sexual health

Question 1

What are the most common types of HPV? which types are linked to cervical cancer?

Answer 1

Most common: Types 6 and 11 are responsible for 90% of genital warts cases

Link to cancer: 16,18 & 33 predisposes to cervical cancer.

Question 2

How often are women with HIV meant to have smears?

Answer 2

Annually

Question 3

What is chancroid?

Answer 3

Tropical disease (Haemophilus ducrey)
Chancroid presents as a deep, painful genital ulcer and is often associated with inguinal lymphadenopathy.

Question 4

What is the treatment for genital warts?

Answer 4

multiple, non-keratinised warts: topical podophyllum
solitary, keratinised warts: cryotherapy

Question 5

How is HIV diagnosed?

Answer 5

combination tests (HIV p24 antigen (present in early disease) and HIV antibody (presnt usually from 6weeks)) are now standard for the diagnosis and screening of HIV

Question 6

Bacterial cause of most BV?

Answer 6

Gardnerella vaginalis

Question 7

BV vs trichomonas? Mx?

Answer 7

Trichomonas vaginalis - offensive ‘musty’, frothy, green vaginal, strawberry cervix

BV- thin, white discharge
clue cells on microscopy
vaginal pH > 4.5
positive whiff test - fishy when add potassium hydroxide

PO metronidazole

Question 8

Gonorrhoea mx

Answer 8

IM ceftriaxone

Question 9

What are the different options for emergency contraception? How would u decide one vs another?

Answer 9

copper coil - 1st line - CI if STI or after 5 days post coital. If pt wants it removed after - take out at next period
Levonorgestrel - can be used up to 72 hrs post coital
Ulipristal - used up to 120 hrs post coital. CI in severe asthma

Question 10

When is PEP given?

Answer 10

Within 72 hrs of exposure, the sooner the more effective

Question 11

Levonorgestrel vs ullipristal as emergency contraception?

Answer 11

Levonorgestrel:
must be taken in 72 hrs
can take normal contraception straight away
the dose should be doubled for those with a BMI >26 or weight over 70kg
dose should also be doubled if taking enzyme-inducing drugs (although a copper IUD as emergency contraception is preferable in this situation)
if vomiting occurs within 3 hours then the dose should be repeated

Ullipristal:
must be taken in 120 hrs
normal contraception wont work for 5 days after
Have to pause breastfeeding
CI in severe asthma eg PO steroids

Both can be used more than once in the same menstrual cycle

Question 12

How far back do you need to notify partners if u are pos for chlamydia?

Answer 12

Chlamydia - partner notification:
symptomatic men: all partners from the 4 weeks prior to the onset of symptoms
women + asymptomatic men: all partners from the last 6 months or the most recent sexual partner

Question 13

Absolute CI of COCP

Answer 13

Absolute contra-indications for the combined oral contraceptive pill (category 4) include:

Migraine with aura
Breastfeeding <6 weeks post-partum
Age 35 or over smoking 15 or more cigarettes/day
Systolic 160mmHg or diastolic 95mmHg
Vascular disease
History of VTE
Current VTE (on anticoagulants)
Major surgery with prolonged immobilisation
Known thrombogenic mutations
Current and history of ischaemic heart disease
Stroke (including TIA)
Complicated valvular and congenital heart disease
Current breast cancer
Nephropathy/retinopathy/neuropathy
Other vascular disease
Severe (decompensated) cirrhosis
Hepatocellular adenoma
Hepatoma
Raynaud’s disease with lupus anticoagulant
Positive antiphospholipid antibodies

Question 14

When can you restart COCP post birth? What about if breastfeeding?

Answer 14

The COCP should not be used in the first 21 days due to the increased venous thromboembolism risk post-partum

6 weeks if breastfeeding

Question 15

How do the different contraceptive work?

Answer 15

All inhibit ovulation, except:
- POP: thickens cervical mucus (Exception to this is desogestrel POP which inhibits ovulation)
- IUD copper: kills sperm
- IUS: prevents endometrial proliferation (get amenorrhea with this)

Question 16

How long does it take for contraceptive to be effective? (if not 1st day of period)

Answer 16

instant: IUD

2 days: POP

7 days: COC, injection, implant, IUS

Question 17

UKMEC 3 criteria for COCP?
Disadvantages generally outweigh the advantages

Answer 17

Examples of UKMEC 3 conditions include
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

Question 18

UMEC 4 criteria for COCP?
Represents an unacceptable health risk

Answer 18

Examples of UKMEC 4 conditions include
Being over 50 years old
more than 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)

Question 19

Is diabetes a CI for COCP?

Answer 19

Diabetes mellitus diagnosed > 20 years ago is classified as UKMEC 3 or 4 depending on severity

Question 20

UKMEC 3 vs 4 for implantable contracpetives?

Answer 20

UKMEC 3: ischaemic heart disease/stroke (for continuation, if initiation then UKMEC 2), unexplained, suspicious vaginal bleeding, past breast cancer, severe liver cirrhosis, liver cancer

UKMEC 4: current breast cancer

Question 21

UKMEC 3 vs UKMEC 4 for depo proverra?

Answer 21

current breast cancer is UKMEC 4, past breast cancer is UKMEC 3

Question 22

What is the rule for missed POPs?
Deogestrel vs other POPs?

Answer 22

Have 12 hours to take desogestrel

Have 3 hours to take other POPs

If outside this window:
take the missed pill as soon as possible. If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day
continue with rest of pack
extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours

Question 23

Mx of chlamdyia?

Answer 23

doxycycline (7 day course) if first-line

if doxycycline is contraindicated / not tolerated / prehanant then either azithromycin or erythromycin or amoxicillin may be used.

Question 24

2nd line mx of BV?

Answer 24

topical metronidazole or topical clindamycin as alternatives

Question 25

What are the risks of IUS/ IUD?

Answer 25

IUDs make periods heavier, longer and more painful
the IUS is associated with initial frequent uterine bleeding and spotting. Later periods lighter and less painful

uterine perforation: up to 2 per 1000 insertions and higher in breastfeeding women

infection: there is a small increased risk of pelvic inflammatory disease in the first 20 days after insertion only
expulsion: risk is around 1 in 20, and is most likely to occur in the first 3 months

Question 26

Missed pill rules cocp?

Answer 26

1 pill is missed (at any time in the cycle)
take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
no additional contraceptive protection needed

If 2 or more pills missed
take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
the women should use condoms or abstain from sex until she has taken pills for 7 days in a row. FSRH: ‘This advice may be overcautious in the second and third weeks, but the advice is a backup in the event that further pills are missed’
if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception*
if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval

*theoretically women would be protected if they took the COC in a pattern of 7 days on, 7 days off

Question 27

When switching from POP to COCP what cover is needed to protect from pregnancy?

Answer 27

Need 7 days contraceptive cover