Sexual health Flashcards
Female infertility
Infertility means not being able to get pregnant after at least one year of trying (or 6 months if the woman is over age 35). If a woman keeps having miscarriages, it is also called infertility.
C: Hypothalamic pituitary failure, hypothalamic-pituitary-ovarian dysfunction due to PCOS, pituitary tumours, hyperprolactinaemia, Cushing’s disease, premature menopause, PID, STIs, female sterilisation, deformity in uterus, fibroids, endometriosis.
S: Unable to get pregnant, frequent miscarriages.
D: Mid-luteal progesterone level, FSH, LH, A hysterosalpingogram (HSG) or a hysterosalpingo-contrast ultrasound, STI screen, laproscopy.
T: Hypothalamic pituitary failure - pulsatile administration of gonadotrophin-releasing hormone or gonadotrophins with luteinising hormone activity.
Clomifene citrate for PCOS. Tubal and uterine surgery. Ovarian hyperstimulation - CC, anastrozole and letrozole. Assisted conception.
HIV
Human immunodeficiency virus (HIV) is a lentivirus from the subfamily of retroviruses.
C: HIV binds to CD4 receptors on helper T-lymphocytes, monocytes, macrophages and neural cells and impairs their function
S: 1-6 weeks fever, malaise, myalgia, pharyngitis, headaches, diarrhoea, neuralgia or neuropathy, lymphadenopathy and/or a maculopapular rash.
May be asymptomatic for a long time.
Prodrome to AIDS - fever, night sweats, diarrhoea, weight loss. AIDS - serious opportunistic infections or diseases.
D: ELISA/Western blot for HIV antibody, HIV RNA or branched DNA (bDNA) assay, FBC, ESR, STI infection, infection screen. CD4 count and viral load monitoring.
T: Patient education. Post-exposure prophylaxis after occupational and sexual exposure also helps to limit HIV spread.
ART - usually used in combination of 3 different drugs.
Nucleoside/tide reverse transcriptase inhibitors (NRTIs).
Non-nucleoside reverse transcriptase inhibitors (NNRTIs).
Protease inhibitors (PIs).
Integrase inhibitors (IIs).
Entry inhibitors (EIs).
Human papillomavirus
A viral infection that’s passed between people through skin-to-skin contact. Over 100 varieties.
C: Usually spread through direct sexual contact, including vaginal, anal, and oral sex. Can be spread from mother to baby during delivery.
S: Asymptomatic. Warts in the throat (known as recurrent respiratory papillomatosis). Genital warts.
D: Women - smear test, HPV test, colposcopy
Men - anal smear test
T: May just resolve on their own. Repeat testing is recommended. Routine screening for HPV and cervical cancer. Genital warts can be treated with prescription medications, burning with an electrical current, or freezing with liquid nitrogen.
Syphilis
Venereal syphilis is a contagious, systemic disease
C: Treponema pallidum enters via abraded skin or intact mucous membrane and distributes via the bloodstream and lymphatics.
S: Small, painless papule that rapidly forms an ulcer. Usually found on coronary sulcus, the glans and inner surface of the prepuce in men and the vulva, labia and, much less frequently, on the cervix in women. Enlarged regional lymph nodes. Systemic symptoms are mild or absent but include night-time headaches, malaise, slight fever and aches. Generalised polymorphic rash often affects the palms, soles and face. May have neurological or cardiovascular complications.
D: STI screen. An EIA/CLIA, preferably detecting both IgM and IgG. Venereal disease reference laboratory (VDRL) or rapid plasmin reagin (RPR).
T: Primary, secondary, early latent syphilis: benzathine penicillin IM. Oral azithromycin is second-line. Neurosyphilis: procaine penicillin IM with oral probenecid.
Gonorrhoea
Neisseria gonorrhoeae is a Gram-negative diplococcus infecting mucous membranes of the urethra, endocervix, rectum, pharynx and conjunctiva.
C: Transmission occurs by the direct inoculation of infected secretions from one mucous membrane to another, usually sexually and, less commonly, perinatally.
Risk factors - young, previous STI, current STI, multiple partners, sexual activity abroad, commercial sex work.
S: Men - discharge, dysuria, pruritus or bleeding, pharyngeal infection.
Women - discharge, low abdo pain, dysuria without frequency.
May be asymptomatic.
D: Culture samples - invasive (e.g., urethral, endocervical) and non-invasive (e.g., first pass urine). STI screen.
T: Partner notification, abstain from unprotected sex.
Uncomplicated - ceftriaxone 500 mg IM stat plus azithromycin 1 g orally stat.
A test of cure (with culture >72 hours or with NAAT >2 weeks following antibiotic treatment).
Pharyngeal infection: Ceftriaxone 500 mg IM with azithromycin 1 g orally as a single dose.
PID - Ceftriaxone followed by oral or IV erythromycin plus metronidazole.
Chlamydia
Chlamydiae are Gram-negative bacteria that infect human epithelium.
Can cause infection in eyes, genitourinary, arthritis.
C: Risk factors - Young, multiple partners, change in partners, non-barrier contraception, other STI, poor socio-economic status, genetic predisposition.
S: Women - discharge, dysuria, lower abdo pain, fever, abnormal bleeding, inflammed cervix.
Men - Urethritis, dysuria, discharge, epididymo-orchitis, fever.
D: NAATs fr chlamydia.
In women, a vulvovaginal swab, in men, a first catch urine specimen, and a urethral swab may also be taken.
T: Doxycycline 100 mg twice-daily for seven days (contra-indicated in pregnancy); OR
A single dose of 1 g of azithromycin.
Alternatively, Erythromycin 500 mg twice-daily for ten to fourteen days.
Ofloxacin 200 mg twice-daily or 400 mg once-daily for seven days.
Partner notification and abstaining from sex.
Sexual Assault
Rape: is defined as the penetration of the vagina, anus or mouth by a penis, without consent. Both men and women can be raped.
Assault by penetration: is the penetration of the vagina or anus with an object or body part, without consent.
Sexual assault: rape or assault by penetration including attempts are ‘serious’; indecent exposure or unwanted touching are ‘less serious’.
Risk factors: childhood abuse, young, people with disabilities, homeless people, sex workers, prisoners, military.
T: Listen and offer help. Encourage them to talk to the police. Need for emergency contraception. STI screen. PEPSE (post-exposure prophylaxis following sexual exposure) if HIV risk. Treatment for PTSD.
Female sexual dysfunction
A subjective dissatisfaction, leading to significant distress, with the level or nature of sexual activity. Includes female orgasmic disorder, genito-pelvic pain/penetration disorder or sexual interest/arousal disorder.
C: Androgen deficiency or oestrogen insufficiency, thyroid disease, diabetes mellitus, Addison’s disease, PCOS, pregnancy, postpartum, pelvic surgery, spinal cord lesions, psychological, chronic pain, musculogenic factors, ageing, medication.
S: Pain, psychological - relationship difficulties, expectations, previous abuse, prolapse, vaginal atrophy or scarring from episiotomy repair, or evidence of vaginismus.
D: Genital examination
Blood tests - FBC, lipid profiles, renal and liver function, blood glucose and TFTs
FSH, LH, oestrogens and testosterone levels
T: Relationship counselling, CBT, Oestrogens are available as oral tablets, dermal patches, vaginal pessaries, implants, creams and jellies. Tibolone (2.5 mg) treatment especially in postmenopausal women. Testosterone for sexual interest/arousal disorder. Phentolamine and yohimbine are vasodilators may be used.
Male infertility
Infertility means not being able to get pregnant after at least one year of trying.
C: Obesity, smoking, alcohol, medication, drugs, tight-fitting underwear,
Cryptorchidism, Varicocele, trauma, pituitary tumours, hyperprolactinaemia, Cushing’s disease, erectile dysfunction, congenital abnormalities, genetic disorders.
S: Unable to conceive, haematospermia, urinary irritability, obstructive urinary symptoms, painful ejaculation, and hot flushes, psychosexual aspects.
D: Semen and sperm analysis, FSH levels, testosterone levels, genetic testing, ultrasound.
T: Obstructive azoospermia - surgical correction of epididymal blockage.
Donor sperm.
Hypogonadotrophic hypogonadism - gonadotrophins.
Erectile dysfunction
It is the inability to attain and maintain an erection sufficient for satisfactory sexual performance.
C: Vascular (HTN, DM, smoking, atherosclerosis), CNS (Parkinson’s, brain or spinal cord injury), PNS (peripheral neuropathy, alcholism, DM, surgery), hormonal (hypogonadism, hyperprolactinaemia, thyroid disease, Cushing’s disease), penile abnormalities, medication, psychosexual.
S: Sudden onset, early collapse of erection, premature ejaculation or inability to ejaculate, psychological changes.
OR gradual onset, normal ejaculation, normal libido but previous surgery, radiotherapy or trauma.
D: Fasting glucose or HbA1c, morning sample of total testosterone, FSH, LH, Nocturnal penile tumescence and rigidity studies, vascular/endocrine/neuro investigations.
T: Lifestyle changes - stop smoking, lose weight, increase physical exercise.
1st line - Phosphodiesterase inhibitors (sildenafil, tadalafil, vardenafil and avanafil).
Vacuum device.
2nd line - Intraurethral alprostadil (prostaglandin E1). Topical alprostadil (prostaglandin E1). Intracavernosal alprostadil (prostaglandin E1).
3rd line - Penile prosthesis
Combined oral contraceptive pill
Combined oral contraceptive pill - synthetic oesotrogen and progesterone.
Suppress the secretion of FSH and LH, thicken cervical mucus, reduces endometrial receptivity.
Benefits: easy to reverse, effective, can relieve menstrual problems, can reduce risk of ovarian cysts, ovarian cancer and endometrial cancer.
Problems: Breakthrough bleeding, breast tenderness, mood swings, increased risk of venous thromboembolism, MI, stroke, breast and cervical cancer.
Progesterone-only contraceptive pill
A synthetic progesterone.
Acts to delay the transport of the ovum, thicken the cervical mucus and reduce endometrial receptivity.
Benefits: effective, easy to reverse, avoids cardiovascular risks, can be used during breastfeeding, can be used in women up to 55.
Problems: Breakthrough bleeding/amenorrhoea, must be taken at the same time every day, increased risk of ovarian cysts, if pregnancy does occur it may be ectopic.
Progesterone-only injections
A synthetic progesterone, or progestogen, is slowly released into the systemic circulation following intramuscular or subcutaneous injection.
Acts to suppress ovulation, thicken the cervical mucus and make the endometrium less receptive.
Benefits: very effective and convenient, can be used during breast-feeding, amenorrhoea is common.
Problems: not quickly reversible (1 year to return to baseline fertility), irregular bleeding, small loss of bone density, weight gain, possible increased risk of breast cancer.
Progesterone-only subdermal implant
The progestogen-only subdermal implant (POSDI) is a long-acting reversible contraceptive. Etonogestrel (a progestogen) contained in a rod is released slowly into the systemic circulation following subdermal insertion in the upper arm.
Acts to inhibit ovulation, thicken the cervical mucus and thin the endometrium, reducing receptivity.
Benefits: highly effective, long duration of action, reversible, convenient, reduction in menstrual problems.
Problems: irregular bleeding in the first year, changes in weight, mood and libido.
Intrauterine contraceptive device
The most effective devices are T-shaped, with 380 mm2 of copper, and additional copper bands on the transverse arms.
IUCDs have a monofilament thread to permit checking of presence and to allow removal.
Acts to kill sperm before they reach the ovum, as well as thickening the cervical mucus and increasing endometrial inflammation leading to an anti-implantation impact.
Benefits: effective, reversible, convenient, no hormones involved, effective for up to 10 years, reduces risk of endometrial cancer.
Problems: insertion may be unpleasant, spotting and bleeding, pelvic pain, displacement or expulsion, increased risk of PID, uterine perforation or ectopic pregnancy.
