Sexual Health

Question 1

IUD

Answer 1

contains copper
reduces sperm motility and reduces survival
inhibits fertilisation, implantation and sperm penetration of cervical mucous
lasts 5-10 years
instantly effective 98-99% (can be used as emergency contraception)
CI - if current pelvic infection or STI or TB, if allergic to copper, if has Wilson’s disease, if pregnant and caution if on anticoagulation

Question 2

IUS

Answer 2

e.g. Mirena
prevents endometrial proliferation and thickens cervical mucous
contains progesterone only - causes reverible endometrium atrophy which reduces likelihood of implantation and makes periods lighter and less painful
last 5 years
>90% effective, effective after 7 days (if not inserted on the first day of the cycle)

Question 3

emergency contraception

Answer 3

• emergency IUD: up to 120hrs after sec, toxic to sperm and ovum, if sex >5 days ago can be inserted up to 5 days after likely ovulation
• ulipristal acetate: within 120 hrs, thought to delay or inhibit ovulation, avoid breastfeeding for 36hrs after
• levonorgestrel: within 72 hrs (best if within 12 hrs), suitable for those with focal migraines and Hx of VTE, believed to inhibit ovulation

Question 4

COCP

Answer 4

inhibits ovulation
taken for 21 days with a 7 day break
effective after seven days (if not started on first day of cycle)

increases risk of cervical and breast cancer
lowers risk of ovarian and endometrial cancer

Question 5

contraceptive patch

Answer 5

transdermal patch applied on day 1 of the cycle, changed on day 8 and day 15, removed on day 22 for a 7 day break

Question 6

contraceptive vaginal ring

Answer 6

inserted on day 1 for 3 week , 7 day ring free interval

Question 7

reasons to avoid combined hormonal contraceptives

Answer 7

history of venous disease or has risk factors (smoker, BMI >30, thrombophilia)
arterial disease - IHD, TIA, stroke, migraine with aura
liver disease - doesn’t work with rifampicin/rifabutin
cancer - history of breast cancer
previous pregnancy complications or is <6 weeks post-partum and breast feeding

Question 8

POP

Answer 8

have a 3hr or 12hr (if desogestrel) in which to take
thickens cervical mucus and prevents sperm penetration
start on day 1-5 of cycle or needs 2 days of condom cover

Question 9

depot progesterone

Answer 9

medroxyprogesterone acetate (12-weekly, deep IM)
norethisterone enantate (8-weekly, gluteus maximus) 

effective after 7 days if not started on first day of cycle
causes weight gain, not used if risk of OP
there may be a delay in the return of ovulation after stopping (can be >2years)

Question 10

implant

Answer 10

e.g. Nexplanon - subdermal upper medial arm
inhibits ovulation and thickens cervical mucus
provides up to three years of protection
implant on day 1-5 or needs 7 day condom cover

Question 11

vasectomy

Answer 11

under LA
vas deferens is ligated and excised or lumen is cauterized
needs two negative sperm ejaculates 8 weeks post-op and 1 month after that
reversal is most successful if within 10 years of initial operation

Question 12

female sterilization

Answer 12

laparoscopic surgery under GA

no more effective than Mirena coil, trickier and risker than vasectomy

Question 13

Pelvic Inflammatory Disease (PID)

Answer 13

infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries and the surrounding peritoneum
commonly caused by chlamydia
features: lower abdo pain, deep dyspareunia dysuria, fever, menstrual abnormalities, vaginal/cervical discharge and cervical excitation
Rx: oral ofloxacin and oral metronidazole OR IM ceftriaxone and oral doxycycline and oral metronidazole
complications:
infertility (10-20% risk after one episode), chronic pelvic pain, ectopic pregnancy, Fitz-Hugh-Curtis syndrome

Question 14

endometriosis

Answer 14

growth of ectopic endometrial tissue outside of the uterine cavity
chronic pelvic pain, dysmenorrhoea, deep dyspareunia, subfertility, urinary symptoms, dyschezia (painful bowel movements)
laparoscopy is the gold standard investigation
Rx: depends on symptoms
NSAIDs and paracetamol
COCP/progestogens
GnRH analogues
surgery - laparoscopic excision and laser treatment of endometriotic ovarian cysts may improve fertility

Question 15

ectopic pregnancy

Answer 15

-97% are tubal, 3% ovary/cervix/peritoneum

Rx: methotrexate, laparoscopy, salpingotomy or salpingectomy

Question 16

menopause

Answer 16

average peak in the UK is 52 years old
said to be 12 months after LMP
problems are related to falling oestrogen levels: menstrual irregularity, vasomotor disturbance (sweats/palpitations/flushing) and atropy of genitalia, breast and skin (vaginal dryness - UTIs, dyspareunia, stress incontinence), osteoporosis - menopause accelerates bone loss
Rx: diet, exercise, Mirena coil, oestrogen cream and HRT

Question 17

HRT

Answer 17

if they have a uterus – COMBINED HRT
if they don’t have a uterus – OESTROGEN ONLY

is not a contraception (women are considered potentially fertile until 2yrs after LMP if <50y/o or for 1 year if >50y/o)

benefits: reduction in vasomotor symptoms due to oestrogen, reduced risk of OP #, reduced risk of colorectal cancer
risks: increased risk of breast and endometrial cancer, risk of VTE, risk of gallbladder disease

Question 18

alternatives to HRT

Answer 18

SSRIs - treat vasomotor symptoms
bisphosphonates and calcium and vitamin D - reduce risk of OP
vaginal oestrogen/ lubricants - treats vaginal dryness

Question 19

types and risk of hysterectomy

Answer 19

• total
• subtotal (leaves cervix behind, still needs smears)
• removal of tubes and ovaries may be done at the same time
• Wertheim’s (includes LN and cuff of vagina) used for malignancy

risks: bleeding, infection, bladder/bowel/vessel/ureter injury, scarring, VTE, early menopause if ovaries retained

Question 20

chlamydia trachomatis

Answer 20

often asymptomatic and detected on screening
can cause dysuria and discharge for both sexes
in females can cause deep dyspareunia and post-coital or intra-menstrual bleeding
diagnosis is by NAAT of vulvovaginal swab or first pass urine (M)
Rx: azithromycin (single dose) or doxycycline (7 days) kr erythromycin in children

women need to deliver via C-section

Question 21

Neisseria gonorrhoea

Answer 21

asymptomatic or urethral/vaginal discharge and dysuria
NAAT and culture for sensitivity
Rx: ceftriaxone (and azithromycin to treat for chlamydia) if a complicated disease then add doxycycline and metronidazole

Question 22

HPV

Answer 22

genial/anal warts 
topical podophyllin/cryotherapy 
vaccine Gardasil protects against 6,11,16 and 18. cervirax protects against 16 and 18.
HPV 6&11 cause genital warts
HPV 16,18&33 cause cancers

Question 23

trichomonas vaginalis

Answer 23

thin, offensive vaginal discharge that causes an itch
only 30% of males will experience a whitish discharge and inflamed foreskin
Rx: metronidazole
can be complicated in pregnancy (risk of preterm, low birth weight)

Question 24

bacterial vaginosis

Answer 24

thin, white, fishy discharge, no itch or soreness
pH >4.5, KOH whiff test
Rx: PO or PV metronidazole
or PV clindamycin

Question 25

genital candidiasis

Answer 25

genital itch, burning, cottage chees like discharge, dyspareunia
Rx: clotrimazole pessary
if severe oral fluconazole

Question 26

HSV (herpes)

Answer 26

painful blisters or sores

Rx: acyclovir (not a cure, just helps with flare ups)

Question 27

syphilis

Answer 27

primary = painless infectious sores
secondary = rash and flu like symptoms
tertiary = heart problems, paralysis, blindness, neurosyphilis
(its hard to associate the stages together)
Rx: penicillin and test of cure follow up

Question 28

endometrial cancer

Answer 28

75% of cases are in post-menopausal women
risk factors: nulliparity, early menarche and late menopause, tamoxifen, PCOS
features: post-menopausal bleeding
COCP is protective

Question 29

ovarian cancer

Answer 29

90% are epithelial, 70-80% are a serious carcinoma
risk factors: nulliparity, early menarche, late menopause, BRCA 1/2 gene, CA125 testing
COCP is protective
5-year survival is 46%

Question 30

cervical cancer

Answer 30

80% are SCC, 20% are adenocarcinomas
risk factors: HPV 16,18,33, high parity, early first intercourse and many sexual partners, COCP

screening 25-64 year olds
25-49 (3-yearly)
50-64 (5-yearly)

Question 31

breast cancer

Answer 31

invasive ductal carcinomas are the most common
risk factors: BRCA genes, p53 gene mutation, nulliparity, first pregnancy later than 30y/o, early menarche and late menopause, not breast feeding, COCP and HRT
Rx: if HER2 positive the Herceptin
if pre-menopause then tamoxifen

Question 32

breast disorders

Answer 32

fibroadenoma (breast mice, <30y/o)
fibroadenoisis (benign, in middle aged, pain may worsen before mensuration)
breast cancer (hard, irregular lump, may have nipple inversion or skin tethering)
mammary duct ectasia (common around menopause, tender lump around areola maybe with green discharge) 
duct papilloma (hyperplastic lesions with possible blood stained discharge)
fat necrosis (commoner in obese women, rare and mimic breast cancer so warrant further investigation)
breast abscess (more common in lactating women, red, hot and tender swelling)
mastitis (affects 10% of breast feeding women, can continue to breast feed, if systemically unwell/ symptoms do not improve after 12-14hr then flucloxacillin PO)