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Year 3 - Reproductive and Sexual Health (DP) > Sexual Health > Flashcards

Sexual Health Flashcards

1
Q

What organs of the female reproductive system lie in the pelvic cavity?

A

Ovaries
Uterine tubes
Uterus
Superior part of the vagina

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2
Q

What organs of the female reproductive system lie in the perineum?

A 
Inferior part of the vagina
Perineal muscles
Bartholin's glands
Clitoris
Labia
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3
Q

What is the most inferior part of the peritoneal cavity? What implications does this have?

A

Pouch of Douglas:

  • Excess fluid tends to collect here
  • Can be drained via a needle through the posterior fornix of the vagina
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4
Q

What is the broad ligament?

A

Double layer of peritoneum

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5
Q

Where does the broad ligament extend between?

A

Uterus and pelvis (lateral walls and floor)

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6
Q

What is the function of the broad ligament?

A

Keeps uterus in midline

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7
Q

What is contained within the broad ligament?

A

Uterine tubes

Proximal part of the round ligament

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8
Q

What is the round ligament?

A

An embryological remnant

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9
Q

Where does the round ligament attach?

A

Lateral aspects of the uterus

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10
Q

Through what does the round ligament pass and attach to?

A

Deep inguinal ring to attach to superficial perineal tissue

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11
Q

What are the 3 layers of support for the uterus?

A 
Strong ligaments (eg. Uterosacral)
Endopelvic fascia
Muscles of pelvis floow
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12
Q

What can weakness in the 3 layers of uterine support result in?

A

Prolapse

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13
Q

What is the most common position of the uterus?

A

Anterverted:
- Cervix tipped anteriorly relative to vaginal axis
AND
Anteflexed:
- Uterus tipped anteriorly relative to cervical axis
- Mass of uterus lies over bladder

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14
Q

What is a normal variation in the uterine position?

A

Retroverted:
- Uterus tipped posteriorly relative to vaginal axis
AND
Retroflexed:
- Uterus tipped posteriorly relative to cervical axis

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15
Q

Why is a speculum needed for cervical examination?

A

Walls of vagina usually collapsed

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16
Q

What does radiopaque dye spilling out into the peritoneal cavity on a hysterosalpinogram indicate?

A

Patency of uterine tubes

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17
Q

Where do ovaries develop?

A

On posterior abdominal wall

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18
Q

The cervix holds apart the walls of the vagina at the superior part, what does this form?

A

A space around the cervix, known as a fornix

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19
Q

What are the four parts of the fornix?

A

Anterior
Posterior
2 lateral

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20
Q

How can the position of the uterus be palpated?

A

Bimanually

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21
Q

How can adnexae be palpated?

A

Place examining fingers into lateral fornix
Press deeply with other hand into ipsilateral iliac fossa
Repeat on oppsite

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22
Q

What are the adnexae?

A

Uterine tubes

Ovaries

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23
Q

What can adnexae examination detect?

A

Large masses

Tenderness

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24
Q

What forms the urogenital triangle?

A 
Pubic symphysis (anteriorly)
Ischial spines (laterally):
- A line between them completes the triangle
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25
Q

What forms the anal triangle

A

Coccyx (posteriorly)
Ischial spines (laterally):
- A line between them completes the triangle

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26
Q

What is the perineum?

A

Shallow space between pelvic diaphragm and skin

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27
Q

What type of muscle is the levator ani?

A

Skeletal

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28
Q

What forms most of the pelvic diaphragm?

A

Levator ani

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29
Q

What is the function of the levator ani?

A

Supports pelvic organs:

  • Tonic contraction
  • Contracts more when intra-abdo. pressure rises
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30
Q

What nerve supplies the levator ani?

A

Nerve to levator ani:

- S3, S4 and S5 sacral plexus

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31
Q

What nerve are the superficial and deep perineal muscles supplied by?

A

Pudendal nerve (S2, S3 and S4)

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32
Q

What is the perineal body?

A

Bundle of collagenous and elastic tissue into which the perineal muscles attach

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33
Q

What is the perineal body important to?

A

Pelvic floor strength

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34
Q

What can damage the perineal body?

A

Labour

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35
Q

Where is the perineal body located?

A

Just deep to skin

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36
Q

What are the Bartholin’s glands?

A

Glands which secrete mucous to lubricate the vagina

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37
Q

Where are Bartholin’s glands located?

A

Slightly posterolateral to the left and right of the vaginal opening

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38
Q

What is the other name for Bartholin’s glands?

A

Greater vestibular glands

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39
Q

Where does the bed of the breast extend from?

A

Ribs 2-6

Lateral border of sternum to mid-axillary line

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40
Q

What does the female breast line on?

A

Deep fascia covering:

  • Pec. major
  • Serratus anterior
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41
Q

What is the pace between the fascia and the breast?

A

Retromammory space

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42
Q

How is the breast attached to the skin?

A

Suspensory ligaments

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43
Q

How can we assess if a breast lump is fixed to any underlying tissue?

A

Ask patient to put hands on hips (contracts pectoralis major)
Assess all four quadrants as well as:
- Axilla
- Supraclavicular area

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44
Q

Where does most of the lymph from the female breast drain to?

A

Ipsilateral axillary nodes (>75%)

Then to supraclavicular nodes

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45
Q

Where can lymph from the inner quadrants drain to?

A

Ipsilateral or contralteral nodes

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46
Q

Where else can lymph from the lower quadrants drain to?

A

Abdominal nodes

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47
Q

Lymph from the upper limbs also drains to axillary nodes; what clinical implications does this have?

A

If nodes removed (eg. in breast cancer treatmet) it can result in lymphedema

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48
Q

Where is level 1 of axillary clearance?

A

Inferior and lateral to pectoralis minor

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49
Q

Where is level 2 of axillary clearance?

A

Deep to pectoralis minor

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50
Q

Where is level 3 of axillary clearance?

A

Superior and medial to pectoralis minor

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51
Q

What is the blood supply to the breast?

A 
Internal thoracic (internal mammary) artery:
- Branch of the subclavian artery
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52
Q

What is the venous drainage of the breast?

A

Internal thoracic

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53
Q

How long is the male urethra?

A

~20cm

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54
Q

Which urethral sphincter is under voluntary control?

A

External

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55
Q

What is the most anterior organ in the pelvis?

A

Bladder

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56
Q

Where does the prostate lie in relation to the bladder?

A

Inferiorly

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57
Q

Where does the rectum lie in relation to the bladder?

A

Posteriorly

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58
Q

What forms the trigone of the bladder?

A

2 ureteric orifices

Internal urethral orifice

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59
Q

What forms the majority of the bladder wall?

A

Detrusor muscle

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60
Q

How does the detrusor muscle prevent reflux of urine into the ureters?

A

Fibres encircle ureteric orifices:

- Tighten when bladder contracts

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61
Q

The detrusor muscle also forms the internal urethral sphincter in men. What is its purpose?

A

Prevents retrograde ejaculation

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62
Q

As the testes travel through the spermatic cord, what 3 layers of coverings do they pick up from the inguinal canal?

A
  1. Internal spermatic fascia:
    - Continuous with transversalis fascia
  2. Cremasteric muscle (and fascia)
    - Formed from internal oblique (and fascia)
  3. External spermatic fascia:
    - Extension of aponeurosis over external oblique
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63
Q

What are the contents of the spermatic cord?

A 
Testicular artery and vein
Vas deferens
Lymphatic vessels
Nerves:
- Autonomic (vas deferens)
- Somatic (cremaster muscle)
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64
Q

Where do the testes sit within in the scrotum?

A

Tunica vaginalis

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65
Q

What is a hydrocoele?

A

Excess fluid in the tunica vaginalis

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66
Q

How many sperm are produced per second?

A

1500

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67
Q

How long does a sperm take to mature?

A

64 days

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68
Q

Where do the sperm pass to after production in the seminiferous tubules?

A
  1. Rete testis
  2. Head of the epididymis
  3. Vas deferens
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69
Q

What is the approximate length of a testis?

A

~5cm

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70
Q

Where are the testis and epididymis attached to the spermatic cord? What are the clinical implications of this?

A

Superiorly:

  • Risk of torsion
  • Disruption of blood supply
  • Severe pain and risk of necrosis
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71
Q

Where is the proximal end of the epididymis located?

A

Posterior aspect of the superior pole of the testis

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72
Q

Where do the arteries supplying the testes arise from?

A

The lateral aspects of the abdominal aorta

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73
Q

Where does the left testicular vein drain to?

A

Left renal vein

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74
Q

Where does the right testicular vein drain to?

A

IVC

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75
Q

Where do the arteries supplying and the veins draining the testes pass through?

A

Deep inguinal ring

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76
Q

What is the inferior aspect of the prostate gland in contact with?

A

Levator ani

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77
Q

What zone of the prostate is felt on PR exam?

A

Peripheral

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78
Q

What zone of the prostate is where most prostate cancers arise?

A

Peripheral

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79
Q

Where does the root of the penis attach to laterally?

A

Ischium

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80
Q

What cylinders of erectile tissue are located posteriorly and what do they transmit?

A 
Corpa cavernosa (right and left)
Transmit the deep arteries of the penis
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81
Q

What cylinder of erectile tissue is located anteriorly and what do they transmit? What do they expand distally to form?

A

Corpus spongiosum
Transmits spongy urethra
Expands distally to form the glans

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82
Q

What contains the root of the penis, the proximal spngy urethra, the superficial transverse perineal muscle and branches of the internal pudendal vessels and the pudendal nerves?

A

Superficial perineal pouch

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83
Q

What does the bulb of the penis form?

A

Corpus spongiosum

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84
Q

What do the crura of the penis form?

A

Corpa cavernosa

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85
Q

What muscles are associated with the bulb of the penis?

A

Bulbospongiosus

Ischiocavernosus

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86
Q

Where do the deep arteries of the penis branch from?

A

Internal pudendal artery (which is a branch of the internal iliac artery)

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87
Q

What blood vessels supply the scrotum?

A

Internal pudendal artery

External iliac artery branches

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88
Q

Where does lymph from the scrotum and the penis (except the glans) drain to?

A

Inguinal lymph nodes in superficial groin fascia

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89
Q

Where does lymph from the testes drain to?

A

Lumbar lymph nodes (around abdominal aorta)

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90
Q

When is basal body temperature measured?

A

Before rising in the morning

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91
Q

How much does the basal body temperature rise by when fertile?

A

> 0.2 degrees celcius

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92
Q

What changes in basal body temperature are indicative of ovulation?

A

Sustained increase for 3 days after at least 6 days of lower temperature

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93
Q

How can cervical mucous be used in natural family planning?

A

Ovulation indicated by thick and sticky mucous for >=3 days after thinner, watery mucous

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94
Q

When fertile, where does the cervix sit? What is it like?

A

High in vagina

Soft and open

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95
Q

When less fertile, where does the cervix sit? What is it like?

A

Low in vagina

Firm and closed

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96
Q

What days is a woman most fertile?

A

Days 8-18

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97
Q

When does breastfeeding work as contraception?

A

If the woman is:

  • Exclusively breast feeding
  • Less than 6 months post-natal
  • Amenorrhoeic
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98
Q

What does the UK MEC apply to?

A

Hormonal contraception
IUDs
Emergency contraception
Barrier methods

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99
Q

What does UK MEC Category 1 indicate?

A

No restriction

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100
Q

What does UK MEC Category 2 indicate?

A

Advantages generally outweigh risks

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101
Q

What does UK MEC Category 3 indicate?

A

Risks generally outweigh advantages

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102
Q

What does UK MEC Category 4 indicate?

A

A condition represents an unacceptable risk if contraceptive method is used

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103
Q

How is the Pearl Index calculated?

A

Number of Pregnancies x 1200
————–DIVIDED BY—————-
Number of women x Number of months

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104
Q

What does the Pearl Index represent?

A

Number of contraceptive failures per 100 women users/year

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105
Q

How is Depo Provera administered?

A

IM

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106
Q

What does Depo Provera contain?

A

Medroxyprogesteron acetate

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107
Q

How is Sayana press administered?

A

S/C

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108
Q

How does Depo Provera primarily work?

A

Inhibits ovulation

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109
Q

How often are Depo Provera IM injections given and how long does it last?

A

Given every 12 weeks

Last 13 weeks

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110
Q

What are the secondary mechanisms of action of Depo Provera?

A

Thickens cervical mucous

Converts endometrium to secretory phase

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111
Q

What is the Pearl Index for Depo Provera?

A

0.2%

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112
Q

What examinations must be done before the prescription of Depo Provera?

A

BP and BMI before first prescription
Check smear status
Risk factors for osteoporosis

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113
Q

When can Depo Provera be started up to without the need for additional contraception?

A

Up to and including day 5 of the cycle

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114
Q

When can Depo Provera be started beyond day 5?

A

If she is ‘reasonably certain’ she is not pregnant
AND
She must use condoms/abstain for 7 days

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115
Q

What is ‘reasonably certain’?

A

No sex since last period
Consistently using reliable contraception
<7 days since last normal period
<4 weeks post-partum (not breastfeeding)
Fully breastfeeding, amenorrhoeic and <6 months post-partum
Negative pregnancy text AND >3 weeks since UPSI

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116
Q

When can Depo be started post-TOP?

A

Up to day 5

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117
Q

When can Depo be started post-partum?

A

Up to day 21 with immediate cover

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118
Q

In the context of a Depo injection, what should be done if pregnancy cannot be excluded?

A

Do pregnancy test in 3 weeks
Give Depo. thereafter
eg. After emergency contraception

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119
Q

What are the side effects of the Depo injection?

A

Weight gain
Delay in return of fertility
Irregular bleeding
Possible risk of osteoporosis

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120
Q

How does the IUD work?

A 
Prevents fertilisation (Cu is toxic to sperm)
Inflammatory response in endometrium
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121
Q

How long is an IUD licensed for?

A

5-10 years

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122
Q

What is the Pearl Index for IUDs?

A

0.6-0.8%

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123
Q

What does Mirena contain?

A

52mg of levonorgestrel:

  • 20mcg released daily
  • Decreased to 10mcg per day after 5 years
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124
Q

What does Jaydress contain?

A
  1. 5mg of levonorgestrel:
    - 14mcg released daily for first 24 days
    - 5mcg released daily after 5 years
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125
Q

How do IUSs work?

A

Primarily affect implantation:

- Endometrium render unfavourable for implantation

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126
Q

What are some secondary effects of IUSs?

A

Cervical mucous thickened

Pre-fertilisation effects

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127
Q

What is the Pearl Index of an IUS?

A

0.2%

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128
Q

What are some contraindications to IUD/IUS?

A 
Current pelvic infection
Abnormal uterine anatomy
Pregnancy
Sensitivity to constituents
Gestational trophoblastic disease:
- When beta-hCG levels abnormal/persistently raised
Endometrial cancer
Cervical cancer awaiting treatment
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129
Q

Within how many days of beginning a period can an IUD be fitted?

A

Within first 7 days when they are reasonably certain they aren’t pregnant

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130
Q

When can an IDU be used for emergency contraception?

A

Up to 5 days after UPSI
OR
Up to 5 days after predicted date of ovulation

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131
Q

When can an IUD be given post-partum?

A

Within 48 hours
OR
>4 weeks post-partum

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132
Q

When can an IUD be given post-TOP?

A

Immediately

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133
Q

Can an IUS be used for emergency contraception?

A

No

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134
Q

If an IUS is fitted outwith the first seven days of a a cycle, how long must condoms be used?

A

For first 7 days

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135
Q

When can an IUS be used post-TOP?

A

Up to day 7

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136
Q

What are some side effects of IUDs?

A

Heavy, prolonged menses
Pain/Infection/PID risk increased in first 20 days
Perforation (1-2/1000)
Expulsion (1/20 - Most in first 3 months)
Higher post-2nd trimester abortion

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137
Q

What is the ectopic risk associated with the use of an IUD?

A

0.08 per 100 women years
If pregnant:
- 9-50%

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138
Q

What are the side effects of using an IUS?

A

Lighter, less frequent bleeding
Pain/Infection/PID risk increased in first 20 days
Perforation (1-2/1000)
Expulsion (1/20 - Most in first 3 months)
Failure

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139
Q

What is the ectopic risk associated with the use of an IUS?

A

0.02 per 100 women years

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140
Q

How long is the subdermal rod licensed for?

A

3 years

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141
Q

What does the subdermal implant contain?

A

68mg Etonogestrel (Nexplanon):

  • Released 60-70mcg per day in weeks 5-6
  • 25-30mcg per day at end of 3rd year
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142
Q

How does the subdermal implant work?

A

Primarily inhibits ovulation
Others:
- Effect on endometrium
- Thickens cervical mucous

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143
Q

What is the Pearl Index of the subdermal implant?

A

0-0.1%

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144
Q

When can a subdermal implant be fitted without any need for additional precautions?

A

If:

  • Within first 5 days of cycle
  • Up to day 5 post-1st/2nd trimester abortion
  • On or bfeore day 21 postpartum
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145
Q

When can a subdermal implant be fitted with the need for additional precautions for first 7 days?

A

She is reasonably certain she is not pregnant
‘Quick start’ after emergency contraception
‘Off-licence’

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146
Q

When is the subdermal implant immediately effective if fitted (in the context of switching from another method)?

A 
After last active COC pill in pack
Within 14 weeks of Depo
If week 2-3 of:
- COC
- CHC patch
- CHC vaginal ring
147
Q

When are additional precautions required when switching to the subdermal implant?

A

For first 7 days if:

  • Changing from POP or IUS
  • Switching from non-hormonal method
148
Q

What are the side effects of the subdermal implant?

A 
Irregular bleeding
Weight gain
Acne
Neurovascular injury
Deep insertion
149
Q

What does the subdermal implant have no know effect on?

A

Bone mineral density
CV risk
VTE risk
MI risk

150
Q

What does the COC contain?

A

35mcg ethinyl estradiol
AND
A progestogen

151
Q

What does the combined transdermal patch contain?

A

33mcg ethinyl estradiol
AND
A progestogen

152
Q

What does the combined vaginal ring contain?

A

15mcg ethinyl estradiol
AND
A progestogen

153
Q

How do combined hormonal contraceptives work?

A

Primary:
- Inhibit ovulation via action on HPO axis
- By reducing FSH and LH release
Secondary:
- Thickens cervical mucous
- Renders endometrium unfavourable for implant

154
Q

What is the Pearl Index for combined hormonal contraceptive?

A

Perfect use - 0.3%

Typical use - 9%

155
Q

Over what weight is there possibly a decreased efficacy on the combined transdermal patch?

156
Q

What is a typical regime for the COC?

A

Daily for 21 days then stopped for 7 days to allow a withdrawal bleed

157
Q

What do the first 7 pills in a COC regime do?

A

Inhibit ovulation

158
Q

What do the last 14 pills in a COC regime do?

A

Maintain anovulation

159
Q

What is a standard CTP regime?

A

One patch applied for 1 week to suppress ovulation
Patch reapplied weekly for 2 weeks
4th week is patch free - Withdrawal bleed

160
Q

What is a standard CVR regime?

A

Placed in vagina and left for 21 days

Removed for 7 days for a withdrawal bleed

161
Q

What is an extended use COC regime?

A

Use pills continuously until a breakthrough bleed:

- Then stop for 4 or 7 days

162
Q

How does cytochrome P-450 induction affect the efficacy of the COC?

A

Increased EE metabolism
Reduces circulating [EE]
Reduces clinical effect

163
Q

What enzyme inducers can affect the efficacy of CHCs?

A

Rifampicin
Some anticonvulsants
St John’s Wort
Some antiretrovirals

164
Q

How can one missed COC pill be managed?

A

If over 24hrs but less than 48hrs:

  • Take missed pill ASAP
  • Remaining pills taken at normal time
  • Emergency contraception not required
165
Q

How are two or more missed COC pills be managed?

A

More than 48 hours without a pill:

  • Take the most recent missed pill
  • Take remaining pills at normal time
  • Use condoms/abstain until 7 consecutive pills take
166
Q

If 2 (or more) pills are missed in Days 1-7, what must be considered?

A

Emergency contraception

167
Q

If 2 (or more) pills are missed in Days 8-14, what must be considered?

A

No extra instructions

168
Q

If 2 (or more) pills are missed in Days 15-21, what must be considered?

A

Omit pill-free interval

169
Q

How long can the CTP be removed for before efficacy is reduced?

170
Q

How long can a patch be worn continuously for before efficacy is reduced?

171
Q

How long can the patch-free interval be extended to before efficacy is reduced?

172
Q

How long can the CVR be removed for before efficacy is reduced?

173
Q

How long can a CVR be worn inserted for before efficacy is reduced?

174
Q

How long can the CVR-free interval be extended to before efficacy is reduced?

175
Q

How can CHCs result in thrombosis?

A

Alteration in clotting factors induced by EE:
Reduced levels of:
- Antithrombin III
- Protein S

176
Q

In who might EE promote superimposed arterial thrombosis?

A

Those with significant arterial wall disease

177
Q

In who is the fibrinolytic activity of CHC reversed?

A

Heavy smokers

178
Q

COC combined with what FHx of VTE results in an increased risk of your own VTE?

A

1st degree relative aged <45 years

179
Q

How long post-natal is the risk of VTE increased?

180
Q

What is the relative risk of the following progestogens in CHC vs. Levonorgestrel:

  • Norgestimate
  • Gestofene (Desogestrel, Drospirenone)
  • Etonogestrel
A 
Norgestimate = 1.0
Gestofene = 1.5-2.0
Etonogestrel = 1.0-2.0
181
Q

What effects does cyproterone acetate have?

A

Anti-androgen
Progestogen
Antigonadotropin

182
Q

What is cyproterone acetate called when combined with EE?

A

Co-cyprindiol (Dianette):

  • 35mcg EE
  • 2mg cyproterone acetate
183
Q

When else is cyproterone acetate with EE used?

A

Acne

Hirsutism

184
Q

What UK MEC score does using a CHC in someone age >35 years have?

185
Q

When should BP be checked when taking a CHC?

A

Initially
At 3 months
Then annually

186
Q

When is the risk of arterial disease while taking a CHC raised?

A

If a smoker (increased MI risk)

If hypertension >=160/95

187
Q

What is a user of a CHC at increased risk of if they have migraines WITH auras?

188
Q

What is the relative risk increase in breast cancer when using a CHC?

189
Q

How long does the risk of breast cancer take to return to normal after stopping a CHC?

190
Q

In the context of breast cancer, when is CHC directly contraindicated?

A

If personal history of CHC

191
Q

If there is a family history of breast cancer, what UK MEC score is assigned to CHCs?

192
Q

If a woman has the BRCA gene, what is the UK MEC score for taking a CHC?

193
Q

How do CHCs affect the risk for cervical cancer?

A

Slightly increased

194
Q

How long does the risk of cervical cancer take to return to normal after stopping a CHC?

195
Q

What effect do CHCs have on ovarian cancer?

A

20% reduction for every 5 years use

Max 50% reduction after 15 years use

196
Q

What effect do CHCs have in endometrial cancer?

A

2-0-50% reduction

197
Q

What effect does stopping CHCs have in its protective functions over certain cancers?

A

Protection can last for years

198
Q

How long can CHCs be used?

A

Up to 50 years of age (provided there are no risk factors)

199
Q

What conditions do CHCs have a benefit in?

A 
Acne:
- Dianette is licensed for acne (not contraception)
Withdrawal bleeds
Functional ovarian cysts
Premenstrual syndrome
PCOS
200
Q

What are some general side effects of CHCs?

A 
Unscheduled bleeding (in 20%):
- Don't change CHC before 3 months
Mood changes
?Weight gain
201
Q

What are some side effects of the CTP?

A

Breast pain
Nausea
Painful periods

202
Q

What are some side effects of CVP?

A

Less bleeding problems
Less acne problems
Less mood changes

203
Q

When can COCs be started without the need for additional contraception?

A

Up to and including day 5

204
Q

When can COCs be started after day 5?

A

At any time:

  • If reasonably certain they aren’t pregnant
  • Use condoms/abstain for 7 days
205
Q

When resuming a CHC after Levonelle 1500 (progestogen) for emergency contraception, what precautions must be used?

A

Condoms/Abstain for 7 days

206
Q

When resuming a CHC after EllaOne (ulipristal acetate) for emergency contraception, what precautions must be used?

A

Do not start CHCs for 5 days:

  • EllaOne is an anti-progesterone
  • CHCs interfere with EllaOne
207
Q

If wanting to start a CHC but pregnancy can’t be excluded, how should this be done?

A

‘Quick start’ (condoms/abstain for 7 days)

Do a pregnancy test in 4-5 weeks

208
Q

What progestogens are in ‘traditional’ POPs?

A

Levonorgestrel

Norethisterone

209
Q

What progestogen is in the ‘newer’ POPs?

A

Etonorgestrel (longer-acting)

210
Q

What are the primary mechanisms of POPs?

A

All:
- Thicken cervical mucous
Etonorgestrel:
- Suppresses ovulation in up to 97% of cycles

211
Q

What are the secondary mechanisms of POPs?

A

All:
- Reduced endometrial receptivity to blastocyst
- Reduced cilia activity in fallopian tubes
Levonorgestrel:
- Ovulation suppressed in 60% of cycles

212
Q

What is the UK MEC score for POPs when their use is deemed ‘safer than pregnancy’?

213
Q

What is the UK MEC score for POPs when the patient has current breast cancer?

214
Q

What drugs does the POP interact with?

A

Liver enzyme inducers (Cytochrome P-450)

215
Q

What are suitable POP alternatives if taking enzyme inducing drugs?

A

Depo
IUS
Cu IUD

216
Q

How long does the effect of POPs continue after stopping?

217
Q

What is the dosing regime for the ‘traditional’ POPs?

A

Daily at same time
No break
Within 24-27 hours of last dose

218
Q

What is the dosing regime for Etonorgestrel?

A

Daily at same time
Within 24-36 hours of last dose
No break

219
Q

When is emergency contraception and condom use/abstaining for 2 days required in the context of missed POPs?

A

One missed pill AND UPSI

220
Q

What are the Pearl Indices for POPs?

A

Perfect use = 0.3%

Typical use = 9%

221
Q

What is the Pearl Index for vasectomy?

A
  1. 1%

0. 05% after clearance

222
Q

How many practitioners must agree than an abortion is justified under The Abortion Act 1967?

223
Q

Where must an abortion take place under the The Abortion Act 1967?

A

NHS hosptial
OR
Approved premises

224
Q

For a planned abortion, what form must be signed in Scotland and how many doctors must sign it? (What is the English/Welsh equivalent)

A

Cert. A (HSA1)

2 doctors

225
Q

After an emergency abortion, what form must be signed in Scotland and how many doctors must sign it? How soon after must it be signed?(What is the English/Welsh equivalent)

A

Cert. B (HSA2)
1 doctor
Within 24 hours of the abortion

226
Q

When is the HSA4 form completed? Who is it sent to?

A

Within 7 days of the abortion

Sent to Chief Medical Officer

227
Q

What are grounds for termination of pregnancy?

A

A) Continuance risk > Termination risks
B) Termination prevents grave mental/physical injury
C) <24 weeks and risk to mum’s physical/mental health
D) <24 weeks and risk to existing child’s health
E) Risk of baby having severe physical/mental deficits

228
Q

What are grounds for emergency termination?

A

F) Necessary to save the woman’e life

G) Necessary to prevent grave physical/mental injury

229
Q

If a doctor has a conscientious object to carrying out a planned abortion, what must they do?

A

Respect patient’s dignity and views
Do not impose views
Do not delay/deny treatment
Timely referral to a willing colleague

230
Q

If a doctor has a conscientious object to carrying out an emergency abortion, what must they do?

A

They cannot object on conscientious grounds - They cannot deny the treatment and must do it if they are the only doctor immediately available

231
Q

How long after a TOP consultation will the patient be referred for termination?

232
Q

What is the legal limit for a social abortion?

A

23 weeks and 6 days

233
Q

What is the legal limit for an abortion of a foetus with an abnormality?

A

Any gestation

234
Q

What is the Tayside limit for a surgical abortion?

235
Q

What is the Tayside limit for a medical abortion?

A

18 weeks and 6 days

236
Q

Up to what gestation is a medical abortion deemed early?

A

Up to 9 weeks

237
Q

Up to what gestation is a medical abortion deemed late?

A

9-12 weeks

238
Q

Up to what gestation is a medical abortion deemed mid-trimester?

A

12-24 weeks

239
Q

What is the process of a medical termination of pregnancy?

A
  1. Oral Mifepristone 200mg:
    - An anti-progesterone
    - Endometrial degeneration
    - Cervical softening and dilatation
  2. Vaginal/Oral prostaglandin:
    - Eg. Misoprostol and Gemeprost
    - Given 24-48 hours later
    - Stimulate contractions
    - Can be done at home in early TOP
    - Repeated doses if late/mid-trimester (3 hourly with a max of 5 does in 24 hours)
240
Q

When can vacuum aspiration be used for termination of pregnancy?

A

Weeks 6-12

241
Q

When can dilatation and evacuation be used for termination of pregnancy?

A

13-24 weeks

Not available in Scotland

242
Q

How is the cervix ‘primed’ prior to surgical TOP?

A

Vaginal prostaglandin

243
Q

What is the procedure for electric vacuum aspiration?

A

Day case
Under GA
Routine USS not required
LARC fitting

244
Q

What is the procedure for manual vacuum aspiration?

A 
For early gestation TOP/RPOC
Under LA
Useful in:
- Resource poor settings
- Developing countries
245
Q

What is the overall risk of a serious complication following TOP?

246
Q

What are some features of the aftercare following a TOP?

A

Urine pregnancy test at 2-3 weeks
Anti-D
Counselling
Contraception

247
Q

What are some indications for emergency contraception following TOP?

A 
UPSI
Barrier fails
'Missed' pills
Late injection
Expelled IUD
248
Q

What does Levonelle 1500 contain?

A

1.5mg Levonorgestrel

249
Q

How does Levonelle 1500 work?

A

Inhibits ovulations

250
Q

How long after UPSI can Levonelle 1500 be used?

A

Up to 72 hours

251
Q

What is the failure rate of Levonelle 1500?

252
Q

What is the cost per unit of Levonelle 1500?

253
Q

What cautions are required when using Levonelle 1500?

A

Enzyme-inducers

254
Q

What does ellaOne contain?

A

30mg Ulipristal acetate

255
Q

How does ellaOne work?

A

Inhibits/Delays ovulation

256
Q

How long after UPSI can ellaOne be used?

A

Up to 120 hours

257
Q

What is the failure rate of ellaOne?

258
Q

What is the cost per unit of ellaOne?

259
Q

What cautions are required when using ellaOne?

260
Q

When should a urine pregnancy test be carried out after emergency contraception?

A

3 weeks after

261
Q

When can an IUD be used as emergency contraception?

A

Up to 120 hours post-UPSI

Up to 5 days after earliest expected date of ovulation

262
Q

What must be screened (+/- treated) for prior to IUD insertion?

263
Q

Where did HIV-2 originate?

A

West African Sootey Mangabey (SIV)

264
Q

Where did HIV-1 originate?

A

Central/West African chimpanzees

265
Q

What group of HIV is responsible for the global pandemic starting in 1981?

A

HIV-1 group M

266
Q

On what cells is CD4 found?

A

Th cells
Dendritic cells
Macrophages
Microglial cells

267
Q

What is the function of CD4+ Th lymphocytes?

A

Recognise MHC II APCs
Activate B and Tc cells (CD8+)
Cytokine release

268
Q

What are normal levels of CD4+ Th lymphocytes?

A

500-1600 cells/mm^3

269
Q

At what CD4+ Th lymphocyte level is there an opportunistic infection risk?

A

<200 cells/mm^3

270
Q

What effects does HIV have on the immune response?

A 
Sequestration of cells in lymphoid tissues:
- Reduces circulating CD4+ cells
Reduces proliferation of CD4+ cells
Reduced CD8+ cell activation:
- Dysregulated expression of cytokines
- Increased viral susceptibility
271
Q

How quickly is a new generation of HIV produced?

A

Every 6-12 hours in the very early and very late stages

272
Q

What is the average time from infection to death without treatment of HIV?

A

9-11 years

273
Q

How does HIV infection someone?

A 
Infects mucosal CD4+ cells:
- Langerhands
- Dendritic cells
Transport to regional lymph nodes
Infection established within 3 days of entry
Dissemination of virus
274
Q

In the primary HIV infection, how many present with symptoms?

275
Q

What is the average timing of onset of primary HIV infection symptoms?

276
Q

What are the features of a primary HIV infection?

A 
Fever
Rash (maculopapular - More on trunk and face)
Myalgia
Pharyngitis
Headache/Aseptic meningitis
277
Q

What causes Pneumocystis pneumonia?

A

Pneumocystis jiroveci

278
Q

At what CD4+ threshold is there a risk of Pneumocystis pneumonia?

279
Q

What are the symptoms/signs of Pneumocystis pneumonia?

A

Insidious onset
SoB
Dry cough
Exercise desaturation

280
Q

What may a CXR show in Pneumocystis pneumonia?

A

Interstitial infiltrates

Reticulonodular markings

281
Q

How is Pneumocystis pneumonia diagnosed?

A

Bronchio-alveolar lavage and immunofluorescence

+/- PCR

282
Q

How is Pneumocystis pneumonia treated?

A

High dose (90-120mg/kg) Co-Trimoxazole in 3 divided doses for 21 days

283
Q

How is Pneumocystis pneumonia prevented?

A

Low dose co-trimoxazole

284
Q

What features of TB are more common in HIV?

A 
Symptomatic primary infection
Reactivation
Lymphadenopathies
Miliary TB
Extrapulmonary TB
MDR-TB
Immun Reconstitution Syndrome
285
Q

What causes Cerebral toxoplasmosis?

A

Toxoplasma gondii

286
Q

What is the CD4+ threshold for the risk of developing Cerebral toxoplasmosis?

287
Q

How does Cerebral toxoplasmosis present?

A 
Reactivation
Chorioretinitis
Signs/Symptoms:
- Headache
- Fever
- Focal neurology
- Seizures
- Reduced consciousness
- Increased ICP
288
Q

What is the CD4+ threshold for CMV infection?

289
Q

What screening is important for all HIV+ patients with a CD4+ of <50?

A

Ophthalamic

290
Q

What does CMV reactiviation result in?

A

Retinitis
Colitis
Oesophagitis

291
Q

What are the signs/symptoms of CMV reactivation?

A 
Reduced visual acuity
Floaters
GI symptoms:
- Abdominal pain
- Diarrhoea
- PR bleeding
292
Q

What are features of HIV-associated herpes zoster?

A

Multidermatomal

Recurrent

293
Q

What are features of HIV-associated herpes simplex?

A

Extensive
Hypertrophic
Aciclovir-resistant

294
Q

What are features of HIV-associated HPV infection?

A

Extensive
Recalcitrant
Dysplastic

295
Q

What other skin infections are common in HIV?

A

Penicilliosis (Penicillium marneffei - a fungus)
Histoplasmosis:
- Lung infection due to Histoplasma capsulatum fungal spores

296
Q

How does HIV-associated neurocognitive impairment present?

A

Reduced short-term memory

+/- motor dysfunction

297
Q

What causes Progressive Multifocal Leukoencephalopathy?

298
Q

What is the CD4+ threshold for developing Progressive Multifocal Leukoencephalopathy?

299
Q

How does Progressive Multifocal Leukoencephalopathy present?

A

Rapidly progressing:

  • Focal neurology
  • Confusion
  • Personality change
300
Q

What is “Slim’s Disease” and what are its potential aetiologies?

A 
HIV-associated wasting
Due to:
- Chronic immune activation
- Anorexia
- Malabsorption/Diarrhoea
- Hypogonadism
301
Q

What causes Kaposi’s Sarcoma?

A

Human Herpes Virus 8

302
Q

What kind of tumour is Kaposi’s Sarcoma?

303
Q

How does Kaposi’s Sarcoma present?

A 
Cutaneous
Mucosal
Visceral:
- Pulmonary
- GI
304
Q

How is Kaposi’s Sarcoma treated?

A

HAART
Local therapies (cryotherapy; surgical excision)
Systemic chemotherapy

305
Q

What causes Non-Hodgkin Lymphoma?

306
Q

What kinds of EBV NHL is HIV associated with?

A

Burkitt’s lymphoma

Primary CNS lymphoma (extranodal)

307
Q

How does NHL present in HIV?

A 
More advanced
B cell symptoms:
- Fever >38
- Night sweats
- Weight loss >10% over =<6 months
Bone marrow involvement
Extranodal disease
Increased CNS involvement
308
Q

What does HPV infection rapidly progress to in HIV?

A

Persistent infection
Cervical:
- Severe dysplasia
- Invasive disease

309
Q

At what CD4+ range is ITP common?

310
Q

How can mother-child HIV transmission occur?

A

In-utero/Trans-placental
At delivery
When breastfeeding

311
Q

How many at risk babies become infected with HIV?

312
Q

How many HIV infants die before their 1st birthday if untreated?

313
Q

What is the prevalence of HIV in the UK?

314
Q

When is universal testing for HIV on all general medical admissions and all new GP patients recommended?

A

When local prevalence is >0.2%

315
Q

What is the window period for HIV Ab tests?

A

~63 days when first established

316
Q

How do 3rd generation HIV Ab tests work?

A 
HIV-1 and HIV-2 Abs detected:
- IgM
- IgG
Very sensitive/specific if infection established
Window period ~20-25 days
317
Q

How do 4th generation HIV Ab tests work?

A

Combined Ab and Ag (p24)
Shortens window period by ~5 days:
- Window period ~15-20 days

318
Q

What does the Recent Infection Testing Algorithm identify?

A

If infection occurred in preceding 4-6 months

319
Q

What does the Recent Infection Testing Algorithm measure?

A

Different types of Abs
OR
Strength of Ab binding

320
Q

What class of drugs do Nucleoside Analogue RTIs (NRTIs) fall under? Give examples.

A

Reverse transcriptase inhibits
Examples:
- Zidovudine
- Emtricitabine

321
Q

What class of drugs do Nucleotide Analogue RTIs (NtRTIs) fall under? Give examples.

A

Reverse transcriptase inhibits
Example:
- Tenofivir

322
Q

What class of drugs do Non-Nucleoside RTIs (NNRTIs) fall under? Give examples.

A

Reverse transcriptase inhibits
Example:
- Efavirenz

323
Q

What type of drug is Raltegravir (the ‘gravirs’)?

A

Integrase inhibitors

324
Q

What types of drugs are the ‘avirs’ (eg. Atazanavir and Darunavir)?

A

Protease inhibitors

325
Q

What type of drug is Enfuvirtide?

A

Fusion inhibitors (entry inhibitor)

326
Q

What type of drug is Maraviroc?

A

CCR5 receptor inhibitors (entry inhibitor)

327
Q

What is HAART?

A

Highly-Active Anti-Retroviral Therapy:

  • A combo of 3 drugs
  • From at least 2 drug classes
  • To which the virus is susceptible
328
Q

What is Atripla?

A 
Tenofovir (NtRTO)
PLUS
Emtricitabine (NRTI)
PLUS
Efavirenze (NNRTI)
329
Q

What is Truvada?

A

Tenofovir
PLUS
Emtricitabine

330
Q

What are the side effects of protease inhibitors?

A

GI symptoms

331
Q

What are the skin side effects of HAART?

A 
Rash
Hypersensitivity
SJS:
- Abacavir (NRTI)
- Nevirapine (NNRTI)
332
Q

What are potential CNS side effects of HAART?

A

Mood changes
Psychoses:
- Efavirenz (NNRTI)

333
Q

What is a potential renal side effect of HAART?

A

Proximal renal tubulopathies:

  • Tenofovir (NtRTI)
  • Atazanavir (Protease inhibitor)
334
Q

What HAART drug can cause osteomalacia?

335
Q

What HAART drugs increase MI risk?

A

Abacavir
Lopinavir
Maraviroc

336
Q

What drug can cause anaemia?

A

Zidovudine

337
Q

What are potential GI side effects of HAART?

A

Transaminitis
Fulminant hepatitis:
- Nevirapine

338
Q

What classes of ARV drugs are potent liver enzyme inducers?

A

Protease inhibitors

NNRTIs

339
Q

When can a vaginal delivery be carried out in a HIV+ mother?

A

If viral load undetectable

340
Q

When should a C-section be carried out in a HIV+ mother?

A

If viral load detectable

341
Q

What treatment should be initiated for a neonate with a HIV+ mother?

A

PEP for 4 weeks

342
Q

How should a neonate be fed?

A

Exclusive formula feeding

343
Q

What is the commonest STI cause of PID? How many women with this STI develop PID?

A

Chlamydia

9%

344
Q

A woman presents with post-coital and IMB. She has some lower abdominal pain and has experienced dyspareunia. There is evidence of a mucopurulent cervicitis.

345
Q

How does chlamdia present in men?

A

Urethral discharge
Dysuria
Urethritis
Epididymo-orchitis

346
Q

What is Fitz-Hugh-Curtis Syndrome?

A

Perihepatitis due do Chlamydia

347
Q

If IM Ceftriaxone is contraindicated for the treament of Gonorrhoea, what is a suitable alternative?

A

Cefixime 400mg PO

348
Q

What is the incubation period for gonorrhoea in the male urethra?

349
Q

What is the incubation period for genital herpes?

350
Q

How long does primary genital herpes tend to last?

A

14-21 days

351
Q

How long do recurrent episodes of genital herpes tend to last?

352
Q

Which HSV virus sheds more?

A

HSV-2 > HSV-1

353
Q

What is the most common viral STI in the UK?

354
Q

What type of HPV is associated with palmar warts?

355
Q

What type of HPV is associated with plantar warts?

356
Q

What is the average incubation period for HPV? (And the possible range)

A

Average is 3 months

Range from 3 weeks to 9 months

357
Q

How can anogenital warts be treated?

358
Q

How long is the incubation period for syphilis?

A

9-90 days (average is 21 days)

359
Q

How does secondary syphilis present?

A 
Macular/Follicular/Pustular rash on palms and soles
Mucous membrane lesions
Generalised lymphadenopthy
Patchy apolpecia
Condylomata Lata:
- Most hightly infectious lesions
360
Q

How is early syphilis treated?

A

2.4 MU Benzathine benzylpenicillin once

361
Q

How is late syphilis treated?

A

2.4 MU Benzathine benzylpenicillin three times

362
Q

How long is serological follow up continued in syphilis?

A

Until rapid plasma reagin is negative or serofast:

- Titres should decrease four-fold by 3-6 months in early syphilis

363
Q

How is relapse/reinfection of syphilis detected serologicallu?

A

If RPR titre increases four-fold

Year 3 - Reproductive and Sexual Health (DP) (7 decks)

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