Sexual Health Flashcards
Combined contraceptives mechanism
Contain oestrogen + progesterone
- Inhibit LH + FSH release + ovulation
- Thicken cervical mucus - prevent sperm passage, thin endometrium
UKMEC - UK medical eligibility criteria
1 - no restriction
2 - benefits > risks
3 - risks > benefits
4 - unacceptable health risk
Combined contraceptives CIs
- Migraine with aura
- Current breast cancer (small increased risk of breast cancer whilst taking - reduces to normal after 10yrs of stopping)
- VTE RFs (AF, SLE, >35 smoking >15 cigarettes / day, hx of stroke/VTE …)
- CV RFs (BP >160/100, IHD)
- Severe liver disease
- Immobility, BMI >35, VTE FHx, BRCA1/2
- Pts who have had gastric sleeve / bypass cannot have oral contraception ever again - due to lack of efficacy
positives and negatives for combined COCP
+VEs
- Lighter, regular periods
- May reduce ovarian, endometrial, bowel ca risk
-VEs
- Increased VTE risk
- Slight breast / cervical ca risk
- headaches, nausea, breast tenderness, mood swings
- Forgetting pill reduces efficacy
examples of COCP + need to know facts r.e. efficacy
- Microgynon, Rigevidon
- 21/7 or maybe 63/7 cycle
- If started within 5d of cycle, no need for additional contraception. If at any other point, use 7d condoms
- UPSI during pill-free period fine as long as next pack started on time
- Efficacy reduced - vomit within 2hrs taking, liver-enzyme inducing drugs, rifampicin, some AEDs
contraceptive patch - need to know facts r.e. use
- One patch for 7 days, then change - typically 21/7 - withdrawal bleed in last week
- If patch change delayed wk 1/2 - if <48hrs delay, change immediately, no further action, >48hrs change + 7d barrier contraception, emergency contraception if UPSI during this >48hr period
- Removal delay at end of wk 3 - remove asap then replace patch on usual day
- Delay applying at start of wk 1 - 7d barrier contraception
POP - examples
- Take every day, no breaks
- Desogestrel - inhibits ovulation, thickens cervical mucus, thins endometrium, take within same 12hrs each day
- Norethisterone / levonorgestrel - thicken cervical mucus, thin endometrium, take within same 3hrs
from when does POP protection start?
- Immediate protection if started in day 1-5 of cycle, otherwise, use condoms for 2d
- Gives immediate protection if continued straight on from COCP
positive and negatives of POP
+VEs
- Can use where oestrogen CI’d
- Take w/o breaks
-VEs
- less protection if pill missed
- Irregular bleeding, amenorrhoea
- Affected by enzyme inducer drug
what is depo-provera and how does it work?
IM progestogen every 3mo
- Inhibits ovulation, thickens mucus, thins endometrium
S/E of depo
- Irregular bleeding, amenorrhoea
- Affects bone mineral density
- Fertility takes months to return after stopping
implant - how does it work and from when are you protected?
- Subdermal, slow release progestogen (eg Nexplanon), lasts 3yrs
- If not inserted between day 1-5 of cycle, need 7d condoms
- irregular bleeding (co-prescribe cOCP to prevent)
- Acne - worsens
how does the IUS / hormonal coil work? how long do you need to use condoms for?
- Release progestogen - thicken mucus, thin endometrium - 3-5yrs
- Use condoms for 7d after insertion
IUS s/e
- Reduce heavy menstruation
- systemic S/E few
- Amenorrhoea, irregular bleeds
- Acne, headaches, breast tenderness, painful
- Uterine perforation risk
- higher risk of ectopic pregnancy
copper coil - mechanism ?
- creates inhospitable environment for sperm - 5-10yrs
- no hormones
- efficacy unaffected by meds
copper coil risks and S/E?
- heavy, long, painful menstruation
- perf risk
- ectopic pregnancy
female sterilisation procedure?
Under GA / during c-section
Clips to occlude fallopian tube / salpingectomy / fallopian implants under hysteroscopy
Can still get pregnant, ectopic likely
Difficult to reverse
male sterilisation procedure?
Vasectomy - under LA, remove section of vas deferens
Less invasive than female
Difficult to reverse
Levonelle / levonorgestrel - emergency contraception - how does it work?
- Progestogen - delays ovulation until after sperm has died
- Take <3d of UPSI
- If vomit <3hrs, rpt dose
- Can start hormonal contraception immediately
- Can take more than once in cycle
- Least effective emergency contraception, affected by enzyme meds
- No benefit if taken after LH surge / ovulation
Ellaone / ulipristal acetate - EC - how does it work?
- Delays / stops ovulation
- Take <5d UPSI
- Wait 5d before starting hormonal contraception
- Delay breastfeeding 1wk after
- Some efficacy after ovulation
- More effective than levonorgestrel
- Use more than once in one cycle
- Affected by meds
- CI - severe asthma, liver problems, PPI / antacids
using copper coil as emergency contraception?
- Insert <5d UPSI / <5d ovulation
- Most effective EC
- Not affected by meds / weight
- CI’d >5d post ovulation
rules if missed COCP
If 1 missed pill at any time
- Take last pill, today’s as normal, continue, no additional contraception
If 2+ missed pills
- Take last pill, todays, continue
- 7d condoms
- if in wk 1 + UPSI - consider EC
- if in wk 2 - no EC need
- if in wk 3 - finish pills in current pack, start next pack immediately, omit pill-free interval
rules if missed POP?
- <3hrs late, continue as normal
- > 3hrs late, action needed
- 12hr timeframe for desogestrel
Action:
- take missed pill asap, as well as next pill in day, continue
- 48hrs condoms
contraception >40?
cOCP may help maintain bone mineral density perimenopause / reduce menopause sx
HRT - use POP alongside, as long as HRT has progestogen component
stopping contraception: non hormonal
<50yo stop after 2yrs amenorrhoea
>50yo stop after 1yr amenorrhoea
stopping contraception: COCP
<50yo - continue to 50yo
>50yo - switch to non-hormonal / progestogen only
stopping contraception: depo
<50yo - continue to 50yo
>50yo - switch to non-hormonal / progestogen only
stopping contraception: implant, POP, IUS
<50yo - can continue >50yo
>50yo - continue, if amenorrhoeic check FSH and stop after 1yr if FSH raised or stop at 55yo - if bleeding consider Ix for abnormal bleeding
post partum contraception?
- need after day 21 after birth
POP
- start at any time breastfeeding or not
- condoms for 2d at start
COCP
- If breastfeeding, UKMEC4 contraindicated <6wks postpartum, UKMEC2 6wks-6mo
- Do not use <21d postpartum - VTE
- May reduce breast milk production
- 7d condoms
IUS/D
- Insert <48hrs or >4wks after childbirth
lactational amenorrhoea?
- Works <6mo post-partum if exclusively breastfeeding
BV
Overgrowth of anaerobic organisms in vagina and raised vaginal pH
Loss of friendly lactobacilli (produce lactic acid, keep vagina pH <4.5)
BV RFs
Multiple sexual partners
Excessive vaginal cleaning
Recent abx
Smoking
Copper coil
BV Px
Vaginal discharge - fishy, offensive, grey/white
Not usually sore, itchy
Asymptomatic in 50%
BV Ix
Speculum exam + high vaginal swab (or self-taken low vaginal swab)
Vaginal pH - with swab / pH paper
BV: Amsel’s dx criteria
Need 3/4 of:
- Thin, white homogenous discharge
- Clue cells on microscopy - stippled vaginal epithelial cells (due to being covered with bacteria)
- Vaginal pH >4.5
- Positive whiff test (Addition of potassium hydroxide -> fishy odour)
BV Mx
5-7d oral metronidazole
Alternatives topical metronidazole / clindamycin / tinidazole
Relapse >50% within 3mo
BV in pregnancy
Increased risk of preterm labour, low birth weight, chorioamnionitis, late miscarriage
Can use oral metronidazole throughout pregnancy, but not high dose, inc breastfeeding
Candidiasis / thrush
Vaginal infection with Candida yeast
Can colonise vagina w/o sx - then develop after abx, pregnancy etc
Thrush RFs
Increased oestrogen - pregnancy
Poorly controlled DM
Immunosuppression, eg corticosteroids
Abx
Thrush Px
Thick, white discharge, not typically smelly (cottage cheese)
Vulval / vaginal itching, irritation, discomfort
More severe infection - erythema, fissures, oedema, dyspareunia, dysuria, excoriation, satellite lesions
Thrush Ix
Tx usually started based on px
Vaginal pH (>4.5 in BV and trichomonas, <4.5 in candidiasis)
Vaginal smear + charcoal swab with microscopy - confirm dx
Thrush Mx Acute Infection
- Fluconazole 150mg oral capsule single dose
- Clotrimazole 500mg intravaginal single-dose pessary if oral therapy contraindicated
- If vulval sx - consider adding topical clotrimazole cream
- Severe infection - repeat antifungal tx after 72rs - oral fluconazole on day 1 and 4
(Canesten Duo - OTC tx - fluconazole tablet and clotrimazole cream
Thrush Mx recurrent infection
Check tx compliance, confirm candidiasis with high vaginal swab (exclude lichen sclerosus)
- Induction - 3 doses oral fluconazole 150mg, every 72hrs
- Maintenance - oral fluconazole 150mg once per week for 6mo
Thrush Mx in pregnancy
Clotrimazole pessary 500mg intravaginally <7 nights
(oral antifungals CI’d in pregnancy)
Chlamydia
Most prevalent STI - Chlamydia trachomatis G-
7-21d incubation, asym in 70% F, 50% M
Spread via anal/oral/vaginal sex
Chlamydia Px - men and women
- Women - abnormal PV discharge, pelvic pain, intermenstrual / postcoital bleeding, dyspareunia, dysuria
- Men - urethral discharge, dysuria, Epididymo-orchitis, reactive arthritis
Chlamydia Ix
- Nuclear acid amplification tests (NAATs)
- Women - vulvovaginal swab (1st line), endocervical swab, first catch urine
- Men - first catch urine (1st line), urethral swab
- Rectal / oral swabs if indicated
- Test 2wks after possible exposure
- Can screen for 15-24yo for free (also gonorrhoea, syphilis, HIV)
Chlamydia Mx
Doxycycline 100mg BD 7d course
If doxy CI’d - azithromycin 1g OD for one day, then 500mg OD for two days
GUM referral, partner notification
Test of cure in rectal cases / pregnancy
Chlamydia Mx pregnancy
azithromycin 1g (first line) / erythromycin / amoxicillin
complications of chlamydia in pregnancy?
preterm, PROM, low birth weight, endometritis, neonatal chlamydial conjunctivitis, pneumonia
Lymphogranuloma venereum (LGV) - including Tx
Affects lymphoid tissue around site of chlamydia infection - tends to affect MSM
First painless ulcer, then lymphadenitis, then inflammation of anus / rectum
Tx - doxycycline 100mg BD for 21d. erythromycin, azithromycin, ofloxacin alternatives
Chlamydial conjunctivitis
When genital fluid comes into contact with eye
Red, irritated, discharge >2wks, unilateral
Tends to be young adults, can affect neonates
Gonorrhoea
STI caused by G- diplococcus Neisseria gonorrhoeae
2-5d incubation
Can occur on any mucous membrane
Transmission through vaginal / oral / anal, also vertical
Gonorrhoea Px
May be asym
Males - urethral discharge (green/yellow), dysuria, epididymo-orchitis
Females - PV discharge (green/yellow), pelvic pain, bleed, dyspareunia, dysuria
Rectal discomfort / sore throat, prostatitis, conjunctivitis
Gonorrhoea Ix
Women - endocervical / vagina swab for NAAT / MC+S
Men - first pass urine for NAAT / swab for MC+S
Rectal / pharyngeal swabs
Take standard charcoal endocervical swabs for MC+S
Gonorrhoea Mx
First line - IM ceftriaxone 1g
If sensitivities known - give oral ciprofloxacin 500mg single dose
Follow up ‘test of cure’ - NAAT if asymptomatic, cultures if sx
GUM referral for contact tracing
Gonorrhoea Mx pregnancy
1g ceftriaxone IM
2g azithromycin is alternative
(cipro CI’d)
Mycoplasma genitalium (MG)
Non-gonococcal STI, mostly asym
MG Px
urethritis, epididymitis, cervicitis, endometritis, PID, reactive arthritis
MG Ix
Grows slowly - cultures not helpful
NAAT - first urine sample in morning (men), vaginal swabs (women)
MG Mx
Doxycycline 100mg BD for 7d, then azithromycin 1g stat then 500mg OD for 2d
Pregnant - azithromycin alone
Trichomoniasis
STI caused by Trichomonas vaginalis - highly motile, flagellated protozoan parasite
Trichomoniasis Px
50% asym
- PV discharge - offensive, yellow/green, frothy
- Vulvovaginitis - itching
- Dysuria, dyspareunia
- Strawberry cervix (colpitis macularis) - red cervix with pinpoint areas of exudate
- pH>4.5
- Usually asymptomatic in men - may cause urethritis, balanitis
Trichomoniasis Ix
High vaginal swab (posterior fornix) - microscopy shows motile trophozites
Urethral swab / first catch urine in men
Trichomoniasis Mx
GUM referral for contact tracing
Oral metronidazole 400-500mg BD for 5-7d, OR 2g metronidazole single dose
Breastfeeding / pregnancy - oral metronidazole 400-500mg BD for 5-7d (no bolus dose)
Genital herpes
HSV1/2 causing cold sores / genital herpes
Many ppl infected w/o sx, virus latent in sensory nerve ganglia (trigeminal typically)
Spread through direct contact
Genital herpes Px
asym / sx develop after reactivation (eg stress)
Painful ulcer + dysuria, pruritis
Primary infection - headache, fever, malaise
Lymphadenopathy
Neuropathic pain
Genital herpes Ix
clinical Dx
NAAT
Could do viral PCR
HSV serology - maybe if recurrent genital ulceration of unknown cause
Genital herpes Mx
Saline bathing, analgesia, topical lidocaine
Oral acyclovir
Genital herpes Mx pregnancy
If primary attack >28wks - elective c-section at term (risk of neonatal HSV infection)
Recurrent herpes - tx with suppressive therapy, risk of transmission low
Syphilis
Bacteria treponema pallidum - gets through skin / mucous membranes, disseminates throughout body
Transmission - oral/vaginal/anal sex, vertical, IVDU, blood transfusions / transplants
Incubation 9-90 days, mostly 21d
Syphilis primary features
- Chancre - painless ulcer at site of sexual contact
- Local non-tender lymphadenopathy
- Often not seen in women (lesion may be on cervix)
Syphilis secondary features
6-10wks after primary
- Systemic - fever, lymphadenopathy
- Rash on trunk, palms, soles
- Buccal ‘snail track’ ulcers
- Condylomata lata - painless, warty lesions on genitalia
Syphilis tertiary features
- Gummas - granulomatous lesions of skin/bones
Neurosyphilis
- Headache, altered behaviour, dementia
- Tabes dorsalis - demyelination of posterior spinal cord columns
- Ocular syphilis
- Paralysis
- Sensory impairment
- Argyll-Robertson pupil - constricted pupil that accommodates when focusing on near object, does not react to light - irregularly shaped
CV syphilis
- Aortic regurg due to valvulitis (diastolic murmur), aortic root dilatation
- Angina - stenosis of coronary ostia
- Dilatation + calcification of ascending aorta (aneurysm
Congenital syphilis Px
- Blunted upper incisor teeth (Hutchinson’s teeth), ‘mulberry’ molars
- Rhagades (linear scars at the angle of the mouth)
- Keratitis
- Saber shins
- Saddle nose
- Deafness
Syphilis Ix
- Bacteria very sensitive, cannot be grown on artificial media
- Dx based on clinical sx, serology, microscopy of tissue
- PCR maybe
Non-treponemal serological tests
- assess quantity of ABs produced (not specific for syphilis - false positive risk)
- eg RPR, VDRL
Treponemal-specific serological tests
- more complex / expensive - test for syphilis
- Qualitative - non/reactive
- eg TP-EIA, TPHA
interpretation of non-trep and trep serological tests
- Positive non-trep + positive trep - active syphilis
- Positive non-trep + negative trep - false positive
- Negative non-trep + positive trep - treated syphilis
Syphilis Mx
IM benzathine benzylpenicillin
Doxycycline, ceftriaxone, amoxicillin alternatives
what is a Jarish-Herxheimer reaction?
may be seen after syphilis tx
- Fever, rash, tachycardia (no wheeze/hypotension)
- Thought to be due to endotoxin release as bacteria die
- No tx, antipyretics maybe
Chancroid
Tropical disease - painful genital ulcers, unilateral painful inguinal lymph nodes
Ulcers have sharply defined, ragged undetermined border
Genital warts
STI caused by HPV, esp 6+11 (16,18,33 predispose to cancer)
Px
2-5mm fleshy bumps, may bleed/itch
Mx
Topical agents (podophyllum / imiquimod) / cryotherapy
balanitis - causes, Px, Ix and Mx?
Inflammation of the glans penis
Causes
Candida / bacterial infection, STIs, dermatitis, psoriasis….
Px
Penile soreness, itch, odour, dysuria, dyspareunia, red, swelling
Ix
Clinical dx
STI screen / candida swab
Mx
Cleaning
Topical hydrocortisone / imidazole, abx for infections
pubic lice - cause, Px, Ix and Mx
infestation with ectoparasite
Sexual and non sexual transmission
Px
Genital pruritis - can affect any coarse hair
Examination
visible lice, yellow/white eggs
Mx
Wash clothing / bedding
Topical permethrin
GUM referral
