Urinogenital Medicine Flashcards
Name 2 types of POP
Desogestrel Only Pill (Cerazette)
Traditional progestogen-only pill (Norgeston)
What is the MOA for POP? (4)
Thickens cervical mucus
Makes endometrium less accepting of implantation
Reduces ciliary action in the fallopian tubes
Inhibits ovulation (desogestrel)
When is it best to start the POP and why?
Starting on day 1-5 of the menstrual cycle provides immediate protection (as ovulation is unlikely during this period and it takes 48 hours for cervical mucus to thicken)
If a POP is started after day 5 of the menstrual cycle, what advice is given?
Use additional contraception (i.e condoms) for 48 hours after starting POP
Can POP be used in pregnancy?
Yes. POP is not harmful in pregnancy.
But, women should do a pregnancy test 3 weeks after last unprotected intercourse.
When is it best to switch from COCP to POP?
Day 1-7 of the hormone free period after finishing the COCP pack. Here no additional contraception is required.
What is the only unacceptable health risk for POP use?
Active breast cancer
If a patient had sex since completing the last pack of COCP what must they do before switching to POP?
Complete at least 7 consecutive days of COCP before switching AND use extra contraception for 48 hours.
List 5 side effects of POP
Unscheduled bleeding (common in 1st 3 months)
Amenorrhoea/Irregular bleeding
Breast tenderness
Headaches
Acne
Give 3 possible complications of POP use
Ovarian cysts
Ectopic pregnancy (due to reduced ciliary action in fallopian tubes)
Breast cancer (small chance)
How are missed pills classified in POP? (3)
Traditional POP - >3 hours late - >26 hours after last pill
Desogestrel POP - >12 hours late - >36 hours after last pill
Diarrhoea or vomiting - Extra contraception is required until 48 hours after diarrhoea and vomiting settles
What should a patient do if they miss a POP pill? (3)
Continue with next pill at usual time (take 2)
Use extra contraception for next 48 hours of regular use
Use emergency contraception if they had sex since missing the pill or within 48 hours of restarting regular pills.
Give 4 examples of COCP and state what they contain
Microgynon - Ethinylestradiol + Levonorgestrel
Loestrin - Ethinylestradiol + Norethisterone
Marvelon - Ethinylestradiol + Desogestrel
Yasmin - Ethinylestradiol + Drospirenone
When is noresthisterone useful?
Useful for delaying periods (i.e if a woman is going on holiday)
When is drospirenone useful? and why?
1st line for premenstrual syndrome
(spironolactone analogue)
Has antimineralocorticoid and antioandrogen effects which helps with bloating, water retention and mood changes.
What is drospirenones pattern of use?
Continuous rather than cyclical
What is the MOA of the COCP? (2)
Prevents ovulation
Thickens cervical mucus, inhibits implantation and reduces ciliary action in fallopian tubes
How does COCP prevent ovulation?
Oestrogen and progesterone have a negative feedback effect on the hypothalamus and anterior pituitary, suppressing the release of GnRH, LH and FHS.
What is a withdrawal bleed (COCP). How often should they occur?
Describes when the pill is stopped (inactive pills) and the endometrium breaks down and sheds, resulting in a withdrawal bleed.
Should occur at lasts 3 times/year
Give 3 regimes for the COCP
21 days on and 7 days off
63 days on (3 packs) and 7 days off (tricycling)
Continuous use without a pill free period
Give 3 side effects of COCP
Unscheduled bleeding (common in 1st 3 months)
Breast pain/tenderness
Mood changes/depression
Give 2 risks of taking the COCP
VTE
Breast + Cervical Cancer
Give 3 non-contraceptive benefits of COCP use
Improves premenstrual symptoms, menorrhagia (heavy periods) and dysmenorrhea (painful periods)
Reduces risk of endometrial, ovarian and colon cancer
Reduces risk of benign ovarian cysts.
Give 5 contraindications for COCP use
Uncontrolled hypertension (>160/100)
Migraine with aura
History of VTE
Smoking >15/ day and >35 years old
SLE/anti-phospholipid syndrome
When is it best to start the COCP? What should you advise if the COCP is started after this period?
Day 1-5 of menstrual cycle - offers immediate protection
Starting > day 5 requires use of extra contraception for the first 7 days of consistent pill use
What antibiotic can reduce the effect of COCP?
Rifampicin
What is classified as a ‘missed pill’ when taking COCP? What should be done if this happens? Is emergency contraception needed? (3)
Missed pill = >24 hours late (48 hours since last pill was taken)
Take missed pill ASAP (even if that means taking 2 pills in 1 day)
No emergency contraception is required (as mons as all other pills have been taken correctly)
What is advised if >1 COCP pill is missed (>72 hours since last pill was taken)? (2)
Take most recent missed pill ASAP (even if it means taking 2 pills in one day)
Use additional contraception regularly for 7 days
Regarding days of the menstrual cycle, what is the emergency contraception advice for missing >1 COCP? (3)
Day 1-7 missed - Emergency contraception required
Day 8-21 missed - No emergency contraception required
List 3 factors that can reduce COCP effectiveness
Vomiting
Diarrhoea
Rifamipicin
For how long does the copper coil remain effective?
5-10 years
How long does it take for the copper coil to act as an effective contraceptive?
Works immediately
How long is the LNG-IUS effective for as a contraceptive?
5 years
How long does it take for the LNG-IUS to become an effective means of contraception?
7 days
Give 7 contraindications for Coil use
PID/Infection
Immunosuppression
Pregnancy
Unexplained bleeding
Pelvic cancer
Uterine cavity distortion (fibroids)
Wilson’s disease (copper coil)
What should all women be screened for before coil implantation?
Gonorrhoea and Chlamydia
What must women do before removal of a contraceptive coil? Why?
Abstain from sex or use condoms for 7 days before the coil is removed.
Sperm can survive for 7 days after sex
If coil threads cannot be seen or palpated, what 3 things must be excluded? And what are the 1sr and 2nd line investigations?
Expulsion
Pregnancy
Uterine perforation
1st line - Ultrasound
2nd line - Abdominal/Pelvic X-ray
Give 3 side effects of the copper coil
Heavy menstrual bleeding
Pelvic pain
Increased risk of ectopic pregnancy
What is Gillick Competency?
Guidance on whether a child (under 16) can consent to their own medical treatment without their parents having to know of give permission.
What are Fraser Guidelines?
Provide advice regarding whether to give contraception to a child under 16 without parental consent.
What 5 factors should be considered in Fraser Guidelines?
Is the child mature and intelligent enough to understand the nature and implications of the treatment proposed?
Is it impossible to persuade the child to tell their parents, or let the Doctor tell them?
Are they likely to begin or continue having sexual intercourse with or without contraception?
Are their physical or mental health likely to suffer unless they get advice or treatment?
Is the advice or treatment in their best interest?
What is the difference between Gillick and Fraser guidelines?
Gillick competence is used to assess a child’s capability to make and understand their decisions in a wider context.
Fraser guidelines are applied specifically to advice and treatment regarding a young persons sexual health and contraception.
What is the commercial name for the progesterone implant?
Nexplanon
Where is the progesterone implant (Nexplanon) implanted?
Subdermally, non-dominant arm
What pathogen commonly causes bacterial vaginosis?
Gardnerella vaginalis
Give 3 risk factors for bacterial vaginosis
Sexual intercourse
Intrauterine devices
Pregnancy
Give 1 ‘exam’ clinical features of bacterial vaginosis
Milky/gray vaginal discharge with fishy odor
How is bacterial vaginosis diagnosed? (4)
3 of the following Amsel criteria;
Presence of Clue Cells (vaginal epithelial cells with fuzzy borders due to bacteria adhering to cell wall)
Vaginal PH >4.5
Positive Whiff test - Intensified fishy odour after adding potassium hydroxide
Thin, homonymous gray-white or yellow discharge that adheres to vaginal wall
How is bacterial vaginosis managed?
Asymptomatic - Reassurance
Symptomatic;
Non pregnant
1st line - Metronidazole
2d line - Clindamycin
Pregnant ;
1st line - Metronidazole
2nd line - Clindamycin
Repeat testing after 1 month
Syphilis is caused by what pathogen?
Treponema pallidum
What is the incubation period of Syphilis?
9-90 days
How many stages of Syphilis are there?
3
Primary, Secondary and Tertiary Stages
Name 3 features of the primary stage of syphilis
Chancre - Painless ulcer at the site of sexual contact
Local non-tender lymphadenopathy
Often not seen in women
Name 4 secondary features of Syphilis. When do they occur?
Occur 6-10 weeks after primary infection
Systemic features; fever, lymphadenopathy
Rash on trunk, palms and soles
Buccal ‘snail track’ ulcers
Condylomata lata (painless, watery lesions on the genitalia)
Name 4 tertiary features of syphilis
Gummas (granulomatous lesions of the skin and bones)
Ascending aortic aneurysms
Tabes dorsalis (sudden lightning like pain/paraesthesias in leg or trunk)]
Argyll Robertson Pupil (small and irregular pupils that have no constriction to light but constricts to near targets)
In what condition would you see Argyll Robertson Pupils? Describe how they present.
Seen in Syphilis
Describes small and irregular pupils that have no constriction to light but constricts to near targets (light-near dissociation)
Give 5 features of congenital syphilis
Blunted upper incisor teeth (Hutchinson’s teeth)
Rhagades (linear scars at the angle of the mouth)
Keratitis
Saber Shins (anterior bowing of the tibia)
Saddle nose
How is syphilis diagnosed?
Treponema pallidum is a very sensitive organism and cannot be grown on artificial media, therefore diagnosis is made on clinical features, serology and microscopic examination of infective tissue.
Name 2 serological tests used to diagnose syphilis
Non-treponemal tests (VDRL)
- Not specific for syphilis (so can have false positives)
- Based on reactivity of serum from infected patients to a cardiolipin-cholesterol-lecithin antigen
Treponemal-specific (TPHA)
- More specific but expensive
Syphilis tests - If Positive Non-treponemal test (VRDL) + Positive treponemal test (TPHA), what is the diagnosis?
Results consistent with active syphilis infection
Syphilis tests - Positive Non treponemal test (VRDL) + negative treponemal test (TPHA)
Consistent with false positive syphilis result (due to pregnancy or SLE)
Syphilis tests - Negative non-treponemal test (VRDL) + positive treponemal test (TPHA)
Consistent with successfully treated syphilis
How is syphilis managed?
1st line - IM Benzathine Penicillin
2nd line - Doxycycline
What reaction may be seen following initiation of syphilis treatment? How may it present?
Jarisch-Herxheimer reaction
May present with fever, tachycardia and rash after 1st dose of antibiotics.
How may chlamydia present in women? (4)
Yellow, odourless vaginal discharge
Deep dyspareunia
PV bleeding
Dysuria
Give 4 complications of chlamydia
Epididymitis
PID
Endometritis
Increased incidence of ectopic pregnancy
What investigations are performed to diagnose chlamydia? How is the sample obtained?
Nuclear acid amplification tests (NAATs)
Female - Vulvovaginal swab
Male - Urine test (first catch)
When should chlamydia testing be performed?
2 weeks after possible exposure
How is chlamydia managed?
1st line - Doxycycline
2nd line - Azithromycin
How is chlamydia managed in pregnancy?
Azithromycin
Alternatives; erythromycin or amoxicillin
How are contacts managed in chlamydia management? (male and female)
Male with urethral symptoms - All contacts since and in 4 weeks prior to onset of symptoms
Female and asymptomatic men - all partners from last 6 months or most recent sexual partner
Give 4 possible neonatal complications of chlamydia exposure
Chorioamnionitis
Neonatal conjunctivitis
Neonatal pneumonia
Prelabour rupture of membranes
Give 4 features of congenital syphilis
Generalised lymphadenopathy
Hepatosplenomegaly
Rash
Skeletal malformations
