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Phase 4 Question Knowledge > Sexual health > Flashcards

Sexual health Flashcards

1
Q

Combined contraceptives

A

Contain oestrogen + progesterone
- Inhibit LH + FSH release + ovulation
- Thicken cervical mucus - prevent sperm passage, thin endometrium

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2
Q

UKMEC - UK medical eligibility criteria

A

1 - no restriction
2 - benefits > risks
3 - risks > benefits
4 - unacceptable health risk

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3
Q

Combined contraceptives CIs

A
  • 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
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4
Q

cOCP

A
  • 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

+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

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5
Q

Contraceptive patches

A
  • 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

+VEs / -VEs similar as cOCP

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6
Q

POP

A
  • 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
  • Immediate protection if started in day 1-5 of cycle, otherwise, use condoms for 2d
  • Gives immediate protection if continued straight on from COCP

+VEs
- Can use where oestrogen CI’d
- Take w/o breaks

-VEs
- less protection if pill missed
- Irregular bleeding, amenorrhoea
- Affected by enzyme inducer drugs

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7
Q

Depo-provera

A
  • IM progestogen every 3mo
  • Inhibits ovulation, thickens mucus, thins endometrium
  • Irregular bleeding, amenorrhoea
  • Affects bone mineral density
  • Fertility takes months to return after stopping
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8
Q

Implant

A
  • 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
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9
Q

Hormonal coil / IUS

A
  • Release progestogen - thicken mucus, thin endometrium - 3-5yrs
  • Use condoms for 7d after insertion
  • Reduce heavy menstruation
  • systemic S/E few
  • Amenorrhoea, irregular bleeds
  • Acne, headaches, breast tenderness, painful
  • Uterine perforation risk
  • higher risk of ectopic pregnancy
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10
Q

Copper coil

A
  • creates inhospitable environment for sperm - 5-10yrs
  • no hormones
  • efficacy unaffected by meds
  • heavy, long, painful menstruation
  • perf risk
  • ectopic pregnancy
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11
Q

Female sterilisation

A

Under GA / during c-section
Clips to occlude fallopian tube / salpingectomy / fallopian implants under hysteroscopy

Can still get pregnant, ectopic likely
Difficult to reverse

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12
Q

Male sterilisation

A

Vasectomy - under LA, remove section of vas deferens

Less invasive than female
Difficult to reverse

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13
Q

Levonelle / levonorgestrel - emergency contraception

A
  • 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
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14
Q

Ellaone / ulipristal acetate - EC

A
  • 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
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15
Q

Copper coil - EC

A
  • Insert <5d UPSI / <5d ovulation
  • Most effective EC
  • Not affected by meds / weight
  • CI’d >5d post ovulation
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16
Q

cOCP Missed Pill

A

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

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17
Q

POP Missed Pill

A
  • <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

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18
Q

Contraception >40yo

A

cOCP may help maintain bone mineral density perimenopause / reduce menopause sx

HRT - use POP alongside, as long as HRT has progestogen component

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19
Q

Stopping contraception

A

Non hormonal
<50yo stop after 2yrs amenorrhoea
>50yo stop after 1yr amenorrhoea

cOCP
<50yo - continue to 50yo
>50yo - switch to non-hormonal / progestogen only

Depo
<50yo - continue to 50yo
>50yo - switch to non-hormonal / progestogen only

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

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20
Q

Post-partum contraception

A
  • 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

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21
Q

BV

A

Overgrowth of anaerobic organisms in vagina and raised vaginal pH

Loss of friendly lactobacilli (produce lactic acid, keep vagina pH <4.5)

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22
Q

BV RFs

A

Multiple sexual partners
Excessive vaginal cleaning
Recent abx
Smoking
Copper coil

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23
Q

BV Px

A

Vaginal discharge - fishy, offensive, grey/white

Not usually sore, itchy

Asymptomatic in 50%

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24
Q

BV Ix

A

Speculum exam + high vaginal swab (or self-taken low vaginal swab)

Vaginal pH - with swab / pH paper

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25
Q

BV Amsel’s dx criteria

A

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)

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26
Q

BV Mx

A

5-7d oral metronidazole

Alternatives topical metronidazole / clindamycin / tinidazole

Relapse >50% within 3mo

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27
Q

BV in pregnancy

A

Increased risk of preterm labour, low birth weight, chorioamnionitis, late miscarriage

Can use oral metronidazole throughout pregnancy, but not high dose, inc breastfeeding

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28
Q

Candidiasis / thrush

A

Vaginal infection with Candida yeast

Can colonise vagina w/o sx - then develop after abx, pregnancy etc

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29
Q

Thrush RFs

A

Increased oestrogen - pregnancy
Poorly controlled DM
Immunosuppression, eg corticosteroids
Abx

30
Q

Thrush Px

A

Thick, white discharge, not typically smelly (cottage cheese)

Vulval / vaginal itching, irritation, discomfort

More severe infection - erythema, fissures, oedema, dyspareunia, dysuria, excoriation, satellite lesions

31
Q

Thrush Ix

A

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

32
Q

Thrush Mx Acute Infection

A
  • 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)

33
Q

Thrush Mx recurrent infection

A

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
34
Q

Thrush Mx in pregnancy

A

Clotrimazole pessary 500mg intravaginally <7 nights

(oral antifungals CI’d in pregnancy)

35
Q

Chlamydia

A

Most prevalent STI - Chlamydia trachomatis G-
7-21d incubation, asym in 70% F, 50% M
Spread via anal/oral/vaginal sex

36
Q

Chlamydia Px

A
  • Women - abnormal PV discharge, pelvic pain, intermenstrual / postcoital bleeding, dyspareunia, dysuria
  • Men - urethral discharge, dysuria, Epididymo-orchitis, reactive arthritis
37
Q

Chlamydia Ix

A
  • 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)
38
Q

Chlamydia Mx

A

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

39
Q

Chlamydia Mx pregnancy

A

azithromycin 1g (first line) / erythromycin / amoxicillin

Cx - preterm, PROM, low birth weight, endometritis, neonatal chlamydial conjunctivitis, pneumonia

40
Q

Lymphogranuloma venereum (LGV)

A

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

41
Q

Chlamydial conjunctivitis

A

When genital fluid comes into contact with eye

Red, irritated, discharge >2wks, unilateral

Tends to be young adults, can affect neonates

42
Q

Gonorrhoea

A

STI caused by G- diplococcus Neisseria gonorrhoeae
2-5d incubation
Can occur on any mucous membrane
Transmission through vaginal / oral / anal, also vertical

43
Q

Gonorrhoea Px

A

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

44
Q

Gonorrhoea Ix

A

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

45
Q

Gonorrhoea Mx

A

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

46
Q

Gonorrhoea Mx pregnancy

A

1g ceftriaxone IM

2g azithromycin is alternative

(cipro CI’d)

47
Q

Mycoplasma genitalium (MG)

A

Non-gonococcal STI, mostly asym

48
Q

MG Px

A

urethritis, epididymitis, cervicitis, endometritis, PID, reactive arthritis

49
Q

MG Ix

A

Grows slowly - cultures not helpful

NAAT - first urine sample in morning (men), vaginal swabs (women)

50
Q

MG Mx

A

Doxycycline 100mg BD for 7d, then azithromycin 1g stat then 500mg OD for 2d

Pregnant - azithromycin alone

51
Q

Trichomoniasis

A

STI caused by Trichomonas vaginalis - highly motile, flagellated protozoan parasite

52
Q

Trichomoniasis Px

A

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

53
Q

Trichomoniasis Ix

A

High vaginal swab (posterior fornix) - microscopy shows motile trophozites

Urethral swab / first catch urine in men

54
Q

Trichomoniasis Mx

A

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)

55
Q

Genital herpes

A

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

56
Q

Genital herpes Px

A

asym / sx develop after reactivation (eg stress)

Painful ulcer + dysuria, pruritis
Primary infection - headache, fever, malaise

Lymphadenopathy
Neuropathic pain

57
Q

Genital herpes Ix

A

clinical Dx

NAAT

Could do viral PCR

HSV serology - maybe if recurrent genital ulceration of unknown cause

58
Q

Genital herpes Mx

A

Saline bathing, analgesia, topical lidocaine

Oral acyclovir

59
Q

Genital herpes Mx pregnancy

A

If primary attack >28wks - elective c-section at term (risk of neonatal HSV infection)

Recurrent herpes - tx with suppressive therapy, risk of transmission low

60
Q

Syphilis

A

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

61
Q

Syphilis primary features

A
  • Chancre - painless ulcer at site of sexual contact
  • Local non-tender lymphadenopathy
  • Often not seen in women (lesion may be on cervix)
62
Q

Syphilis secondary features

A

6-10wks after primary

  • Systemic - fever, lymphadenopathy
  • Rash on trunk, palms, soles
  • Buccal ‘snail track’ ulcers
  • Condylomata lata - painless, warty lesions on genitalia
63
Q

Syphilis tertiary features

A
  • 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)

64
Q

Congenital syphilis Px

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
65
Q

Syphilis Ix

A
  • 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

Tests interpretation
- Positive non-trep + positive trep - active syphilis
- Positive non-trep + negative trep - false positive
- Negative non-trep + positive trep - treated syphilis

66
Q

Syphilis Mx

A

IM benzathine benzylpenicillin

Doxycycline, ceftriaxone, amoxicillin alternatives

Jarish-Herxheimer reaction may be seen after tx
- Fever, rash, tachycardia (no wheeze/hypotension)
- Thought to be due to endotoxin release as bacteria die
- No tx, antipyretics maybe

67
Q

Chancroid

A

Tropical disease - painful genital ulcers, unilateral painful inguinal lymph nodes

Ulcers have sharply defined, ragged undetermined border

68
Q

Genital warts

A

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

69
Q

Balanitis

A

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….

70
Q

Pubic lice

A

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

71
Q

Sexual dysfunction

A

Various bits in notes….

Phase 4 Question Knowledge (30 decks)

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