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GOSH > Sexual Health & Contraception > Flashcards

Sexual Health & Contraception Flashcards

1
Q

What is UKMEC

A 
Risk score 
1- Always use
2- Advantages>Risks
3- Risks> Advantages so Consider other
4- Unacceptable health risk
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2
Q

Examples of Combined contraception

A

Pills- Microgynon, Yasmin, Glaira
Evra patch
NuvaRing (Vaginal ring)

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3
Q

Mechanism of Action of combined contraceptive devices

A

Stops ovulation and increases cervical mucus

Also thin endothelium

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4
Q

Absolute CI to Combined contraception

A

Smoker >35 yrs, <6/52 post partum, breast feeding, HTN, Hx VTE, Migraine with Aura, CVD, Current Breast Ca, Liver cirrhosis

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5
Q

Relative CI TO combined contraception

A

Controlled HTN, Migraine >35, FHx VTE, BMI>35, Enzyme inducing meds

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6
Q

Treatment course for combined contraception

A

Pill- 3 weeks on, 1 week off
Patch- Change weekly and 1 patch free week per month
Ring- Leave in for 3 weeks then 1 ring free week

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7
Q

Advantages of COCP

A

Controls bleeding and pain (spotting 1st few months)

Protective vs Ovarian and endometrial cancer and CRC

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8
Q

What are ‘Hormonal Side effects’? Which contraception causes these?

A

Wx inc, Acne, Mood change, Headache

COCP. POP, Implant, Injection,

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9
Q

Risks associated with the COCP

A

Breast and cervical cancer
Blood clots
Decreased lamotrigine efficacy

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10
Q

What problems can the Combined ring cause? How do you alleviate this problem?

A

Discomfort during intercourse

Removal for a max of 3 hours to alleviate this

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11
Q

When is a COCP defined as ‘missed?

A

> 24 hours late

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12
Q

Advice for a missed COCP?
1st week
2nd week
3rd week

A

Take ASAP even if with the next one.
If you miss 2 then take one immediately and use condom for 7/7 +/-
1st= EC (Or if sex in pill-free interval)
2nd= No action
3rd= Omit pill free week

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13
Q

What is the 7 day condom rule for COCP?

A

D&V, Enzyme inducing drugs

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14
Q

What contraception should be stopped 4 weeks before surgery?

A

Any oestrogen containing

Swap to POP

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15
Q

Key enzyme inducers

A 
CRAPS
CBZ, 
Rifampicin 
bArbituates
Phenytoin 
St John's wart
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16
Q

Examples of POPs with 3 hour and 12 hour windows

A 
3= Micronor, Noriday, Norgestron, Femulemn
12= Cerazette, Desogestrel
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17
Q

MoA of POP

A

Increases cervical mucus, This endothelium

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18
Q

CI to POP

A

Forgetfullness
Breast cancer
Undiagnosed PV bleeding
Liver disease

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19
Q

Treatment course of PoP

A

Daily at same time

No pill free interval

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20
Q

Which contraception devices are progesterone based?

A

POP
Injection
Implant
IUS

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21
Q

Main SE of POP

A

Hormonal SE

Irregular bleeding possible

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22
Q

Rules for a missed PoP

A

Take ASAP even if with next one
If outside the defined window (>3 or >12 hrs depending on type) then condom for 2/7
EC if 2-3 days before missed pill or had sex since missed

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23
Q

Most effective form of contraception

A

Implant

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24
Q

How does the IUD work?

A

Spermicide

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25
Q

CI for any form of Intrauterine contraception

A 
Pelvic infection
PID <3/12 ago
Gynae cancer
UnDx PV bleeding
Copper allergy (IUD)
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26
Q

How long does the IUD last?

A

5-10 years

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27
Q

What are the risks of coil insertion?

A 
Infection risk in first 3/52
Bleeding
1/1000 Perforate 
5% Expulsion 
Vasovagal 1/10
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28
Q

Aside from the risks of coil insertion, What is a major SE of the IUD

A

Heavier more painful periods (UNLIKE IUS)

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29
Q

After what age can the IUD stay in until the menopause?

A

> 40

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30
Q

What must be done before an IUD/IUS insertion? When in relation to a period can they be inserted?

A

STI check

Not had sex since period or first 5 days of period

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31
Q

When after insertion can an IUS be relied upon?

A

7/7

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32
Q

How does an IUS work?

A

Stops ovulation
Thins endothelium
Increases cervical mucus

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33
Q

Advantages of IUS

A

Periods become lighter therefore good for menorrhagia

There is spotting in the first 6 /12 though

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34
Q

CI to Implant/Injection

A

Breast/Liver/Genital cancer
Undiagnosed PV bleeding
Enzyme inducers (implant only)

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35
Q

Which contraceptive device is no affected by enzyme inducers?

A

Injection

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36
Q

Trade name of the implant and injection

A

Implant= Implanon/Nexplanon

Injection- Depo-Provera

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37
Q

How do the Implantant and injection work?

A

Stops ovulation, Thins endo, Cervical mucus

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38
Q

How long does the IUS last? When can is stay in indefinitely until the menopause?

A

3-5 years

> 45YRS

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39
Q

How long does the implant last?

A

3 years

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40
Q

How long does the injection last?

A

3/12

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41
Q

Risks/SE of implant

A

Hormonal SE
Insertion risks- Bruising, Expulsion, Scarring, Infection
Periods may become irregular and longer!

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42
Q

Risks/SE of Injection

A 
WEIGHT GAIN
Irregular/Longer periods (70% amenorrhoea though)
Hormonal SE
Osteoporosis 
Can take 12/12 for fertility to return
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43
Q

Given the Osteoporosis risk for the Injection, after what time period would you stop it?

A

> 5 yrs Stop

>2yrs ?stop

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44
Q

How long must you use condoms after an injection or implant is given?

A

7/7

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45
Q

What cancers is COCP protective against?

A

Endometrial, Ovarian and CRC

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46
Q

What cancers does the COCP increase your risk of?

A

Breast, Cervical

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47
Q

What age group is the IUD UKMEC2 for?

A

Women <20 years

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48
Q

When is the diaphragm used? How does it work?

A

Only when having sex

Laced with a spermicide

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49
Q

Failure rate for tubal ligation and vasectomy?

A

Tubal ligation - 1/200

Vasectomy- 1/2000

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50
Q

Which method of sterilisation is safer?

A

Vasectomy (Simpler, done under LA)

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51
Q

What does tubal ligation increase your risk of?

A

Ectopic pregnancy (Only small increase)

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52
Q

Main risks of a vasectomy?

A

Bruising, Haemoatoma, Infection

Some have ongoing testicular pain

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53
Q

How does tubal ligation affect the periods?

A

It doesn’t

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54
Q

The three types of EC

A

IUD- BEST
Ella One (Ulipristal)
Levonelle (Levonorgestrel)

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55
Q

How does Ella One work?

A

Selective progesterone modulator 90% effectuve

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56
Q

When can the three types of EC be used?

A

IUD/Ella One- within 5/7 of unprotected sex or earliest likely calculated ovulation
Levonelle- 72 hours of unprotected sex

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57
Q

How do Ella One and Levonelle work?

A

Delays or prevents ovulation and implantation

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58
Q

CI to Ella One

A

Been on Hormonal contraception 5/7 before
Severe Asthma/Liver disease
Enzyme inducers (CRAPS)
Caution if previous use in this cycle…

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59
Q

CI to Levonorgestrel

A 
Porphyria 
Enzyme inducers (CRAPS)
BMI >26 (Need in double dose)
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60
Q

Which EC can you double the dose of?

A

Levonorgestrel (Levonelle)

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61
Q

Does an IUD increase the risk of an ectopic?

A

No because less likely to get pregnant

But if you do get pregnant the risk is higher than someone not using an IUD

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62
Q

SE of Ella One and Levonorgestrel

A

PV bleeding, N&V, Headache, Breast/Pelvic pain

ELLA ONE DECREASES THE Effectiveness of hormonal contraception

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63
Q

After an ELLA ONE when is the right time to restart hormonal contraception

A

5/7

Use barrier methods inbetween

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64
Q

Advice to patient given Ella One/Levonorgestrel

A

Vomit within 2-3 hours= Repeat dose with domperidone
Abstain until PV bleeding gone or after 7/7 COCP/ or 2/7 POP
7/7 Breastfeeding delay

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65
Q

If IUD is used as EC when can it be removed?

A

Option for long term

4 weeks if not; check up at 6 weeks

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66
Q

When is the earliest point of implantation?

A

D6-12 Post fertilisation therefore aim to give EC by D5 post-intercourse
(D21 if post-childbirth, D5 post-abortion/miscarriage)

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67
Q

When is a woman most fertile?

A

D9-D14 of cycle

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68
Q

At what point is a PT most reliable after an episode of risk of pregnancy?

A

3/52

69
Q

Before what age can a person not consent to sex?

A

13

70
Q

Fraser guidelines for <16 years

A

Understands, Likely to Continue, Best interests to give without Parents’ consent, Health suffers without, Cannot be persuaded

71
Q

Most common type of STI

A

Chlamydia Trachomatis

72
Q

What is Chlamydia Trachomatis?

A

Intracellular G-ve

Hard to see on microscopy

73
Q

1st choice investigation for Chlamydia in Heterosexual Males and females

A 
Males= 1st Void urine NAAT 
Females= VVS NAAT
74
Q

Treatment of choice for Chlamydia?

A

Doxycycline 100mg PO BD 7/7

1g stat Azithromycin PO is an alternative esp. in pregnancy

75
Q

Advice to someone being treated for chlamydia/Gonorrhoea?

A

No sex 1/52 until they and partner finished
Contact tracing 4 weeks prior to symptoms (6/12 if asymptomatic)
“Test Then Treat”

76
Q

Complications of chlamydia trachomatis

A

PID
Ectopic pregnancy
Tibal infertility
FITZ-HUGH CURTIS SYNDROME (Perihepatitis)

77
Q

What is Lymphogranuloma venerum?

A

Serovar of chlamydia

78
Q

How does Lymphogranuloma venerum present (3 stages)?

A

S1- Painless pustule -> Ulcer
S2- Painful inguinal lymphadenopathy
S3- Proctocolitis ?Haemorrhaging

79
Q

What is Neisseria Gonorrhoea?

A

Intracellular Gram negative diplococci

80
Q

How do you investigate for Gonorrhoea in Heterosexual Males and Females?

A

Males= NAAT Urethral or 1st void urine
Females= VVS or EC NAAT
+/- Culture for gonorrhoea (Directly from Urethra or OS)
+/- Rectal or pharyngeal swabs

81
Q

Incubation time for Chlamydia?

A

1-3 weeks

Can be 2 week window period post-PSI where it may not be detected

82
Q

Treatment of Gonorrhoea?

A

Ceftriaxone 500mg IM and 1g Azithromycin oral stat

83
Q

What is the routine Sexual Health screen

A

NAAT for CT/NG

Serology for syphilis and HIV

84
Q

What are the long term complications of Gonorrhoea?

A

PID, Ectopics, Perihepatitis, Infertility, Chronic pain, Dyspareunia, Gonoccoccal arthritis

85
Q

What are the symptoms of a disseminated gonoccocal infection?

A

Tenosynovitis especially in the hand, Migratory polyarthritis, Maculopapular and vesicular dermatitis

86
Q

What is Trichomonas?

A

A Flagellated Protozoan

87
Q

How do you diagnose Trichomonas infection?

A

HVS from the posterior fornix

Can also do an endocervical swab

88
Q

What does the Charcoal HVS look for?

A

Trichomonas, BV, Candida

89
Q

What does trichomonas look like on microscopy?

A

Motile trophozites

90
Q

What is the PH of the culture in a trichomonas infection?

A

PH>4.5

91
Q

Treatment of trichomonas?

A

5-7 days of Metronidazole 400mg BD for both them and partner
Avoid sex 1/52

92
Q

Classic signs of a trichomonas infection?

A

Strawberry cervix
Symptoms not resposive to BV/Candida treatment
Frothy yellow Green discharge +/- Offensive
Vulvovaginitis
Dysuria

93
Q

What areas of the body does gonorrhoea commonly infect?

A

Vagina, cervix, Urethra, Rectum, Conjunctiva, Pharynx

94
Q

What is ‘3 site testing’?

A

MSM who present with urethritis/symptoms

This is 3 site NAAT and Culture

95
Q

Key symptoms to ask about in a Male sexual History?

A

Dysuria, Discharge, Testicular pain, Skin changes, Swelling, Rectal discharge, Blood, Bowel Habit, Tenesmus

96
Q

Investigations for urethritis in Males?

A

1st catch urine

NAAT and culture swab if discharge

97
Q

What is Acute- Epididymo-Orchitis?

A

Pain swelling ad inflammation involving the epididymis +/- Testes
Musts exclude torsion

98
Q

What investigations would you do if someone presented with Acute- Epididymo-Orchitis?

A 
Urethral culture
1st catch urine for NAAT
Dipstick and MSU
Mumps serology
Doppler
99
Q

Key symptoms to cover in a female sexual history?

A 
Urinary symptoms 
Vaginal discharge- Colour, Consistency, Odour, Amount
Bleeding-IMB, PCB
Dyspaerunia- Superficial or Deep
Skin changes
100
Q

What is thrush?

A

Fungal infection

Not an STI

101
Q

Key features of thrush?

A 
Curd white discharge
Superficial dyspareunia
Dysuria 
Itch
Skin changes- Excoriations, Erythema
102
Q

Risk factors for Thrush?

A

Abx use, pregnancy, COCP, DM, Anaemia, Immunosuppression

103
Q

Treatment of thrush

A

Clotrimazole Pessary 500mg or Fluconazole 150mg PO

104
Q

PH of culture in thrush?

A

<4.5

105
Q

PH of culture in BV?

A

> 4.5-<6

106
Q

What is BV?

A

Commonest cause of abnormal vaginal discharge in women of childbearing age, Not an STI
Anaerobic overgrowth decrease lactic acid production thereby increasing the PH of the vagina above 4.5

107
Q

Risk factors for BV

A

Receptive Cunnilingus, Douching, Black, Smoking, Change in sexual partner, STI

108
Q

What is the discharge typically described as in BV?

A

Offensive fish smelling thin watery discharge

109
Q

What symptoms does BV lack?

A

No soreness, No itching, No Irritation

110
Q

Diagnosis of BV

A

Microscopy after swab

Clue cells- Epithelial cells surrounded by lactobacilli

111
Q

How do you measure vaginal PH?

A

Swab from lateral Vaginal wall and roll over PH paper

112
Q

Causes of raised vaginal PH >4.5

A

Trichomonas and BV

113
Q

Advice/Management of BV

A

Avoid douching, antiseptic, bath products
5-7 day oral metronidazole or topical
50% relapse in 3 months

114
Q

Difference between Lichen sclerosis and Lichen Planus

A

L.Sclerosis- Loss of vulvovaginal architecture, itchy, sore, erosions and telangectasia, inc SCC risk

L.Planus- Itching is main symptoms, affects vulvovaginal, head, mouth

BOTH TREATED WITH TOPICAL STEROIDS LIKE CLOBETASOL or DERMOVATE

115
Q

For any Vulval presentation what investigations do you do?

A

Candida and BV HVS for culture
HSV/Syphilis PCR (swab or serology)
STI screen
Biopsy

116
Q

What causes superficial dyspareunia?

A

Candida, Lichen sclerosis, Eczema

PID/Endometriosis causes deep

117
Q

How do you treat scabies and Pthirs pubis

A

Permethrin 5%

118
Q

What is Lichen simplex?

A

Chronic rubbing leads to poorly demarcated plaques of thick skin or labia majora or scrotum

119
Q

Difference between HSVT1 and HSVT2?

A

HSVT1- Oral

HSVT2- Genital

120
Q

Gold standard Dx of HSV?

A

Viral PCR of vesicle fluid following skin swabs

121
Q

Symptoms of a Primary infection of HSV vs recurrence of HSV?

A

Primary= MOST SEVERE… Flu like, Lymphadenopathy, Small vulval painful vesicles, Discharge, Dysuria

Recurrence= Short, Less severe, triggered by sex/stress/Menstruation

122
Q

Treating HSV?

A

Saline baths, Lignocaine gel, Rest, analgesia

Aciclovir can be given to decrease the severity and duration of attacks if frequent exacerbations

123
Q

Risk of HSV transmission in pregnancy?

A

Low, Suppressive therapy if recurrent

124
Q

What are Genital warts?

A

Recurrent flare ups of HPV Types 6 +11 commonly

125
Q

Median incubation time of Genital warts?

A

3 months

126
Q

Presentation of genital warts?

A

Condulomata accuminata, local skin irritation, Fleshy painless lumps spread in lines of trauma
MOST ASYMPTOMATIC

127
Q

What must you check for if someone presents with Genital warts?

A

Another STI

128
Q

Advice to patient with warts

A

Majority clear within 1-2 years
VERY COMMON
Can try Podophyllotoxin or Imiquimod or Cryotherapy

129
Q

What is Mycoplasma Genitalium?

A

STI- Symptoms like NG/CT
Mostly resolves spontaneosuly
NAAT= Dx

130
Q

What is Molluscum Contagiosum? How do you treat it?

A

Pox virus sexually transmitted in young adults
Do routine STI screen
Clears on its own weeks-months

131
Q

What does Molluscum Contagiosum look like?

A

Central umbillication and pearly edge lesion

Smooth firm Dome shaped papules

132
Q

What is Syphilis?

A

Spirochaete- Treponema Pallidum

Presents 10-90 days post-infection

133
Q

Which demographic is very high risk of syphilis?

A

MSM 25-34yrs

30% co-infected with HIV

134
Q

What is primary syphilis?

A

Initial infection
Chancre- Indurated and painful +/- Multiple
-> It is raised, red and well demarcated
+/- Whole body rash +/- Inguinal lymphadenopathy
Resolution 3-8 weeks

135
Q

What is secondary syphilis?

A

Develops within the first 2 years of infection in 25% with syphilis
-Condylomata lata= Painless warty lesions
Hepatitis, Splenomegaly, Glomerulonephritis, Neurological involvement, Widespread rash

136
Q

What is teritary syphilis?

A

Typically seen in 40% of those infected for >2 years

  • Tabes Dorsalis (Locomotor ataxia) and Dementia
  • Aortic root dilatation and Ascending Aortic Aneurysm
  • Gummata
137
Q

How do you diagnose syphilis?

A

Serology blood test-,Treponemal Enzyme Immunoassay (EIA- IGM/G good one for primary), VDRL carbon Ag or RPR test
Smears can also be used from primary lesion using Dark Field Microscopy or PCR
(Permanently +ve once acquired)

138
Q

Treatment of syphilis?

A

Benzathine penicillin IM 3 weeks

Contact tracing and HIV testing

139
Q

What pregnancy issues does syphilis cause?

A

Preterm delivery, Still birth, Congential syphilis (Saddle nose, Blunted upper incisors, Wrinkling around mouth)

140
Q

What type of virus is HIV?

What immune cells are particularly affected?

A

Retrovirus

CD4+ cells

141
Q

What happens to the CD4+ count during HIV infection?

A

Steadily decreases over years

May be a transient rise after the primary infection

142
Q

What happens to the HV RNA copies during a HIV infection?

A

Rapid rise at initial infection over weeks
Then drops and plateaus
Years later will begin to rise again until death of infected person

143
Q

Who is tested for HIV?

A 
All patients with an STI
Sexual contact with Africa/Far East/Caribbean
IVDUS
MSM
Blood/Organ donation
Sexual assault
144
Q

What types of sex are highest risk (most to least)?

A

Receptive anal, Insertive anal, Receptive vaginal, Insertive vaginal

145
Q

What antigen is usually detectable before the HIV Ab?

A

P24 Ag

146
Q

What test is best to diagnose HIV; when can you use it?

A

4th generation Ab/Ag blood test
4 weeks and then confirm 3 months later
May still be -ve at 1-3 weeks post-incident but still do test anyway

147
Q

Timeline of a HIV infection post-exposure?

A 
Binding and integration at 3/7-5/7 
Seroconversion 3/52-12/52
Asymptomatic phase 5-10 years
Then constitutional symptoms 
AIDS arounds 8 years post-infection 
Death within 2 years of AIDS if untreated
148
Q

What symptoms may present during HIV seroconversion?

A

Flu-like
Maculopapular trunk rash
Ulceration
Rarely meningoencephalitis

149
Q

What is the window period for 3rd gen (just Ab) HIV test?

A

12 weeks (4th Gen is 4 weeks)

150
Q

How do you monitor HIV disease progression and treatment response?

A

Viral load

151
Q

In HIV what is the main indicator of risk of advanced disease

A

CD4+ count

152
Q

What does advanced HIV increase your risk of?

A

Opportunistic infectons
B-cell lymphoma
Morbidity and Mortality
Cannot really use IUD/IUS

153
Q

What drugs does HAART use?

A

3 different drugs from at least 2 classes

2x Nucleoside Reverse Transcriptase Inhibitors, Protease inhibitors, Non-nucleoside reverse transcriptase inhibitors

154
Q

Aim of HAART?

A

Undetectable viral load <50
Must be on it for 6/12; takes 1-6 months
At this point they cannot pass it on
CD4 count every 3-6 months

155
Q

What is Post-exposure HIV Prophylaxis (PEP)

A

Used when UPSI/Condom failure/High risk source in last 72 hours
Ideally used within 48 hours
28 day course

156
Q

What is given for occupational exposure to HIV?

A

Prompt HAART 28 days

Goal within 1 hour

157
Q

What is Pre-Exposure Prophylaxis?

A

Before during and after sex for HIV -ve people

158
Q

Advice for a HIV+ve pregnant woman

A

There is a risk of verticle transmission
HAART to suprpess viral load; good suppression= VD possible
4 week Neonatal PEP + Triple ART if Mat VL>50
AVOID BREASTFEEDING
C-Section + Zidovudine infusion lower risk than VD

159
Q

In addition to the usual STI screens and 3 site testing what should MSM also be screened for?

A

Hep B/C

Along with sex workers

160
Q

DDx of testicular pain?

A

Infections, Tumours, Trauma, Torsion

161
Q

What is Reiter’s syndrome?

A

Triad of Conjunctivitis, urethritis and Arthritis as a complication of an STI

162
Q

What is reactive arthritis?

A

Sterile polyarthralgia triggered by a distal infection

Unlikely if co-existent urethritis (Then think Reiter’s)

163
Q

What are the symptoms of disseminated Gonococcal infection?

A

Skin lesions, Arthalgia, Arthritis, Tenosynovitis

164
Q

Chlamydial vs Gonoccocal conjuctivits?

A

CT- unilateral low grade irritation

NG- Purulent discharge q

165
Q

What is Opthalmia Neonatorum

A

Conjucntivitis/Chemists/Purulent exudate following birth of mother infected with CT or NG
NAAT + Culture the eyelid +STI screen parents

166
Q

What is Neonatal pneumonitis?

A

Chlamydial infection 1-3 months of age
Staccato cough
CXR shows- Bilateral diffuse infiltrates and hyperinflation

167
Q

What are the colours of the following swabs?

  • Urine NAAT
  • VVS NAAT
  • EC NAAT
  • Culture/HVS
  • Viral (Weeping ulcers)
A
  • Urine NAAT- Yellow
  • VVS NAAT- Orange
  • EC NAAT- White
  • Culture- Pink
  • Viral- Red
168
Q

Key areas to cover in a sexual history?

A

HPC + PMHX
Sexual History- When, With whom, Regular, Type
Protection
Risk assessment- Known +ve, IVDU, MSM, Abroad, CSW
Menstrual History
Obstetric History
Gynae History- Smear, Contraception

169
Q

Outline the window periods for the STI tests

A

CT/NG- 2 weeks

HIV- 4 weeks (wait 8 if high risk)

GOSH (5 decks)

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