Sexually transmitted diseases Flashcards
1
Q
Bacterial vaginosis
A
Refers to an overgrowth of bacteria in the vagina, specifically anaerobic bacteria. It is not a sexually transmitted infection.
2
Q
The loss of what bacteria causes Bacterial vaginosis?
A
Loss of the lactobacilli “friendly bacteria” in the vagina. Bacterial vaginosis can increase the risk of women developing sexually transmitted infections.
3
Q
What bacteria is the main componenet of healthy vaginal bacterial flora?
A
Lactobacilli which produce lactic acid & keeps the vaginal pH low (under 4.5). The acidic environment prevents other bacteria from overgrowing. When there are reduced numbers of lactobacilli in the vagina, the pH rises. This more alkaline environment enables anaerobic bacteria to multiply.
4
Q
How does Lactobacilli keep the vagina healthy?
A
Lactobacilli which produce lactic acid & keeps the vaginal pH low (under 4.5).
The acidic environment prevents other bacteria from overgrowing. When there are reduced numbers of lactobacilli in the vagina, the pH rises. This more alkaline environment enables anaerobic bacteria to multiply.
5
Q
Examples of anaerobic bacteria associated with bacterial vaginosis
A
- Gardnerella vaginalis (most common)
- Mycoplasma hominis
- Prevotella species
6
Q
Risk factors for bacterial vaginosis
A
- Multiple sexual partners
- Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes)
- Recent antibiotics
- Smoking
- Copper coil
7
Q
Symptoms of bacterial vaginosis
A
Fishy-smelling watery grey or white vaginal discharge.
Half of women with BV are asymptomatic.
Itching, irritation and pain are not typically associated with BV and suggest an alternative cause or co-occurring infection.
8
Q
Investigations in bacterial vaginosis
A
A speculum examination
Vaginal pH can be tested using a swab and pH paper. BV occurs with a pH > 4.5.
A standard charcoal vaginal swab can be taken for microscopy. This can be a high vaginal swab taken during a speculum examination or a self-taken low vaginal swab.
Bacterial vaginosis gives “clue cells” on microscopy.
9
Q
What are clue cells?
A
Clue cells are epithelial cells from the cervix that have bacteria stuck inside them, usually Gardnerella vaginalis.
Specific to bacterial vaginosis
10
Q
Whats the normal vaginal pH?
A
The normal vaginal pH is 3.5 – 4.5.
11
Q
Microscopy changes in bacterial vaginosis
A
“Clue cells” on microscopy.
12
Q
Management of bacterial vaginosis
A
Asymptomatic BV does not usually require treatment.
Metronidazole is the antibiotic of choice for treating bacterial vaginosis.
Always assess the risk of additional pelvic infections, with swabs for chlamydia and gonorrhoea where appropriate.
Provide advice and information about measures that can reduce the risk of further episodes of bacterial vaginosis,
13
Q
What advice should be given to patients when prescribing Metronidazole?
A
Avoid alcohol for the duration of treatment.
Alcohol and metronidazole can cause a “disulfiram-like reaction”, with nausea and vomiting, flushing and sometimes severe symptoms of shock and angioedema.
14
Q
Why should alcohol not be taken with metronidazole?
A
Alcohol and metronidazole can cause a “disulfiram-like reaction”, with nausea and vomiting, flushing and sometimes severe symptoms of shock and angioedema.
15
Q
Complications of bacterial vaginosis
A
Increase the risk of catching STIs
Also associated with several complications in pregnant women
16
Q
Complications of bacterial vaginosis in pregnant women
A
- Miscarriage
- Preterm delivery
- Premature rupture of membranes
- Chorioamnionitis
- Low birth weight
- Postpartum endometritis
17
Q
Candidiasis
A
Commonly referred to as “thrush”. It refers to vaginal infection with a yeast of the Candida family. The most common is Candida albicans.
18
Q
Most common organism to cause Candidasis
A
Candida albicans
19
Q
Risk factors for candidiasis
A
- Increased oestrogen (higher in pregnancy, lower pre-puberty and post-menopause)
- Poorly controlled diabetes
- Immunosuppression (e.g use of corticosteriods)
- Broad-spectrum antibiotics
20
Q
Presentation of candidiasis
A
Thick, white discharge that does not typically smell
Vulval and vaginal itching, irritation or discomfort
21
Q
Investigations for candidiasis
A
Testing the vaginal pH using a swab and pH paper can be helpful in differentiating between bacterial vaginosis and trichomonas (pH > 4.5) and candidiasis (pH < 4.5).
A charcoal swab with microscopy can confirm the diagnosis.
22
Q
Management options in candidiasis
A
Antifungal cream (i.e. clotrimazole) inserted into the vagina with an applicator
Antifungal pessary (i.e. clotrimazole)
Oral antifungal tablets (i.e. fluconazole)
23
Q
What is Canesten Duo?
A
It contains a single fluconazole tablet and clotrimazole cream to use externally for vulval symptoms (e.g. in candidiasis)
They also recommend recurrent infections (more than 4 in a year) can be treated with an induction and maintenance regime over six months with oral or vaginal antifungal medications. This is an off-label use.
24
Q
What advice should be given to women taking anti-fungal creams and pessaries?
A
Can damage latex condoms and prevent spermicides from working, so alternative contraceptive is required for at least five days after use.
25
Chlamydia
Chlamydia is the most common sexually transmitted infection in the UK and a significant cause of infertility - caused by Chlamydia trachomatis
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Chlamydia trachomatis
A gram-negative bacterium. It is an intracellular organism, meaning it enters and replicates within cells before rupturing the cell and spreading to others. Causes Chlamydia
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National Chlamydia Screening Programme (NCSP).
Aims to screen every sexually active person under 25 years of age for chlamydia annually or when they change their sexual partner.
Everyone that tests positive should have a re-test three months after treatment.
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What diseases are tested for in STI screening in GUM clinics?
* Chlamydia
* Gonorrhoea
* Syphilis (blood test)
* HIV (blood test)
29
Charcoal swabs
Allow for microscopy, culture and sensitivities (testing which antibiotics are effective against the bacteria).
The transport medium is called Amies transport medium and contains a chemical solution for keeping microorganisms alive during transport.
Charcoal swabs can be used for endocervical swabs and high vaginal swabs (HVS).
30
Nucleic acid amplification tests (NAAT) use in men and women
In women, a NAAT test can be performed on a vulvovaginal swab (a self-taken lower vaginal swab), an endocervical swab or a first-catch urine sample.
In men, a NAAT test can be performed on a first-catch urine sample or a urethral swab.
Rectal and pharyngeal NAAT swabs can also be taken to diagnose chlamydia in the rectum and throat. Consider these swabs where anal or oral sex has occurred.
31
What is the Nucleic acid amplification tests (NAAT)?
Nucleic acid amplification tests (NAAT) check directly for the DNA or RNA of the organism. NAAT testing is used to test specifically for chlamydia and gonorrhoea.
32
Chlamydia presentation in women
```
Most are asymptomatic.
Abnormal vaginal discharge
Pelvic pain
Abnormal vaginal bleeding
Painful sex (dyspareunia)
Painful urination (dysuria)
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Dysuria
Painful urination
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Dyspareunia
Painful sex
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Presentation of Chlamydia in men
* Urethral discharge or discomfort
* Painful urination (dysuria)
* Epididymo-orchitis
* Reactive arthritis
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Examination findings in chlamydia
* Pelvic or abdominal tenderness
* Cervical motion tenderness (cervical excitation)
* Inflamed cervix (cervicitis)
* Purulent discharge
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Investigations for chlamydia
NAAT are used to diagnose chlamydia. This can involve a:
• Vulvovaginal swab
• Endocervical swab
• Urethral swab in men
• Rectal swab (after anal sex)
• Pharyngeal swab (after oral sex)
• First-catch urine sample (in women or men)
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Management of chlamydia
First-line for uncomplicated chlamydia infection is doxycycline 100mg twice a day
Doxycycline is contraindicated in pregnancy and breastfeeding. Alternatives options for treatment in pregnant or breastfeeding women are:
1. Azithromycin 1g stat then 500mg once a day for 2 days
2. Erythromycin 500mg four times daily for 7 days
3. Erythromycin 500mg twice daily for 14 days
4. Amoxicillin 500mg three times daily for 7 days
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Complications from chlamydia
* Pelvic inflammatory disease
* Chronic pelvic pain
* Infertility
* Ectopic pregnancy
* Epididymis-orchitis
* Conjunctivitis
* Lymphogranuloma venereum
* Reactive arthritis
40
Pregnancy-related complications of chlamydia
* Preterm delivery
* Premature rupture of membranes
* Low birth weight
* Postpartum endometritis
* Neonatal infection (conjunctivitis and pneumonia)
41
Lymphogranuloma venereum (LGV)
A condition affecting the lymphoid tissue around the site of infection with chlamydia. It most commonly occurs in men who have sex with men (MSM).
42
The three stages of Lymphogranuloma venereum (LGV)
The primary stage involves a painless ulcer (primary lesion).
The secondary stage involves lymphadenitis. This is swelling, inflammation and pain in the lymph nodes infected with the bacteria.
The tertiary stage involves inflammation of the rectum (proctitis) and anus. Proctocolitis leads to anal pain, change in bowel habit, tenesmus and discharge.
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Tenesmus
A feeling of needing to empty the bowels, even after completing a bowel motion.
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Chlamydial conjunctivitis
Conjunctival infection is usually as a result of sexual activity, when genital fluid comes in contact with the eye.
It presents with chronic erythema, irritation and discharge lasting more than two weeks. Most cases are unilateral.
Chlamydial conjunctivitis occurs more frequently in young adults. It can also affect neonates with mothers infected with chlamydia.
45
Neisseria gonorrhoeae
Gram-negative diplococcus bacterium.
It infects mucous membranes with a columnar epithelium, such as the endocervix in women, urethra, rectum, conjunctiva and pharynx.
It spreads via contact with mucous secretions from infected areas.
46
Gonorrhoea
A sexually transmitted infection. Being young, sexually active and having multiple partners increases the risk of infection with gonorrhoea. Having other sexually transmitted infections, such as chlamydia or HIV, also increases the risk.
47
Presentation of gonorrhea in women
Infection with gonorrhoea is more likely to be symptomatic than infection with chlamydia.
• Odourless purulent discharge, possibly green or yellow
• Dysuria
• Pelvic pain
48
Presentation of gonorrhea in men
* Odourless purulent discharge, possibly green or yellow
* Dysuria
* Testicular pain or swelling (epididymis-orchitis)
49
Why are both NAAT tests and charcoal swabs required for diagnosis of gonorrhea?
It is worth remembering that NATT tests are used to check if a gonococcal infection is present or not by looking for gonococcal RNA or DNA. They do not provide any information about the specific bacteria and their antibiotic sensitivities and resistance.
This is why a standard charcoal swab for microscopy, culture and sensitivities is so essential, to guide the choice of antibiotics to use in treatment.
50
Diagnosis of gonorrhea
Nucleic acid amplification testing (NATT) is use to detect the RNA or DNA of gonorrhoea. Genital infection can be diagnosed with endocervical, vulvovaginal or urethral swabs, or in a first-catch urine sample. Rectal and pharyngeal swab are recommended in all men who have sex with men (MSM), and in those with risk factors (e.g. anal and oral sex) or symptoms of infection in these areas.
A standard charcoal endocervical swab should be taken for microscopy, culture and antibiotic sensitivities before initiating antibiotics.
51
Management of uncomplicated gonococcal infections
A single dose of intramuscular ceftriaxone 1g if the sensitivities are NOT known
A single dose of oral ciprofloxacin 500mg if the sensitivities ARE known
52
Do gonococcal infections require follow up?
All patients should have a follow up “test of cure” given the high antibiotic resistance.
This is with NAAT testing if they are asymptomatic, or cultures where they are symptomatic.
• 72 hours after treatment for culture
• 7 days after treatment for RNA NATT
• 14 days after treatment for DNA NATT
53
Complications of gonorrhea
* Pelvic inflammatory disease
* Chronic pelvic pain
* Infertility
* Epididymis-orchitis (men)
* Prostatitis (men)
* Conjunctivitis
* Urethral strictures
* Disseminated gonococcal infection
* Skin lesions
* Fitz-Hugh-Curtis syndrome
* Septic arthritis
* Endocarditis
54
Whats a serious complication of gonorrhea in newborns?
Gonococcal conjunctivitis in a neonate.
This is a medical emergency and is associated with sepsis, perforation of the eye and blindness.
55
Disseminated gonococcal infection (GDI)
A complication of untreated gonococcal infection, where the bacteria spreads to the skin and joints.
56
Pelvic inflammatory disease (PID)
Inflammation and infection of the organs of the pelvis, caused by infection spreading up through the cervix. It is a significant cause of tubular infertility and chronic pelvic pain.
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Endometritis
inflammation of the endometrium
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Salpingitis
is inflammation of the fallopian tubes
59
Oophoritis
Inflammation of the ovaries
60
Parametritis
Inflammation of the parametrium, which is the connective tissue around the uterus
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Peritonitis
is inflammation of the peritoneal membrane
62
Causes of Pelvic inflammatory disease (PID)
* Neisseria gonorrhoeae tends to produce more severe PID
* Chlamydia trachomatis
* Mycoplasma genitalium
* Gardnerella vaginalis (associated with bacterial vaginosis)
* Haemophilus influenzae (a bacteria often associated with respiratory infections)
* Escherichia coli (UTIs)
63
Presentation of PID
* Pelvic or lower abdominal pain
* Abnormal vaginal discharge
* Abnormal bleeding (intermenstrual or postcoital)
* Pain during sex (dyspareunia)
* Fever
* Dysuria
64
Examination findings in PID
* Pelvic tenderness
* Cervical motion tenderness (cervical excitation)
* Inflamed cervix (cervicitis)
* Purulent discharge
65
Investigations in PID
NAAT swabs for gonorrhoea and chlamydia
NAAT swabs for Mycoplasma genitalium if available
HIV test
Syphilis test
A high vaginal swab can be used to look for bacterial vaginosis, candidiasis and trichomoniasis.
A microscope can be used to look for pus cells on swabs from the vagina or endocervix.
66
Management of PID
Antibiotics are started empirically, before swab results are obtained, to avoid a delay and complications.
• A single dose of intramuscular ceftriaxone 1g (to cover gonorrhoea)
• Doxycycline 100mg twice daily for 14 days (to cover chlamydia and Mycoplasma genitalium)
• Metronidazole 400mg twice daily for 14 days (to cover anaerobes such as Gardnerella vaginalis)
Ceftriaxone and doxycycline will cover many other bacteria, including H. influenzae and E. coli.
67
Complications of PID
* Sepsis, Abscess
* Infertility, Chronic pelvic pain
* Ectopic pregnancy
* Fitz-Hugh-Curtis syndrome
68
Fitz-Hugh-Curtis Syndrome
A complication of pelvic inflammatory disease. It is caused by inflammation and infection of the liver capsule (Glisson’s capsule), leading to adhesions between the liver and peritoneum.
Results in right upper quadrant pain that can be referred to the right shoulder tip if there is diaphragmatic irritation.
69
Trichomonas vaginalis
Trichomonas vaginalis is a type of parasite spread through sexual intercourse. Trichomonas is classed as a protozoan and is a single-celled organism with flagella. Spread through sexual activity and lives in the urethra of men and women and the vagina of women.
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Risks of Trichomonas vaginalis
* Contracting HIV by damaging the vaginal mucosa
* Bacterial vaginosis
* Cervical cancer
* Pelvic inflammatory disease
* Pregnancy-related complications
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Presentation of Trichomonas vaginalis
```
Usually asymptomatic and non-specific
• Vaginal discharge
• Itching
• Dysuria (painful urination)
• Dyspareunia (painful sex)
• Balanitis (inflammation to the glans penis)
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Characteristic features of vaginal discharge in Trichomonas vaginalis
frothy and yellow-green, although this can vary significantly. It may have a fishy smell.
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Examination findings in Trichomonas vaginalis
Examination of the cervix can reveal a characteristic “strawberry cervix” (also called colpitis macularis). A strawberry cervix is caused by inflammation (cervicitis) relating to the trichomonas infection. There are tiny haemorrhages across the surface of the cervix, giving the appearance of a strawberry.
Testing the vaginal pH will reveal a raised ph (above 4.5), similar to bacterial vaginosis.
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Diagnosis of Trichomonas vaginalis
Standard charcoal swab with microscopy
A self-taken low vaginal swab may be used as an alternative.
A urethral swab or first-catch urine is used in men.
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Management of Trichomonas vaginalis
Patients should be referred to a genitourinary medicine (GUM) specialist service for diagnosis, treatment and contact tracing.
Treatment is with metronidazole.
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Genital herpes
The herpes simplex virus (HSV) is commonly responsible for both cold sores (herpes labialis) and genital herpes. There are two main strains, HSV-1 and HSV-2.
After an initial infection, the virus becomes latent in the associated sensory nerve ganglia. Typically this is the trigeminal nerve ganglion with cold sores and the sacral nerve ganglia with genital herpes.
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HSV-1
Most associated with cold sores. It is often contracted initially in childhood (before five years), remains dormant in the trigeminal nerve ganglion and reactivates as cold sores, particularly in times of stress.
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HSV-2
HSV-2 typically causes genital herpes and is mostly a sexually transmitted infection. It can also cause lesions in the mouth.
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Presentation of genital herpes
* 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
80
Diagnosis of genital herpes
The diagnosis can be made clinically based on the history and examination findings.
A viral PCR swab from a lesion can confirm the diagnosis and causative organism.
81
Management of genital herpes
```
Acyclovir is used to treat genital herpes.
• Paracetamol
• Topical lidocaine 2% gel
• Cleaning with warm salt water
• Topical Vaseline
• Additional oral fluids
• Wear loose clothing
• Avoid intercourse with symptoms
```
82
Genital herpes is known to cause pregnancy-related complications or congenital abnormalities; what are they?
The main issue with genital herpes during pregnancy is the risk of neonatal herpes simplex infection contracted during labour and delivery. Neonatal herpes simplex infection has high morbidity and mortality. Neonatal infection should be avoided as much as possible and treated early if identified.
83
Management of genital herpes in pregnant women who contract it less than 28 weeks gestation
Primary genital herpes contracted before 28 weeks gestation is treated with aciclovir during the initial infection.
This is followed by regular prophylactic aciclovir starting from 36 weeks gestation onwards to reduce the risk of genital lesions during labour and delivery.
Women that are asymptomatic at delivery can have a vaginal delivery (provided it is more than six weeks after the initial infection).
Caesarean section is recommended when symptoms are present.
84
Management of genital herpes in pregnant women who contract it after 28 weeks gestation
Primary genital herpes contracted after 28 weeks gestation is treated with aciclovir during the initial infection followed immediately by regular prophylactic aciclovir. Caesarean section is recommended in all cases to reduce the risk of neonatal infection.
85
HIV=
Refers to the human immunodeficiency virus. AIDS refers to acquired immunodeficiency syndrome. AIDS occurs as an HIV infection progresses, and the person becomes immunodeficient. This immunodeficiency leads to opportunistic infections and several AIDS-defining illnesses, such as Kaposi’s sarcoma. AIDS is now mostly referred to as late-stage HIV.
86
HIV pathophysiology
HIV is an RNA retrovirus. HIV-1 is the most common type, and HIV-2 is rare outside West Africa. The virus enters and destroys the CD4 T-helper cells of the immune system.
An initial seroconversion flu-like illness occurs within a few weeks of infection. The infection is then asymptomatic until the condition progresses to immunodeficiency.
87
Transmission of HIV
* Unprotected anal, vaginal or oral sexual activity
* Mother to child at any stage of pregnancy, birth or breastfeeding (called vertical transmission)
* 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
88
AIDS-Defining Illnesses
There is a long list of AIDS-defining illnesses associated with end-stage HIV infection. These occur where the CD4 count has dropped to a level that allows for unusual opportunistic infections and malignancies to appear.
89
What are examples of AIDS-Defining Illnesses?
1. Kaposi’s sarcoma, Pneumocystis jirovecii pneumonia (PCP)
2. Cytomegalovirus infection
3. Candidiasis (oesophageal or bronchial)
4. Lymphomas, Tuberculosis
90
Testing options for HIV
Antibody testing is the typical screening test for HIV. This is a simple blood test.
Testing for the p24 antigen, checking directly for this specific HIV antigen in the blood.
PCR testing for the HIV RNA levels tests directly for the number of viral copies in the blood, giving a viral load.
91
Monitoring - CD4 Count in HIV patients
500-1200 cells/mm3 is the normal range
Under 200 cells/mm3 is considered end-stage HIV (AIDS) and puts the patient at high risk of opportunistic infections
92
Viral load in HIV
Viral load is the 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). The viral load can be in the hundreds of thousands in untreated HIV.
93
Vaccinations in HIV patients
Vaccinations should be up to date, including influenza, pneumococcal, hepatitis A and B, tetanus, diphtheria and polio vaccines. Patients should avoid live vaccines.
94
Management of HIV infected pregnant women
* Normal vaginal delivery is recommended for women with a viral load < 50 copies / ml
* Caesarean section is considered in patients with > 50 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
95
Management of babies born to HIV infected mothers
Prophylaxis treatment may be given to the baby, depending on the 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
96
HIV and breastfeeding
HIV can be transmitted during breastfeeding, even if the mother’s viral load is undetectable. Breastfeeding is not recommended for mothers with HIV. However, if the mother is adamant and the viral load is undetectable, sometimes it is attempted with close monitoring by the HIV team.
97
Post-exposure prophylaxis (PEP) in HIV
Post-exposure prophylaxis (PEP) can be used after exposure to HIV to reduce the risk of transmission. PEP is not 100% effective and must be commenced within a short window of opportunity (less than 72 hours).
HIV tests are done immediately and also a minimum of three months after exposure to confirm a negative status.
98
Syphilis
Caused by bacteria called Treponema pallidum. This bacterium is a spirochete, a type of spiral-shaped bacteria. The bacteria gets in through skin or mucous membranes, replicates and then disseminates throughout the body.
It is mainly a sexually transmitted infection.
99
Transmission of Syphilis
* 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
100
Neurosyphilis
occurs if the infection involves the central nervous system, presenting with neurological symptoms.
101
Tertiary syphilis
can occur many years after the initial infection and affect many organs of the body, particularly with the development of gummas and cardiovascular and neurological complications.
102
Latent syphilis =
Latent syphilis occurs after the secondary stage of syphilis, where symptoms disappear and the patient becomes asymptomatic despite still being infected. Early latent syphilis occurs within two years of the initial infection, and late latent syphilis occurs from two years after the initial infection onwards.
103
Secondary syphilis
Secondary syphilis involves systemic symptoms, particularly of the skin and mucous membranes. These symptoms can resolve after 3 – 12 weeks and the patient can enter the latent stage.
104
Primary syphilis
Primary syphilis involves a painless ulcer called a chancre at the original site of infection (usually on the genitals).
105
What are the stages of syphilis?
Primary, secondary, latent, tertiary,
106
Primary syphilis presentation
* A painless genital ulcer (chancre). This tends to resolve over 3 – 8 weeks.
* Local lymphadenopathy
107
Secondary syphilis presentation
* Maculopapular rash
* Condylomata lata (grey wart-like lesions around the genitals and anus)
* Low-grade fever, Lymphadenopathy
* Alopecia (localised hair loss), Oral lesions
108
Condylomata lata
grey wart-like lesions around the genitals and anus
109
Tertiary syphilis presentation
* Gummatous lesions (gummas are granulomatous lesions that can affect the skin, organs and bones)
* Aortic aneurysms, Neurosyphilis
110
Neurosyphilis presentation
* Headache, Altered behaviour
* Dementia, Tabes dorsalis (demyelination affecting the spinal cord posterior columns)
* Ocular syphilis (affecting the eyes), Paralysis, Sensory impairment
111
Argyll-Robertson pupil in neurosyphilis.
It is a constricted pupil that accommodates when focusing on a near object but does not react to light. They are often irregularly shaped. It is commonly called a “prostitutes pupil” due to the relation to neurosyphilis and because “it accommodates but does not react“.
112
Diagnosis of syphilis
Antibody testing for antibodies to the T. pallidum bacteria
• Dark field microscopy
• Polymerase chain reaction (PCR)
The rapid plasma reagin (RPR) and venereal disease research laboratory (VDRL) tests are two non-specific but sensitive tests used to assess for active syphilis infection.
113
What is the antibody in syphilis?
T. pallidum bacteria
114
Management of syphilis
A single deep intramuscular dose of benzathine benzylpenicillin (penicillin) is the standard treatment for syphilis.
Ceftriaxone, amoxicillin and doxycycline are alternatives.
115
The rapid plasma reagin (RPR) and venereal disease research laboratory (VDRL) tests in syphilis
The rapid plasma reagin (RPR) and venereal disease research laboratory (VDRL) tests are two non-specific but sensitive tests used to assess for active syphilis infection.
These tests assess the quantity of antibodies being produced by the body to an infection with syphilis. A higher number indicates a greater chance of active disease.
116
Menopause
A retrospective diagnosis, made after a woman has had no periods for 12 months. It is defined as a permanent end to menstruation. On average, women experience the menopause around the age of 51 years, although this can vary significantly.
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Post menopause
Post menopause describes the period from 12 months after the final menstrual period onwards.
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Perimenopause
Perimenopause refers to the time around the menopause, where the woman may be experiencing vasomotor symptoms and irregular periods. Perimenopause includes the time leading up to the last menstrual period, and the 12 months afterwards. This is typically in women older than 45 years.
119
Premature menopause
Premature menopause is menopause before the age of 40 years. It is the result of premature ovarian insufficiency.
120
Physiology of menopause
The process of the menopause begins with a decline in the development of the ovarian follicles. Without the growth of follicles, there is reduced production of oestrogen. Oestrogen has a negative feedback effect on the pituitary gland, suppressing the quantity of LH and FSH produced. As the level of oestrogen falls in the perimenopausal period, there is an absence of negative feedback on the pituitary gland, and increasing levels of LH and FSH.
121
Perimenopausal Symptoms
* Hot flushes, Emotional lability or low mood
* Premenstrual syndrome, Irregular periods
* Joint pains, Heavier or lighter periods
* Vaginal dryness and atrophy, Reduced libido
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Risks in menopause
* Cardiovascular disease and stroke, Osteoporosis
| * Pelvic organs prolapse, Urinary incontinence
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Diagnosis of perimenopause and menopause
A diagnosis of perimenopause and menopause can be made in women over 45 years with typical symptoms, without performing any investigations.
A FSH blood test to help with the diagnosis in:
• Women under 40 years with suspected premature menopause
• Women aged 40 – 45 years with menopausal symptoms or a change in the menstrual cycle
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Contraception and menopause
Fertility gradually declines after 40 years of age. However, women should still consider themselves fertile. Pregnancy after 40 is associated with increased risks and complications. Women need to use effective contraception for:
• Two years after the last menstrual period in women under 50
• One year after the last menstrual period in women over 50
