Sexual Health Flashcards
What is the normal vaginal pH.
How is this beneficial?
<4.5
inhibits growth of other bacteria
What maintains the normal vaginal pH
lactobacilli produce hydrogen peroxide - maintains acidic pH
What is the pathophysiology of bacterial vaginosis
disturbance of normal vaginal flora
decrease in lactobacilli
increase in Gardnerella vaginalis, anaerobes and mycoplasma
increase in vaginal pH >4.5
What are the risk factors for BV?
new or multiple sexual partners scented soaps/douching STIs recent abx IUD receptive oral sex smoking
What are the symptoms of BV
50% asymptomatic
fishy odour
white/grey homogenous thin vaginal discharge
no soreness/irritation
What is the differential diagnosis for BV
vaginal candidiasis
STI
trichomonas vaginalis
What investogations are done for BV
high vaginal smear of discharge, gram stained
What are Amsel’s criteria
help to diagnose BV - need >=3
homogenous white/grey thin discharge
bacilli on microscopy of smear - clue cells
pH >4.5
positive KOH whiff test
What are clue cells
vaginal epithelium studded with gram variable coccobacilli - indicate presence BV
What are the Ison/Hay criteria?
Way of classifying BV depending on gram stained smear of vaginal discharge
Grade 1 - mainly lactobacilli = normal
grade 2 - some lactobacilli, others present = intermediate
grade 3 - few lactobacilli, others predominate = BV
What is the management of BV
metronidazole 400mg BD 5 days
avoid scented shower gels, douching
?removal IUD
What are the risks of BV in pregnancy
premature birth
miscarriage
chorioamnionitis
What microorganism is involved in Vaginal candidiasis
Candida albicans - 90%
Describe the pathophysiology of vaginal candidiasis
opportunistic - immunocompromised leads to infection
hypersensitivity - changes in oestrogen etc leads to hypersensitivity reaction
What are the risk factors for candida
pregnancy DM immunocompromised recent course of broad spectrum Abx corticosteroids
What are the symptoms of candida
vulval itch
superficial dysruria
vaginal discharge -white, curd like, non-offensive
What can be seen in examination in candida
white curd like vaginal discharge
satellite lesions
erythema and swelling of vulva
Differential diagnosis of candidiasis
BV TV UTI contact dermatitis eczema/psoraisis
What investigations are needed to diagnose candidiasis
if uncomplicated - none! do on history + examination
if complicated eg. DM, pregnancy, recurrent
- do vaginal smear and microscopy (see spores adn mycelia)
What is the management of candidiasis
topical clotrimazole for vagina
oral fluconazole
What is the management of recurrent candidiasis
3 x 150mg oral fluconazole over 10 days
500mg clotrimazole once a week for 6 months
What is the management of candidiasis in pregnancy
NOT oral
pessary of clotrimazole - avoid damaging cervix with applicator for vaginal cream
check for otehr STIs which could be dangerous in pregnancy
How quickly should candidiasis clear up with treatment
What should be done if the infection does not clear?
within 7-10 days
consider alternative diagnosis
modify predisposing factors eg. diabetic control
consider concordance
When is emergency contraception used?
after sexual intercourse if:
unprotected sex
failed method of contraception
What are the options for emergency contraception
levonorgestrel
ullipristal acetate
copper IUD
Which method of emergency contraception is most effective?
copper IUD
How does levonorgestrel work?
synthetic progesterone
prevents ovulation for 5-7days
no effect on implantation
How does ullipristal acetate work?
progesterone receptor modulator
delay ovulation for 5-7days
prevents development of follicles/rupture of follicles at time of LH surge but not after
How does the copper IUD work as emergency contraception?
toxic to sperm
makes implantation impossible due to inflammation of endometrium
What time frame can each form of emergency contraception be used within?
levonorgestrel - 72 hours
ullipristal acetate - 72-120 hours
copper IUD - 5 days/ 5 days ovulation
What are the contraindications to levonorgestrel
malabsorption eg crohn’s
enzyme inducing drugs
What are the contraindications to ullipristal acetate
malabsorption eg crohn’s
enzyme inducing drugs
breast feeding
hepatic dysfucntion
What are the contraindications to copper IUD
uterine fibroids
suspected/documented PID
suspected/documented STI
What needs to be done before inserting a copper IUD
test for STI - chlamydia at least
can give dose of prophylactic abx to cover
What are the side effects of hormonal emergency contraception
nausea - should take second dose if vomit within 2/3 hours diarrhoea menstrual disturbance breast tenderness abdo pain
What are the complications of copper IUD emergency contraception
increased risk of ectopic pregnancy pelvic infections expulsion IUD bleeding pelvic pain
What causes chlamaydia and what kind of organism is it?
Chlamydia trachomatis
obligate intracellular gram -ve bacteria
What do the different serotypes of chlamydia cause?
A-C = conjuntivitis D-K = urogenital L1-L3 = lymphogranuloma venereum causing proctitis
How is chlamydia transmitted
skin to skin contact
oral, anal, vaginal sex
What is the incubation period for chlamydia
7-21 days
What are the risk factors for chlamydia
<25y sexual partner who is chlamydia +ve change in sexual partner unprotected sex co-infection with another STI
What are the symptoms of chlamydia in a male?
none -50%
testicular pain
urethral discharge
dysuria
What are the symptoms of chlamydia in a female?
none- 70% change in discharge dysuria IMB/PCB deep dyspareunia lower abdo pain
What are the signs of chlamydia in a male?
epididymal tenderness
mucopurulent discharge
What are the signs of chlamydia in a female?
mucopurulent endocervical discharge
cervicitis/contact bleeding
cervical motion tenderness
pelvic tenderness
How is chlamydia investigated
NAAT
- male: first catch urine, urethral swab
- female: vulvo/vaginal swab, endocervical swab, first catch urine
full STI screen
How is chlamydia managed
uncomplicated:
- doxycycline 100mg BD 7days
OR
- single dose 1g azityhromycin
avoid sex until treatment finished
contact tracing
When should a test of cure be sought following for chlamydia treatment
if pregnant
poor compliance
symptoms persist
What are the complications of chlamydia for women
salpingitis or endometritis leading to PID
leading to:
perihepatitis
increased risk ectopic pregnancy
infertility
What are the complications of chlamydia for men
epididymitis
epididymo-orchitis
could lead to infertility
What are the risks of chlamydia in pregnancy
premature birth
low birth weight
neonatal chlamydial conjunctivitis in first 2 weeks
pneumonia at 1-3months
What is the treatment of chlamydia during pregnancy
azithromycin and erythromycin
Which STI can lead to reactive arthritis?
Chlamydia
What organism causes gonorrhoea?
Neisseria gonorrhoeae
Gram-negative diplococcus
How is gonorrhoea transmitted?
unprotected sex - vaginal, oral, anal
vertical
What is the incubation period for gonorrhoea?
2-5days
What are the risk factors for gonorrhoea
<25y
new sexual partner
MSM
prev infection
What are the symptoms of gonorrhoea in a man?
mucopurulent urethral discharge
dysuria
What are the symptoms of gonorrhoea in a woman?
50% asymptomatic change in discharge - watery, thin, green/yellow dyspareunia dysuria lower abdo pain
What are the signs of gonorrhoea in a man?
mucopurulent urethral discharge epididymal tenderness (rare!)
What are the signs of gonorrhoea in a woman?
normal examination
mucopurulent endocervical discharge
cervix bleeds easily
pelvic tenderness
What investigations should be done to investigate gonorrhoea
males: first pass urine NAAT, urethral swab microscopy and culture
females: endocervical/vaginal swab - NAAT and microscopy and culture
full STI screen - G+C, HIV, syphilis
What is the management of gonorrheoa
ceftriaxone 500mg IM STAT
azithromycin 1g PO STAT
abstain until finished treatment
contact tracing
advice on safe sex
test of cure after 2 weeks
What are the complications of gonorrheoa?
females: PID
males: epididymo-orchitis, prostatitis
both: disseminated gonococcal infection
What are the some of the problems caused by disseminated gonococcal infection?
arthritis
skin lesions
meningitis
endocarditis
What problems can gonorrhoea cause in pregnancy>
premature labour
spontaneous abortion
early fetal membrane rupture
vertical transmission
What problems are associated with vertical transmission of gonorrhoea
gonococcal conjunctivitis in neonate - can lead to blindness
What organism causes genital warts
HPV6 or HPV11 - double-stranded-DNA papovaviruses
causes 90% genital warts
How are genital warts transmitted?
skint o skin contact
Can you still catch genital warts if you use a condom?
yes! condom does not completely cover all skin in genital area
Which strains of HPV cause cervical cancer
HPV16
HPV18
What are genital warts
benign proliferative epithelial growths
What are the risk factors for genital warts
early age at first sexual intercourse multiple sexual partners immunosupression smoking DM
What are the symptoms of HPV
no symptoms at all - infection occurs with no warts and then resolves
warts! - painless, fleshy. can be soft/hard, singular/multiple
What is the differential diagnosis for HPV
molluscum contagiosum vestibular papillomatosis Epidermoid cysts. Hair follicles. Sebaceous glands. Skin tags. Pearly penile papules
What investigations should be done in someone with genital warts?
full STI screen
vaginal speculum/rectal proctoscopy
biopsy if atypical ?cancer
What is the management of genital warts?
reassurance - they are benign and do resolvev spontaneously!
multiple warts:
- podophyllotoxin BD 3d/week.
- review after 4 weeks, continue if >50% improvement, change to imiguimod OD alternate days 3d/week for 16 weeks
- excision
One or few warts
- podophyllotoxin BD 3d/week. OR cryo once per week
- review after 4 weeks, continue if >50% improvement, change to imiguimod OD alternate days 3d/week for 16 weeks/podo regime
- excision
What treatments for genital warts are able to be used in pregnancy
NOT podophylllotoxin or imiquimod
give cryo once weekly
consider excision or defer untila fter pregnanvy
Do genital warts cause any problems during pregnancy
no risks to mother or fetus
warts can multiply or enlarge
What has been done to reduce the incidence of genital warts?
HPV vaccine to 12-13 year old girls
2008 HPV 16 and 18 only
2012 also HPV 6 and 11
What causes syphilis?
Treponema pallidum
gram negative spirochete
How is syphilis transmitted?
break in skin or via mucous membrane in sexual contact
vertical transmission to fetus
Describe the stages of syphilis
primary
= 9-90 days after infection. chancre formation. resolves spontaneously
secondary
= 6-12 weeks after infection. generalised symptoms, lymphadenopathy, rash on soles and palms
resolves in 2/3 months
latent phase - no sx
early = less than 2 years since infection
late = more than two years since infection
teartiaty
type IV hypersensitivity reaction
neurosyphilis, cardiovascular syphilis or gummatous syphilis
Describe the chancre seen in primary syphilis
raised border, hard base, painless, non-itchy
found on genitals
What are the risk factors for syphilis
UPSI
multiple sexual partners
HIV
MSM
What are the signs and symptoms of secondary syphilis?
fever headaches malaise arthralgia skin rash on palms and soles weight loss painless lymphadenopathy
What are the signs and symptoms of gummatous syphilis?
Inflammatory fibrous nodules or plaques (granulomas) in bone, skin, mucous membranes, connective tissue, organs
What are the signs and symptoms of neurosyphilis?
tabes dorsalis = (loss of dorsal column) ataxia, numb legs, absence of deep tendon reflexes, lightning pains, loss of pain and temperature sensation, skin and joint damage.
dementia
meningovascular
Argyle-robertson pupils = loss of light reflex, accomodation remains
What are the signs and symptoms of cardiovascular yphilis?
aortitis -usually involves the aortic root but may affect other parts of the aorta
aortic regurgitation,
aortic aneurysm
angina.
What investigations are done for syphilis?
swab and dark field microscopy
blood serology
- EIA for treponemal IgG and IgM = exposure to treponemes
- TPHA/TPPA selective for T pallidum
RPR is used to stage syphilis and show response to treatment
What is the management of syphilis
early: benzathine penicillin 2.4 megaunits IM STAT
late: benzathine penicillin 2.4 megaunits IM 3 doses at weekly intervals
avoid sexual contact screen for other STIs contact tracing follow up serology repeat screening to find re-infection
What are the risks of having syphilis during pregnancy
stillbirth
miscarriage
pre-term labour
congenital syphilis
What STIs are pregant women screened for
syphilis
HIV
hepatitis B
Describe congenital syphilis
early = <2y old
rash on palms and soles, hemorrhagic rhinitis, lymphadenopathy, hepatosplenomegaly
late = >2y
arthritis of the knees, Hutchininson’s incisors, saddle nose deformity
What reaction can occur after treating syphilis? Descibe this
Jarisch Herxheimer reaction
Flu like symptoms 24 hours after treatment due to inflammation secondary to death of treponemes
can be dangerous in pregnancy - can cause contractions, fetal heart rate abnormalities and even stillbirth
What causes trichomoniasis
Trichonomas vaginalis
anaerobic flagellated protozoan
How is trichomoniasis transmitted
only through unprotected vaginal sex
not anal or oral!
What are the risk factors for TV
multiple sexual partners
UPSI
other STIs
older age!
What are the symptoms of TV in males?
urethral discharge
dysuria
frequency
painful/ithching foreskin
What are the symptoms of TV in females?
offensive frothy green/yellow discharge
dysuria
dyspareunia
itchy/sore vuvla
What are the signs of TV in males?
urethral discharge
What are the signs of TV in females?
offensive frothy green/yellow discharge
strawberry cervix
vulvitis
vaginitis
What investigations should be done in suspected TV
males: urethral swab/first pass urine for NAAT and MC+S
females: high vaginal swab from posterior fornix/vaginal swab - NAAT and MC+S
What is the management of TV
metronidazole 2g PO STAT
contact tracing
full STI screen
abstain for 1 week after treatment
what are the risks of TV during pregnancy
premature labour
low birth weight
maternal post partum sepsis
What causes genital herpes
HSV1 or HSV2
How is herpes transmitted
skin to skin contact during sexual intercourse
can be transmitted via oral sex - coldsores
NB: asymptomatic shedding - pt does not need to have symptoms to transmit virus
Describe the relationship between primary and recurrent herpes
primary = initial infection
virus travels to local sensory ganglion
reactivation = moves back down to skin to cause recurrent infections
What are the risk factors for herpes
multiple sexual partners UPSI other STIs oral sex MSM HIV
What are the symptoms of primary herpes
bilateral red painful blisters around genitals urethral/vaginal discharge fever muscles aches itchy genitals
resolves after 20 days
What are the symptoms of recurrent herpes
burning/itching around the genitals
painful red blisters - often unilateral
shorter duration - 10 days
less severe lesions
decrease in severity over time
What investigations can be done in suspected herpes?
swab from open sore - PCR
can do serology - can identify those with asymptomatic infection but may take up to 12 weeks to become positive after primary infection
What is the management of herpes
counselling - this is a life long infection
full STI screen
antivirals can decrease the size and number of lesions, but cannot cure it
abstain during outbreaks
contact tracing
primary: aciclovir 400mg TDS for 5 days
recurrent: 800mg TDS 2 days
When can suppresive therapy for herpes be considered?
> 6 episodes a year
take 400mg BD every day
What problems can herpes cause during pregancy
risk of transmission to baby at birth causing neonatl herpes
Which trimester is a new primary infection of herpes most likely to cause neonatal herpes in?
third trimester
How is herpes managed during pregnancy
primary infection
first/second trimester: aciclovir initially, aciclovir from 36 weeks (400mg TDS), normal vaginal delivery
third trimester:
first/second trimester: aciclovir initially, aciclovir from 36 weeks. C SECTION to reduce risk transmission
recurrent infection
aciclovir at 36 weeks, vaginal delivery
Describe neonatal herpes
occurs 2 days - 6 weeks after delivery
localised infection - vesciles on skin, eyes or moith
CNS infection can cause lethargy, feeding difficulties and seizures
disseminated infection can cause jaundice, hepatosplenomegaly and DIC
What causes HIV
human immunodeficiency virus
single stranded RNA retrovirus
Describe the pathophysiology og HIV
HIV virus infects CD4 T Helper cells
repilicates inside them using reverse transcriptase and integrase enzymes
How is HIV transmitted
unprotected sex - vaginal, oral, anal
contaminated needles
pregnancy - in utero, at delivery and via breast feeding
What are the risk factors for HIV
UPSI with someone who has lived in/travelled to Africa
MSM
IVDU
from a high prevalence area
Describe the presentation and time course of HIV
- seroconversion illness
occurs 2-6 weeks after infection
flu like - fever, muscle aches, malaise, lymphadenopathy, maculopapular rash, pharyngitis - latent - asymptomatic
- symptomatic = AIDS related complex
weight loss, fever, diarrhoea, night sweats, freq opportunistic infections eg. candida, herpes simplex, HZV - AIDS
presence of defining illness eg. Hodgkin’s lymphoma, pneumocystis jiroveci
How is HIV tested for?
serum ELISA - for HIV Ab and p24 antigen
Ab show up 4-6 weeks after infection
p24 antigen shows in active infection even if no Ab yet
How is HIV monitored
CD4 count
viral load
How is HIV treated
highly active antiretroviral therapy (HAART) is begun as soon as HIV diagnosis is given
eg. atripla, stribild, triumeq
contact tracing
counselling
What other investigations should be done at time of HIV diagnosis
Assessment for other infections: eg, tuberculosis, hepatitis B, cytomegalovirus (CMV), toxoplasma, syphilis, varicella.
Screening for co-existing sexually transmitted infections (STIs).
Baseline CXR and cervical smear
What are the risks of HIV during pregnancy and how is this reduced?
risk of tranmission to fetus in utero, at birth or during breast feeding
HAART during pregnancy and delivery
avoid breastfeeding
neonatal PEP
C section not recommended if viral load is undetectable
Explain what PEP is
post exposure prophylaxis
given within 72 hours of exposure to HIV
one month course
Describe the pathophysiology of PID
ascending infective inflammation of upper female genital tract
caused by Chlamydia, gonnorhoea, normal vaginal flora, mycoplasma etc
What are the risk factors for PID
15-24 UPSI sexually active recent change in sexual partner history of STI prev hx of PID IUD TOP gynae surgery
What are the symptoms of PID
sometimes none bilateral pelvic pain PCB, IMB, heavy bleeding purulent vaginal or cervical discharge deep dyspareunia
What are the signs of PID
bilateral lower abdominal tenderness
speculum: purulent endocervical discharge, cervicitis
bimanual: cervical motion tenderness, adnexal tenderness
fever
N+V
What is the differential diagnosis for PID
ectopic pregnancy appendicitis tubo-ovarian abscess ruptured ivarian cyst endometriosis UTI
What investigations should be done in suspected PID
pregnancy test
urine dip and MSU
endocervical and vaginal swab - G+C, TV, BV
full STI screen
TV US scan
laparoscopy - severe cases if diagnostic uncertainty
What is the management of mild/moderate PID
Abx at home for 14 days
ceftriaxone - 500mg IM STAT
doxycycline 100mg BD PO
metronidazole 400mg BD PO
analgesia
abstain from sexual intercourse until treatment finished
contact tracing
What suggests that hospital admission is needed in severe cases of suspected PID
If pregnant and especially if there is a risk of ectopic pregnancy.
Severe symptoms: nausea, vomiting, high fever.
Signs of pelvic peritonitis.
Unresponsive to oral antibiotics, need for IV therapy.
Need for emergency surgery or suspicion of alternative diagnosis.
What is the treatment for severe PID
IV abx in hospital
stop IV when improved for 24 hours and swithv to oral for 14 day course
what are the long term consequences of PID
infertility ectopic pregnancy - due to narrowing and scarring of the fallopian tubes chronic pelvic pain Fitz-High-Curtis tubo ovarian abscess
What is androgen insensitivity syndrome
X-linked recessive condition
due to end-organ resistance to testosterone
causing genotypically male children (46XY) to have a female phenotype.
What are the features of androgen insensitivity syndrome
primary amenorrhoea
undescended testes - leading to bilateral groin swellings
no pubic hair
can have small breasts (testosterone converted to oestrogen peripherally)
