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
2
Q
Examples of Combined contraception
A
Pills- Microgynon, Yasmin, Glaira
Evra patch
NuvaRing (Vaginal ring)
3
Q
Mechanism of Action of combined contraceptive devices
A
Stops ovulation and increases cervical mucus
Also thin endothelium
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
5
Q
Relative CI TO combined contraception
A
Controlled HTN, Migraine >35, FHx VTE, BMI>35, Enzyme inducing meds
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
7
Q
Advantages of COCP
A
Controls bleeding and pain (spotting 1st few months)
Protective vs Ovarian and endometrial cancer and CRC
8
Q
What are ‘Hormonal Side effects’? Which contraception causes these?
A
Wx inc, Acne, Mood change, Headache
COCP. POP, Implant, Injection,
9
Q
Risks associated with the COCP
A
Breast and cervical cancer
Blood clots
Decreased lamotrigine efficacy
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
11
Q
When is a COCP defined as ‘missed?
A
> 24 hours late
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
13
Q
What is the 7 day condom rule for COCP?
A
D&V, Enzyme inducing drugs
14
Q
What contraception should be stopped 4 weeks before surgery?
A
Any oestrogen containing
Swap to POP
15
Q
Key enzyme inducers
A
CRAPS CBZ, Rifampicin bArbituates Phenytoin St John's wart
16
Q
Examples of POPs with 3 hour and 12 hour windows
A
3= Micronor, Noriday, Norgestron, Femulemn 12= Cerazette, Desogestrel
17
Q
MoA of POP
A
Increases cervical mucus, This endothelium
18
Q
CI to POP
A
Forgetfullness
Breast cancer
Undiagnosed PV bleeding
Liver disease
19
Q
Treatment course of PoP
A
Daily at same time
No pill free interval
20
Q
Which contraception devices are progesterone based?
A
POP
Injection
Implant
IUS
21
Q
Main SE of POP
A
Hormonal SE
Irregular bleeding possible
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
23
Q
Most effective form of contraception
A
Implant
24
Q
How does the IUD work?
A
Spermicide
25
CI for any form of Intrauterine contraception
```
Pelvic infection
PID <3/12 ago
Gynae cancer
UnDx PV bleeding
Copper allergy (IUD)
```
26
How long does the IUD last?
5-10 years
27
What are the risks of coil insertion?
```
Infection risk in first 3/52
Bleeding
1/1000 Perforate
5% Expulsion
Vasovagal 1/10
```
28
Aside from the risks of coil insertion, What is a major SE of the IUD
Heavier more painful periods (UNLIKE IUS)
29
After what age can the IUD stay in until the menopause?
>40
30
What must be done before an IUD/IUS insertion? When in relation to a period can they be inserted?
STI check
| Not had sex since period or first 5 days of period
31
When after insertion can an IUS be relied upon?
7/7
32
How does an IUS work?
Stops ovulation
Thins endothelium
Increases cervical mucus
33
Advantages of IUS
Periods become lighter therefore good for menorrhagia
| There is spotting in the first 6 /12 though
34
CI to Implant/Injection
Breast/Liver/Genital cancer
Undiagnosed PV bleeding
Enzyme inducers (implant only)
35
Which contraceptive device is no affected by enzyme inducers?
Injection
36
Trade name of the implant and injection
Implant= Implanon/Nexplanon
| Injection- Depo-Provera
37
How do the Implantant and injection work?
Stops ovulation, Thins endo, Cervical mucus
38
How long does the IUS last? When can is stay in indefinitely until the menopause?
3-5 years
>45YRS
39
How long does the implant last?
3 years
40
How long does the injection last?
3/12
41
Risks/SE of implant
Hormonal SE
Insertion risks- Bruising, Expulsion, Scarring, Infection
Periods may become irregular and longer!
42
Risks/SE of Injection
```
WEIGHT GAIN
Irregular/Longer periods (70% amenorrhoea though)
Hormonal SE
Osteoporosis
Can take 12/12 for fertility to return
```
43
Given the Osteoporosis risk for the Injection, after what time period would you stop it?
>5 yrs Stop
| >2yrs ?stop
44
How long must you use condoms after an injection or implant is given?
7/7
45
What cancers is COCP protective against?
Endometrial, Ovarian and CRC
46
What cancers does the COCP increase your risk of?
Breast, Cervical
47
What age group is the IUD UKMEC2 for?
Women <20 years
48
When is the diaphragm used? How does it work?
Only when having sex
| Laced with a spermicide
49
Failure rate for tubal ligation and vasectomy?
Tubal ligation - 1/200
| Vasectomy- 1/2000
50
Which method of sterilisation is safer?
Vasectomy (Simpler, done under LA)
51
What does tubal ligation increase your risk of?
Ectopic pregnancy (Only small increase)
52
Main risks of a vasectomy?
Bruising, Haemoatoma, Infection
| Some have ongoing testicular pain
53
How does tubal ligation affect the periods?
It doesn't
54
The three types of EC
IUD- BEST
Ella One (Ulipristal)
Levonelle (Levonorgestrel)
55
How does Ella One work?
Selective progesterone modulator 90% effectuve
56
When can the three types of EC be used?
IUD/Ella One- within 5/7 of unprotected sex or earliest likely calculated ovulation
Levonelle- 72 hours of unprotected sex
57
How do Ella One and Levonelle work?
Delays or prevents ovulation and implantation
58
CI to Ella One
Been on Hormonal contraception 5/7 before
Severe Asthma/Liver disease
Enzyme inducers (CRAPS)
Caution if previous use in this cycle...
59
CI to Levonorgestrel
```
Porphyria
Enzyme inducers (CRAPS)
BMI >26 (Need in double dose)
```
60
Which EC can you double the dose of?
Levonorgestrel (Levonelle)
61
Does an IUD increase the risk of an ectopic?
No because less likely to get pregnant
| But if you do get pregnant the risk is higher than someone not using an IUD
62
SE of Ella One and Levonorgestrel
PV bleeding, N&V, Headache, Breast/Pelvic pain
| ELLA ONE DECREASES THE Effectiveness of hormonal contraception
63
After an ELLA ONE when is the right time to restart hormonal contraception
5/7
| Use barrier methods inbetween
64
Advice to patient given Ella One/Levonorgestrel
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
65
If IUD is used as EC when can it be removed?
Option for long term
| 4 weeks if not; check up at 6 weeks
66
When is the earliest point of implantation?
D6-12 Post fertilisation therefore aim to give EC by D5 post-intercourse
(D21 if post-childbirth, D5 post-abortion/miscarriage)
67
When is a woman most fertile?
D9-D14 of cycle
68
At what point is a PT most reliable after an episode of risk of pregnancy?
3/52
69
Before what age can a person not consent to sex?
13
70
Fraser guidelines for <16 years
Understands, Likely to Continue, Best interests to give without Parents' consent, Health suffers without, Cannot be persuaded
71
Most common type of STI
Chlamydia Trachomatis
72
What is Chlamydia Trachomatis?
Intracellular G-ve
| Hard to see on microscopy
73
1st choice investigation for Chlamydia in Heterosexual Males and females
```
Males= 1st Void urine NAAT
Females= VVS NAAT
```
74
Treatment of choice for Chlamydia?
Doxycycline 100mg PO BD 7/7
| 1g stat Azithromycin PO is an alternative esp. in pregnancy
75
Advice to someone being treated for chlamydia/Gonorrhoea?
No sex 1/52 until they and partner finished
Contact tracing 4 weeks prior to symptoms (6/12 if asymptomatic)
"Test Then Treat"
76
Complications of chlamydia trachomatis
PID
Ectopic pregnancy
Tibal infertility
FITZ-HUGH CURTIS SYNDROME (Perihepatitis)
77
What is Lymphogranuloma venerum?
Serovar of chlamydia
78
How does Lymphogranuloma venerum present (3 stages)?
S1- Painless pustule -> Ulcer
S2- Painful inguinal lymphadenopathy
S3- Proctocolitis ?Haemorrhaging
79
What is Neisseria Gonorrhoea?
Intracellular Gram negative diplococci
80
How do you investigate for Gonorrhoea in Heterosexual Males and Females?
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
Incubation time for Chlamydia?
1-3 weeks
| Can be 2 week window period post-PSI where it may not be detected
82
Treatment of Gonorrhoea?
Ceftriaxone 500mg IM and 1g Azithromycin oral stat
83
What is the routine Sexual Health screen
NAAT for CT/NG
| Serology for syphilis and HIV
84
What are the long term complications of Gonorrhoea?
PID, Ectopics, Perihepatitis, Infertility, Chronic pain, Dyspareunia, Gonoccoccal arthritis
85
What are the symptoms of a disseminated gonoccocal infection?
Tenosynovitis especially in the hand, Migratory polyarthritis, Maculopapular and vesicular dermatitis
86
What is Trichomonas?
A Flagellated Protozoan
87
How do you diagnose Trichomonas infection?
HVS from the posterior fornix
| Can also do an endocervical swab
88
What does the Charcoal HVS look for?
Trichomonas, BV, Candida
89
What does trichomonas look like on microscopy?
Motile trophozites
90
What is the PH of the culture in a trichomonas infection?
PH>4.5
91
Treatment of trichomonas?
5-7 days of Metronidazole 400mg BD for both them and partner
Avoid sex 1/52
92
Classic signs of a trichomonas infection?
Strawberry cervix
Symptoms not resposive to BV/Candida treatment
Frothy yellow Green discharge +/- Offensive
Vulvovaginitis
Dysuria
93
What areas of the body does gonorrhoea commonly infect?
Vagina, cervix, Urethra, Rectum, Conjunctiva, Pharynx
94
What is '3 site testing'?
MSM who present with urethritis/symptoms
| This is 3 site NAAT and Culture
95
Key symptoms to ask about in a Male sexual History?
Dysuria, Discharge, Testicular pain, Skin changes, Swelling, Rectal discharge, Blood, Bowel Habit, Tenesmus
96
Investigations for urethritis in Males?
1st catch urine
| NAAT and culture swab if discharge
97
What is Acute- Epididymo-Orchitis?
Pain swelling ad inflammation involving the epididymis +/- Testes
Musts exclude torsion
98
What investigations would you do if someone presented with Acute- Epididymo-Orchitis?
```
Urethral culture
1st catch urine for NAAT
Dipstick and MSU
Mumps serology
Doppler
```
99
Key symptoms to cover in a female sexual history?
```
Urinary symptoms
Vaginal discharge- Colour, Consistency, Odour, Amount
Bleeding-IMB, PCB
Dyspaerunia- Superficial or Deep
Skin changes
```
100
What is thrush?
Fungal infection
| Not an STI
101
Key features of thrush?
```
Curd white discharge
Superficial dyspareunia
Dysuria
Itch
Skin changes- Excoriations, Erythema
```
102
Risk factors for Thrush?
Abx use, pregnancy, COCP, DM, Anaemia, Immunosuppression
103
Treatment of thrush
Clotrimazole Pessary 500mg or Fluconazole 150mg PO
104
PH of culture in thrush?
<4.5
105
PH of culture in BV?
>4.5-<6
106
What is BV?
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
Risk factors for BV
Receptive Cunnilingus, Douching, Black, Smoking, Change in sexual partner, STI
108
What is the discharge typically described as in BV?
Offensive fish smelling thin watery discharge
109
What symptoms does BV lack?
No soreness, No itching, No Irritation
110
Diagnosis of BV
Microscopy after swab
| Clue cells- Epithelial cells surrounded by lactobacilli
111
How do you measure vaginal PH?
Swab from lateral Vaginal wall and roll over PH paper
112
Causes of raised vaginal PH >4.5
Trichomonas and BV
113
Advice/Management of BV
Avoid douching, antiseptic, bath products
5-7 day oral metronidazole or topical
50% relapse in 3 months
114
Difference between Lichen sclerosis and Lichen Planus
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
For any Vulval presentation what investigations do you do?
Candida and BV HVS for culture
HSV/Syphilis PCR (swab or serology)
STI screen
Biopsy
116
What causes superficial dyspareunia?
Candida, Lichen sclerosis, Eczema
| PID/Endometriosis causes deep
117
How do you treat scabies and Pthirs pubis
Permethrin 5%
118
What is Lichen simplex?
Chronic rubbing leads to poorly demarcated plaques of thick skin or labia majora or scrotum
119
Difference between HSVT1 and HSVT2?
HSVT1- Oral
| HSVT2- Genital
120
Gold standard Dx of HSV?
Viral PCR of vesicle fluid following skin swabs
121
Symptoms of a Primary infection of HSV vs recurrence of HSV?
Primary= MOST SEVERE... Flu like, Lymphadenopathy, Small vulval painful vesicles, Discharge, Dysuria
Recurrence= Short, Less severe, triggered by sex/stress/Menstruation
122
Treating HSV?
Saline baths, Lignocaine gel, Rest, analgesia
| Aciclovir can be given to decrease the severity and duration of attacks if frequent exacerbations
123
Risk of HSV transmission in pregnancy?
Low, Suppressive therapy if recurrent
124
What are Genital warts?
Recurrent flare ups of HPV Types 6 +11 commonly
125
Median incubation time of Genital warts?
3 months
126
Presentation of genital warts?
Condulomata accuminata, local skin irritation, Fleshy painless lumps spread in lines of trauma
MOST ASYMPTOMATIC
127
What must you check for if someone presents with Genital warts?
Another STI
128
Advice to patient with warts
Majority clear within 1-2 years
VERY COMMON
Can try Podophyllotoxin or Imiquimod or Cryotherapy
129
What is Mycoplasma Genitalium?
STI- Symptoms like NG/CT
Mostly resolves spontaneosuly
NAAT= Dx
130
What is Molluscum Contagiosum? How do you treat it?
Pox virus sexually transmitted in young adults
Do routine STI screen
Clears on its own weeks-months
131
What does Molluscum Contagiosum look like?
Central umbillication and pearly edge lesion
| Smooth firm Dome shaped papules
132
What is Syphilis?
Spirochaete- Treponema Pallidum
| Presents 10-90 days post-infection
133
Which demographic is very high risk of syphilis?
MSM 25-34yrs
| 30% co-infected with HIV
134
What is primary syphilis?
Initial infection
Chancre- Indurated and painful +/- Multiple
-> It is raised, red and well demarcated
+/- Whole body rash +/- Inguinal lymphadenopathy
Resolution 3-8 weeks
135
What is secondary syphilis?
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
What is teritary syphilis?
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
How do you diagnose syphilis?
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
Treatment of syphilis?
Benzathine penicillin IM 3 weeks
| Contact tracing and HIV testing
139
What pregnancy issues does syphilis cause?
Preterm delivery, Still birth, Congential syphilis (Saddle nose, Blunted upper incisors, Wrinkling around mouth)
140
What type of virus is HIV?
| What immune cells are particularly affected?
Retrovirus
CD4+ cells
141
What happens to the CD4+ count during HIV infection?
Steadily decreases over years
| May be a transient rise after the primary infection
142
What happens to the HV RNA copies during a HIV infection?
Rapid rise at initial infection over weeks
Then drops and plateaus
Years later will begin to rise again until death of infected person
143
Who is tested for HIV?
```
All patients with an STI
Sexual contact with Africa/Far East/Caribbean
IVDUS
MSM
Blood/Organ donation
Sexual assault
```
144
What types of sex are highest risk (most to least)?
Receptive anal, Insertive anal, Receptive vaginal, Insertive vaginal
145
What antigen is usually detectable before the HIV Ab?
P24 Ag
146
What test is best to diagnose HIV; when can you use it?
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
Timeline of a HIV infection post-exposure?
```
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
What symptoms may present during HIV seroconversion?
Flu-like
Maculopapular trunk rash
Ulceration
Rarely meningoencephalitis
149
What is the window period for 3rd gen (just Ab) HIV test?
12 weeks (4th Gen is 4 weeks)
150
How do you monitor HIV disease progression and treatment response?
Viral load
151
In HIV what is the main indicator of risk of advanced disease
CD4+ count
152
What does advanced HIV increase your risk of?
Opportunistic infectons
B-cell lymphoma
Morbidity and Mortality
Cannot really use IUD/IUS
153
What drugs does HAART use?
3 different drugs from at least 2 classes
2x Nucleoside Reverse Transcriptase Inhibitors, Protease inhibitors, Non-nucleoside reverse transcriptase inhibitors
154
Aim of HAART?
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
What is Post-exposure HIV Prophylaxis (PEP)
Used when UPSI/Condom failure/High risk source in last 72 hours
Ideally used within 48 hours
28 day course
156
What is given for occupational exposure to HIV?
Prompt HAART 28 days
| Goal within 1 hour
157
What is Pre-Exposure Prophylaxis?
Before during and after sex for HIV -ve people
158
Advice for a HIV+ve pregnant woman
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
In addition to the usual STI screens and 3 site testing what should MSM also be screened for?
Hep B/C
| Along with sex workers
160
DDx of testicular pain?
Infections, Tumours, Trauma, Torsion
161
What is Reiter's syndrome?
Triad of Conjunctivitis, urethritis and Arthritis as a complication of an STI
162
What is reactive arthritis?
Sterile polyarthralgia triggered by a distal infection
| Unlikely if co-existent urethritis (Then think Reiter's)
163
What are the symptoms of disseminated Gonococcal infection?
Skin lesions, Arthalgia, Arthritis, Tenosynovitis
164
Chlamydial vs Gonoccocal conjuctivits?
CT- unilateral low grade irritation
| NG- Purulent discharge q
165
What is Opthalmia Neonatorum
Conjucntivitis/Chemists/Purulent exudate following birth of mother infected with CT or NG
NAAT + Culture the eyelid +STI screen parents
166
What is Neonatal pneumonitis?
Chlamydial infection 1-3 months of age
Staccato cough
CXR shows- Bilateral diffuse infiltrates and hyperinflation
167
What are the colours of the following swabs?
- Urine NAAT
- VVS NAAT
- EC NAAT
- Culture/HVS
- Viral (Weeping ulcers)
- Urine NAAT- Yellow
- VVS NAAT- Orange
- EC NAAT- White
- Culture- Pink
- Viral- Red
168
Key areas to cover in a sexual history?
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
Outline the window periods for the STI tests
CT/NG- 2 weeks
| HIV- 4 weeks (wait 8 if high risk)
