Sexual + Reproductive Health Flashcards
What proportion of couples experience infertility?
15%
What is the definition of infertility?
- failure to achieve pregnancy within 12 months of regular unprotected intercourse in women aged <35 - or within 6 months in a women aged > 35
Clinical factors which increase risk of subfertility
- oligomenorrhoea - amenorrhoea - known or suspected peritoneal disease - severe endometriosis - multiple surgeries - loss of an ovary - previous chemotherapy or radiotherapy
Which hormone should be tested for if ovulation is uncertain?
- serum progesterone should be performed mid-luteal phase (seven days before next expected menses)
What history would confirm ovulatory cycles?
- history of regular cycle intervals of between 21-35 days with consistent characteristics and moliminal symptoms - in these patients serum progesterone is not required to confirm ovulation
Which investigations should be undertaken for women with oligo/amenorrhoea?
- FSH - LH - oestradiol (E2) - TSH - prolactin
Which blood tests should be ordered in suspected PCOS?
- free testosterone, free androgen index, DHEAs - need to rule out non-classical congenital adrenal hyperplasia with 17-hydroxyprogesterone concentration - in cases of severe hyoerandrogenism consider excluding Cushing’s disease
Ovarian reserve testing
- quantity and quality are both important factors! - oocyte number peaks at 20 weeks gestation, this declines throughout reproductive life resulting in menopause - routine markers: day 2-4 FSH, E2, AMH and assessment of antral follicle count on TV ultrasound - provides information r.e. predicted response to assisted reproductive treatment - does not predict spontaneous conception!
Day 2-4 (basal) FSH as measure for ovarian reserve
- indirect marker of ovarian reserve - based on feedback inhibition of pituitary FSH secretion - if diminished ovarian reserve ovarian steroidogenesis will be insufficient to suppress early follicular FSH - measurement of E2 increases FSH sensitivity - E2 will be raised with low ovarian reserve due to increased FSH but causes pituitary FSH suppression meaning FSH falls within normal range
Where is AMH produced?
- by granulosa cells of the pre-antral and antral follicles - hence reflexes the size of primordial follicle pool - serum AMH concentration is inversely related to age - can be tested on any day of cycle
Antral follicle count on US as measure for ovarian reserve
- total number of follicles in both ovaries with mean withdth of 2-10mm on USS - assessment in early follicular phase avoids underestimation of follicular number
Which USS features are suggesting of andemomysos?
- venetian blind shadowing - globular uterine appearance - loss of junctional zone definition - “question mark sign”
What are the recommended preliminary fertility investigations?
- day 2-4 FSH, LH, oestradiol - AMH - TSH - transvaginal USS with AFC and anatomy and to check for deep infiltrating endometriosis - blood group and antibody screen - rubella and varicella igG - hep b/c/HIV/syphilis serology=
How long should women defer contraception for after rubella or varicella immunisation?
28 days
What is the most important determinant for women considering oocyte cyropreservation?
AGE! Infertility is most common in >35 year age group - frozen eggs have survival rates of >84% compared to IVF
How long should women defer contraception for after rubella or varicella immunisation?
28 days
What is the most important determinant for women considering oocyte cyropreservation?
AGE! Infertility is most common in >35 year age group - frozen eggs have survival rates of >84% compared to IVF
Which forms of contraception are first line options 0-6 week post partum (breast feeding or not)?
Implanon and POP
Which form of contraception is generally recommended to be avoided in smokers?
COCP - contraindicated in women > 35 who are smoking > 15 cigarettes/day (cat 4) - however still increased risk if smoking <15/day or have quit smoking for <1 year (cat 3) - if have quit for > 1 year (cat 2) - women < 35 and smoking (cat 2)
What are the categories for contraception in patients with previous VTE?
Copper IUD = cat 1 Mirena/implanon/depot/POP = cat 2 COCP = cat 4
When is the COPC contraindicated in patients with HTN?
- sustained BP > 160/ > 100 = cat 4 - BP 140-159/90-99 OR even if hypertension is well managed COPC is still cat 3
What are the categories for contraception in patients with previous VTE?
Copper IUD = cat 1 Mirena/implanon/depot/POP = cat 2 COCP = cat 4
What category is the COCP in patients with migraine with aura?
CAT 4!
What are the categories in patients with a history of breast cancer?
Copper IUD = cat 1 Current breast cancer = any hormonal contraception is cat 4 Past breast cancer = any hormonal contraception is cat 3
Which contraception is contraindicated in patients with family history of breast cancer?
Nil, all methods cat 1 Unless known BRCA carrier > copper IUD cat 1 > progesterone contraception cat 2 > COCP cat 3
What are the WHO classes of anovulation?
- Hypogonadotropic anovulation 2. Normogonadotropic anovulation 3. Hypergonadoropic anovulation
How common is idiopathic male infertility?
30-40% of male infertility cases
What are the WHO classes of anovulation?
- Hypogonadotropic anovulation 2. Normogonadotropic anovulation 3. Hypergonadoropic anovulation
Causes of hypergonadoropic anovulation
- premature ovarian insufficiency HIGH: FSH, E2, ?LH
Causes of normogonadotropic anovulation
- PCOS - congenital adrenal hyperplasia NORMAL: FSH, LH, E2
What are the classes of male infertility by mechanism?
- Pre-testicular - Testicular - Post-testicular
What is Kallmann syndrome?
Hypogonadortophic hypogonadism - results fro failure of hypothalamic-pituitary axis to stimulate normal gonadal function
What is Kallmann syndrome?
Hypogonadortophic hypogonadism
Testicular causes of male infertility
- varicocele - cryptorchidism (undescended teste) - testicular cancer - radiation - chemotherapy/pharmacological - genertic azoospermia or oligospermia - Y-chromosome microdeletions - Klinefelter syndrome - infection/injury/trauma - primary cilia dyskinesia - sertoli cell only syndrome - anti-sperm antibodies
What is Klinefelter’s syndrome?
47 XXY - additional copy of the X chromosome - features: infertility, small and poorly functioning testicles
Post-testicular causes of male infertility
- coital - retrograde ejaculation - congenital abscence of vas deferens - obstruction - vasectomy or iatrogenic damage to vas deferens - Young’s syndrome - nerve or spinal cord injury - systemic disease
Describe the baseline endocrine evaluation of suspected male infertility
- FSH - morning testosterone levels
What further investigation should be done if low morning testosterone?
- repeat morning testosterone level - free testosterone - LH - prolactin
What is the role of endogenous testosterone in patients experiencing infertility?
- exogenous testosterone is contraindicated - even if hypogonadism is identified! - spermatogenesis requires level of intra-testicular testosterone and exogenous testosterone inhibits the production of LH which feeds back to suppress the endogenous testicular testosterone function
Key features on physical examination in male fertility
- secondary sexual characteristics: hair distribution, muscle mass, adiposity - gynaecomastia - abdomen/inguinal: scars from previous surgery - penis: position of meautus - scrotum: testicular size, consistency, location, presence of masses - epididymus: induration, cyst, engorgement - vas deferentia: agenesis, atresia - present of varicoele
Semen analysis
- the most important test - adequate collection of sample is paramount - 2-3 days of abstinence prior may be optimal - collection should be straight into sterile container - need to be analysed within one hour - if normal = single sample is preferable - if abnormal = repeat analysis after 1-3 months if mild/mod derangement or in 2-4 weeks if severe derangement (oligospermia or azoospermia)
Investigation of leukocytes in semen analysis
- urine culture - urine PCR for chlamydia and gonorrhoea - semen culture - causes: infections of male accessory glands (urethritis, prostatitis, orchitis, epididmyitis) are potentially treatable causes of infertility
When is scrotal US indicated?
- indicated in patients with infertility and risk factors for testicular cancer - low threshold for US is appropriate - consider if first degree relative has hx of testicular cancer
What hormone profile would you expect in hypogonadotrophic hypogonadism?
FSH: low LH: low Testosterone: low Prolactin: normal/high
What hormone profile would you expect in abnormal spermatogenesis?
FSH: high or normal LH: normal Testosterone: low Prolactin: normal
What hormone profile would you expect in testicular failure?
FSH: high LH: high Testosterone: low Prolactin: normal (similar to hypergonadotrophic anovulation in women)
What hormone profile would you expect in prolactinoma?
FSH: normal or low LH: normal or low Testosterone: low Prolactin: high
What is a normal sperm concentration and sperm count?
Sperm concentration > 15 million/ml Sperm count > 39 million
What is normal morphology or total motility for a semen analysis?
Normal morphology > 4% Total motility > 40%
What is a normal leukocyte count for a semen analysis?
<1.0 x 10`6/mL
Lifestyle recommendations for possible male infertility
- alcohol: up to 3-4 units/day unlikely to affect sperm quality but excessive consumption is detrimental - smoking: associated with decreased semen quality - obesity: BMI >30 likely to reduce fertility - scrotal temperature: exposure to elevated temps is associated with reduced semen quality - drugs: testosterone, opioids, psychotrophic agents, cannabis - occupations involving radiation/head, vibration and pesticides may reduce fertility - frequency of intercourse: vaginal intercourse timed around ovulation or every 2-3 days
Specialist testing for male infertility
- post-ejaculatory urine analysis - TRUS - testicular FNA - Anti sperm antibodies - genetic testing
Karyotyping in male infertility
- indicated in severe oligospermia (<5million/L) - most common abnormality is Klinefelter syndrome (47, XXY), responsible for 2/3 of male infertility
What is the median age of menopause in Australia?
51
Which contraceptions are generally not recommended in women > 50?
- combined OCP - vaginal ring - depot injection
What are the UKMEC categories for contraception use?
MEC 1 = no restriction for use MEC 2 = advantages out weight theoretical/proven risk MEC 3 = risks outweigh the advantages, provision requires expert clinical judgement and or referral to specialist MEC 4 = represents unacceptable health risk
Levonorgestrel IUD and perimenopause
- notable contraindications: current or present breast cancer (MEC 4 and 3) - if inserted in patients >45 can leave for 7 years in those who continue to bleed until menopause if amenorrhoeic - also licensed (not PBS though) as part of HRT to protect endometrium in women using oestrogen for vasomotor symptoms - always r/o other causes of inter-menstrual/abnormal bleeding!
Copper intrauterine device
- highly effective contraception without hormonal side effects or risks - also provide emergency contraception within five days of unprotected intercourse - not PBS listed and are associated with heavier menstrual bleeding - any copper IUD inserted > 40 can be retained until menopause (off label use) - complications: perforation, infection, failure, expulsion
Implanon in perimenopause
- can be used until menopause - contraindicated in breast cancer - not linked to reduction in BMD - be wary to have low threshold to investigate symptoms of troublesome bleeding in patients >40 - nil indication to extend implant use in perimenopause women - amenorrhea cannot be used as indicator of menopause in implanon in situ!
COCP and perimenopause
- can be used by medically eligible women in their 40s (MEC 2) but not generally recommended > 50 - baseline risk of VTE, AMI and stroke are significantly higher in older women - should choose lowest hormone dose
High risk conditions + COCP
Multiple vascular risk factors = MEC 3 > 35 and smoking = MEC 3/4 BMI 30-34 = MEC 2 BMI > 35 = MEC 3 Controlled HTN = MEC 3 BP 140-159/90-99 = MEC 3 BP >160/>100 = MEC 4 Hx of IHD/stroke/TIA = MEC 4 FHx of VTE < 45 = MEC 3 FHx of VTE >45 = MEC 2 Breast cancer = previous MEC 3, current MEC 4 Diabetes = MEC 2
Which COPC have lowest VTE/AMI/stroke risk?
20mcg ethinyl oestradiol + levornogestrel 100mcg - however there is a higher risk of breakthrough bleeding
POP in perimenopause
- more effective in women > 40 than in younger women - 3 hour window to be taken every day - works to thickening cervical mucus
Advice on ceasing LNG-IUD, POP and implant in women > 50
- amenorrhoeic for > 12 months - check 2 x FSH levels at least 6 weeks apart - if both > 30 advice that contraception is only required for a further 12 months OR - continue until aged > 55
Advice on ceasing Cu-IUD or barrier methods in women > 50
- stop method after 12 months of amenorrhoea
Advice on ceasing depot in women > 50
- generally not recommended in women > 50 - either switch to non-hormonal method until amenorrhoea for 24 months (2 years) OR - switch to alternative progesterone only method and check FSH x 2 when amenorrhoeic for 12 months
Advice on ceasing COCP
- generally not recommended in women > 50 - switch to non-horomonal method until amenorrhoea for 12 months OR - switch to POP, LNG-IUG or implant and repeat FSH when amenorrhoeic for 12 months
Emergency contraception options
- 1.5mg levonorgestrel up to 72 hours after unprotected sex, but effective up to 96 hours - ulpristal acetate has superior efficacy and licensed up to 120 hours after unprotected sex - both are available without prescription - Cu-IUD can also provide effective emergency contraception
What is ulipristal acetate?
- selective progesterone receptor modulatory - partial agonist - used for emergency contraception - taken as a single dose of 30mg as soon as possible after unprotected intercourse - has efficacy for up to 5 days later (120 hours) compared to the 72 hours from the levonorgestrel ECP - action is to prevent or delay ovulation and it does this more effectively than levonorgestrel
At what stage during the cycle do emergency contraceptions affect ovulation?
- after LH surge neither levonorgestrel or ulipristal acetate have any effect on ovulation
Common side effects of ulipristal acetate?
- headache, nausea, abdominal pain, dsymenorrhea - generally mild - safety comparable to lebvonorgestrel - delay breastfeeding for 1 week after ulipritsal
Starting contraception after ulipristal acetate?
- shouldn’t start hormonal contraceptive for at least 5 days (OR unit next period to simplify) - hence need to either use barrier methods or abstain - all patients should be encouraged to repeat pregnancy test 3 weeks after starting the new contraceptive
Breastfeeding and contraception
- no need to cover with emergency contraception up to 3 weeks postpartum - “lactational amenorrhoea”: fully breastfedding day and night with no long intervals between feeds day or night (>4 hrs during the day or > 6 hrs during night) and < 6 months post partum
Advice to give patients r.e. emergency contraceptions
- take a soon as possible, if vomiting within 3 hours take another one - no ECP is 100% effective (risk of pregnancy for UA 0.9% if within 24 hours and 2.3% with levonorgestrel) - period may come early or late - take a pregnancy test if period is > 7 days late - either start OCP 5 days after UA or immediately if levornogestrel - opportunistic STI screen should be offered
What are the 3 main recommendations when caring for a victum of sexual assault?
- Offer first-line support to women and men who are survivors of sexual assault by any perpetrator 2. Consider and ask about post trauma responses by assessing for mental health problems – acute stress, PTSD depression, alcohol and drug use problems, suicidality or self-harm and offering appropriate support and treatment 3. Offer emergency contraception if within 72 hours of assault and offer all women sexually transmitted infection investigation, prophylaxis and treatment as appropriate
Management of sexual assault
- baseline STI screening: HIV, hepB, syphilis, chlamydia, gonorrhoea, trichomonas - azithromycin 1g PO - offer hep B vaccination if required - treated for gonorrhoea, syphilis and HIV if at high risk
Review program post sexual assault
- review in 2-3 days: assess injury healing if evident - 2 weeks: test results, pregnancy testing, coping - 3 months: follow up serology for HIV, hep B and syphilis - 6 months: follow up for hep C if high risk
What is the most commonly communicable disease in Australia?
Chlamydia - greatest risk <30 - frequently asymptomatic
What are the common presentations of chlamydia?
Men: 50% asymptomatic, dysuria, urethral discharge, testicular pain, ano-rectal symptoms Females: 75% asymptomatic, dysuria, vaginal discharge, pelvic pain, intermenstrual bleeding, post coital bleeding
Complications of chlamydia
Men: epidymo-orchitis, reactive arthritis (arthralgia, rash on soles, balanitis, psoriatic rash) Females: PID, infertility, ectopic pregnancy, reactive arthritis
Diagnosis of chlamydia in males
- NAAT: first pass urine - consider pharyngeal and ano-rectal swabs if MSM
Diagnosis of chlamydia in females
- NAAT: endocervical test (best test if examined) - NAAT: self collected swab if not examined - NAAT: first pass urine (not as sensitive as self collected swabs)
Clinical indications for chlamydia testing
- < 30 and sexually active - partner change in last 12 months - history of STI in last 12 months - sexual partner with STI - increased risk of STI complication (TOP, IUD insertion) - signs and symptoms of STD - requesting STI screening
Empirical treatment of chlamydia
- doxycycline 100mg BD for 7 days OR - azithromycin 1g PO STAT If urethritis symptoms use doxycycline while awaiting test results. Treat patient and partner/s without waiting for results
Advice after diagnosis and treatment of chlamydia
- no sexual contact for 7 days after treatment - no sex with partners from the last 6 months until partners have been tested and treated - contact tracing back to 6 months prior
Treatment of chlamydia in pregnant women
Azithromycin 1g PO STAT
Is a clearance confirmation required for patients treated for chlamydia?
NO Unless pregnant or diagnosed with rectal chlamydia - in these circumstances repeat NAAT in 4 weeks
Genital warts
- HPV - skin to skin transmission - generally caused by HPB 6 and 11 - long latency period hence doesn’t imply infidelity - Men: warty growths, may be itchy, rarely malignant - Women: warty growths, cervical lesions, cervical cancer - nil specific diagnostic test, clinical diagnosis
Treatment of genital warts
- podophyllotoxin 0.15% cream of 0,5% paint BD for 3 days and then 4 days off, repeated weakly for 4-6 cycles until resolution - cream best perianal area, introital area or under foreskin OR Imiquimod 5% topically 3 times per week at bed time (wash after 6-10 hours) until resolution (up to 16 weeks)
What is the most common STI in MSM?
Gonorrhoea
What is the most common STI in patients returning from high prevalence areas overseas?
Gonorrhoea
What is the most common STI in young heterosexual First Nations people living remote or very remote?
Gonorrhoea
Cause and clinical presentation of gonorrhoea
Cause: neisseria gonorrhoeae (GNB) Men: urethral discharge, dysuria, conjunctivitis (sight threatening) Females: vaginal discharge, dyspareunia with cervicitis, conjunctivitis (sight threatening)
Complications of gonorrhoea
Men: epidymo-orchitis, disseminated disease (macular rash with necrotic pustules, septic arthritis), meningitis or endocarditis, prostatitis Females: PID, disseminated disease (macular rash with necrotic pustules, septic arthritis), meningitis or endocarditis