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Gynae > Sexual health: Contraception, Abortion, GUM, psychosexual medicine > Flashcards

Sexual health: Contraception, Abortion, GUM, psychosexual medicine Flashcards

1
Q

List some types of contraception

A
  • Barrier methods: male and female condoms, diaphragm/cap
  • Long-acting reversible contraception (hormonal + non-hormonal): copper IUD, Mirena/LNG-IUS, progestogen implant
  • Hormonal contraception: COCP, progesterone-only-pill, progesterone depot injection, CHC ring/patch
  • Others: natural rhythm method, spermicide, etc.
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2
Q

What is the mechanism of action of hormonal contraception?

A
  • CHC (pill, ring, patch): prevent ovulation by suppressing GnRH/LH/FSH release
  • Mirena: prevents thickening of the endometrial to reduce implantation + thickens cervical mucus to prevent passage of sperm
  • POP: some amount of ovulation prevention, thickening of cervical mucus, etc.
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3
Q

What is the effectiveness of different contraceptives?

A

IUD/IUS/implant: very effective. <1% get pregnant
COCP/POP: less effective due to imperfect use. ~9% get pregnant a year
Condoms: quite ineffective. Work 85% of the time

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4
Q

What determines if a specific form of contraception is appropriate for a specific patient?

A

The WHO medical eligibility criteria (MEC). 4 categories, 1 being acceptable, 4 being absolutely unacceptable

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5
Q

What are the MEC category 4 criteria for CHC?

A 
Age >35 and smoker
Previous VTE or known thrombophilia
Hypertension >160/100
Current breast cancer
Liver disease 
Migraine with aura
Previous MI/stroke/TIA or multiple RFs 
Breastfeeding and <6 weeks PP
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6
Q

What are the Fraser criteria? When do they apply?

A
  • Understands information
  • Will not tell parents
  • Will likely have sex anyway with or without contraception
  • Will come to harm if not given contraception (emotional etc)
  • It is in the best interests of the patient to receive contraception

The Fraser criteria apply to any person aged 13-15

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7
Q

Describe the laws around age of consent to sex.

A

-Above the age of 16, people can give consent to sex
(caveat- if someone is >18 and in a position of trust, it is an offence to have sex with someone <18)

  • Between the ages of 13-15, it is still an offence to have sex but the Home Office will not prosecute
    eg. if both partners are 15, this is technically OK

-Below the age of 13 (eg. 12 and under), it is always an offence to have sex

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8
Q

A 22 year old woman comes to the sexual health clinic for contraception because she has just started a relationship with a new partner and would like something more effective than condoms. What is important to ask about?

A
  • History of contraception
  • Periods (LMP, regularity, heaviness, pain), other gynae Hx
  • STI screen (discharge, dyspareunia, last STI check, current partner RFs for HIV)
  • PMH (VTE, hypertension, BMI, breast cancer, migraine, diabetes) and drug Hx, allergies
  • Smoking
  • Any ideas of preferred methods. Hormonal/non-hormonal? Long acting?
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9
Q

A 22 year old woman comes to the sexual health clinic for contraception because she has just started a relationship with a new partner and would like something more effective than condoms. After a discussion, she decides she would like to start the COCP. There are no contraindications to use. Her LMP was 13 days ago and her menstrual cycles are usually 29 days long. How would you advise this patient on taking the pill?

A

-Explain how to take: 3 weeks of pills followed by 7 days off. During these 7 days she will have a withdrawal bleed which is similar to a period. Start the next pack after 7 days.
-Because she is on day 13 of the cycle, it is likely that she will still ovulate. If she starts now, it is important to use barrier contraception for the next 7 days
-If she misses pills: go to NHS website or speak to pharmacist or GP for more info
1 pill: take when you remember and continue as normal (eg. 2 pills in 1 day)
2 pills: take the most recently missed pill and continue as normal, use condoms for at least 7 days
-If in the last week of the pack: go straight without break
-If in the first week of the pack: get advice about emergency contraception

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10
Q

Please explain the risks and benefits of the COCP as if to a patient

A
  • Benefits: with perfect use, very small risk of pregnancy. Reduces risk of endometrial, ovarian and bowel cancer, regulates periods and reduces heaviness + pain, reduces PMS and acne
  • Side effects: bloating, breast tenderness, mood swings, abnormal bleeding for the first 3 months, headaches
  • Risks: small increase risk of blood clots, breast + cervical cancer
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11
Q

Explain how to take the POP

A
  • Take 1 pill at the same time every day for 28 days. No pill free week like with the COCP
  • Depending on the type, must take within 3 hours (traditional) or 12 hours (desogestrel) of the normal time
  • Starting on day 1-5 covered, other days use condoms for 2 days
  • If you miss the window (eg. >3 hours, >12 hours), then take when you remember (only 1 is missed multiple) and use condoms for 2 days
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12
Q

What are the risks and benefits of the POP?

A
  • Benefits: with perfect use good effect, no risks of COCPs

- Risks/SEs: irregular bleeding, bloating, breast tenderness, small window for taking the pill

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13
Q

How are the combined hormonal patch and ring used?

A

Patch: 1 patch per week for 3 weeks, off for 1 week
-Delayed is >48 hours, condoms for 7 days
Ring: 1 ring for 3 weeks, remove for 1 week and replace

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14
Q

What is the risk of blood clots on the COCP?

A

Increases from 5 in 10,000 to 10 in 10,000

But this is still much lower than the risk of clots in pregnancy/PP

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15
Q

Describe the insertion of LARCs

A

Implant/Nexplanon: size of matchstick, sits under the skin in the upper arm. Use local anaesthesia before injection. Stays for 3 years

LNG-IUS + copper IUD: small device into the uterus, takes 15 minutes including internal examination to feel the direction of the uterus. Some pain + bleeding is common, small risk of infection (swab at insertion), rare risk of perforation (1/1000), small risk of falling out (1/20).
LNG-IUS lasts for 3-5 years (Jaydess vs Mirena), copper 5-10 years also emergency contr.

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16
Q

What are the types of sterilisation? How effective is sterilisation?

A

Female: tubal ligation (1/200 risk) by clipping tubes and hysteroscopic tubal occlusion (1/500 risk) with coils -> fibrosis

Male: vasectomy (1/2000 risk of failure). OP procedure, access scrotum and cauterise vas deferens

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17
Q

How does the fertility based awareness method work?

A
  • Measure cycles over 6 cycles to be certain
  • First fertile day: shortest cycle length - 20 days
  • Last fertile day: longest cycle length -10 days
    eg. 28 day cycle: abstain from day 8-18.
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18
Q

What drugs can interact with contraceptives?

A
  • Anticonvulsants eg. carbamazepine, phenytoin
  • Antibiotics eg. rifampicin
  • Antivirals eg. ritonavir (avirs) and efavirenz
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19
Q

What are the various forms of emergency contraception? When can they be used?

A
  • Copper IUD: up to 5 days post UPSI/5 days post predicted ovulation. Most effective, provides LARC also
  • Ulipristal acetate 30mg (ellaOne): selective progesterone receptor modulator, delays ovulation. Up to 5 days (120 hours) post UPSI
  • Levonorgestrel (1.5mg): up to 72 hours post UPSI, delays ovulation

*If on hormonal contraception, resume immediately after LNG or 5 days after ellaOne

20
Q

What are the side effects of emergency contraception?

A

N+V, breast tenderness, irregular bleeding, disruption to the menstrual cycle

21
Q

What are the legal grounds for abortion in England? Under which are most abortions performed?

A

There are 7 grounds for abortion under the 1967 Abortion Act
A: Risk to life of the woman if pregnancy is continued
B: Necessary to prevent grave permanent injury
C: <24 weeks, risk of injury to the physical/mental health of the woman if pregnancy continues is greater than risk if terminated
D: <24 weeks, risk of injury to the physical/mental health of existing children than risk if terminated
E: risk of physical/mental abnormality to cause severe handicap
F: for the purpose of saving the woman’s life
G: literally B

Most are performed under ground C, also ground E.

22
Q

What are the methods available for termination of pregnancy?

A

Medical: mifepristone + misoprostol
Surgical: MVA

23
Q

Describe medical TOP management

A

<10 weeks: home management. Mifepristone PO -> 24-48 hours later misoprostol PO/PV

> 10 weeks: can have home expulsion. Mifespristone PO -> 36-48 hours later misoprostol PO/PV every 3 hours until expulsion
-Simple analgesia

24
Q

Describe surgical TOP management

A

-Check anti-D status pre-op
-Local anaesthesia as OP or GA
-Consent and explain risks
<14 weeks: MVA with cervical softening with misoprostol PV (400ug 1 hour before)
>14 weeks: dilation and evacuation. Dilation with misoprostol/mifepristone/osmotic dilators -> gradual dilators during operation -> aspiration. Confirm with USS
-Prophylactic antibiotics and analgesia postop, antiD

25
Q

How should TOP be followed up?

A

No need for follow up appointment. Safety net is important!!

  • Give information on recovery/after TOP SEs (normal to have cramping pain for several days, bleeding may last for several weeks)
  • If bleeding gets worse after improving, lots of pain, fever, or offensive discharge -> medical attention
  • Ask to do hCG test after 3 weeks to confirm, seek medical advice if +ve still
  • Encourage contraception, especially LARC
  • Acknowledge range of emotions are common, encourage to seek support from family/friends or medical professionals via charities or GP if needed (Marie Stopes, Life Charity)
26
Q

What is the difference between 1˚ and 2˚ psychosexual dysfunction?

A

1˚: from the first sexual activity

2˚: sexual difficulties arising from pain or emotional issues after being sexually active

27
Q

What approach can be used in consultations of psychosexual dysfunction?

A

The LOFTI model

  • Listening
  • Observing
  • Feelings (transference)
  • Thinking
  • Interpreting
28
Q

What is vaginismus? How does it present, what is the management?

A
  • Vaginismus is a condition caused by involuntary contraction of the vaginal muscles
  • Presents as inability to achieve penetration, superficial dyspareunia, relationship issues, etc.
  • Management: encourage self exploration at home, perineal massage + masturbation, explore anxieties, refer to psychosexual medicine clinic
29
Q

Define female genital mutilation. What are the different types?

A

Any procedure that involves partial or total removal or injury to the female genitals (eg. labia, clitoris), whether for cultural, religious, or non-therapeutic reasons

1: clitoroidectomy. Removal of the clitoral hood
2: excision of the clitoris with partial/total removal of labia minora
3: excision of part/all of the genitalia with stitching of the vaginal opening (infibulation)
4: piercing, cauterising, cutting, corrosive substances, plastic surgery

30
Q

What should be done if FGM is observed during examination?

A
  • Document!!!

* If a minor, report to safeguarding is required

31
Q

What is de-infibulation?

A

The process of reversing infibulation (closure of the vaginal), done with sufficient anaesthesia

32
Q

A 25 year old woman attends the sexual health clinic complaining of a swollen and tender vulva which is preventing her from having sex. What would you like to ask?

A
  • Symptoms: site, onset, progression, character, alleviating factors (if tried any creams, etc), associated symptoms of itching/stinging, discharge, bleeding (also PCB), smell, abdo pain, lumps/bumps (eg cyst), dysuria
  • Sexual Hx: partners in last 3 months with gender, type of sex, protection. History of STIs. Smears.
  • Periods: LMP, cycle length and regularity
  • PMH, allergies, DHx
  • Social: alcohol, drugs, smoking
  • DV and sexual abuse screen
33
Q

Name some causes of abnormal vaginal discharge

A
  • Infection, sexually transmitted: chlamydia, gonorrhoea, trichomonas
  • Infection, non-STI: Candida, BV
34
Q

What is the causative pathogen in BV? Describe the pathogenesis

A
  • Gardnerella vaginalis

- Caused by an overgrowth of Gardnerella and depletion of normal lactobacilli –> rise in pH

35
Q

Name some risk factors for BV. What is the presentation?

A
  • Douching, new sexual partners, new IUD, oral sex

- Presents with watery off-white, fishy-smelling discharge +/- vulvovaginitis

36
Q

How is BV diagnosed? What does it look like?

A

Microscopy and Gram stain using different criteria eg.

  • Hay-Ison (spectrum of normal lactobacilli -> Gardnerella)
  • Nugent
  • Historically with Amsels (need 3/4): discharge, high pH, clue cells, fishy smell with KOH test

On microscopy: ‘clue cells’ are vaginal epithelium surrounded by lots of gram-ve bacteria

37
Q

How is BV managed?

A

Conservative: reduce douching to balance flora

Oral metronidazole 7 days

38
Q

Describe the presentation of vulvovaginal Candidiasis. How is it diagnosed? What is the management?

A
  • Presents with vulvovaginitis (swollen, erythematous, tender), pruritus, thick white cottage cheese like discharge, can have fissuring
  • Diagnosed clinically. Swab for microscopy + culture is indicated if recurrent/treatment failure, very severe
  • Management: conservative (avoid washing/douching, wear cotton underwear, etc), topical intravaginal pessaries/creams (eg clotrimazole) or oral fluconazole
39
Q

Describe trichomonas vaginalis infection. How is it diagnosed? What is the management?

A
  • TV is a flagellated protozoa that causes STI
  • Presents with frothy yellow/green discharge +/- vulvovaginitis
  • Diagnosis: wet slide microscopy (to visualise protozoa), gold standard is NAAT
  • Management: oral metronidazole 7 days
40
Q

How do chlamydia and gonorrhoea present? How are they diagnosed? What is the management?

A

-Both can be asymptomatic or cause abnormal discharge (purulent), cervicitis and PID
-Cervicitis: discharge, deep dyspareunia, PCB
-Diagnosis: NAAT is gold standard. MC&S is needed if gonorrhoea +ve.
-Management: chlamydia is 1g azithromycin or 14 days doxycycline. Gonorrhoea is IM injection ceftriaxone.
Important to notify sexual partners for treatment.

41
Q

Describe the presentation of PID. What is the management?

A

-PID is caused by ascending infection from the vaginal into the cervix, endometrium, and tubes
-Symptoms: Bilateral lower abdo pain, dyspareunia, abnormal discharge, IMB/PCB
-Signs: pelvic tenderness +/- masses, cervicitis + cervical excitation, abnormal discharge
-Management: depends on acuteness of presentation. Very acute: consider admission, IV antibiotics to cover all pathogens eg. ceftriaxone, azithro, metronidazole
Chronic: oral antibiotics

42
Q

Describe the presentation of genital HSV. How is it diagnosed? What is the management?

A
  • Primary presents with painful eruption of vesicles preceded by prodromal phase -> burst and form tender small shallow ulcers.
  • Also possibly lymphadenopathy, dysuria, cervicitis
  • Diagnosis: viral PCR for HSV 1 and 2.
  • Management: oral aciclovir 400mg BD
43
Q

Describe the presentation of genital warts. How is it diagnosed? What is the management?

A
  • Genital warts are benign growths of the vulval epithelium caused by HPV infection (usually 6+11)
  • Diagnosis is clinical
  • Management: topical creams (podophyllotoxin, imiquimod). Can also use cryotherapy, ablation, etc.
44
Q

Describe the presentation of syphilis.

A
  • Syphilis is caused by infection with Treponema pallidum
  • Primary infection: painless chancre (ulcer) on the genitals +/- lymphadenopathy
  • Secondary (weeks-months): erythematous rash including the palms and soles, condylomata lata, 8th nerve palsy
  • Tertiary (years): can affect the brain/nervous system, heart/vasculature, gummatous lesions
45
Q

How is syphilis diagnosed? What is the management?

A
  • Serology is main method of initial diagnosis. For screening: treponemal tests eg. EIA
  • If active primary lesion: dark ground microscopy, PCR
  • To monitor after treatment/confirm diagnosis: non-treponemal test eg. VDRL or RPR
  • Management: depot penicillin eg. IM benpen
46
Q

Why is HIV infection relevant to O&G?

A
  • Obstetrics: risk of vertical transmission. Important to screen for at booking as will affect antenatal, intrapartum and postnatal care.
  • Gynaecology: increased risk of other STIs, risk of cervical cancer (annual smears), effect of HIV medication on hormonal contraception

Gynae (6 decks)

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