SEXUAL/REPRODUCTIVE MEDICINE Flashcards
What is the triple swab assessment?
High vaginal swab
Endocervical swab
Chlamydia swab
What does high vaginal swab diagnose?
Trichomonas vaginalis, BV, candida, group b strep
What does endocervical swab diagnose?
Gonorrhoea
What is contact tracing?
Identification and notification of recent sexual contacts for screening and treatment, usually by patient
Asymptomatic female STI check? (3)
Self taken swab (can be clinician if preferred) for gonorrhoea and chlamydia
Bloods for syphilis and HIV
Test for hep B/C if at risk
Asymptomatic male STI check? (3)
First void urine for chlamydia and gonorrhoea
Bloods for syphilis and HIV
Hep b/c if at risk
Asymptomatic gay male STI check? (6)
Throat swab First void urine Rectal swab Bloods for HIV and syphilis Vaccine for hep b offered Hep C if at risk
Symptomatic STI check? (10)
Examine external genitalia, swab from any ulcer/fissure for herpes
Female: Speculum exam of cervix if no herpes, clinician vaginal swab
Male: first void urine
Rectal, urethral, throat swabs if high risk for gonorrhoea
Bimanual exam if indicated
Bloods for syphilis and HIV
MSU if UTI/blood suspected
Pregnancy test if suspected
Hep/c if at risk
Symptoms of chlamydia trachomatis? (3)
Usually asymptomatic
Urethritis
Vaginal discharge
Complications of untreated chlamydia? (5)
PID Tubal damage Subfertility Chronic pelvic pain Reiter's syndrome - urethritis, arthritis, conjunctivitis
Management of chlamydia?
Azithromycin or doxycyline
Symptoms of neisseria gonorrhoeae? (5)
Usually asymptomatic Vaginal discharge Urethritis Bartholinitis Cervicitis
Type of bacteria in gonorrhoea
Gram negative diplococcus
Complications of gonorrhoea? (2)
Bacteraemia
Septic arthritis
Treatment of gonorrhoea?
IM ceftriaxone
What are genital warts caused by?
HPV human papillomavirus
What types of HPV are associated with CIN?
16 and 18
Treatment of genital warts?
Cream - podophyllin
Cryotherapy or electrocautery
What is thrush?
Infection with candida albicans fungus, most common vaginal infection
Risk factors for thrush? (3)
Pregnancy
Diabetes
Antibiotics
Symptoms of thrush? (5)
Cottage cheese discharge Itching and irritation Superficial dyspareunia Dysuria Inflammation
Treatment of thrush?
Topical imidazoles - clotrimazole
Oral fluconazole
What is bacterial vaginosis?
Normal lactobacilli in the vagina are overgrown by other mixed flora
Symptoms of bacterial vaginosis? (4)
Grey white discharge
Fishy odour
Raised pH
Clue cells on microscopy
Treatment of BV?
Metranidozole
What type of herpes commonly causes genital infection?
HSV2
Symptoms of primary herpes infection? (4)
Multiple small painful ulcers around the introitus
Lymphadenopathy
Dysuria
Systemic symptoms
Complications of herpes? (4)
Secondary bacterial infection
Aseptic meningitis
Acute urinary retention
Neonatal herpes has high mortality
Explain herpes reactivation?
After primary infection virus lies dormant in dorsal root ganglia
In 75% it reactivates
Secondary attacks are less painful and severe
Treatment of herpes?
Aciclovir
What causes syphilis?
Infection with treponema pallidum
Symptoms of primary syphilis?
Solitary painless vulvar or penile ulcer - chancre
What happens if primary syphilis is left untreated?
Secondary syphilis - rash, flu like symptoms, warts around genitals and mouth
What happens after secondary syphilis?
Latent syphilis
Tertiary syphilis many years later
Symptoms of tertiary syphilis?
Aortic regurgitation, dementia, neurological effects, skin and bone gummata (swellings)
Treatment of syphilis?
IM penicillin
What is trichomonas vaginalis?
Flagellate protozoan
Symptoms of trichomonas? (5)
Offensive grey-green discharge
Vulval irritation
Superficial dyspareunia
Cervicitis
Treatment of trichomonas?
Metronidazole
Risk factors for HIV? (4)
Multiple sexual partners
Migration from high risk countries
Lack of barrier contraception
IV drug use
What 2 gynae conditions are more common with HIV?
Candida
CIN
Management of HIV?
Antiretrovirals
C section and no breastfeeding if pregnant
What is seroconversion?
Time period in which a specific antibody develops and is present in the blood
In HIV, flu like symptoms and rash
Women commonly no symptoms
How is AIDS diagnosed?
Development of opportunistic infection or malignancy or a CD4 <200
What is contraception?
Prevention of pregnancy, some reduce spread of STIs
Is breastfeeding contraceptive?
If fully breastfeeding, amenorrheic, less than 6 months postpartum it is >98% effective
Contraceptive contraindications in breastfeeding?
Avoid COCP before 6 weeks PP, relatively contraindicated 6 weeks - 6 months
Progestogen only methods can be used
What is the COCP?
Combined oral contraceptive pill
How does the COCP work? (3)
Exert negative feedback effect on gonadotrophin release and inhibit ovulation
Thin the endometrium
Thicken cervical mucus
How is the COCP taken?
Daily tablet containing oestrogen and progesterone taken for 3 weeks, 1 week break with withdrawal bleed
Side effects of the COCP? (7)
Depression PMT symptoms Bleeding or amenorrhoea Acne Weight gain Breast pain Reduced libido
Missed COCP advice?
1 pill - take as soon as possible and continue
2 pills - continue packet as normal but use condoms for 7 days
If less than 7 pills remaining, avoid break and start another pack
Complications of COCP? (6)
Venous thrombosis Myocardial infarction Cerebrovascular accidents Focal migraine Hypertension Cervical and breast carcinoma
Absolute contraindications to COCP? (10)
History of VTE, CVA, IHD, severe hypertension Migraine with aura Active breast/endometrial cancer Inherited thrombophiia Pregnancy Smokers >35 years and >15 a day BMI >40 Vascular complications of diabetes Active/chronic liver disease Breastfeeding up to 6 weeks
Relative contraindications to COCP? (7)
Smokers Chronic inflammatory disease Renal impairment Diabetes Age >40 BMI >35 Breastfeeding up to 6 months
What is the contraceptive patch?
Combined transdermal patch that releases oestrogen and progestogen, every week for 3 weeks then break
What is the contraceptive ring?
Nuvaring, releases daily dose of oestrogen and progestogen, worn for 3 weeks in the vagina then removed for 7 days and a new ring inserted after
What is the mini pill?
Progestogen only pill containing a slow dose of progestogen, taken every day without a break at the same time within 3 hours (cerazette within 12)
Contraceptive effects of the progestogen only pill?
Makes cervical mucus hostile to sperm
Inhibits ovulation in 50%
Side effects of the progesterone only pill?
Vaginal spotting Weight gain Breast pain PMT symptoms Functional ovarian cysts
Missed progestogen only pill advice?
If missed for more than 3 hours, take as soon as possible and use condoms for 2 days
What are LARCs?
Long acting reversible contraceptives, not user dependent and highly effective
What is Depo-Provera?
Medroxyprogesterone acetate (progestogen only) IM injection every 3 months
Side effects of depo-provera? (4)
Spotting
Then amenorrhoea - may be prolonged after stopping
Progestogenic side effect as mini pill
Decrease bone density in first 2/3 months then stabilises, regained after stopping
What is the implant?
Nexplanon - rod containing progestogen inserted into the upper arm subdermally with anaesthetic, lasts 3 years
Side effects of the implant?
Progestogenic
Irregular bleeding
What is emergency contraception?
Drug or IUD used shortly after unprotected intercourse in an attempt to prevent pregnancy
What is the morning after pill?
Levonelle - single dose of progestogen, best taken within 24 hours can be up to 72
EllaOne - single dose selective progesterone receptor modulator, can be used up to 5 days after
Efficacy of both decreases with time
What is an IUD?
Intrauterine device, copper, prevents implantation, can be used up to 5 days after unprotected sex or as a LARC changed every 5-10 years
How do IUDs work?
Copper devices, operate by preventing fertilisation as copper is toxic to sperm and also blocking implantation
What is an IUS?
Intrauterine system, progestogen released locally over 5 years
How do IUSs work? (2)
Changes to cervical mucus and uterotubal fluid which impair sperm migration
Endometrial changes impeding implantation
Complications of intrauterine device/system? (6)
IUD - heavy bleeding Pain/cervical shock Expelled device Perforated uterus Risk of PID if current STI Ectopic more likely if pregnancy occurs as blocked implantation in the uterus
Considerations with IUD/IUS (6)
Previous ectopic Young/nulliparous Pelvic infection Endometrial/cervical cancer Undiagnosed bleeding Pregnancy
Barrier methods of contraception? (3)
Male condom - sheath over the penis, afford best protection against disease
Female condom
Diaphragms and caps - fitted before sex and stay for 6 hours after, used with spermicide
Permanent methods of contraception? (2)
Female sterilisation - clips on the fallopian tubes, hysterectomy if indicated
Male sterilisation - vasectomy more effective than female- ligation and removal of section of vas deferens preventing sperm passage
What is natural family planning?
Using own body temperature, cervical mucus thickness, urinary hormones (LH, oestrogen) etc to predict ovulation and avoiding intercourse in specific times
Less effective
What is the withdrawal method?
Removing penis just before ejaculation, not effective as sperm can be released before orgasm
Define subfertility
Subfertility is when conception does not occur within a year of regular unprotected intercourse in the absence of known reproductive pathology - low chance of conception but may also be infertile
Define primary and secondary subfertility
Primary if woman has never conceived
Secondary if previous pregnancy
Causes of subfertility
Male factor 30% Female factor 30% (anovulation, tubal factors, PID) 25% Unexplained 10% combined 5% other
Causes of anovulation (6)
PCOS Hypothalamic hypogonadism - low GnRH, low oestrogen Hyperprolactinaemia - inhibits GnRH Premature ovarian failure Pituitary damage - LH, FSH Hypo/hyperthyroidism
How is hypothalamic hypogonadism treated?
Normal weight
Give gonadotrophins
How is hyperprolactinaemia treated?
Give bromocriptine - inhibits prolactin
What is second line treatment of subfertility once primary causes have been treated?
ART e.g. IVF
Causes of male infertility (6)
Drug exposure - alcohol, smoking, steroids Varicocoele Antisperm antibodies Testicular abnormality Obstructions i.e. of vas deferens in CF Hypogonadism Impotence
Name 3 barriers to fertilisation
Tubal damage e.g. PID
Endometriosis
Previous surgery - adhesions
When is ART considered (5)
Other treatments failed Unexplained cause Male factor subfertility - ICSI Tubal damage - IVF Genetic problems
Physiology of sperm production? (4)
Spermatogenesis in the testis is dependent on pituitary LH and FSH
LH stimulates testosterone production in Leydig cells in the testis
FSH and testosterone control Sertoli cells which synthesise sperm
Testosterone inhibits LH.
Types of abnormal semen in men? (3)
Azoospermia - no sperm
Oligospermia - reduced levels of sperm
Asthenospermia - low motility
Common causes of sperm abnormalities? (8)
Smoking/alcohol/drugs/chemicals Inadequate cooling of testis Genetics Antisperm antibodies Infection - epididymitis Klinefelters - XXY Hypogonadotrophic hypogonadism Retrograde ejaculation
What is varicocoele?
Varicosities of the pampiniform plexus, usually on left, present in 25% of infertile men
Management of male factor infertility?
Treat treatable causes
Optimise lifestyle factors
ART
Investigations for female infertility? (6)
Mid-luteal phase progesterone Urinary LH FSH, testosterone, prolactin, TFTs USS Hysterosalpingogram Laparoscopy
General treatment of infertility?
Lose weight
Folic acid
Treat treatable causes - i.e. clomifene, gonadotrophins, ovarian diathermy
What is IUI?
Intrauterine insemination, sperm are injected directly into the cavity of the uterus timed with ovulation or after gonadotrophin ovulation induction
When is IUI used?
Unepxlained subfertility
Mild-moderate sperm dysfunction
What is IVF?
In vitro fertilisation, embryos are fertilised outside the uterus then transferred back
When is IVF used?
If tubes not patent
Unexplained infertility
How does IVF work? (5 stages)
Multiple follicular development - 2 weeks of gonadotrophin injections (FSH and LH)
With 21 day GnRH analogue to suppress pituitary and prevent LH surge before stimulation starts, or short daily GnRH antagonist from day 5 stimulation until egg collection
Ovulation and egg collection once follicles optimal size confirmed with scan - single dose LH given to trigger ovulation and collected under aspiration
Fertilisation and culture - eggs incubated with sperm and growth medium, spares can be frozen
Embryo transfer - best blastocyst transferred (can be 2 if indicated) and progesterone given for luteal support
What is ICSI?
Intracytoplasmic sperm injection
How does ICSI work?
Injection of one sperm into oocyte cytoplasm, adjunct to IVF when sperm are not motile
What is oocyte donation?
Donor goes through ovarian stimulation and her eggs are fertilised with recipient’s partner’s sperm
Recipient given oestrogen and progesterone to prepare endometrium and embryo transferred
What is surrogacy?
Another woman carries a biological child of the patients, when the patient has uterine problems or coexisting health issues so cannot carry a child
What is ovarian hyperstimulation syndrome?
Occurs with gonadotrophin ovulation induction, in PCOS or IVF - use lowest effective dose
Symptoms of OHSS? (5)
Overstimulates the follicles which become large and painful Hypovolaemia Electrolyte disturbance VTE Pulmonary oedema
Treatment of OHSS?
Admit for restoration of volume, monitoring, analgesia, thromboprophylaxis
What is PGD?
Preimplantation genetic diagnosis, can remove a cell or 2 from the developing blastocyst in IVF and examine DNA to look for genetic mutation, unaffected embryos transferred
When is PGD used?
Couples where single gene defects are carries (cystic fibrosis) or who have chromosome translocations so risk of an aneuploidic child high
Sex linked conditions
What are the 4 broad categories sexual disorders fall into?
Chronic medical conditions
Hormonal
Iatrogenic
Psychiatric
Investigations for sexual problems? (6)
Fasting glucose/lipid ratio Testosterone, SHBG, albumin Prolactin TFTs Oestrogen FBC
What is hypoactive sexual desire disorder?
Lack or loss of sexual desire, not secondary to physical problems, causing distress
Does not exclude sexual enjoyment or arousal but makes initiation less likely
Causes of hypoactive sexual desire disorder? (9)
Diabetes, CVD, obesity Androgen deficiency Hypothyroid Hyperprolactinaemia Depression/anxiety/trauma Relationship issues Substance abuse Meds - COCP, tamoxifen, antidepressants Post surgery or birth
4 psychosexual treatment options?
Integrative - combination of psych and physical
CBT
Psychodynamic - past events, attachments
Systemic - individual, couple, family
Treatment of hypoactive sexual desire disorder?
Testosterone replacement for males
Flibanserin for women
Psychosexual - CBT etc.
What is erectile disorder?
Difficulty in developing or maintaining an erection suitable for satisfactory intercourse
Causes of erectile disorder? (6)
CVD, Diabetes, Neuro conditions (cauda equina, MS)
Low androgen, high prolactin
Post surgery, antidepressants
Age
Ineffective sexual stimuli, relationship problems
Pain
Treatment of erectile disorder?
Phosphodiesterase inhibitors - sildenafil
2nd line alprostadil injection or intraurethral
Vacuum device, rings
Psych treatments
Side effects and contraindications of sildenafil?
Headaches, flushing
CI - Hypotension, recent unstable angina
What is female sexual arousal disorder?
Failure of genital response (mainly vaginal dryness) and reduced interest in sexual activity, response to sex stimuli and reduced pleasure
Causes of female sexual arousal disorder? (5)
Diabetes, CVD, neuro Oestrogen deficiency i.e. menopause SSRIs Lactation Psychological
Treatment of female sexual arousal disorder?
Behavioural - sensate focus, eros therapy devise, lubricants
Psychosexual couples therapy
Common psychological causes of sexual problems? (8)
Depression/anxiety Substance misuse Previous abuse or trauma Couples script problems Decreased intimacy Relationship problems Stress Cultural/religious problems
What is sensate focus?
Behavioural intervention
Programme of exercises to enable couple to identify sexual likes and explore new techniques
Overcome negative thinking patterns
What is eros therapy?
Handheld device used for greater clitoral and genital engorgement, increased vaginal lubrication
What is female orgasmic disorder?
Orgasm either does not occur or is markedly delayed, reduced intensity
Causes of female orgasmic disorder? (6)
CVD, Diabetes, neuro Oestrogen/androgen insufficiency Pelvic floor weakness Age SSRIs Psych problems
Treatment of female orgasmic disorder? (3)
Topical oestrogen
Education, guided masturbation, vibrators
Psychotherapy - attitudes to sex
How does the menopause affect sexual function? (6)
Vaginal/pelvic pain Vaginal atrophy Dryness Change in self image Change in desire Sleeplessness, night sweats
What is sexual aversion disorder?
Disorder characterised by disgust, fear, revulsion, or lack of desire in relationships
Causes of sexual aversion?
Past trauma
Interpersonal problems - infidelity, violence, lack of hygiene of partner
Treatments of sexual aversion? (3)
Psychotherapy
Couples counselling
Medications for anxiety
What is rapid ejaculation?
Inability to control ejaculation sufficiently for both partners to enjoy sexual interaction
Persistent
1 minute after vaginal peneration
Cause of rapid ejaculation? (5)
Genetic susceptibility Hyperthyroid Penile hypersensitivity Comorbid erectile dysfunction Performance anxiety, lack of experience, trauma
Treatment of rapid ejaculation? (4)
Topical local anaesthetic STUD 100
SSRIs - dapoxetine
Couples therapy
Behaviour - Stop/start technique, sensate focus
What is delayed ejaculation?
On almost all occasions without the individual desiring there is a marked delay (>30min) in ejaculation or infrequent/absent ejaculation
Causes of delayed ejaculation? (8)
Congenital disordres Trauma/surgery Age Infection Neuro disorders Depression/other psych SSRIs Low testosterone
Treatment for delayed ejaculation? (3)
Individual and couples therapy
Kegel exercises
Use of vibration/superstimulation
What is retrograde ejaculation?
Entry of semen into the bladder instead of going out through the urethra during ejaculation, causes aspermia
Cause of retrograde ejaculation? (4)
Malfunction of bladder sphincter - autonomic nervous system dysfunction, TURP (prostate surgery)
Nerve damage
S/e of tamsulosin, antidepressants
Diabetes
Investigations of retrograde ejaculation?
Urine sample for presence of sperm and fructose - disinguishes between this and anejaculation
Treatment of retrograde ejaculation? (5)
Some untreatable - if radiation damage, cut nerves from surgery Tricyclic antidepressants Antihistamines Decongestants - ephedrine Infertility treatments
What is anejaculation?
Pathological inability to ejaculate in males, with or without orgasm
Causes of anejaculation? (7)
Sexual inhibition Medications - SSRIs. antipsychotics Autonomic nervous system Prostate surgery Duct obstruction Spinal cord injury Old age
Treatment of anejaculation? (3)
Penile vibratory stimulation
Electroejaculation, percutaneous epididymal sperm aspiration for sperm removal
What is vaginismus?
Spasm of the pelvic floor muscles that surround the vagina, causing occlusion of the vaginal opening, penile entry is painful/impossible
Causes of vaginismus? (5)
Irritated vulva - thrush, lichen sclerosis
Painful conditions
FGM
Congenital abnormality
Psych - fear, religious issues, previous trauma, relationship issues
Treatment of vaginismus?
Psychosexual therapy
Self exploration, vaginal dilator, graded penetration
What is dyspareunia?
Pain during intercourse, occurs in women and men, if there is no primary nonorganic sexual dysfunction
Cause of dyspareunia in women? (6)
STIs Episiotomy Vaginal atrophy Pelvic inflammatory disease Endometriosis Psych issues
Cause of dyspareunia in men? (4)
STIs
Urethral strictures
Varicocoele
Psych issues
Treatment of dyspareunia?
Treat cause
Lubricants
Couples therapy
Behavioural therapy - sensate focus
What is vulvodynia?
Chronic pain syndrome affecting the vulvar area, occurs without an identifiable cause
Cause of vulvodynia? (6)
History of STIs
Sjogrens syndrome
Autoimmune disorders causing inflammation
Eczema
Former oral contraceptive use before age of 16
Injury/neuropathy
Treatment of vulvodynia? (5)
Lubricants Psychotherapy Oestrogen creams/lidocaine cream Amitriptyline, gabapentin Vestibulectomy surgery - cut nerves
What is aspermia?
Complete lack of semen with ejaculation
Causes of aspermia? (4)
Retrograde ejaculation
Ejaculatory duct obstruction
Androgen deficiency
Treatment of prostate cancer - maximal androgen blockade
What is Peyronie’s disease?
Development of fibrous scar tissue inside the penis that causes curved, painful erections - can cause erectile dysfunction
Cause of Peyronie’s disease? (4)
Repeated injury and disorganised healing
Genetics
Connective tissue disorders
Age
Treatment of Peyronie’s disease? (3)
Pentoxifylline to reduce scar tissue
Penile injections - collagenase, verapamil, interferon (break down fibrous tissue)
Surgery to suture unaffected side, excise tissue, implants
What is hypospadias?
Congenital condition in males in which the opening of the urethra is on the underside of the penis, normally diagnosed at birth
Treatment of hypospadias?
Surgical correction
What is sex?
Male/female based on external genitalia
What is gender identity?
Intrinsic sense of being male/female/alternative
From genes, oestrogen, testosterone on developing brain
What is gender expression?
Personality, appearance, behaviour in a cultural and historical context
What are primary and secondary sex characteristics?
Primary - penis and scrotum and testis maturation, vagina/vulva/ovary maturation
Secondary - enlargement of genitalia, pubic and armpit hair, breast development, voice pitch lowering in men
What is transgender?
Diverse gender variance including transsexual/agender/genderqueer
What is gender dysphoria?
Distress due to incongruence between gender identity and sex assigned at birth
What is transsexual?
Individuals who seek to change their primary/secondary sex characteristics
Transmale - female at birth changing to male
Transfemale - male at birth changing to female
What is sexual orientation?
Sex of persons to whom sexual fantasies, arousal, activities directed
When are the external genitalia and gonads developed?
8 weeks
How does masculinisation occur?
SRY gene - testes development
Mullerian inhibiting substance
Management for transmale?
Fertility options Androgens +/- GnRH analogue Voice Male chest reconstruction Hysterectomy and bilateral oophorectomy Phalloplasty
Management for transfemale?
Fertility options Oestrogens and antiandrogens Voice Facial hair removal Vaginoplasty Mammoplasty Facial feminisation surgery
