Sexual Health Flashcards
What test can be done to assess for ovulation and how is the timing of this worked out if the patient doesn’t have a regular menstrual cycle.
21 day progesterone level test
If a patient doesn’t have a regular cycle. Subtract 7 days from when the period will start. This will give you the 7 day post ovulation - in which progesterone should be high.
*remember luteal phase is more consistent than follicular phase
*normal level is >25picommol.
What are the most common causes of anovulation?
PCOS
Hypothalamic amenorrhea
- physiological stress stops GnRH being released
Endocrine disorders
- Hypothyroidism
- Hyper-prolactinomas
List 6 main types of contraception:
- Barrier - condoms
- Pill
- combined
- Progesterone only - Implant
- last 3 years - Injection
- every 3 months
- long acting progesterone - intrauterine
- Copper
- Mirena
* Mirena up to 5 years use - Sterilisation
Female - Clips on tubes or Tubal ligation
Male - Vasectomy
What are some risk factors for STIs?
Not using Barrier protection
<25 years of age
High number of sexual partners
New sexual partners
Men who have sex with men
Commercial sex workers
Why should two condoms not be used at once?
More like to tear
Following a positive screen for chlamydia, when should a person be retested?
3-6 months later
What are some of the clinical signs of chlamydia?
Cervicitis
Cervical contact bleeding
PID
Reactive arthritis*
Typical symptoms:
- Lower abdominal pain
- Dyspareunia
- Dysuria
- Intermenstrual bleeding
- Post-coital bleeding
What type of urine sample is required for STI testing in men?
First void urine
*not MSSU
What is the treatment for chlamydia? how long should one abstain from sex and what else should be done?
Doxycycline or Azithromycin
Pregnant:
- Erythromycin
7 days no sex - even with condom.
Contact tracing
What is the management of Gonorrhoea?
Referral to sexual health clinic.
Ceftriaxone 500mg STAT
+
Azithromycin 1G STAT
What are the Urogenital complications of Gonorrhoea?
Females:
- PID
- Bartholin’s cyst
- Endometritis
Male:
- Epididymitis
- Infection of penile glands (Tyson’s glands)
What are the symptoms of primary HSV and what are the complications?
Malaise with flu like symptoms. Lymphadenopathy Stinging/ tingling sensation in genital area Vesicle formation in genitals Dysuria
Complications:
- Urinary retention
- Constipation
- Aseptic meningitis
What is the cause of genital warts and what is the treatment?
HPV
Treatment:
- Podophyllotoxin cream
- Imiquimod
- Cryotherapy
What is the vaccine against HPV?
HPV vaccine against:
- 6
- 11
- 16
- 18
Administered to all girls at school
+
Men who have sex with men <45 years old
What in the clinical history and symptoms can help differentiate between bacterial vaginosis and Trichomonas vaginalis?
Discharge:
BV: grey and watery
TV: Frothy and Yellow
Symptoms:
BV: Usually asymptomatic
TV: Dysuria
What investigations should be done into vaginal discharge?
Vaginal pH
High Vaginal swab / HVS
Pregnancy test (retained products of conception can cause discharge)
Chlamydia and gonorrhoea swab
+/-
urethral/ rectal and pharyngeal swab
What are the Emergency contraception options? and which is the most effective contraception?
Copper IUD
- most effective
Levonorgestrel
Ulipristal Acetate (progesterone receptor modulator)
When is a copper IUD effective for Emergancy contraception till?
Up to 5 days following the unprotective sex
or
5 days after ovulation (day 19 in normal cycle)
When can ulipristal acetate be used up till for Emergancy contraception?
Up to 120 hours
Inhibits or delays ovulation
How long after unprotected sex is levonorgestrel effective?
72 hours
1.5mg given.
Dose should be 3mg (Doubled) if:
- BMI >26
- On liver enzyme inducing medication
Inhibits ovulation - delaying or preventing follicular rupture.
What are the grounds of a termination?
An abortion can only be carried out if 2 or more doctors agree that the pregnancy should be terminated on 1 or more grounds.
These include:
• Continuance of pregnancy would involve risk to the life of the pregnant woman greater than if continued.
* Termination is necessary to prevent grave physical or mental injury of the pregnant woman * Pregnancy has not exceeded 24 weeks and the continuance of pregnancy would not involve greater risk to pregnant woman both physically and mentally * Pregnancy has not exceeded 24 weeks and the continuance of pregnancy would not involve greater risk to the family of the pregnant woman both physically and mentally
That there is a sufficient risk if the child was born it would suffer such severe mental or physical handicaps
What pre-abortion investigations are needed?
Bloods:
- FBC
- Blood grouping
- Kleihaur test
- Rh Negative will need prophylactic anti D
Orifices:
- STI screen
- cervical cytology
Baby:
- gestational age
What are the medical options for abortion?
- Mifepristone (progesterone antagonists)
24-48 hours later given: - Misoprostol (prostaglandin)
**used most successfully <7 weeks but can be used late 1st trimester
What are the surgical options for a late abortion (2nd trimester)
Dilation and evacuation
- cervical dilation
- surgical removal of fetus
What type of surgical abortion can be performed in 1st trimester?
<7 weeks:
- manual vacuum aspiration
7-14 weeks:
- suction or vacuum aspiration achieved by manual or electrical pump
*follow up of hCG is needed
What are the complications of abortion?
Retained products of conception
- prophylactic antibiotics
+/- surgical removal
Failure of abortion
Post abortion infection
- pre- STI screen/ prophylactic antibiotics
Trauma to genital tract
Psychological sequalae
What is the screening programme for cervical cancer?
25 - 64 years old.
- 25 - 49: every 3 years
- 50 - 64: every 5 years.
**liquid cytology is conducted
CIN 1 - observe
CIN 1 + High grade HPV - colposcopy
CIN >2 - referral for colposcopy
When is the best time to take a cervical smear?
Mid - menstrual cycle
What is the management of a woman with an abnormal smear?
*high grade HPV + Dyskarosis
Colposcopy \+ Acetic acid. \+/- Punch biopsy
Options are:
- see and treat
- punch biopsy and treat later
What is follow up after treatment of CIN?
Test of cure
- 6 month smear for HPV testing
if normal - discharge onto normal screening
if abnormal - refer back to colposcopy
Women post partum can be protected from pregnancy naturally depending on what? what is this called? and what is the criteria to make it effective?
Breast feeding exclusively protects from pregnancy.
Called: Lactational Amenorrhoea Method (LAM)
- Exclusively breast feeding (>85%)
- Amenorrhoeic
- <6 months post- partum
After birth when is the mother at risk of becoming pregnant again?
21 days post partum
How long following an abortion will a urinary pregnancy test remain high for?
4 weeks
Which cancer is the combined oral contraceptive pill protective against?
Endometrial and ovarian
Where is the rod inserted into?
Non dominant arm - Sub dermally
1/3rd up.
When starting the combined oral contraceptive, when in the cycle is a woman safe from pregnancy?
If started in the first 5 days of the cycle she is safe.
If started afterwards she will need to use barrier protection for 7 days
What are the complications of IUCs?
Lost threads
Abnormal bleeding
Ectopic pregnancy
Actinomyces infection and PID
**PID infection true for first 20 days then returns to normal thereafter
What are the contraindications to the COCP?
Previous VTE
Thrombophilia disease
BMI >35
Smokes >15 a day + >35 years old
Arterial disease
Migraine with aura
Breast cancer
Rifampicin use
If the progesterone only pill is started after the 1st day of menstrual cycle, how long does it take to work? how to does this compare to the COCP?
2 days
COCP = 7 days
At what age would you refer to social services for underage sex?
Under 13
How long does contraceptive cover need to be given for women when menopausal?
<50 years and menopausal (over 1 year since last period)
- 2 years of contraception
> 50 years and menopausal
- 1 year of contraception
How long does the implant work for, how does it work and what are some common side effects?
3 years.
Progesterone:
- stops ovulation
- thickens cervical mucus
- thins lining of womb
Side effects:
- no periods
- irregular bleeding
- unpredictable bleeding
What is the injection that can be used and name some side effects:
Given every 13 weeks./ 3 months
Uses progesterone.
Side effects:
- stop periods, irregular bleeding
- weight gain
- Osteoporosis
- can take up to 1 year to start ovulating again
Contrast the difference between the IUD copper device and the progesterone device:
Copper:
- non- hormonal
- can be used as emergency contraception
- can cause heavier bleeds to begin with
- last 5-10 years
Progesterone:
- hormonal
- lasts for 3-5 years
- lighter and less painful periods
- abnormal bleeding
Other than the contraindications to the COCP what other factor must you consider when prescribing it?
RIsk of pregnancy
- contraindicated if pregnant
*hence why not used as emergency contraception
HIghlight the differenceis between Fraser guidelines and Gillick’s compotence:
Frasers: concerned with contraception
Gillicks: concerned with treatment of any medical condition
What are the aspects to Fraser’s guidelines?
Understanding
Parental involvement - encourage them to speak to parents
Sexual activity - is it going to occur even without contraception
Suffering - mental and physical well being suffer?
Interests - is it in their interest?
Which act governs abortion in the UK mainland, and what is needed for an abortion to take place?
1967 abortion act
*need 2 doctors to sign it off and to be on the medical grounds for the patient
Which act limits the abortion to 24 weeks? and what are some caveats to this?
The human fertilisation and embryology Act 1990
abortion can take place later if there is:
- serious deformity
- life threatening risk to mother
Do partners of the pregnant women have any legal rights over the abortion?
no.
How many women by the age of 45 have had an abortion?
1 in 3
In scotland what are the time frames for an abortion?
Medical up to 18 weeks
- home (< 10weeks)
- > 10 weeks inpatient
Surgical up to 13 weeks
If >18 weeks then need to be referred to England via British Pregnancy Advisory Service (BPAS)
Highlight the medical procedure of abortion:
- Mifepristone - progesterone antagonist
followed 24-48 hours by - Misoprostol - to promote uterine expulsion
*starts within 2-3 hours
*painful
*completed within 24 hours
What things need to be considered other than gestational age in an abortion?
Contraception
- needed 5 days following procedure
Antibiotics?
Anti D prophylaxis - if mother Rh - and:
- < 10 weeks medical not needed
> 10 weeks medical needed
Surgical
Cervical screening
STI screening
Gender based violence
List some abortion complications and their management:
Failure to end pregnancy
Retained products of conception
- additional dose of misoprostol
- surgical wash out
Infection / endometritis
- broad spectrum Abx +/- Sepsis 6 if septic
Uterine perforation
- laparotomy/ laparoscopy procedure
Cervical tear
**these can account for symptoms of bleeding, abdo pain etc following an abortion and must be investigated for.
What are some contraindications to medical abortion? and surgical abortion?
Medical: Corticosteroid use Adrenal disease Hypertension High Cholesterol Sickle cell
Surgical:
BMI 40
BMI 35 + comorbidities
Anaesthesia
What is the major side effect of the intrauterine copper device?
Heavy bleeding with cramping
What are the antibody screening tests for syphilis and how does it relate to treatment?
Group specific antigens
- TPHA (Treponema pallidum haemagglutinin antigen)
- remains positive even after treatment
Non-specific antigens
- VDRL
- RPR
- changes to negative following treatment
How long following insertion of a IUS or rod is protection effective?
7 days
How would you advise someone who missed taken their COCP?
If one pill has been missed then:
- take the missed pill immediately, even if it means taking two pills in one day
If more than one pill has been missed then:
- Take the last missed pill immediately, even if it means taking two pills in one day
+
Barrier protection for 7 days
*if she had unprotected sex during the first 1-7 days of the cycle and missed more than 1 pill then Emergancy contraception is also needed.
What would you advise if someone misses their POP?
Out with 3 hours of normally taking it.
Take the missed pill immediately, even if it means taken 2 in one day.
+
Barrier protection for 48 hours
+/-
Emergancy contraception if she had unprotected sex in that time
What is the progesterone only injection known as and how is provided?
DMPA
Sub cut
or
IM
What are the two unique side effects to progesterone injection?
Weight gain
Osteoporosis
Long time to recovery of normal cycle
What is the contraindication to the progesterone implant and injection?
Active breast cancer
What tests / should be done in women prior to implanting the coil?
Tests:
- STI screen in those at risk
BP and HR monitored before and after
Examination:
- bimanual examination to assess for the position of the uterus
What advice should be given to females prior to removal of coils?
Refrain from sex or use condoms for least 7 days prior#
*due to the risk of ectopic
What disease is the copper IUD contraindicated in?
Wilson’s disease
What things need to be considered when giving the emergency contraception?
BMI of patient
Malabsorption (including D&V)
Enzyme inducers/ inhibitors
If you have to give ulipristal acetate as Emergancy contraception how long should you wait before restarting COCP or POP?
5 days
What contraception is considered safe during breast feeding?
POP
Rod
Copper coil
IUD
*all except oestrogen
If levongestrol is taken and the patient vomits within 3 hours what should she do?
Take a second dose
- if vomiting within 3 hours
When is COCP contraindicated following pregnancy?
< 6 weeks postpartum
What are some of the relative and absolute contraindications to the COCP?
UKMEC3 (relative)
- > 35 years old and smoking <15 cigarettes
- Controlled HTN
- family history of DVTs
- Immobile (wheelchair use)
- BRCA1/ BRCA2 mutation
UKMEC 4 (absolute)
- > 35 years old and smoking >15 cigarettes
- Migraine with aura
- DVTs
- Breast cancer
- Ischemic heart disease
- Major surgery with immbolity
- Postpatum <6 weeks
- Breast feeding
What advice should be given to females starting the pill?
Hypertension
- need regular BP monitoring
DVT advice
- to seek immediate help if they haves symptoms of DVT
If they develop migraines to seek help
D&V
- may need additional cover due to lack of absorption
Missed pill advice
Drug interactions which may reduce efficacy of the pill:
- St John’s wort
- Ridampicin
- Anti-epileptics - phenytoin
Doesn’t protect against STIs
What are some advantages and disadvantages of the COCP?
Advantages;
- Effective 99%
- Easy to use
- Reduced risk of ovarian and endometrial cancer
- Doesn’t interfere with sex
Disadvantages:
- Increased risk of cervical and breast cancer
- Increased risk of stroke
- increased risk of heart disease
- Temporary side effects N&V, breast tenderness
What advice can be given for those trying to conceive?
Optimise BMI
Regular vaginal sex
Stop smoking
Don’t try and time with ovulation
- causes unwanted stress
Which drug can cause ovarian hyperstimulation and what are the symptoms?
Clomiphene
and
GnRH
N&V
Abdominal pain (follicular cyst formation)
Ascites
Pleural effusions
How can pre-menstrual syndrome be treated?
Lifestyle
New- generation COCP
SSRIs if severe
What test can be conducted to assess ovarian reserve?
Anti- Mullerian Hormone
When testing someone for an STI - what other infections are routinely investigated for as well?
Chlamydia
Gonorrhoea
Syphilis
HIV
Hep B
