Sexual health (GUM medicine) Flashcards
(150 cards)
1
Q
What is BV?
A
Overgrowth of bacteria in the vagina, specifically anaerobic bacteria – not an STI
2
Q
What is BV caused by?
A
Loss of lactobacilli “friendly bacteria” in the vagina
3
Q
What risk does BV put women in?
A
Developing STIs
4
Q
What are lactobacilli? What its function?
A
The main component of the healthy vaginal bacterial flora - produces lactic acid which keeps the vaginal pH low (under 4.5)
5
Q
What does the acidic environment in the vagina do?
A
Prevents other (anaerobic) bacteria from overgrowing
6
Q
What is the normal pH of the vagina and what happens when the pH of the vagina rises?
A
- Normal pH is < 4.5
- This is maintained by lactobacilli (healthy bacterial flora) which produce lactic acid in the vagina
- More alkaline environment enables anaerobic bacteria to multiply
7
Q
List some bacteria associated with bacterial vaginosis?
A
Anaerobic bacteria:
- Gardnerella vaginalis (most common)
- Mycoplasma hominis
- Prevotella species
BV can also occur alongside other infections- candidiasis, chlamydia, gonorrhoea
8
Q
What are the risk factors for BV?
A
- Multiple sexual partners (although it is not sexually transmitted)
- Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes)
- Recent antibiotics
- Smoking
- Copper coil
- UPSI
- Menstruation
- Receptive oral sex
9
Q
What to ask when taking a history for BV?
A
Further details of discharge-
- Colour- off white
- Odour- fishy
- Consistency- homogenous
- Blood-staining
Other symptoms- not commonly associated with BV, may suggest alternative diagnosis
- Associated itch or soreness
- Intermenstrual/ post-coital bleeding
- Dyspareunia
- Genital rash/ lesions
Sexual hx
Ask Qs to assess the causes-
- Use of soaps to clean the vagina
- Vaginal douching
10
Q
What is the presenting feature of BV?
A
Fishy-smelling watery grey or white vaginal discharge (half of women are asymptomatic)
11
Q
What would suggest a diagnosis other than BV?
A
Itching, irritation and pain are not associated with BV and suggest an alternative cause
12
Q
How do you make a diagnosis of bacterial vaginosis?
A
Speculum examination – high vaginal swab can be done
Examination is not always required where the symptoms are typical and the woman is low risk of STIs
Amsel’s criteria for diagnosis of BV - 3 of the following 4 points should be present
- Thin, white homogenous discharge
- Clue cells on microscopy: stippled vaginal epithelial cells
- Vaginal pH > 4.5
- Positive whiff test (addition of potassium hydroxide results in fishy odour)
13
Q
What type of swab is used for BV?
A
Standard charcoal swab – high vaginal swab
14
Q
How does BV appear on microscopy?
A
“Clue cells” – epithelial cells from the cervix that have bacteria stuck inside them – usually Gardnerella vaginalis
15
Q
What is the management of BV?
A
Asymptomatic BV doesn’t usually require treatment
Symptomatic BV treated with oral metronidazole
- 400mg bd for 5 days
BNF suggests topical metronidazole or topical clindamycin as alternatives
16
Q
What advice to give when prescribing metronidazole?
A
Avoid alcohol for the duration of treatment as it causes a “disulfiram-like reaction” with nausea and vomiting, flushing and sometimes shock and angioedema
17
Q
What complications is BV associated with in pregnant women?
A
- Miscarriage
- Preterm delivery
- Premature rupture of membranes
- Chorioamnionitis- infection of the placenta and the amniotic fluid
- Low birth weight
- Postpartum endometritis
Recent guidelines recommend that oral metronidazole is used throughout pregnancy but the BNF advises against the use of high dose metronidazole regimes
18
Q
What is vaginal candidiasis?
A
- Commonly referred to as thrush
- Vaginal infection with a yeast of the candida family – most commonly candida albicans
19
Q
What are some risk factors for thrush?
A
- Increased oestrogen (higher in pregnancy, lower pre-puberty and post-menopause)
- Poorly controlled diabetes
- Immunosuppression (e.g. using corticosteroids, HIV, chemotherapy)
- Broad-spectrum antibiotics
- Mucosal breakdown (sexual contact, dermatitis)
- Recurrent candidiasis ?associated w/ atopy
- High oestrogen levels (pregnancy, luteal phase, some COCs)
20
Q
How does vaginal candidiasis present?
A
- Thick white discharge which doesn’t typically smell - cottage-cheese like
- Vulval and vaginal itching, irritation or discomfort
- More severe infection can lead to erythema, fissures, oedema, dyspareunia, dysuria, excoriation
21
Q
What are the investigations for thrush?
A
- Often treatment for thrush is started impirically, based on presentation
- Test vaginal pH to rule out BV and trichmonas (pH>4.5)
- Charcoal swab with microscopy can confirm the diagnosis
22
Q
What are the management options for thrush?
What advice can you give to patients for self-management?
A
Antifungal medications:
- Single dose fluconazole 150mg oral
- If this is contraindicated, single dose 500mg clotrimazole PV pessary at night
- Can give clotrimazole pessary for 3 nights 200mg
- For relief of vulval symptoms, clotrimazole 1% (+/- hydrocortisone 1%) cream topical bd for 2 weeks
- If pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated
Advise on self-management measures to provide symptom relief:
- Use simple emollients as a soap substitute to wash and/or moisturize the vulval area.
- Avoid contact with potentially irritant soap, shampoo, bubblebath, or shower gels, wipes, and daily or intermenstrual ‘feminine hygiene’ pad products.
- Avoid vaginal douching.
- Avoid wearing tight-fitting and/or non-absorbent clothing, which may irritate the area.
- Avoid use of complementary therapies such as application of yoghurt, topical or oral probiotics, and tea tree or other essential oils.
23
Q
How is recurrent vaginal candidiasis deifned & how is it treated?
A
- BASHH define recurrent vaginal candidiasis as 4 or more episodes per year
- Check compliance w/ previous treatment
- Confirm diagnosis of candidias- high vaginal swab, consider blood glucose test to exclude diabetes
- Exclude differentials eg lichen sclerosus
- Induction-maintenance regime
- Induction: oral fluconazole 150mg every 72 hrs for 3 doses
- Maintenance: oral fluconazole weekly for 6/12
24
Q
What advice needs to be given to women using antifungal creams and pessaries?
A
Can damage condoms and prevent spermicides from working – alternative contraception is needed for at least 5 days after use
25
What type of bacteria is chlamydia trachomatis?
* Gram-negative bacteria
* Obligate intracellular bacterium- not visible under light microscope
* Enters and replicates within cells before rupturing the cell & spreading to others
26
What is the National Chlamydia Screening Programme?
A programme aimed to **screen every sexually** active person **under 25 years of age** for chalamydia **annually or when they change their sexual partner** – everyone who tests positively should have a **re-test three months** after treatment to **ensure they have not contracted chlamydia again**, rather than to check that the treatment has worked
* In June 2021 changes were made: opportunistic screening (the proactive offer of a chlamydia test to young people w/o symptoms) will be only offered proactively to **young women**
* Everyone can still get tested if they need, but men will not be proactively offered a test unless an indication has been identified, such as being a partner of someone with chlamydia or having symptoms.
27
What are patients tested for when they attend a GUM clinic?
* Chlamydia
* Gonorrhoea
* Syphilis (blood test)
* HIV (blood test)
28
What are the two kinds of swabs used for sexual health screening? What are they used for?
Charcoal swabs
* These allow for microscopy, culture and sensitivities
* Endocervical swab, high vaginal swabs
* Can confirm BV, candidiasis, gonorrhoea (endocervical swab), trichomonas vaginalis (swab from posterior fornix), other bacteria- group B strep (GBS)
Nucleic acid amplification test (NAAT) swabs
* Check directly the DNA or RNA
* Specifically for chlamydia and gonorrhoea- not useful for other pelvic infectins
* Women: vulvovaginal swab (self-taken lower vaginal swab), endocervical swab or first-catch urine sample
* Men: first-catch urine sample or urethral swab
29
What swabs can be taken to diagnose chlamydia in the rectum and throat?
**Rectal** and **pharyngeal** NAAT swabs
* Considered where oral/ anal sex has occurred
30
How to confirm a diagnosis of gonorrhoea after a positive NAAT test?
Endocervical charcoal swab is required for microscopy, culture and sensitivities
31
What presentations suggest chlamydia in women?
- Asymptomatic in 70% women
- Cervicitis- Abnormal vaginal discharge, bleeding (intermenstrual or postcoital)
- Pelvic pain
- Painful sex (dyspareunia)
- Painful urination (dysuria)
32
What presentation suggests chlamydia in a man?
- Asymptomatic 50% men
- Urethral discharge
- Painful urination (dysuria)
- Epididymo-orchitis
- Reactive arthritis
33
What are the examination findings in chlamydia?
- Pelvic or abdo tenderness
- Cervical motion tenderness (cervical excitation)
- Inflamed cervix (cervicitis)
- Purulent discharge
34
What tests are used to diagnose chlamydia?
Nucleic acid amplification tests (NAAT)
* urine (first void urine sample), vulvovaginal swab or cervical swab may be tested using the NAAT technique
* for women: the vulvovaginal swab is first-line
for men: the urine test is first-line
* Chlamydia testing should be carried out two weeks after a possible exposure
35
What is the first line treatment for uncomplicated chlamydia?
* **Docycycline** 100mg bd for 7 days
* If contraindicated or not tolerated, azithromycin (1g od for one day, then 500mg od for two days)
* If pregnant then azithromycin, erythromycin or amoxicillin may be used
* Other advice-
* Abstain from sex for seven days of treatment of all partners to reduce the risk of re-infection
* Refer all patients to genitourinary medicine (GUM) for contact tracing and notification of sexual partners
* Test for and treat any other sexually transmitted infections
* Provide advice about ways to prevent future infection
* Consider safeguarding issues and sexual abuse in children and young people
36
Why is a single dose of 1g of azathioprine no longer recommended first line for chlamydia?
37
Is contact tracing for chlamydia diagnosis required & if so, who needs to be contacted?
* Patients diagnosed with Chlamydia should be offered a choice of provider for initial partner notification - either trained practice nurses with support from GUM, or referral to GUM
* For men with urethral symptoms: all contacts since, and in the four weeks prior to, the onset of symptoms
* For women and asymptomatic men all partners from the last six months or the most recent sexual partner should be contacted
* Contacts of confirmed Chlamydia cases should be offered treatment prior to the results of their investigations being known (treat then test)
38
When is a **test of cure** used for clamydia?
- Rectal cases of chlamydia
- Pregnancy
- Symptoms persist
39
What are the possible complications from infection with chlamydia?
* Pelvic inflammatory disease
* Chronic pelvic pain
* Infertility
* Ectopic pregnancy
* Epididymo-orchitis
* Conjunctivitis
* Lymphogranuloma venereum
* Reactive arthritis
Pregnancy related
* Preterm delivery
* Premature rupture of membranes
* Low birth weight
* Postpartum endometritis
* Neonatal infection (conjunctivitis and pneumonia)
40
What is lymphogranuloma venereum?
What are some risk factors?
Condition **affecting the lymphoid tissue** around the **site of** infection with **chlamydia** -
RF
* Men who have sex with men
* The majority of patients who present in developed countries have HIV
* Historically was seen more in the tropics
3 stages
* Stage 1: small painless pustule which later forms an ulcer
* Stage 2: painful inguinal lymphadenopathy
* may occasionally form fistulating buboes
* Stage 3: proctocolitis
41
What is the first line treatment for LGV?
**Doxycycline** 100mg twice daily for 21 days
Alternatives- erythromycin, azithromycin, ofloxacin
42
How does chlamydial conjunctivits occur?
How does it present?
When genital fluid comes into contact with the eye
Can affect neonates with mothers infected w/ chlamydia
Presentation:
* Chronic erythema
* Irritation
* Discharge lasting more than 2 weeks
* Usually unilateral
43
What type of bacteria is Neisseria Gonorrhoeae?
Gram negative diplococcus bacteria
44
Where does gonorrhoea infect? What is the typical incubation period?
* Infects mucous membranes with a columnar epithelium e.g. endocervix, urethra, rectum, conjunctiva and pharynx
* The incubation period of gonorrhoea is 2-5 days
45
What increases the risk of gonorrhoea?
* Young age
* Sexually active
* Having multiple partners
* Having other STIs
46
What is the problem with treating gonorrhoea?
High level of **antibiotic resistance** - traditionally **ciprofloxacin** or **azithromycin** was used to treat gonorrhoea - there are now high levels of **abx resistance**
47
How does Gonorrhoea present?
More likely to be symptomatic than infection with chlamydia:
Odourless purulent discharge, possibly green/yellow
* Urethral discharge in male
* Vaginal discharge in female caused by cervicitis
Dysuria
Pelvic pain
Testicular pain or swelling- epididymo-orchitis
Rectal & pharyngeal infection usually asymptomatic - may cause anal or rectal discomfort & discharge
Pharyngeal infection may cause sore throat
Prostatitis- perineal pain, urinary symptoms, tender prostate o/e
Conjunctivitis- erythema, purulent discharge
48
How is gonorrhoea diagnosed?
NAAT testing to detect the RNA or DNA of gonorrhoea
* Should be taken at least 3 days after sexual contact w/ infected person
* Female: vulvovaginal swab (may be self-taken)
* Male: first pass urine specimen
49
What samples for gonorrhoea are advised in MSM?
**Rectal** and **pharyngeal** in all MSM and in those with **risk factors** (e.g. **anal and oral sex**)
50
Describe the management plan for gonorrhoea?
Uncomplicated:
* Sensitivites are NOT known: single dose of **intramuscular ceftriaxone 1g**
* Sensitivites are known: single dose of **oral ciprofloxacin** 500mg
* Alternative regimens: azithromycin 2g PO, gentamycin IM
* Test for cure:
* If asymptomatic, NAAT at least 2 weeks after completion of treatment
* If signs and symptoms persist, test with culture at least 3 days after completion of treatment
* If culture is negative test with NAAT after 7 days
Other factors to consider
* Avoid sex for 7 days
* Test for other STIs
* Advise on how to prevent STIs
* Safeguarding issues and sexual abuse in children/ young people
51
What are some complications of gonorrhoea?
* Pelvic inflammatory disease
* Chronic pelvic pain
* Infertility
* Epididymo-orchitis (men)
* Prostatitis (men)
* Conjunctivitis
* Urethral strictures
* Disseminated gonococcal infection
* Skin lesions
* Fitz-Hugh-Curtis syndrome
* Septic arthritis
* Endocarditis
52
What is a key complication to remember of gonorrhoea in pregnancy?
**Gonococcal conjunctivitis** in a neonate - contracted from the mother during birth - called **ophthalmia neonatorum** - medical emergency and associated with **sepsis**, **perforation of the eye** and **blindness**
53
What is **disseminated gonococcal infection**?
Complication of untreated gonococcal infection where the **bacteria spreads to the skin and joints**
It causes:
- Various non-specific skin lesions
- Polyarthralgia (joint aches and pains)
- Migratory polyarthritis (arthritis which moves between joints)
- Tenosynovitis
- Systemic symptoms such as fever and fatigue
54
What are some causes of Non Specific Urethritis (NSU)?
STIs
* Chalmydia trachomatis
* Mycoplasma genitalium
* Trichomonas vaginalis
* Herpes simplex
* HPV
Non-STI infective agents
* UTI
* Adenovirus
* Candida
Non-infective agents
* Drugs
* Alcohol
* Trauma
* Foreign body
55
What is **mycoplasma genitalium** (MG)?
* A bacteria which causes **non-gonococcal urethritis** - STI
* Gram pos; smallest bacterium
* Unique flask shaped slightly curved
56
What is a concern with mycoplasma genitalium?
Developing problems with **antibiotic resistance,** particularly with **azithromycin**
57
How does mycoplasma genitalium present?
Many cases do not cause symptoms - **urethritis** is a **key feature**
* ****Male:
* Urethral discharge
* Dysuria
* Penile irritation
* Urethral discomfort
* Urethritis (acute, persistent, recurrent)
* Female:
* Dysuria
* Post-coital bleeding
* Painful inter-menstrual bleeding
* Cervicitis
* PID- lower abdo pain
58
What complications may infection with **mycoplasma genitalum** lead to?
* Urethritis
* Epididymitis
* Cervicitis
* Endometritis
* Pelvic inflammatory disease
* Reactive arthritis
* Preterm delivery in pregnancy
* Tubal infertility
59
What are the investigations for mycoplasma genitalium?
* Cultures not useful- MG bacteria is too slow-growing
* NAAT- Vulvovaginal swab for female, first pass urine sample for male
* Check every positive sample for macrolide resistance
* Perform Test of Cure after treatment in every positive pt
60
What organisms cause non-gonococcal urethritis? (NGU)
* Chlamydia trachomatis - most common cause
* Mycoplasma genitalium - thought to cause more symptoms than Chlamydia
* Ureaplasma urealyticum (UTI)
61
What is the management for mycoplasma genitalium?
*_According to the 2018 BASHH guidelines:_*
* **Doxycycline** 100mg twice daily for 7 days then;
* **Azithromycin** 1g stat then **500mg** once a day for **2 days** (unless it is known to be resistant to macrolides)
* Moxifloxacin 400mg orally once daily for 10 days if organism known to be macrolide-resistant or where treatment with azithromycin has failed
* Pregnancy: azithromycin for 3 days (doxycycline is contraindicated)
62
What factors make an STI more likely?
* Recent partner changes
* Multiple contacts
* Recurrent symptoms
* Other symptoms
* Women: abdo pain, menstrual problems
* Men: testicular pain
* Extragenital signs & symptoms of STIs
63
What is used to treat MG in pregnancy and breastfeeding?
* **Azithromycin** alone (doxycyclin is contraindicated)
* 3 day course
64
What is Pelvic Inflammatory Disease?
* Pelvic inflammatory disease (PID) is a term used to describe infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries and the surrounding peritoneum
* Caused by infection spreading up through the cervix
65
What can PID result in?
**Tubular infertility** and **chronic pelvic pain**
* Endometritis (inflammation of endometrium)
* Salpingitis (inflammation of fallopian tubes)
* Oophoritis (inflammation of ovaries)
* Parametritis (inflammation of parametrium- the connective tissue around the uterus)
* Peritonitis (inflammation of peritoneal membrane)
66
What are the causes of PID?
STIs
* Neisseria gonorrhoeae
* Chlamydia trachomatis
* Neisseia and chlamydia account for 25% of cases in the UK
* Mycoplasma genitalium
Non-STIs
* Vaginal flora introduced by surgery, IUD insertion etc
* Anaerobes (Prevotella, Atopobium, Leptotrichia)
* Gardnerella vaginalis
67
What are the risk factors for PID?
* Not using barrier contraception
* Multiple sexual partners
* Younger age \< 25
* Existing sexually transmitted infections
* Previous pelvic inflammatory disease
* Intrauterine device (e.g. copper coil)
* This is only a risk 4-6 weeks after insertion
* Highest risk in women w/ pre-existing gonorrhoea or trachomatis
* Low socioeconomic status
* Low educational attainment
* New sexual partner
* Appendicitis- inflammation of nearby organs can spread to the pelvis
68
How does PID present?
* May be asymptomatic
* Pelvic or lower abdominal pain- typically bilateral
* Abnormal vaginal discharge- often purulent
* Abnormal bleeding (intermenstrual or postcoital or HMB)
* Pain during sex (dyspareunia)
* Fever, rigors, chills, night sweats
* Dysuria
* Secondary dysmenorrhoea
69
What are the **examination findings of PID**?
* Pelvic/ lower abdomen tenderness
* Cervical motion tenderness (cervical excitation)
* Inflamed cervix (cervicitis)
* Muco-purulent discharge
* Adnexal mass
* Tenderness in RUQ- Fitz-Hugh
* (Fever and other signs of sepsis)
70
What are some other causes of pelvic pain beside PID?
* Gynaecological
* Ectopic pregnancy
* Ovarian cyst (torsion, rupture, haemorrhage)
* Endometriosis
* Urinary tract
* Cystitis/ UTI
* GI tract
* Appendicitis
* IBD
* IBS
* Functional pain
71
What are the investigations for PID?
* Testing for causative organisms and other STIs:
* NAAT swab for **gonorrhoea** and **chlamydia**
* NAAT swab for **mycoplasma genitalium**
* **HIV** test
* **Syphilis** test
* High vaginal swab for **BV, candidiasis and trichomonias**
* **Microscope for pus cells** on swabs from vagina or endocervix
* Pregnancy test to exclude **ectopic pregnancy**
* **Inflammatory markers (CRP and ESR) are raised in PID and can help support the diagnosis**
* *Negative swabs do not exclude the diagnosis of PID*
72
What is the management of PID?
* Diagnosis of PID and empirical antibiotic treatment should be considered and usually offered in any woman under 25 who has recent onset, bilateral lower abdominal pain associated with local tenderness on bimanual examination, in whom pregnancy has been excluded.*
* Low threshold for treatment as delay may lead to worse outcomes*
Further ix:
* STI screening including HIV
* Pregnancy test
Start antibiotics empirically (according to guidelines)
An example regimen:
* Single dose of intramuscular **ceftriaxone** 1g (to cover gonorrhoea)
* **Doxycycline** po 100mg bd for 14 days (to cover chlamydia and mycoplasma genitalium)
* **Metronidazole** po 400mg bd for 14 days (to cover anaerobes such as gardnerella vaginalis)
* Ceftriaxone and doxy will cover other bacteria e.g. H. influenzae and E.Coli
General advice:
* Rest if severe disease
* Analgesia
* IV therapy if severe clinical disease eg pyrexia \> 38⁰C, signs of tubo-ovarian abscess or pelvic peritonitis
* Avoid unprotected test until pt & partner completed treatment & follow-upRefer patients to GUM specialist service for contact tracing
73
When may PID patients require admission for IV abx / managment?
What sort of follow-up is required for PID pts?
Admit if-
* Signs of sepsis
* Pregnant
* Drainage of pelvic abscess
Example regimen
* IV Ceftriaxone 2g daily + IV doxycycline 100mg bd (oral if tolerated)
* Then Oral metronidazole 400mg bd for 14 days + Oral doxycycline 100mg bd for 14 days
* IV treatment should be continued until 24 hrs after clinical improvement & then switched to oral
Follow up-
* Review after 72 hrs
* If no/ minimal improvement- consider IV therapy
* Remove IUD if in-situ (balance with risk of pregnancy if UPSI in last 7/7, consider emergency contraception)
* Review in 2-4 weeks
* Ensure symptoms resolved
* Check compliance w/ abx
* Follow-up contacts- have they been screened & treated?
74
What are some complications of PID?
* Sepsis
* Tubo-ovarian abscess
* Infertility
* Chronic pelvic pain
* Ectopic pregnancy
* Fitz-Hugh-Curtis syndrome
* Peri-hepatitis
* RUQ pain
* More commonly associated with CT PID
75
What is Fitz-Hugh-Curtis syndrome & how does it present?
Complication of PID caused by **inflammation and infection of the liver capsule** (**Glisson's capsule**) leading to adhesions between the liver and peritoneum .
RUQ pain that can be referred to the right shoulder tip if there is diaphragmatic irritation
76
How is Fitz-Hugh-Curtis syndrome treated?
Laparoscopy to visualise and treat adhesions by **adhesiolysis**
77
What is **trichomonas vaginalis**?
Type of parasite spread through sexual intercourse - classed as a protozoan and is a single celled organism with flagella
78
What are flagella and there are they on trichomonas?
Appendages stretching from the body, similar to limbs
**Four flagella at the front** and a **single flagellum at the back** giving a characteristic appearance to the organism
The flagella are used for movement, attach to tissues and cause damage
79
Where does **trichomonas live**?
In women it is found in the vagina, urethra and paraurethral glands. Urethral infection is present in 90% of infected women, although the urethra is the sole site of infection in less than 5% of cases.
In men infection is usually of the urethra, although trichomonads have been isolated from the subpreputial sac and lesions of the penis.
80
What does trichomonas increase the risk of?
* Contracting HIV by damaging the vaginal mucosa
* Bacterial vaginosis
* Cervical cancer
* Pelvic inflammatory disease
* Pregnancy-related complications such as preterm delivery.
81
How does trichomonas infection present?
50% of cases are asymptomatic, when they do occur:
* Vaginal/ urethral discharge
* Vulval itching
* Dysuria
* Offensive odour (women)
* Dyspareunia
* Urinary frequency
* Balanitis (inflammation to the glans penis)
* Prostatitis (rarely)
82
How is the vaginal discharge in trichomonas?
* From thin and scanty to profuse and thick
* Classic: frothy and yellow-green (may have fishy smell)
83
How does the cervix appear in trichomonas?
"**Strawberry cervix**" (aka **colpitis macularis**) - cervicitis
Tiny haemorrhages across surface of the cervix, giving the **appearance of a strawberry**
84
What is the pH of the vagina in trichomonas?
Raised pH (above 4.5) similar to BV
85
How is a diagnosis of trichomonas made?
* Standard charcoal swab with microscopy (examination under a microscope)
* Detection of motile trichomonads by light-field microscopy. Vaginal discharge is collected with swab or loop, mixed with a drop of saline on a glass slide and coverslip placed on top.
* The wet preparation should be read within 10 minutes of collection. Sensitivity is highest in women presenting with vaginal discharge and a visualisation of motile trichomonads in these women indicates the presence of infection.
* Swabs taken from the posterior fornix of the vagina (behind the cervix) in women via speculum
* Self taken low vaginal swab may be used as an alternative
* Urethral swab or first-catch urine is used in men
86
What is the treatment of trichomonas infection?
* Metronidazole 2g orally in a single dose **or**
* Metronidazole 400-500mg twice daily for 5-7 days
Other
* Screening for other STIs
* Treat sexual contacts too
* Abstain from sex for 1 week until pt & partner have completed treatment & follow-up
Treatment failure- repeat course of 7 day standard therapy metronidazole
87
What are some possible causes of genital sores/ soreness?
Infective
* Candida
* Herpes simplex
* Herpes zoster
* Syphilis
* Tropical diseases
* LGV, Granuloma inguinale
Non-infective
* Trauma
* Physical
* Chemical
* Inflammatory/ immune
* Crohns
* Aphthous (stress-related)
* Drug-related
* FDE
* Topical reaction
* IVDU
* Foscamet
* Dermatological conditions
* Fixed drug reactions
* Behçets
* Apthosis
* Lichen planus
* Pemphigus
* Malignancy
88
What does the **herpes simplex virus** cause- what is the difference between HSV-1 and HSV-2?
* Both cold sores (herpes labialis) and genital herpes
* HSV1 - cold sores (herpes labialis)
* HSV2 - genital herpes, mostly an STI
89
Where does herpes simplex virus remain latent after initial infection?
Associated **sensory nerve ganglia** - typically the **trigeminal nerve ganglion** with **cold sores** and the **sacral nerve ganglia** with genital herpes
90
How is the herpes simplex virus spread?
Through **direct contact** with **affected mucous membranes** or **viral shedding** in **mucous secretions** - virus can be spread even when no symptoms are present
Asymptomatic shedding is more common in the first 12 months of infection & where recurrent symptoms are present
91
How does genital herpes present?
What would you expect to see on examination?
Up to how long can an initial infection of genital herpes last?
Pt may be asymptomatic
Initial presentation is the most severe:
* Ulcers or blistering lesions affecting the genital area
* Neuropathic type pain (tingling, burning or shooting)
* Flu-like symptoms (e.g. fatigue and headaches)
* Dysuria (painful urination)
* Inguinal lymphadenopathy
O/E:
* Blistering and ulceration of the external genitalia or perianal region (cervix/rectum)
* Tender inguinal lymphadenitis, usually bilateral
* In first episodes, lesions and lymphadenitis are usually bilateral. In recurrent disease, it is usual for lesions to affect favoured sites. They may alternate between sides but are usually unilateral for each episode. Lymphadenitis occurs in around 30% of patients
* Recurrent outbreaks are limited to the infected dermatome
Can last up to 3 weeks in a primary infection- recurrent episodes are usually milder & resolve more quickly
92
What are some complications of herpes simplex virus?
* Urinary retention esp. in females due to autonomic neuropathy
* Superinfection of lesions w/ candida and strep species (typically in 2nd week of lesion progression)
* Autoinoculation to fingers and adjacent skin eg on thighs
* Aseptic meningitis
* Emotional distress
* Recurrences
93
How is a diagnosis of herpes made?
Can be made **clinically** based on the history and examination findings
**Viral PCR** swab from a lesion can confirm the diagnosis and causative organism
* If pt is comfortable can swab lesion on same day
* However they may want to wait till the lesion heals a bit to avoid pain/ discomfort
94
What is the management of genital herpes?
Delayed ix-
* Referal to a **genitourinary medicine** specialist service
* Full STI screen
* Syphilis serology
* HIV antibody test
**Aciclovir** to treat geniral herpes (alternatives are valaciclovir and famciclovir)
* Oral antiviral drugs are indicated within 5 days of the start of the episode, while new lesions are still forming, or if systemic symptoms persist
* Aciclovir 400 mg three times daily, or
* Valaciclovir 500 mg twice daily
General advice-
* Saline bathing
* Analgesia
* Topical anaesthetic agents eg 5% lidocaine ointment may be useful to apply esp. before micturition
* Topical vaeline
* Avoid intercourse w/ symptoms (will be infectious)
* Advise to disclose to partners
* Additional oral fluids
95
What is the main issue to genital herpes during pregnancy?
Risk of **neonatal herpes simplex infection** contracted during labour and deliver - **high morbidity and mortality** (however **passive** immunity to the virus as antibodies can cross the placenta into the fetus)
Mx in pregnancy
* Primary genital herpes cpmtracted before 28 days gestation can be treated w/ aciclovir
* This is then followed by regular prophylactic aciclovir from 36 weeks gestation to reduce the risk of genital lesions during labour and delivery
* If primary genital herpes occurs after 28 weeks gestation
* Treated w/ aciclovir during the initial infection followed by immediate prophylactic regular aciclovir
* Elective caesarean section at term is advised to reduce the risk of neonatal infection
* Recurrent genital herpes during pregnancy carries a low risk of neonatal lesions
* Regular prophylactic aciclovir is still considered from 36 weeks gestation to reduce the risk of symptoms at the time of delivery
96
What does HIV stand for?
Human immunodeficiency virus
97
What does AIDS stand for?
Acquired immunodeficiency syndrome
* Occurs as HIV infection progresses and the person becomes immunodeficient leading to opportunistic infections and several AIDS-defining illnesses such as Kaposi's sarcoma
* AIDS is now mostly referred to as late-stage HIV
98
What type of virus is HIV? Describe the pathophysiology of infection
* RNA retrovirus
* HIV is a lentivirus, a genus within the family of retroviruses
* There are 2 forms
* HIV-1 is the most common, worldwide
* HIV-2, not really found outside West Africa
* HIV type 1 has glycoprotein-120 (GP-120), a viral envelope protein, which attaches to cluster of differentiation 4 (CD4) found on a number of immune cells.
* This process is assisted by binding of a co-receptor on the host cell
* HIV produces three key enzymes, reverse transcriptase, protease, and integrase
* Reverse transcriptase facilitates the transcription of viral RNA to DNA which is incorporated into the host cells own genome catalysed by integrase
* HIV-1 protease is important in protein processing
* This leads to the production of more viruses, driven by the host's own cells
99
How does an infection with HIV present?
Initial seroconversion flu-like illness within the first few weeks of infection - then asymptomatic until the condition progresses to immunodeficiency - where AIDS-definiing illnesses and oppourtunic infections occur - potentially years after the initial infection
* Common symptoms or infections that are unusually severe, prolonged, recurrent, or unexplained
* Persistent enlarged lymph nodes other than in the inguinal area
* Conditions related to immunosuppression
* Glandular fever-like illness
* Lifestyle and social risk factors for contracting HIV, such as living in, working in, or coming from a high prevalence area; men who have sex with men; and injecting drug users
100
How is HIV transmitted?
* **Unprotected** anal, vaginal or oral **sexual** activity
* **Mother to child** at any **stage of pregnancy**, birth or breastfeeding (called vertical transmission)
* **Inoculation: mucous membrane, blood or open wound exposure** to infected blood or bodily fluids, for example, through sharing needles, needle-stick injuries or blood splashed in an eye
101
What are some AIDS definining illnesses?
**Kaposi’s** sarcoma
**Pneumocystis jirovecii pneumonia** (PCP)
**Cytomegalovirus infection**
**Candidiasis** (oesophageal or bronchial)
**Lymphomas**
**Tuberculosis**
102
Who should be tested for HIV?
* Everyone admitted to hospital with an infectious disease should be tested for HIV
* Can take up to 3 months to develop antibodies to the virus after infection
* Hence HIV antibody tests can be negative for three months following exposure
* HIV testing should be offered as part of routine antenatal care
* If the pt requests a test, has a risk factor for HIV, or another STI
* To people presenting with symptoms of primary HIV or long-standing HIV infection
103
Describe the progression of HIV infection?
* Primary HIV infection (PHI) or HIV seroconversion illness often presents with a flu-like illness in the first few weeks following infection and can be mild or severe
* Pt is highly infectious during PHI
* An asymptomatic stage once symptoms of PHI resolve — some people progress rapidly to advanced HIV infection or AIDS within 1–2 years, while others may remain immunocompetent more than 10 years later
* Advanced HIV infection occurs when the number of CD4 cells is very low (less than 200 cells per microlitre) and certain opportunistic infections (such as pneumocystis pneumonia) or malignancies (such as Kaposi’s sarcoma) develop
104
What testing is typical for HIV?
* Antibody testing - simple blood test
* May get a false negative in early infection
* Test and repeat over time
* Testing for the p24 antigen can give a positive result earlier in the infection
* PCR testing for the HIV RNA levels tests directly for the number of viral copies in the blood giving a viral load
* A viral load may help to diagnose an infection within window period where antibodies have not yet developed
* CD4 count
* Gives an indication of how advanced the disease is, how immunosuppressed they are
* HIV resistance testing
* To figure out which drugs can be used?
* How is the patient: FBC, U&Es, LFT, bone profile, physical assessment, fundoscopy, urine dip
105
How is HIV disease monitored?
CD4 count
* These cells are destroyed by the virus
* 500-1200 cells/mm3 is the normal range
* \<200 cells/mm3 is considered end stage HIV and puts the patient at high risk of opportunistic infections
Viral load
* Number of copies of HIV RNA per ml of blood
* "Undetectable" refers to a viral load below the lab's recordable range (usually 50-100 copies / ml)
* Can be in the hundreds and thousands in untreated HIV
106
What is HIV treatment aimed at?
Achieve a **normal CD4 count** and **undetectable viral load**
107
How would you treat physical health problems (e.g. routine chest infection) on patients with **normal CD4** and an **undetectable viral load on ART?**
As you would a HIV negative patient - check for medication interactions
108
What are some of the different classes of Highly Active Anti-Retrovirus Therapy (HAART) medications?
* Protease inhibitors (PIs)
* Always co-prescribed with a booster resulting in increased risk drug interactions
* Integrase inhibitors (IIs)
* Block the action of integrase, a viral enzyme that inserts the viral genome into the DNA of the host cell
* Eg raltegravir, elvitegravir, dolutegravir
* Nucleoside reverse transcriptase inhibitors (NRTIs)
* Often the 'backbone'
* Eg tenofovir, abacavir, lamivudine
* Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
* Side effects: p450 enzyme interaction (nevirapine induces), rashes
* Entry inhibitors (EIs)
* Prevent HIV-1 from entering and infecting immune cells
109
Describe the management of HIV? Include general advice
Triple Anti-retroviral therapy
* 3 drugs- typically NRTIs eg tenofovir and emtricitabine plus a third agent
Additional mx
* Prophylactic **co-trimoxazole** (septrin) is given to patients with a CD4 of under 200/mm3 to protect against **pneumocystis jirovecii pneumonia (PCP)**
* Patients with HIV have increased risk of developing CVD so close monitoring of **risk factors** and **blood lipids** - appropriate treatment (e.g. statins) may be required to reduce their risk of **developing CVD**
* Yearly **cervical smears** for women with HIV as it predisposes patients to developing **HPV and cervical cancer**
* **Vaccinations** up to date, including influenza, pneumococcal, hep A and B, tetanus, diptheria and poli vaccines - patients should **avoid live vaccines**
General advice
* Advise condoms for vaginal and anal sex, dams for oral sex, even when both partners are HIV positive
* If the viral load is undetectable, transmission through unprotected sex is unheard of although infection is not impossible- partners should have regular HIV tests
110
If both partners are HIV positive, do they still need to use condoms?
Yes for **vaginal and anal sex and dams for oral sex**
If the viral load is undetectable then transmission through unprotected six is unheard of - even in extensive studies - infection is **not impossible**
111
How may patients who are HIV positive concieve safely?
Techniques like **sperm washing** and **IVF**
112
How may a HIV positive mother give birth? What are some factors that reduce vertical transmission?
* The mother’s viral load will determine the mode of delivery:
* Normal vaginal delivery is recommended for women with a viral load \< 50 copies / ml
* Caesarean section is considered in patients with \> 50 copies copies / ml and in all women with \> 400 copies / ml
* IV zidovudine should be given during the caesarean if the viral load is unknown or there are \> 10000 copies / ml
Factors which reduce vertical transmission (from 25-30% to 2%)
* Maternal antiretroviral therapy
* Mode of delivery (caesarean section)
* Neonatal antiretroviral therapy
* Infant feeding (bottle feeding)
113
What prophylaxis against HIV for newborns is there?
Depends on mothers viral load:
* **Low-risk babies**, where the mother’s **viral load is \< 50 copies** per ml, are given **zidovudine** for **four** weeks
* **High-risk babies**, where the mother’s viral load is **\> 50 copies** / ml, are given **zidovudine, lamivudine and nevirapine for four weeks**
114
Can HIV be transmitted during breast feeding?
**Yes,** even if the mother's viral load is undetectable
Baby should be bottle fed to reduce this risk
115
What is the window of oppourtinity for post-exposure prophylaxis for HIV?
Less than 72 hours - it's **not 100% effective**
Risk assessment of probability of developing HIV balanced against the **side effects of PEP**
116
What does post exposure prophylactic therapy for HIV involve?
Combination of ART therapy, current regime:
- **Truvada** (emtricitabine and tenofovir) and **raltegravir** for 28 days
117
Post HIV exposure, when are HIV tests done?
**Immediately** and also a **minimum** of **three months** after exposure to **confirm a negative status** - individuals should **abstain** from unprotected sexual activity for a minimum of three months until **confirmed as negative**
118
What bacteria causes syphillis?
* Treponema pallidum
* Spirochete - type of spiral-shaped bacteria - gets in through skin or mucous membranes, replicates and then disseminates throughout the body
* Mainly an STI
119
22 year old male, painless penile ulcer present for 1 week.
* Associated inguinal lymphadenopathy.
* Insertive anal intercourse w/o condom 4 weeks ago with casual male partner
* Otherwise well
Differentials?
* Syphilis
* Herpes simplex
* Lymphogranuloma venerum
* Aphthous ulceration
* Trauma
120
How long is the incubation period for syphillis?
The incubation period is between 9-90 days
**21 days** on average
121
How can syphillis be contracted?
* Oral, vaginal or anal sex involving direct contact with an infected area
* Vertical transmission from mother to baby during pregnancy
* Intravenous drug use
* Blood transfusions and other transplants (although this is rare due to screening of blood products)
122
What are the different stages / types of syphillis?
Primary
* Painless ulcer called a **_chancre_** at the original site of infection (usually on the genitals)
Secondary
* If primary syphilis is untreated, 25% will develop secondary syphilis
* Occurs 4-10 weeks after initial chancre
* **_Multi-system_**: systemic symptoms, particularly of the skin and mucous membranes - symptoms can resolve after 3-12 weeks and the patient can enter the latent stage
Latent
* Secondary syphilis will resolve spontaneously in 3–12 weeks and the disease enters an **_asymptomatic_** latent stage
* Approx 25% pts will develop a recurrence of secondary disease during the early latent stage
Tertiary / Late disease
* Occurs in approximately 1/3 untreated pts
* **_20-40 years_** after initial infection
* Divided into gummatous, cardiovascular and neurological complications
* See attached table
Neurosyphilis
* If the infection involves the CNS, presenting with neurological symptoms
123
Describe some signs of primary syphilis?
* A painless genital ulcer (chancre) develops from a single papule
* Anogenital, single, painless and indurated with clean base, non purulent
* Can be multiple, painful and purulent (usually extra-genital)
* Resolve over 3-8 weeks
* Local inguinal lymphadenopathy
124
How does **secondary syphilis** present?
Typically starts after the chancre is healed:
* Maculopapular rash, widespread, may be itchy, can affect palms and soles
* Condylomata lata (grey wart-like lesions around the genitals and anus, highly infectious)
* Mucous patches (buccal, lingual and genital)
* Low-grade fever
* Lymphadenopathy
* Alopecia (localised hair loss)
* Oral lesions
* Hepatitis
* Splenomegaly
* Glomerulonephritis
* Neurological complications- acute meningitis, cranial nerve palsies, uveitis, optic neuropathy, interstitial keratitis & retinal involvement
125
How does tertiary syphilis present?
**Gummatous lesions** (gummas are granulomatous lesions that can affect the skin, organs and bones)
## Footnote
**Aortic aneurysms**
**Neurosyphilis**
126
How does neurosyphilis present?
* Headache
* Altered behaviour
* Dementia
* Tabes dorsalis (demyelination affecting the spinal cord posterior columns)
* Ocular syphilis (affecting the eyes)
* Paralysis
* Sensory impairment
127
What is argyll-robertson pupil?
* A specific finding in neurosyphilis
* A constricted pupil which accommodates when focusing on a near object but doesn't react to light - often irregularly shaped - commonly called a 'prostitutes pupil' because it accomodates but doesn't react and due to its relation to neurosyphilis
128
How is a diagnosis of syphilis made?
* **Blood:**
* **Antibody testing** for antibodies to the **T.pallidum** bacteria can be used as a screening test
* Treponemal enzyme immunoassay (EIA)
* Treponema pallidum particle agglutination assay (TPPA)
* Rapid plasma reagin test (RPR)
* Samples from lesions can be tested for T. pallidum with:
* **Dark ground microscopy**
* ****Less reliable for rectal and non-penile genital lesions
* Cannot be used for oral lesions due to presence of commensal treponemes
* **Treponemal polymerase chain reaction** (PCR)
* Can be used on oral or other lesions where commensal treponemes may also be present
* Full STI screen including HIV testing
129
Which tests can be used to assess the **quantity** **of antibodies** being produced by the body to an infection with syphilis?
**Rapid plasma reagin** (RPR) and **venereal disease research laboratory** (VDRL) (non-specific but sensitive)
Higher number indicates a greater chance of active disease
130
What are the key things to ask in a history to aid with making a diagnosis of syphilis?
* Full sexual hx
* Direct questioning of symptoms of syphilis
* Explore previous sypihlis diagnoses & treatment
* Previous syphilis testing & tests used
* Potential for previous infection for non-venereal T.pallidum infection
* Obstetrics hx
131
What does the management of a patient with syphilis involve?
* A single, deep IM dose of benzathine benzylpenicillin is the standard treatment
* Ceftriaxone, amoxicillin, doxycylcine are all alternatives
* For late latent, cardiovascular and gummatous syphilis- benzathine penicillin is given weekly for 3 weeks (3 doses, IM)
Other mx-
* Full screening for other STIs
* Advice about avoiding sexual activity until treated
* Contact tracing
* Prevention of future infections
132
What is a side effect of syphilis treatment?
The Jarisch-Herxheimer reaction is sometimes seen following treatment
* Fever, rash, tachycardia after the first dose of antibiotic
* In contrast to anaphylaxis, there is no wheeze or hypotension
* It is thought to be due to the release of endotoxins following bacterial death and typically occurs within a few hours of treatment
* No treatment is needed other than antipyretics if required
133
What are alternative medications for syphilis e.g. late syphilis and neurosyphilis?
**Ceftriaxone**
**Amoxicillin**
**Doxycycline**
134
What are the key things to ask in a sexual hx?
* Past hx of STI
* Last episode of sex
* Gender
* Sexual contact- regular or causal?
* Duration of sexual relationship
* ? condoms
* Type of sex
* Partner symptoms
* Partner details for contact tracing
135
What are some risk factors for contracting a blood borne virus?
* Hep B, Hep C, HIV
* IVDU/ partner IVDU
* Sexual partner MSM
* Swingers
* Partners from high risk countries/ with known infection
* Blood products before 1985 or abroad
* Paid for/ been paid for sex
* Tattoos/ piercings- reputable place/ disposable needles/ abroad
136
What is the rationale for partner notification regarding STIs?
* Break the chain of transmission
* Prevent re-infection of the index pt
* Prevent complications of untreated infections
* Moral duty/ ethics to inform?
137
If a patient has an STI but is worried about telling their partner(s) and wishes to remain anonymous, what can you offer them?
* Contact slips/ cards
* Can provide anonymity and confidentiality for the index patient
* Enable sexual contacts to seek medical advice or treatment
* Inform the contact’s clinic of index patient’s diagnosis, and date of diagnosis
* Enable cross-referencing and evaluation of partner notification
138
Describe the pathophysiology of Human Papilloma Virus (HPV)?
* Cells of the basal layer of the epidermis are invaded by HPV, through activity of 2 viral genes called E6 and E7, which usually inhibit p53 and pRbcausing uncontrolled cell growth of the epithelial cells leading to warts and lesions
* Some types of HPV can cause squamous epithelial cells to become koilocytes which are pre-cancerous
* A latent virus phase begins and may lay dormant for months/years
* Following latency, production of viral DNA, capsids, and particles begins resulting in development of the genital warts
* Virus escapes detection as only replicates in superficial layer where cells shed and infect other cells
139
What is the mode of transport of HPV?
* Nearly always sexual contact
* Infectivity of sexually acquired wards is ~60^
* Incubation period 2 weeks-8 months
* Average incubation time 3/12
* Condoms do not give full protection against genital warts- transmission through skin to skin contact
140
What are the important types of HPV?
Subtypes 16,18 & 33 are particularly carcinogenic.
* 16 & 18- 70% cervical cancers, targeted with HPV vaccine
The other most common subtypes (6 & 11) are non-carcinogenic and associated with genital warts.
141
When HPV infects endocervical cells, they may undergo changes resulting in the development of koilocytes. Describe the characteristics of these cells?
* Enlarged nucleus
* Irregular nuclear membrane contour
* The nucleus stains darker than normal (hyperchromasia)
* A perinuclear halo may be seen
142
What are your differentials for genital lumps?
Normal anatomy
* Fordyce spots, pearly papules, skin tags, follicles
* Tyson's glands, Vestibular papillosis
* Haemangiokeratoma, skin tags
* Sebaceous cysts
Other things to consider
* Conylomata Lata (syphilis)
* VIN, PIN or squamous cell carcinomas
* Molluscum contagiosum
143
What is the mx of HPV warts?
* Screen for other STIs
* Detailed explanation of condition
* Significant psychological distress sometimes
* Reassure that HPV often clears spontaneously
* Reassure that the strains that cause warts are generally not those associated with HR HPV (and therefore enhanced cervical cytology not required)
* Reassure that can occur in the context of monogamous relationship due to dormant phase
* Condom use with regular sex partners has not been shown to affect the treatment outcome but may prevent transmission to uninfected partners
* Treatment is largely aimed at getting rid of the appearance of the warts but will not clear the virus, body clears over time
* Destruction (cryoRx)
* Anti-mitotic agents (Podophyllotoxin)
* Immune modifiers (Imiquimod cream)
* Surgery
144
What are the causes of epididymo-orchitis?
Male, \<35: STI- neisseria gonorrhoea or chlamydia
Male, \>35: UTI, particular risks include recent catheter or instrumentation
145
What are the clinical features of epididymo-orchitis & what is the key differential diagnosis?
Clinical features
* Unilateral scrotal pain and swelling of relatively acute onset
Differential: testicular torsion
* Order urgent doppler ultrasound of the scrotum to assess the arterial blood flow
146
Describe the treatment of epidiymo-orchitis?
* Ceftriaxone 500mg IM single dose, plus
* Doxycycline 100mg orally bd for 10-14 days
147
What are some barriers to taking a sexual hx and how can you overcome these barriers?
* Presence of a third party
* Lack confidence
* Clinician's gender
* Time pressure
* Lack of opportunity
* Societal taboos
* Pt too young
* Inadequate training in sexual health
* Shame & embarassment
* Fear of offending pt
* Clinician's personal discomfort
Overcoming these barriers
* Safe private environment
* No friends or family!
* Clarifying limits of confidentiality & reassuring pt
* Be clear & specific with your Qs
* Explaining the rational of asking personal Qs
148
List some causes of vaginal discharge
Infective
* BV
* Candida
STI
* CT
* NG
* Trichmonas
* HSV
Non-infective
* Foreign bodies- retaiend tampons, condoms
* Cervical polyps and ectopy
* Genital tract malignancy
* Allergic reactions
* Fistulae
149
Key things to ask in seuxal hx?
* Contraception
* Cycle- last period
* Children
* Cytology- last smear
150
Most important thing to exclude in recurrent candidiasis?
A blood test to exclude diabetes should be considered in women with recurrent vaginal candidiasis - HbA1C
