtis Syndrome)
occurs in around 10% of cases
it is characterised by right upper quadrant pain and may be confused with cholecystitis
infertility - the risk may be as high as 10-20% after a single episode
chronic pelvic pain
ectopic pregnancy
43
Fitz-Hugh Curtis Syndrome
Inflammation of the liver capsule, without the involvement of the liver parenchyma, with adhesion formation accompanied by right upper quadrant pain.
44
Thrush/ candidasis
Vaginal candidiasis ('thrush') is an extremely common condition which many women diagnose and treat themselves
common cause is Candida albicans
45
predispositioning factors to thrush (4)
diabetes mellitus
drugs: antibiotics, steroids
pregnancy
immunosuppression: HIV
46
Signs and symptoms of Thrush
'cottage cheese', non-offensive discharge
vulvitis: superficial dyspareunia, dysuria
itch
vulval erythema, fissuring, satellite lesions may be seen
47
Investigations of thrush
a high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis
48
Managment of thrush
options include local or oral treatment
NICE Clinical Knowledge Summaries recommends:
oral fluconazole 150 mg as a single dose first-line
clotrimazole 500 mg intravaginal pessary as a single dose if oral therapy is contraindicated
If there are vulval symptoms, consider adding a topical imidazole in addition to an oral or intravaginal antifungal
if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated
49
Recurrent thrush managment
- BASHH define recurrent vaginal candidiasis as 4 or more episodes per year
-compliance with previous treatment should be checked
-confirm the diagnosis of candidiasis
-high vaginal swab for microscopy and culture
consider a blood glucose test to exclude diabetes
exclude differential diagnoses such as lichen sclerosus
consider the use of an induction-maintenance regime
induction: oral fluconazole every 3 days for 3 doses
maintenance: oral fluconazole weekly for 6 months
50
what is the definitive treatment of Bartholin's abcess called?
-marsupialization.
- Insertion of a catheter to treat the abcess with antibioitics
51
Bartholins abcess
Bartholin's abscess is a painful swelling or lump that forms when the Bartholin's gland becomes blocked, causing fluid buildup and infection.
52
Symptoms of Bartholin's abcess
Pain and tenderness in the vaginal area
Swelling or lump near the vaginal opening
Discomfort or pain during sexual intercourse
Difficulty walking or sitting
Fever and chills (if infection is present)
Pain with urination or bowel movements (if the abscess is large)
53
Causes of Bartholin's abcess
Blockage of the ducts of the Bartholin's glands, often due to infection or inflammation
Bacterial infection, usually by bacteria such as Escherichia coli (E. coli), Streptococcus, or Staphylococcus aureus
54
Treatment of Bartholin's abcess
Warm compresses or sitz baths to relieve pain and promote drainage
Incision and drainage (I&D) of the abscess to remove pus and relieve pressure
Antibiotics to treat bacterial infection, if present
Marsupialization (surgical procedure to create a permanent opening) for recurrent or large abscesses
Bartholin's gland excision in severe or recurrent cases
55
Prevention of Bartholin's abcess
Good genital hygiene
Avoidance of vaginal irritants (such as harsh soaps or douches)
Safe sexual practices (including condom use)
Prompt treatment of genital infections
56
Bartholin's cyst
-Bartholin's cyst develops when the entrance to the Bartholin duct becomes blocked.
-The gland continues to produce mucus which builds up behind the blockage, eventually leading to the formation of a mass.
-The initial blockage is most commonly caused by vulvar oedema. These are usually sterile.
57
Symptoms of Bartholin's cyst
Small painless lump or swelling near the vaginal opening
Discomfort or pressure in the vaginal area
Difficulty walking or sitting if the cyst is large
Discharge from the cyst (if it becomes infected)
58
Treatment of bartholin’s cyst (4)
-Warm compresses or sitz baths to promote drainage and relieve discomfort
-Surgical drainage (incision and drainage) for symptomatic or recurrent cysts
-Marsupialization (surgical procedure to create a permanent opening) for recurrent or large cysts
-Antibiotics to treat infection, if present
59
Vulval carcinoma
Vulval carcinoma is a type of cancer that develops in the tissues of the vulva, which is the external part of the female genitalia.
60
types of vulval cancers
Squamous cell carcinoma: The most common type, accounting for the majority of vulvar cancers.
Melanoma: A less common but more aggressive type that arises from melanocytes in the skin of the vulva.
Adenocarcinoma: Arises from the glandular cells in the vulva.
61
Risk factors of vulvar cancer
Age (risk increases with age, most common in women over 60)
Human papillomavirus (HPV) infection
Smoking
Chronic vulvar inflammation or irritation (such as lichen sclerosus)
Immunodeficiency
Previous history of cervical, vaginal, or anal cancer
History of vulvar intraepithelial neoplasia (VIN)
62
Symptoms of vulvar cancer
Persistent itching, pain, or tenderness in the vulvar area
Lump, mass, or ulcer on the vulva that doesn't heal
Changes in the color or texture of the skin of the vulva
Bleeding or discharge not related to menstruation
Burning or pain during urination
63
Diagnosis of vulvar cancer
Physical examination of the vulva, including visual inspection and palpation
Biopsy of suspicious lesions for pathological examination
Imaging tests (such as ultrasound, CT scan, or MRI) to assess the extent of the cancer and identify metastasis
64
Preventative measures of vulvar cancer
HPV vaccination (for prevention of HPV-related vulvar cancers)
Avoidance of smoking
Regular gynecological examinations and screening tests (Pap smear, HPV testing)
65
risk factors for vulvar cancer
Human papilloma virus (HPV) infection
Vulval intraepithelial neoplasia (VIN)
Immunosuppression
Lichen sclerosus
66
Features of vulvar cancer
lump or ulcer on the labia majora
inguinal lymphadenopathy
may be associated with itching, irritation
67
features of genital herpes
painful genital ulceration
may be associated with dysuria and pruritus
the primary infection is often more severe than recurrent episodes
systemic features such as headache, fever and malaise are more common in primary episodes
tender inguinal lymphadenopathy
urinary retention may occur
68
Genital herpes investigation
nucleic acid amplification tests (NAAT) is the investigation of choice in genital herpes and are now considered superior to viral culture
HSV serology may be useful in certain situations such as recurrent genital ulceration of unknown cause
69
Managment of genital herpes
general measures include:
saline bathing
analgesia
topical anaesthetic agents e.g. lidocaine
oral aciclovir
some patients with frequent exacerbations may benefit from longer-term aciclovir
70
Pregnancy and genital herpes
elective caesarean section at term is advised if a primary attack of herpes occurs during pregnancy at greater than 28 weeks gestation
women with recurrent herpes who are pregnant should be treated with suppressive therapy and be advised that the risk of transmission to their baby is low
71
Causes of genital herpes
There are two strains of the herpes simplex virus (HSV) in humans: HSV-1 and HSV-2.
72
Transmission of genital herpes
Direct skin-to-skin contact with an infected person during vaginal, anal, or oral sex
Transmission can occur even if the infected person does not have visible sores or symptoms (asymptomatic shedding)
Vertical transmission from mother to baby during childbirth (can lead to neonatal herpes, a potentially serious condition)
73
Lichen Sclerosus
Lichen sclerosus is a chronic inflammatory skin condition characterized by thin, white patches of skin that may appear shiny, smooth, or wrinkled.
74
Symptoms of Lichen Sclerosus
Itching (pruritus) in the affected area, often severe
Pain or discomfort, especially during sexual intercourse or urination
Thinning and tightening of the skin (atrophy), leading to a paper-like appearance
White, patchy lesions that may spread and coalesce
Bleeding, blistering, or ulceration of the affected skin
Scarring and changes in the appearance of the genital or anal area
75
Location of Lichen Scelrosus
Genital area: Commonly affects the vulva (in women) and the foreskin or glans penis (in men)
Anal area: Can affect the perianal region, causing itching, discomfort, and pain
76
Risk factors for Lichen Sclerosus
Age: Most commonly diagnosed in postmenopausal women, but can occur at any age
Autoimmune diseases (such as thyroid disorders)
Genetic predisposition
Hormonal imbalances
Trauma or irritation to the skin
77
Diagnosis of Lichen sclerosus
Clinical examination of the affected skin by a healthcare provider
Skin biopsy to confirm the diagnosis and rule out other conditions
78
Treatment of Lichen Sclerosus
Topical corticosteroids: First-line treatment to reduce inflammation, itching, and discomfort (e.g., clobetasol propionate)
Emollients or moisturizers: Used to keep the skin hydrated and reduce dryness and cracking
Immunosuppressive agents (such as tacrolimus or pimecrolimus) for cases resistant to corticosteroids
Phototherapy (narrow-band ultraviolet B therapy) in refractory cases
Regular follow-up and monitoring for early detection of complications (e.g., squamous cell carcinoma)
79
Complications of Lichen Sclerosus
Scarring of the genital or anal area
Sexual dysfunction
Phimosis (in men), leading to difficulty retracting the foreskin
Increased risk of squamous cell carcinoma, especially in long-standing or severe cases
80
Prognosis of Lichen Sclerosus
Lichen sclerosus is a chronic condition with no cure, but symptoms can often be managed effectively with appropriate treatment.
Regular follow-up with a healthcare provider is important to monitor the condition and prevent complications.
81
Vulval Intraepithelial Neoplasia (VIN)
Vulval intraepithelial neoplasia (VIN) refers to precancerous changes in the skin of the vulva, characterized by abnormal growth of cells within the vulvar epithelium.
82
Types of VIN
-VIN 1 (mild dysplasia): Minimal abnormal changes in the cells, often considered low-grade or low-risk lesions.
-VIN 2 (moderate dysplasia): Moderate abnormal changes in the cells, indicating a higher risk of progression to vulvar cancer compared to VIN 1.
-VIN 3 (severe dysplasia or carcinoma in situ): Severe abnormal changes in the cells, with a high risk of progression to invasive vulvar cancer if left untreated.
83
Risk factors for VIN
-Infection with high-risk types of human papillomavirus (HPV)
-Smoking
-Immunosuppression
-History of vulvar or cervical dysplasia
-Chronic vulvar inflammation or irritation (e.g., lichen sclerosus)
84
Symptoms of VIN
-Itching, pain, or burning in the vulvar area
-Redness, thickening, or changes in the color or texture of the vulvar skin
-Presence of lesions or sores on the vulva
-Bleeding or discharge not related to menstruation
85
Diagnosis of VIN
-Visual inspection of the vulvar area by a healthcare provider
-Colposcopy: Examination of the vulvar tissue under magnification using a colposcope
-Biopsy: Removal of a small sample of tissue from the abnormal area for pathological examination
86
Treatment of VIN
-Observation and monitoring for low-grade lesions (VIN 1)
-Surgical excision or destruction of the abnormal tissue (e.g., laser ablation, electrocautery) for moderate to severe lesions (VIN 2 and VIN 3)
-Topical treatments (e.g., imiquimod cream) for selected cases of VIN
-Regular follow-up and surveillance to monitor for recurrence or progression
87
Prevention of VIN
HPV vaccination: Helps prevent infection with high-risk types of HPV, which are associated with VIN and vulvar cancer
Smoking cessation
Safe sexual practices: Condom use may reduce the risk of HPV transmission
88
Prognosis of VIN
-Prognosis depends on the grade and extent of -VIN, as well as the effectiveness of treatment.
-Early detection and intervention can prevent progression to invasive vulvar cancer and improve outcomes.
89
Bacterial Vaginosis
Bacterial vaginosis is a common vaginal infection caused by an imbalance of bacteria in the vagina, characterized by an overgrowth of harmful bacteria.
90
Etiology of bacterial vaginosis
Disruption of the normal balance of vaginal bacteria, particularly a decrease in beneficial lactobacilli and an increase in harmful anaerobic bacteria (such as Gardnerella vaginalis)
Exact cause remains unclear, but factors such as sexual activity, douching, and hormonal changes may contribute to the development of BV
91
Symptoms of BV
Thin, white, or gray vaginal discharge with a fishy odor (especially after sexual intercourse or menstruation)
Vaginal itching or irritation
Burning sensation during urination
Discomfort or pain during sexual intercourse
92
Diagnosis of BV
Clinical examination of the vaginal discharge and pH testing (pH > 4.5)
Whiff test: Addition of potassium hydroxide (KOH) to vaginal discharge, producing a fishy odor (positive whiff test)
Microscopic examination of vaginal discharge: Presence of clue cells (vaginal epithelial cells covered with bacteria), increased numbers of harmful bacteria, and absence of lactobacilli
Gram stain or culture of vaginal discharge (not routinely performed)
93
Treatment of BV
Antibiotic therapy: Oral or vaginal antibiotics (such as metronidazole, clindamycin, or tinidazole) to eliminate the overgrowth of bacteria and restore the normal balance of vaginal flora
Topical treatments (such as vaginal creams or gels) may be used for localized or recurrent BV
Treatment of sexual partners is not routinely recommended unless they have symptoms of BV
94
Complications of BV
Increased risk of acquiring sexually transmitted infections (STIs), including HIV
Pelvic inflammatory disease (PID) in severe or recurrent cases
Pregnancy complications (such as preterm birth or low birth weight) in pregnant women with untreated BV
95
Prevention of BV
Avoidance of douching and other vaginal irritants
Limiting the number of sexual partners and practicing safer sex (consistent condom use)
Avoiding excessive use of antibiotics, which can disrupt the normal vaginal flora
Regular gynecological examinations and screenings
96
Prognosis of BV
Bacterial vaginosis is generally a benign condition but may recur after treatment, particularly in women with certain risk factors.
Prompt diagnosis and appropriate treatment can alleviate symptoms and reduce the risk of complications.
97
Cervical Ectropion
Cervical ectropion is a benign condition characterized by the presence of glandular cells from the cervical canal on the outer surface of the cervix.
98
Etiology of cervical ecrtopion
Normal physiological variant, especially common in young women and women of reproductive age
Hormonal changes: Estrogen dominance can contribute to the development of cervical ectropion
Pregnancy: Cervical ectropion is often observed during pregnancy due to hormonal fluctuations
99
Symptoms of cervical ectropion
Typically asymptomatic
Vaginal discharge: Increased discharge, often clear or white in color
Spotting or bleeding: May occur after sexual intercourse or pelvic examination
Mild discomfort or irritation: Occasionally reported by some individuals
100
Diagnosis of cervical ectropion
Visual examination of the cervix during pelvic examination
Cervical cytology (Pap smear): May reveal the presence of glandular cells on the ectocervix, which can help differentiate cervical ectropion from other cervical abnormalities
Colposcopy: Magnified examination of the cervix using a colposcope, which may show the characteristic appearance of cervical ectropion
101
Treatment of cervical ectropion
Typically not required in asymptomatic cases
Symptomatic management: Addressing symptoms such as discharge or bleeding, if present, with conservative measures (e.g., panty liners, topical estrogen cream)
Hormonal contraception: Some individuals may benefit from hormonal methods of contraception (e.g., combined oral contraceptives), which can help regulate hormonal fluctuations and reduce symptoms
Cauterization or cryotherapy: Rarely indicated for severe or refractory cases
102
Complications of cervical ectropion
Generally considered a benign condition with no long-term adverse effects
Rarely, persistent or severe symptoms may necessitate further evaluation to rule out other cervical abnormalities or infections
103
Prognosis of cervical ectropion
Cervical ectropion is typically a self-limiting condition that resolves spontaneously over time, especially after menopause when hormonal fluctuations decrease.
Regular gynecological examinations may be recommended to monitor the condition, especially in symptomatic individuals.
104
Trichomonas Vaginalis
Trichomonas vaginalis is a protozoan parasite that causes trichomoniasis, a common sexually transmitted infection (STI).
105
Transmission of Trichomonas vaginalis
Transmission primarily occurs through sexual contact with an infected individual, including vaginal, anal, or oral sex.
Infection can also occur through non-sexual transmission, such as sharing contaminated objects (e.g., towels, sex toys).
106
Symptoms of trichomonas
Vaginal discharge: Often frothy, greenish-yellow, or gray in color, with a foul odor
Genital itching or irritation
Pain or discomfort during sexual intercourse (dyspareunia)
Pain or burning sensation during urination (dysuria)
Some individuals may remain asymptomatic
107
Diagnosis of Trichomonas
Microscopic examination of vaginal fluid: Identification of motile trichomonads under a microscope (wet mount)
Nucleic acid amplification tests (NAATs): Highly sensitive and specific tests that detect Trichomonas DNA in vaginal or urine samples
Culture: Growth of Trichomonas organisms in culture medium, although less commonly performed
108
Treatment of Trichomonas
Oral antibiotics: Metronidazole or tinidazole are commonly used to treat trichomoniasis and eliminate the parasite.
Treatment of sexual partners: All sexual partners should be treated simultaneously to prevent reinfection.
109
Complications of Trichomonas
Increased risk of acquiring or transmitting other sexually transmitted infections (STIs), including HIV
Pelvic inflammatory disease (PID) in women, which can lead to infertility or ectopic pregnancy
Preterm birth or low birth weight in pregnant women with untreated trichomoniasis
Increased risk of cervical neoplasia in women with long-standing trichomoniasis
110
Prevention of Trichomonas
Safe sexual practices: Consistent and correct use of condoms during sexual intercourse can reduce the risk of trichomoniasis and other STIs.
Limiting the number of sexual partners
Routine screening for STIs, including trichomoniasis, in sexually active individuals
111
Prognosis of Trichomonas
Trichomoniasis is generally curable with appropriate treatment, although reinfection can occur if sexual partners are not treated simultaneously.
Early detection and treatment can help prevent complications and reduce the risk of transmission.
112
Candida discharge
Cottage cheese' discharge
Vulvitis
Itch
113
Trichomonas vaginalis discharge
Offensive, yellow/green, frothy discharge
Vulvovaginitis
Strawberry cervix
114
Bacterial vaginosis discharge
Offensive, thin, white/grey, 'fishy' discharge
115
Alpha-fetoprotein
Alpha-fetoprotein is a protein produced primarily by the fetal liver during pregnancy.
116
Function of alpha-fetoprotein
Transport of nutrients: AFP binds to various molecules (such as fatty acids and steroids) and transports them across the placenta to the developing fetus.
Regulation of fetal growth: AFP may play a role in regulating the growth and development of fetal tissues during pregnancy.
117
Diagnosing uses of alpha-fetoprotein
-Prenatal screening: AFP levels in maternal blood are measured as part of prenatal screening tests, such as the triple or quadruple screen, to assess the risk of certain birth defects, including neural tube defects (such as spina bifida) and chromosomal abnormalities (such as Down syndrome).
-Monitoring fetal health: Elevated or decreased AFP levels in amniotic fluid may indicate certain fetal health conditions, such as neural tube defects or gastrointestinal abnormalities.
-Cancer diagnosis and monitoring: Elevated AFP levels in adults may indicate certain types of cancer, particularly liver cancer (hepatocellular carcinoma) and germ cell tumors (such as testicular cancer or ovarian cancer).
118
Elevated alpha-fetoprotein
During pregnancy: May indicate an increased risk of
-neural tube defects,
-abdominal wall defects (such as gastroschisis or omphalocele), or
-chromosomal abnormalities in the fetus.
- mutliple pregnancy
In adults: May indicate liver cancer (hepatocellular carcinoma), germ cell tumors, or other types of cancer.
119
Decreased alpha-fetoprotein
Down's syndrome
Trisomy 18
Maternal diabetes mellitus
120
How to measure alpha-fetoprotein
Maternal serum screening: AFP levels are measured in maternal blood as part of prenatal screening tests, such as the triple or quadruple screen, usually between 15 and 20 weeks of pregnancy.
Amniocentesis: AFP levels can be measured in amniotic fluid obtained through amniocentesis, a procedure performed during pregnancy to assess fetal health.
121
how much fluid is removed from amniocentesis
20 ml of fluid is removed by transabdominal needle under ultrasound guidance
122
Amniocentesis
-erformed between 15-20 weeks (typically at 16 weeks) and the risk of fetal loss quoted by the NHS is 0.5%
-karyotype can take 3 weeks to come back.
123
Chancroid
Chancroid is a sexually transmitted infection caused by the bacterium Haemophilus ducreyi, characterized by painful genital ulcers and swollen lymph nodes.
124
Etiology of chancroid
Caused by the bacterium Haemophilus ducreyi, a fastidious gram-negative bacillus.
Transmission occurs through sexual contact with an infected individual, including vaginal, anal, or oral sex.
125
Symptoms of Chancroid
Painful genital ulcers: Typically develop on the penis in men or on the labia, vulva, or perianal area in women. Ulcers are soft, irregular, and often have a friable base.
Swollen lymph nodes (buboes): Enlarged and tender lymph nodes may develop in the groin area.
Pain or discomfort during urination or sexual intercourse
In some cases, systemic symptoms such as fever and malaise may occur
126
Diagnosis of Chancroid
Clinical examination: Evaluation of genital ulcers and associated symptoms.
Laboratory tests:
Gram stain or Giemsa stain of ulcer exudate: Identification of gram-negative bacilli or characteristic "school of fish" appearance.
Culture of ulcer swab: Growth of Haemophilus ducreyi in culture medium, although less commonly performed.
Polymerase chain reaction (PCR) testing: Detection of Haemophilus ducreyi DNA in ulcer swab samples, with higher sensitivity compared to culture.
127
Treatment of Chancroid
Antibiotic therapy: Oral antibiotics such as azithromycin, ceftriaxone, or erythromycin are commonly used to treat chancroid and eradicate the bacteria.
Drainage of buboes: Large or painful lymph node swellings (buboes) may require aspiration or surgical drainage to relieve symptoms.
Treatment of sexual partners: All sexual partners should be treated simultaneously to prevent reinfection.
128
Chancroid complications
If left untreated, chancroid can lead to complications such as chronic genital ulcers, scarring, or the formation of genital fistulas.
Increased risk of acquiring or transmitting other sexually transmitted infections (STIs), including HIV.
129
Prevention of Charccoid
Safer sex practices: Consistent and correct use of condoms during sexual activity can reduce the risk of chancroid and other STIs.
Limiting the number of sexual partners and avoiding high-risk sexual behaviors.
130
Benefits of the COOP (7)
- highly effective (failure rate < 1 per 100 woman years)
- doesn't interfere with sex
- contraceptive effects reversible upon stopping
- usually makes periods regular, lighter and less painful
- reduced risk of ovarian, endometrialand colorectal cancer
- may protect against pelvic inflammatory disease
- may reduce ovarian cysts, benign breast disease, acne vulgaris
131
Disadvantages of COOP (6)
- may forget to take
- not STI protection
- increased VTW risk
- increased breast and cervical cancer tisk
- increased risk of stroke and ischaemic heart disease
- temporary headaches/ breast tenderness
132
Definition of UKMEC 2
advantages generally outweigh the disadvantages
132
Definiton of UKMEC 1
a condition for which there is no restriction for the use of the contraceptive method
133
UKMEC 3
disadvantages generally outweigh the advantage
134
UKMEC 4 defintion
represents an unacceptable health risk
135
examples of UKMEC 3 (7)
- more than 35 years old and smoking less than 15 cigarettes/day
- BMI > 35 kg/m^2*
- family history of thromboembolic disease in first degree relatives < 45 years
- controlled hypertension
- immobility e.g. wheel chair use
- carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
- current gallbladder disease
136
UKMEC 4 include
- >35 years old and smoking more than 15 cigarettes/day
- migraine with aura
- history of thromboembolic disease or thrombogenic mutation
- history of stroke or ischaemic heart disease
- breast feeding < 6 weeks post-partum
- uncontrolled hypertension
- current breast cancer
- major surgery with prolonged immobilisation
positive antiphospholipid antibodies (e.g. in SLE)>
137
Adenomyosis
presence of endometrial tissue within the myometrium. It is more common in multiparous women towards the end of their reproductive years.
138
Features of Adenomyosis
dysmenorrhoea
menorrhagia
enlarged, boggy uterus
139
Investigations of adneomyosis
NICE recommend transvaginal ultrasound as the first-line investigation
MRI is an alternative
140
Managment of adenomyosis
1. symptomatic treatment
- tranexamic acid to manage menorrhagia
- GnRH agonists
- uterine artery embolisation
2. considered the 'definitive' treatment
- hysterectomy
141
Primary amenorrhoea
- failure to establish menstruation by 15 years of age in girls with normal secondary sexual characteristics (such as breast development), or by 13 years of age in girls with no secondary sexual characteristics
142
Secondary amenorrhoea
cessation of menstruation for 3-6 months in women with previously normal and regular menses, or 6-12 months in women with previous oligomenorrhoea
143
Causes of primary amenorrhoea (6)
- gonadal dysgenesis (e.g. Turner's syndrome) - the most common causes
- testicular feminisation
- congenital malformations of the genital tract
- functional hypothalamic amenorrhoea (e.g. secondary to anorexia)
- congenital adrenal hyperplasia
- imperforate hymen
144
Seondary amenorrhoea causes
- pregnancy
- hypothalamic amenorrhoea (e.g. secondary stress, excessive exercise)
- polycystic ovarian syndrome (PCOS)
- hyperprolactinaemia
- premature ovarian failure
- thyrotoxicosis*
- Sheehan's syndrome
- Asherman's syndrome (intrauterine adhesions)
145
Primary managment of amenorrhoea
- investigate and treat underlying cause
- consider hormone replacement.
146
Secondary amenorrhoea managment
- exclude pregnancy, lactation, and menopause (in women 40 years of age or older)
- treat the underlying cause
147
Investigations of amenorrhoea
- exculde pregancy
- FBC, U+E, coeliac screen, thyroid functon
- gonadotrophins
- prolactin
- oestradiol
- androgen levels (PCOS concern)
148
Amniotic fluid embolism
This occurs when fetal cells or amniotic fluid enter the mother's bloodstream, triggering a reaction that leads to various signs and symptoms.
149
Amniotic fluid embolism epidemiology
Rare complication of pregnancy
High mortality rate
Incidence: 2 per 100,000 in the U.K
150
AFE aetiology
- Clear cause not proven, but several risk factors identified
- Associated with maternal age and induction of labor
-Occurs when maternal circulation is exposed to fetal cells/amniotic fluid
- Underlying pathology not well understood, possibly immune-mediate
151
AFE clinical presentation
- Often occurs during labor but can also happen during cesarean section or postpartum
- Symptoms: Chills, shivering, sweating, anxiety, coughing
- Signs: Cyanosis, hypotension, bronchospasms, tachycardia, arrhythmia, myocardial infarction
152
Diagnosis of AFE
Clinical diagnosis of exclusion
No definitive diagnostic tests
153
Managment of AFE
Requires care in a critical care unit
Managed by a multidisciplinary team
Predominantly supportive treatment
154
Androgen Insensitivity Syndrome
An X-linked recessive condition caused by end-organ resistance to testosterone. Genotypically male children (46XY) present with a female phenotype. Complete androgen insensitivity syndrome is the modern term for testicular feminization syndrome.
155
Features of AIS
Primary amenorrhea
Little or no axillary and pubic hair
Undescended testes causing groin swellings
Breast development may occur due to the conversion of testosterone to estradiol
156
Diagnosis of AIS
Buccal smear or chromosomal analysis: reveals 46XY genotype
After puberty: testosterone concentrations in the high-normal to slightly elevated range for postpubertal males
157
Diagnosis of AIS
Counseling: Raise the child as female
Bilateral orchidectomy: Due to increased risk of testicular cancer from undescended testes
Estrogen therapy
158
Antenatal care nutitional supplements
- Folic Acid: 400 mcg from before conception until 12 weeks to reduce neural tube defects; higher doses may be needed for women on antiepileptics
- Iron: Not offered routinely
- Vitamin A: Avoid intake above 700 mcg (teratogenic risk); avoid liver
- Vitamin D: 10 mcg/day recommended; higher-risk women (darker skin or cultural clothing coverage) should be given special attention
159
Alcohol antenatal
- do not drink
160
Smoking antenatal
Discuss risks like low birthweight and preterm birth
NRT: Can be used if women have stopped smoking; discuss risks/benefits
Varenicline/Bupropion: Not offered to pregnant or breastfeeding women
161
Food acquired infections antenataly
Listeriosis: Avoid unpasteurized milk, ripened soft cheeses (e.g., Camembert, Brie, blue-veined), pâté, and undercooked meat
Salmonella: Avoid raw/partially cooked eggs and meat, especially poultry
162
Air travel during pregnancy
>37 weeks (singleton pregnancy, no risk factors): Avoid air travel
>32 weeks (uncomplicated multiple pregnancies): Avoid air travel
Increased risk of venous thromboembolism (VTE); use correctly fitted compression stockings
163
Exercise during pregnancy
Moderate exercise is safe; not associated with adverse outcomes
Avoid high-impact sports (risk of abdominal trauma) and scuba diving
164
Tamoxifen (SERM)
Mechanism: Acts as an estrogen receptor antagonist and partial agonist
Use: Management of estrogen receptor-positive breast cancer
165
Tamoxifen adverse effects
Menstrual disturbances: vaginal bleeding, amenorrhea
Hot flushes (3% of patients discontinue due to climacteric side effects)
Venous thromboembolism
Endometrial cancer
166
Examples of aromatase inhibitors
Anastrozole, Letrozole
167
Adverse effects of aromatase inhibitors
Osteoporosis (NICE recommends DEXA scan at initiation)
Hot flushes
Arthralgia, myalgia
Insomnia
168
Aromatase inhibitors
Mechanism: Reduce peripheral estrogen synthesis
Use: ER-positive breast cancer in postmenopausal women (as aromatization is a major source of estrogen production)
169
What is a significant risk factor for developing venous thromboembolism (VTE)?
Pregnancy
## Footnote
Pregnancy increases the likelihood of VTE due to physiological changes and factors such as increased clotting factors.
170
When should a risk assessment for VTE be completed during pregnancy?
At booking and on any subsequent hospital admission
## Footnote
This ensures ongoing evaluation of risk factors that may change over time.
171
What is the protocol for a woman with a previous history of VTE during pregnancy?
Considered high risk and requires low molecular weight heparin throughout the antenatal period
## Footnote
Additionally, expert input is necessary for managing these patients.
172
What factors may categorize a woman as intermediate risk for VTE?
Hospitalisation, surgery, co-morbidities, or thrombophilia
## Footnote
These conditions warrant consideration for antenatal prophylactic low molecular weight heparin.
173
List some risk factors that increase the likelihood of developing VTE in pregnant women.
* Body mass index > 30
* Parity > 3
* Smoker
* Gross varicose veins
* Current pre-eclampsia
* Immobility
* Family history of unprovoked VTE
* Low risk thrombophilia
* Multiple pregnancy
* VF pregnancy
## Footnote
Identifying these factors helps in assessing the overall risk for VTE.
174
True or False: A woman with a body mass index greater than 30 is at increased risk for VTE during pregnancy.
True
## Footnote
Higher body mass index is associated with increased venous stasis and clotting risk.
175
Fill in the blank: A woman who is a _______ is at increased risk of VTE during pregnancy.
[Smoker]
## Footnote
Smoking is known to impair endothelial function and increase clot formation.
176
What is the significance of a family history of unprovoked VTE in pregnancy risk assessment?
It increases the likelihood of developing VTE
## Footnote
Family history can indicate a genetic predisposition to thrombosis.
177
What should be considered for a pregnant woman who is immobile?
Antenatal prophylactic low molecular weight heparin
## Footnote
Immobility is a known risk factor for venous thromboembolism.
178
What is the treatment duration for low molecular weight heparin if there are four or more risk factors?
Continued until six weeks postnatal
## Footnote
Immediate treatment is warranted with low molecular weight heparin.
179
When should low molecular weight heparin be initiated for women with three risk factors?
From 28 weeks and continued until six weeks postnatal
## Footnote
This is crucial for managing risk during pregnancy.
180
What should be done if a diagnosis of DVT is made shortly before delivery?
Continue anticoagulation treatment for at least 3 months
## Footnote
This is similar to the protocol for other patients with provoked DVTs.
181
What is the treatment of choice for VTE prophylaxis in pregnancy?
Low molecular weight heparin
## Footnote
It is preferred over other anticoagulants in this context.
182
Which anticoagulants should be avoided in pregnancy?
Direct Oral Anticoagulants (DOACs) and warfarin
## Footnote
These medications pose risks during pregnancy.
