Sexual health Flashcards
1
Q
Combined contraceptives
A
Contain oestrogen + progesterone
- Inhibit LH + FSH release + ovulation
- Thicken cervical mucus - prevent sperm passage, thin endometrium
2
Q
UKMEC - UK medical eligibility criteria
A
1 - no restriction
2 - benefits > risks
3 - risks > benefits
4 - unacceptable health risk
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
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
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
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
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
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
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
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
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
12
Q
Male sterilisation
A
Vasectomy - under LA, remove section of vas deferens
Less invasive than female
Difficult to reverse
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
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
15
Q
Copper coil - EC
A
- Insert <5d UPSI / <5d ovulation
- Most effective EC
- Not affected by meds / weight
- CI’d >5d post ovulation
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
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
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
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
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
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)
22
Q
BV RFs
A
Multiple sexual partners
Excessive vaginal cleaning
Recent abx
Smoking
Copper coil
23
Q
BV Px
A
Vaginal discharge - fishy, offensive, grey/white
Not usually sore, itchy
Asymptomatic in 50%
24
Q
BV Ix
A
Speculum exam + high vaginal swab (or self-taken low vaginal swab)
Vaginal pH - with swab / pH paper
25
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)
26
BV Mx
5-7d oral metronidazole
Alternatives topical metronidazole / clindamycin / tinidazole
Relapse >50% within 3mo
27
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
28
Candidiasis / thrush
Vaginal infection with Candida yeast
Can colonise vagina w/o sx - then develop after abx, pregnancy etc
29
Thrush RFs
Increased oestrogen - pregnancy
Poorly controlled DM
Immunosuppression, eg corticosteroids
Abx
30
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
31
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
32
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)
33
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
34
Thrush Mx in pregnancy
Clotrimazole pessary 500mg intravaginally <7 nights
(oral antifungals CI'd in pregnancy)
35
Chlamydia
Most prevalent STI - Chlamydia trachomatis G-
7-21d incubation, asym in 70% F, 50% M
Spread via anal/oral/vaginal sex
36
Chlamydia Px
- Women - abnormal PV discharge, pelvic pain, intermenstrual / postcoital bleeding, dyspareunia, dysuria
- Men - urethral discharge, dysuria, Epididymo-orchitis, reactive arthritis
37
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)
38
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
39
Chlamydia Mx pregnancy
azithromycin 1g (first line) / erythromycin / amoxicillin
Cx - preterm, PROM, low birth weight, endometritis, neonatal chlamydial conjunctivitis, pneumonia
40
Lymphogranuloma venereum (LGV)
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
Chlamydial conjunctivitis
When genital fluid comes into contact with eye
Red, irritated, discharge >2wks, unilateral
Tends to be young adults, can affect neonates
42
Gonorrhoea
STI caused by G- diplococcus Neisseria gonorrhoeae
2-5d incubation
Can occur on any mucous membrane
Transmission through vaginal / oral / anal, also vertical
43
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
44
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
45
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
46
Gonorrhoea Mx pregnancy
1g ceftriaxone IM
2g azithromycin is alternative
(cipro CI'd)
47
Mycoplasma genitalium (MG)
Non-gonococcal STI, mostly asym
48
MG Px
urethritis, epididymitis, cervicitis, endometritis, PID, reactive arthritis
49
MG Ix
Grows slowly - cultures not helpful
NAAT - first urine sample in morning (men), vaginal swabs (women)
50
MG Mx
Doxycycline 100mg BD for 7d, then azithromycin 1g stat then 500mg OD for 2d
Pregnant - azithromycin alone
51
Trichomoniasis
STI caused by Trichomonas vaginalis - highly motile, flagellated protozoan parasite
52
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
53
Trichomoniasis Ix
High vaginal swab (posterior fornix) - microscopy shows motile trophozites
Urethral swab / first catch urine in men
54
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)
55
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
56
Genital herpes Px
asym / sx develop after reactivation (eg stress)
Painful ulcer + dysuria, pruritis
Primary infection - headache, fever, malaise
Lymphadenopathy
Neuropathic pain
57
Genital herpes Ix
clinical Dx
NAAT
Could do viral PCR
HSV serology - maybe if recurrent genital ulceration of unknown cause
58
Genital herpes Mx
Saline bathing, analgesia, topical lidocaine
Oral acyclovir
59
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
60
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
61
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)
62
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
63
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)
64
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
65
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
Tests interpretation
- Positive non-trep + positive trep - active syphilis
- Positive non-trep + negative trep - false positive
- Negative non-trep + positive trep - treated syphilis
66
Syphilis Mx
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
Chancroid
Tropical disease - painful genital ulcers, unilateral painful inguinal lymph nodes
Ulcers have sharply defined, ragged undetermined border
68
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
69
Balanitis
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
Pubic lice
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
Sexual dysfunction
Various bits in notes....
