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Y4 ObGyn > Sexual health > Flashcards

Sexual health Flashcards

1
Q

What are the advantages to barrier contraception (male/ female condoms and diaphragm)

A
  • not contraindicated by any condition other than latex allergy, when others can be used as effectively
  • widely available and simple to use
  • protective against STIs (male condom, femidom provides some protection)
  • no hormones
  • diaphragm inserted up to 3 hrs before intercourse, femidom up to 8 hrs before
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2
Q

What are the disadvantages to barrier contraceptives

A
  • perfect use rarely achieved
  • may reduce sensitivity and/ or arousal
  • lack of motivation to use every time
  • femidoms may be uncomfortable and/ or noisy and require prior planning
  • diaphragms associated with increased risk UTIs and STI transmission not reduced and may need refitting
  • failure rate 2% with condom with perfect use and 16% in reality, female condoms and diaphragms have even higher failure rates
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3
Q

How do combined hormonal contraceptives work

A

inhibit ovulation due to negative feedback response of oestrogen and progesterone on the HPA, this prevents LH surge and so preventing ovulation.
The progesterone also inhibits proliferation of the endometrium, creating unfavourable conditions for implantation and increases thickness of the cervical mucus, stopping sperm getting in.

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4
Q

What are the different types of combined hormonal contraceptives?

A

COCP:
- monophasic (each pill has same levels of O and P, eg microgynon, 21 days on, 7 off)
- phasic (O and P changes throughout cycle, can be bi tri or quadraphasic- eg qlaira which is 28 days no break but 2 pills are inactive)
- also low oestrogen pills
Transdermal patch:
- stuck onto upper arm, buttock or back
- ortho evra is the brand name- give O+ P and use 1 per week for 3 weeks then week break
- can be used while bathing and swimming
Contraceptive vag ring:
- stays in for 21 days then removed for 7 then insert new one

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5
Q

What are the advantages to combined hormonal contraception

A
  • non invasive
  • more effective than barrier if taken correctly
  • no interruption to sex
  • menses become more regular, lighter and less painful
  • reduced risk ovary uterus and colon ca
  • reduced risk functional ovarian cyst
  • normal fertility returns immediatly after stopping
  • can control menses by carrying on taking pill
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6
Q

What are the disadvantages to combined hormonal contraceptives

A
  • user dependant
  • some temporary adverse effects inc headaches, breast tenderness, mood changes
  • blood pressure may increase
  • some women experience breakthrough bleeding and spotting in first few months
  • increased risk VTE
  • small increased risk MI and stroke
  • small increased risk cervical and breast ca
  • no protection from STIs
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7
Q

Give 5 contraindications of combined hormonal contraception

A
  • BMI >35
  • breast feeding
  • smoking over age of 35
  • hypertension
  • history of or a fhx of VTE
  • prolonged immobility due to surgery or disability
  • DM with complications eg retinopathy
  • hx migraines with aura
  • breast cancer of primary liver tumours
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8
Q

how do progesterone only pills work?

A
  • thickens cervical mucus so sperm cant get in
  • thins endometrium which inhibits implantation
  • most also will inhibit ovulation
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9
Q

Describe the advantages of progesterone only pills

A
  • more effective than barrier when used properly
  • no interruption to sex
  • can be used in many pts which COCP is contraindicated
  • may reduce risk of endometrial ca
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10
Q

Describe the disadvantages of POP

A
  • user dependant and has to be taken at same time every day
  • can produce irregular menstruation (4 in 10) or amenorrhoea (in 2 in 10)
  • side effects such as headaches, breast tenderness, skin changes
  • 30% increased risk ovarian cysts
  • small increased risk breast cancer
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11
Q

State 4 contraindications of POP

A
  • current or past history of breast cancer
  • liver cirrhosis or tumours
  • low efficacy in women over the weight of 70kg
  • stroke or coronary heart disease
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12
Q

How does nexplanon (the progesterone only implant) work and how long does it work for?

A
  • main mechanism is that it inhibits ovulation
  • also thickens cervical mucus
  • thins endometrium
  • lasts for 3 yrs
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13
Q

Describe the advantages of the progesterone implant

A
  • extremely effective and not user dependant
  • can be used when COCP is contraindicated
  • dont even have to think about contraception for 3 yrs
  • can be used when breast feeding
  • normal fertility returns as soon as it is removed
  • effective in woman of all bodymass (need to replace earlier if low BMI)
  • may reduce endometrial ca risk
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14
Q

Describe the disadvantages of the implant

A
  • 50% get changes in menstrual bleeding and bleeding patterns likely to remain irregular
  • fitting and removing implant causes some pain, bruising and irritation
  • small increased risk breast ca
  • implant can sometimes break or bend insitu
  • no STI protection
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15
Q

Give 4 contraindications for the implant

A
  • pregnancy
  • unexplained vaginal bleeding
  • liver cirrhosis or tumours
  • hx breast cancer
  • stroke or tia while using the implant
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16
Q

How often are progesterone injections needed to be given?

A
  • vary between brands
  • depo-provera is 12 weekly IM injection
  • satana press is 13 weeks
  • noristerat less commonly used now as is 8 weeks
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17
Q

What are the key adv and disadv to progesterone injections

A

adv: can be used when breast feeding, when BMI >35, effective and not user dependant, no drug interactions
Disadv: not rapidly reversible- fertility may take up to a year to return, many gain weight, 50% stop within a year due to altered bleeding patterns and persistent bleeding. Contraindicated by pregancy, breast ca, diabetes w/ vascular disease

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18
Q

What are the two types of intrauterine contraceptives and how do they work?

A

IUD: copper coil- releases copper which makes uterus unfavourable for sperm and inhibits fertilisation and implantation, effective immediately
IUS: mirena coil, releases progesterone which thins endometrium to prevent implantation and thickens cervical mucus, effective immediately if fitted within first 7 days of cycle, if not takes 7 days

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19
Q

Give 5 contraindications for IUS and IUD

A
  • infection (hx PID, recent exposure to STI, recent uterus infection)- need STI test 2 weeks prior to insertion
  • current pregnancy or up to 4 weeks post partum
  • uterine structural abnormality
  • gynae maligancy
  • unexplained vaginal bleeding
  • allergy to copper (IUD only)
  • current DVT, PE, liver disease or pmh breast cancer also for IUS
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20
Q

Describe the main advantages to the IUS and IUD

A
  • very effective
  • IUS also treated dysmenorrhoea and menorrhage
  • IUD can be used as emergency contraceptive up to 5 days after UPSI
  • fetility normally returns immediatly after removal
  • can be fitted at any stage in cycle
  • can be used while breast feeding
  • can be used in most women who are contraindicated by COCP
  • IUD uses no hormones
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21
Q

What are the disadvantages to IUS and IUD

A
  • no STI protection
  • risk of ascending or iatrogenic infection
  • risk of uterine perforation at time of fitting
  • risk of body expelling IUS/IUD
  • IUD makes periods more painful and heavy
  • irregular bleeding for up to 6 months after insertion
  • coil insertion may be painful
  • higher risk of ectopic
  • increased risk of seizures in epileptics at time of cervical dilation
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22
Q

What are the two types of pills licensed for use as emergency contraception and when can they be used

A
  • levonorgestrel 1.5mg tablet: progesterone only, can delay ovulation by 5-7 days, after which any sperm is non viable, licensed for use within 72 hrs of UPSI
  • ulipristal acetate (30mg tablet)- progesterone receptor modulator, also delays ovulation by 5-7 days, can be used within 120 hrs of UPSI
  • IUD: 5 days after
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23
Q

What are the contraindications for the two morning after pills

A

Levonorgestrel: none, but efficiacy may be reduced by malabsorbtion eg crohns and enzyme inducing drugs eg rifampicin (if refuses IUD they just take double dose)
Ulipristal acetate:
- diseases of malabsorbtion eg crohns
- hypersensitivty to UA
- severe hepatic dysfunction
- enzyme inducers
- breast feeding
- asthma insufficiently controlled by corticosteroids
- drugs increasing gastric pH eg omeprazole/ ranitidine

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24
Q

What is gillicks competence and fraser guidelines?

A
  • gillicks: concerned with determining a childs capacity to consent
  • fraser guidelines: used specifically to decide if a child can consent to contraceptive or sexual health advice and treatment
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25
Q

What are the fraser guidelines?

A

A child can be given advice and consent to treatment relating to sexual health without parental consent as long as:

  • they are sufficiently mature and intelligent to understand the nature and implications of the treatment
  • they cannot be persuaded to tell their parents
  • theyre very likely to continue having sexual intercourse with or without contraceptives
  • their physical or mental health would likely suffer if they dont get the advice or treatment
  • the advice or treatment is in the young persons best interests
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26
Q

List 4 RFs for thrush (candida albicans) infection?

A
  • pregnancy
  • diabetes
  • use of broad spectrum abx
  • use of corticosteroids
  • immune surpression of compromised immune system
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27
Q

Describe the clinical features of thrush

A
  • prutitis vulvae
  • vaginal discharge (usually white, curd like and non offensive)
  • dysuria + dyspareunia
  • erythema and swelling of vulva
  • satellite lesions: red pustular lesions with superficial white/ creamy pseudomembranous plagues what can be scraped off
  • white curd like plaques may be visible on anterior vaginal wall
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28
Q

How should thrush be diagnosed and managed initially?

A
  • if uncomplicated, no investigations are necessary. If complicated (preg, diabetes, immunocompromise) then do vaginal smear and microscopy
  • intravaginal antifungal eg clotrimazole
  • oral antifungal eg fluconazole
  • topical imidazole can be given with oral or intravaginal treatments to address vulval symptoms or alone if age 12-15
  • advise them to avoid douching, cleaning the vulval area with soaps/ shower gels, tight fitting/ non absorbant clothing, biological washing powder and fabric conditioner
  • advise them to wash with soap substitute, use simle emollient to moisturise vulval areas and consider probiotics
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29
Q

How should thrush thats not resolved within 7-14 days be managed?

A
  • consider alternative diagnosis by measuring vaginal pH (candida<4.5, vaginosis or trichonmonas >4.5) and taking swab for microscopy and culture
  • consider predisposing factors and address them
  • consider concordance with meds and administration
  • give extended course
  • refer or seek advise if: age 12-15, doubt diagnosis, symptoms not improving and treatment failure unexplained, non albicans candida or treatment fails twice
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30
Q

How should thrush be treated in pregnancy?

A
  • give intravaginal antifungal
  • do not give oral treatment
  • treat vulval symptoms with topical antifungal
  • refer to GUM if suspect STI
  • advise them to return if not resolved in 7-14 days
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31
Q

What causes bacterial vaginosis?

A
  • normal flora is disturbed leading to REDUCED lactobacilli
  • NORMALLY lacobacilli usually produce hydrogen peroxide and reduce vag pH to <4.5 and inhibit growth of organisms
  • the infection is commonly polymicrobial but gardnerella vaginalis, anaerobes and mycoplasmas are most commonly found
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32
Q

Give 5 RFs for bacterial vagonisis

A
  • sexual activity (particularly new partner of multiple partners)
  • used of IUD
  • receptive oral sex
  • presence of STI
  • vaginal douching or using soaps/ vaginal deoderant
  • recent abx use
  • ethnicity
  • smoking
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33
Q

Describe the clinical features of bacterial vaginosis

A
  • 50% asymptomatic
  • thin, white/ grey, offensive fishy smelling homogenous discharge
  • not usually associated with soreness, itching irritation
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34
Q

how is bacterial vaginosis diagnosed?

A
  • high vaginal smear and gram stain showing clue cells (vag epithelial cells studded with gram variable coccobacilli)
  • reduced numbers of lactobacillus
  • absence of pus cells
  • vaginal ph >4.5
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35
Q

How should bacterial vaginosis be managed?

A
  • metronidazole orally for 5-7 days or 2g as single dose
  • or as a gel applied directly to vagina
  • clindamycin and tinidazole can also be used
  • avoid vag douching, scented shower gels, antiseptic agents, shampoos
  • treatment is same in pregnancy but lower doses of metronidazole reccommended if breast feeding as it can affect the taste of breast milk, untreated it increases risk of prem, miscarriage and chorioamnionitis
36
Q

What is the cause of pelvic inflammatory disease?

A
  • inflammation due to spread of bacterial infection from the vagina or cervix to the upper genital tract
  • may affect endometriu, uterus, fallopian tubes, ovaries of peritoneum
  • chlamydia trachomatis and neisseria gonorrhoea are responsible for 25% of the cases
37
Q

Give 5 RFs for PID

A
  • sexually active
  • age 15-24
  • recent partner change
  • lack of barrier contraception
  • history of STI
  • pmh PID
  • instumentation of cervix eg gynae surgery, termination of pregnancy, insertion of IUD
38
Q

Describe the clinical features of PID

A
  • lower abdo pain
  • deep dyspareunia
  • menstrual abnormalities (menorrhagia, dysmenorrhoea, intermenstrual bleeding)
  • post coital bleeding
  • dysuria
  • abnormal vaginal discharge
  • fever and n+v if advanced
  • uterine tenderness
  • cervical excitation
  • may have palpable mass in lower abdomen
39
Q

How should suspected PID be investigated?

A
  • endocervical swab for chlamydia and gonorrhea
  • high vaginal swab for trichomonas vaginalis and bacterial vaginosis
  • full STI screen
  • urine dipstick and MSU
  • pregnancy test (exclude differentials)
  • transvaginal USS if severe or diagnostic uncertainty
  • laparoscopy (to obtain peritoneal biopsy and observe inflammation, only used if severe or uncertain)
40
Q

How is PID managed?

A
  • 14 days broad spectrum abx- IM ceftriaxone single dose then PO doxy and metronidazole for 14 days or IV cef + IV doxy + PO metronidazole then metronidazole for 14 days after discharge if in pt start before swab results
  • paracetamol
  • bed rest
  • avoid sexual intercourse until abx finished and partner treated
  • test all partners from last 6 months
  • follow up after 2-3 days and again after 2 weeks
    Admit if:
  • pregnant and risk of ectopic
  • severe symptoms eg N+V, fever
  • pelvic peritonitis/ tuboovarian abcess signs
  • unresponsive to, or unable to take oral abx
  • need for surgery or suspicious of alternative diagnosis
  • concern for non adherance
41
Q

List 4 complications of PID

A
  • infertility
  • fitz- hugh curtis syndrome (perihepatitis which causes RUQ pain)
  • tubo- ovarian abscess
  • chronic pelvic pain
  • ectopic pregnancy (due to narrowing and scarring of fallopian tubes)
  • peritonitis
  • intestinal obstruction (adhesions)
  • DIC
    I FACE PID
42
Q

What are the different serotypes of chlamydia?

A

A-C cause ocular infection
D-K cause gentiourinary infections
L1-L3 cause lymphogranula venerum, a new infection in MSM resulting in proctitis

43
Q

How may chlamydia present?

A
  • asymptomatic in 50% men and 70% women
  • W: dysuria, abdo discharge, deep dysparenuia, intermenstrual or post coital bleeding, lower abdo pain, cervisitis, mucopurulent endoervical discharge, cervical excitation
  • M: urethritis, epididymo-orchitis, testicular tenderness, mucopurulent discharge
44
Q

How is chlamydia diagnosed?

A
  • NAAT of swabs
  • women: vulvo vaginal is first choice, then do endocervical swab or first catch urine sample
  • men: first catch urine sample or urethral swab
  • swabs may be taken from rectum, eyes and throat if indicated
  • if positive they need contract tracing
  • full STI screen also reccommended due to possibility of co infection
45
Q

How is chlamydia managed?

A
  • doxy 100mg BD for 7 days or azithromycin 1g single dose
  • if contra indicated then erythromycin or oflaxacin can be used
  • avoid sex for have been completed treatment
  • test of cure not needed unless pregnant, compliance poor, symptoms persist
  • if age <25, repeat is recommended after 3 months
46
Q

give 4 complications of chlamdyia

A
  • PID, ectopics, infertility in women
  • epididmyo- orchitis, infertility in men
  • reactive arthritis, more common in men
47
Q

How should chlamydia be managed in pregnancy?

A
  • associated with prem and low birth weight

- azithromycin and erythromycin to be used as doxy and ofloxacin are contraindicated

48
Q

Describe the clinical features of gonorrhoea

A
  • 50% asymptomatic
  • symptoms usually develop within 2-5 days
  • F: altered vaginal discharge, dysuria, dyspareunia, lower abdo pain, intermenstrual and/ or post coital bleeding
  • F signs: mucopurulent endocervical discharge, easily induced cervical bleeding, pelvic tenderness
    M: mucopurulent/ purulent urethral discharge, dysuria, epididymal tenderness
  • rectal infections usually asymptomatic, anal discharge, anal pain/ discomfort
  • 90% pharyngeal infections are asymptomatic
49
Q

How should gonnorhoea infections be investigated?

A

F: endocervical/ vaginal swab for NAAT (for chlamydia) and microscopy and culture (for gonorrhoea)
M: first pass urine for NAAT and urethral/ meatal swab for M&C
- swabs for both from rectum, throat and eye if indicated

50
Q

how is gonorrhoea managed and what are the possible complications?

A
  • single dose 1g IM ceftriaxone (will also treat coexisting chlamydia infection)
  • educate about safer sex
  • abstain from sex until both partners treated
  • admit to hopsital if signs of systemic infection (DGI) of severe or complicated PID
  • treatment is the same in pregnancy- neonatal gonorrhoea an lead to long term eye damage and blindness
  • test of cure is recommended in follow up appt
  • complicatons: PID, epididymyo- orchitis, prostatitis, disseminated gonoccocal infection (uncommon but get joint pain and skin lesions)
51
Q

Describe the pathophysiology of HIV

A
  • single strand RNA retrovirus
  • infects CD4 (t helper) cells
  • viral RNA convered to dsDNA by reverse transciptase
  • viral DNA incorperated into cell DNA by integrase
  • cell creates more viral RNA, reproducing the virus and destroying the cell in the process
  • seroconversion (making anti HIV antibodies during primary infection) may cause flu like symptoms, then the CD4 levels fall over the next months to years and they become more susceptible to infections
  • transmission is by: unprotected vag, anal or oral sex, sharing needles, medical procedures eg blood products, skin grafts, organ donation and vertical transmission from mother to baby during childbirth of feeding
52
Q

Which groups are at highest risk of HIV infection in the UK

A
  • MSM
  • IVDU
  • those in high prevalence areas (london and north west)
  • those who have unprotected sex with a partner who has lived or travelled in africa
53
Q

Describe the seroconversion illness and symptomatic HIV?

A 
Seroconversion illness:
- 2-6 weeks after infection
- fever
- muscle aches
- malaise
- Lymphadenopathy
- maculopapular rash
- pharyngitis
Symptomatic HIV:
- weight loss
- high tempreatures 
- diarrhoea
- frequent minor infections eg herpes zoster or candidiasisi
54
Q

What are the AIDS defining illnesses?

A
  • pneumocystitis jiroveci or carinii pneumonia
  • non hodkins lymphoma
  • TB
  • kaposi sarcoma
  • disseminated or extrapulmonary mycobacterium infections
  • CMV infection anywhere except liver, spleen or glands
  • extrapulmonary cryptococcus
55
Q

How is HIV diagnosed?

A
  • fourth generation tests first line: ELISAs that test for serum or salivary HIV antibodies and p24 antigen, they normally give reliable results 4-6 weeks after exposure
  • other rapid tests can give results in 30 mins, home sampling kits are available, however less accuate and still need ELISA to confirm if positive
56
Q

how should HIV be managed?

A
  • Highly active antiretrovial therapy (HAART)- aim to reduce viral load to undetectable levels rather than cure, but if this is acheived LE is normal and onward transmission rates are very low
  • number of classes of drugs eg nuceloside and non- nucleoside reverse transcriptase inhibitors, protease inhibitors and integrase strans transfer inhibitors are used to target the enzymes used in replication and maturation
  • eg atripla is tenofovir + emtricitabine + efavirenz
  • they need regular monitoring of: CD4 count, HIV viral load, FBC, U+E urinalysis, LFT, pregnancy tests
57
Q

What is the PEP for HIV

A
  • Must be commenced within 72 hrs of exposure

- one month course of truvada (one tablet daily) + raltegravir (one tablet BD)

58
Q

How can vertical HIV infection risk be reduced?

A
  • antenatal antiretroviral therapy
    during pregnancy and delivery
  • avoidance of breastfeeding
  • neonatal PEP
  • this all reduced transmission rates to <1%, without them, transmission rates are >25%
  • c section no longer routinely recommended if mother has undetectable viral load at delivery
59
Q

What are the most and lead risky HIV transmssion methods?

A
  • Blood transfusion and mother to child most risky
  • then receptive anal intercourse
  • then IV needle sharing
  • then percutaneous needle stick
  • then insertive anal
  • then vaginal intercourse
  • then oral (v low risk)
60
Q

What are the two types of herpes simplex virus

A

HSV-1: causes orofacial herpes and cold sores, can also cause genital herpes
HSV2: only causes genital herpes

61
Q

Describe the clinical features of herpes

A

Primary infection:
- small red blisters around genitals that are very painful and can form open sores
- vaginal or penile discharge
- flu like symptoms
- itchy genitals
- after around 20 days the lesions will crust and heal
Secondary infection:
- burning anf itching around genitals
- painful red blisters
- recurrent outbreaks generally get less frequent and severe over time
Cold sores:
- painful lesions around mouth and nose lasting 7-10 days
- lie dormant and get outbreaks like with genital herpes

62
Q

How is herpes diagnosed?

A
  • swab from open sore for HSV and PCR will differentiate from 1 or 2
  • if swab negative, diagnosis can still be made later on if flare ups persist
63
Q

how should herpes infections be treated (primary, recurrent and in pregnancy)

A
  • Primary: Aciclovir can be given to reduce size and number of lesions, avoid all sexual contact during outbreak, offer full STI screen
  • Secondary: OTC painkillers, petroleum jelly, ice packs should be used to reduce pain and discomfort. If episodes are regular than episodic treatment (take aciclovir as soon as symptoms begin) is recommended. If outbreaks more then 6x per year or very severe then suppressive treatment is recommended (daily aciclovir)
  • if get herpes during pregnancy = recommend c section (no antibodies to baby so vag delivery transmission is 40%)
  • If herpes then pregnant= offer c section but transmission rate only 1-3%, she may be required to take aciclovir
64
Q

What causes genital warts

A
  • HPV6 and 11 responsible for 90%
  • spread through skin to skin contact
  • virus penetrates epithelial barrier, infects basal keratinocytes and causes rapid growth manifesting as lesions
  • HPV 16 and 18 are the types that result in pre cancerous lesions
65
Q

Describe the clinical features of genital warts

A
  • most HPV infections are actually asymptomatic and resolve spontaneously
  • warts are soft or hard, fleshy, painless and singular or multiple. Occasionaly they can cause irritation and become inflamed.
  • warts can grow on penis, scrotum, vulva, inside vagina, cervix, perianal skin or inside the anus
  • can grow weeks, months or years after initial infection
66
Q

How should diagnosis of genital warts be made?

A
  • usually made on basis of examination only
  • biopsy for atypical lesions
  • if add acetic acid the lesion should turn whitish, if not it is more likely to be vestibular papillomatosis
67
Q

How should genital warts be treated?

A
  • topical treatments: podophyllotoxin (for culsters of small, non keratinised warts), imiquimod (larger, keratinised warts). Contraindicated in pregnancy and breast feeding, cause local inflammation, may weaken latex condoms)
  • Physical ablation (used in pregnancy): excision if pedunculated/ large warts or accessible small hard warts, cryotherapy if multiple and small, electrosurgery for large warts, laser surgery if difficult to access
  • change in therapy recommended if <50% response to treatment after 4-5 weeks (12 for imiquimod)
  • since 2012 the vaccine protects against HPV 16,18,6 and 11
  • transmission during childbirth is rare but can lead to respiratory papillomatosis
68
Q

what causes syphillis and what is the pathophysiology of the infection?

A
  • treponema pallidium
  • can enter through breaks in skin or intact mucous membranes
  • bacteria divides and infectious hard ulcer (chancre) forms at site of contact after incubation period of 2-3 weeks
  • if untreated, the bacteria perists and causes systemic damage by obliterating arteritis - endothelial cells of vessles excessively proliferate causing lumen to be narrowed, this results in ischaemia and symptoms of syphillis
69
Q

Describe the clinical features of primary and secondary syphillis?

A

Early (2 yrs since infection)
- primary: papule will appear before ulcerating into a chancre (painless, usually singular, hard and non itchy), generally these heal within 3-10 weeks
Secondary:
- skin rash (hands and soles of feet, non itchy or painful)
- fever
- malaise
- arthralgia
- weight loss
- headaches
- codylomata lata (elevated plaques liek warts at moist areas of skin)
- painless lymphadenopathy
- silvery- grey mucous membrane lesions
- may also manifest as disease affecting kindeys, liver and brain
- after secondary syphilis it enters a latent phase

70
Q

Describe the clinical feature of tertiary syphilis

A

Gummatous syph:
- granulomas form in skin, bone, mucous membranes, connective tissue
Neurosyph:
- tabes dorsalis: ataxia, numb legs, asbence of deep tendon reflexed, lightning pains, loss of pain and temp sensation, skin and joint damage
- dementia
- CN palsies, stroke, cerebral gummas
- argyll robertson pupil (constricted and unreactive but reacts to accomodation)
Cardiosphy:
- aortic regurg due to aortic vasculitits and root dilation
- angina due to stenosis of coronary ostia
- dilation and calcification of ascending aorta

71
Q

how should syphillis be diagnosed?

A
  • dark feild microscopy of chancre fluid detects spirochaete in primary syphillis
  • PCR tests of swabs from active lesions
  • serology: treponemal ELISA , TPPA or TPHA (both remain +ve for life)
  • LP: CSF antibody test in neurosyphilis
72
Q

How is syphilis managed?

A
  • Early: Benzathine penacillin IM single dose
  • later: Benzathine penilicin IM once weekly x 3
  • Neuro: procaine penicillin IM plus probenecide PO or benzylpenicillin IV for 14 days
  • avoid sexual contact
  • screen for other STIs
  • contact tracing
  • pt education
  • f/u serology to determine response to treatment
  • if allergic to penicillin, consider desensitisation
  • jarisch herxheimer reaction is inflammatory response to treponemes death causing flu like illness, give steroids before abx if neuro or cardio syph to avoid this
  • screened for at start of pregnancy, treat if found as congenital syph causes abnormalities such and increases risk stillbirth, miscarriage etc
73
Q

What type of organism is trichomonas vaginalis?

A
  • anaerbic flagellated protozoan
74
Q

Describe the clinical features of trichomonas vaginalis?

A 
Female:
- offensive vaginal odour
- abnormal vaginal discharge (thin, yellow- green, throthy)
- itchiness/ soreness of vulva
- dysparenuria
- dysuria 
- vulvitis
- vaginitis
- strawberry cervix- punctate and papilliform appearance 
Male:
- urethral discharge
- dysuria
- urinary frequency
- pain or itching around foreskin
- balanoposthitis (inflammation of the glans penis)
75
Q

how is trichomonas vaginalis diagnosed?

A
  • high vaginal swab from posterior fornix during examination or self administered vaginal swab
  • males get urethral swab or first void urine sample
76
Q

how is trichomonas vaginalis managed? (and how managed in pregnancy)

A
  • metronidazole 2g single dose or 500mg BD 5-7 days (tinidazole is alternative)
  • contact tracing and testing of all partners from up to 4 weeks prior
  • abstain from sex until fully treated or 1 week after single dose
  • test of cure not necessary unless non responding or re infected
  • if pregnant there is risk of LBW or prem and may predispose to post partum sepsis, treat same as non pregnant but dont use high dose regime. metronidazole can affect taste of breast milk so dont use high dose here either or dont breast feed until 24hrs after single dose
  • treat male partners empirically
77
Q

What is the difference between primary and secondary infertility?

A

1- lack of conception after 1 yr regular sex, no baby before

2- same but after already had kid before

78
Q

What causes infertility?

A
  • ovulation defects (PCOS, age related, high or low BMI, premature ovarian failure, RT related, hyperprolactinaemia)
  • male factors (smoking, alcohol, infections, varicocele)
  • tubual disease (PID, pelvic surgery, endometroisis)
  • unexplained
  • endometriosis and uterine factors can also influence it
79
Q

What investigations are needed for M and F infertility?

A

F: LH, FSH, luteal phase oestrogen, rubella status, tests of tubal patency, cervical screening, STI, pelvic USS, prolactin, TFTs, testosterone levels, SHBG, HIV test
M: semen analysis (>1.5ml, ph >7.2, >15million/ ml, >58% live sperm), FSH, LH, testosterone, USS,

80
Q

What tests are for tubal patency?

A
  • hysterosalpinography

- diagnostic laparoscopy and dye

81
Q

How is anovulation treated?

A
  • clomiphamine citrate
  • dopamine agonists
  • pulsatile gnrh analogues
  • weight loss
82
Q

How is poor tubual patency managed?

A
  • surgery

- IVF (more common)

83
Q

What needs to be assesed in lifestyle history of infertility presenatation?

A
  • smoking- affect M and F
  • alcohol- no more than 14 units for man and 1-2 units and avoid getting drunk for women
  • drugs
  • folic acid- women should take while trying to conceive and 1st trimester
  • BMI- >19
  • as well as PMH, PSH, sexual history, menstrual history, obstetric history and familly histroy
84
Q

What screen tests are done at sexual health clinics for symptomatic and asymptmatic females?

A

asymptomatic: self taken vulo- vaginal swab for GC and CT dual NAAT, bloods for HIV, Hep B/C and urinalysis and pregnancy test if appropriate
Symptomatic: as above + high vaginal swab for microscopy and pH testing for TV, BV and candida +/- pharyngeal and rectal swabs for GC, CT NAAT culture and dark ground microscopy for spyhillis, herpes PCR, urinalysis and pregnancy test

85
Q

What screening tests are done at sexual health clinics for symptomatic and asymptomatic males?

A

Asymptomatic: first pass urine for GC and CT dual NAATs, rectal and pharyngeal swabs if MSM and bloods for HIV, syphilis, hep B and C
Symptomatic: as above plus urethral smear (for GC and non gonococcus), GC culture and sensitivities, dark ground microscopy for syphilis, herpes simplex PCR, urinalysis)

Y4 ObGyn (8 decks)

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