Week 2 Flashcards
Contact tracing in chlamydia
Male urethral - past 4 weeks
Any other infection - past 6 months
Contact tracing in gonorrhoea
Male urethral - past 2 weeks
Any other infection - past 3 months
When is contact tracing not req?
Warts (asymptomatic)
Herpes (asymptomatic)
Thrush (not STI)
BV (not STI)
Vax available for STI
Hep B/A
HPV
Mpox
PEP
3 antiretrovirals
Within 72H
28 days total
Hep B PEP
HBV vax up to 7 days
OR Immunoglobulin in vax non-responders
Contraception involving prevention of ovulation
Suppression of FSH/LH
Most common type e.g. COCP, implant
Emergency contraception delays ovulation
Contraception involving prevention of fertilisation
Mechanical/surgical barrier
External - condoms, diaphragm, spermicides
Internal - tubal ligation, vasectomy
Hormonal - mirena coil, causes hostile cervical mucous effect to reduce sperm penetration
Negative effect on tubal motility e.g. POP, CHC
Contraception involving prevention of implantation
Hormonal creating hostile thin endometrium
IUDs causing local endo inflam reaction and toxicity to sperm/ova (this is secondary mech of copper coil, esp in emergency)
Contraception which thickens cervical mucous
LNG-IUD,
DMPA, POP,
SDI
Contraception causing endometrial change
Cu- and LNGIUD, SDI,
DMPA, POP,
CHC
What is LARC?
Long-acting reversible contraception
5 most effective contraceptive methods
Subdermal implant
Vasectomy
IUS (mirena)
Female sterilisation
IUD (copper)
Non-contraceptive benefits of hormonal contraception
DECREASE IN:
Period pain
Heavy menstrual bleeding
Irregular PV bleeding (mainly CHC, LNG-IUD and DMPA)
Ovulation pain (if ov supp)
PMS (mainly CHC)
Cyclical breast tenderness
Ovarian cysts (if ov supp)
Endometriosis
Ovarian cancer (if ov supp)
Acne or hirsutism (CHC only)
Perimenopausal symptoms (CHC only)
Contraindications of coils
Submucosal fibroids
Uterine malformation etc
How is copper bearing IUD used as emergency contraception?
Up to 5 days after sex or 5 days after earliest estimated day of ovulation
Copper coil causes direct toxicity to sperm and egg and prevents implantation
Use of mirena coil other than contraception
Treatment of heavy period
HRT
Therapeutic use in endometriosis, hyperplasia
Describe SDI and its main side effect
Most effective, safe, lasts 3 years
Low stable level of hormones - less hormonal side effects
Main SE - prolonged PV bleeding
Bleeding may be cervicitis/endometritis from STI, preg complication, cancer/polyp
Bleeding can be controlled by additional COC
How to take COCP?
Start in first 5 days of period
OR
At any time in cycle when prob sure not pregnant, plus condoms for 7 days
Take daily for 21 days and then 7 day break
Some can be taken continuously with no interval
Factors affecting effectiveness of CHC
Impaired absorption
– GI conditions (COC)
Increased metabolism
– Liver enzyme induction or
drug interaction
Patch
– less effective >90kg
Main risks of CHC
- Venous thrombosis
- depends on dose, but more common with other RFs present, prescribe with lowest risk - Arterial disease
- incr risk of MI esp with smokers/incr BP, incr ischaemic stroke, check BP initially and annually - Adverse effects on some cancers
- WHILE USING, RETURNS TO BASELINE AFTER 10Y: incr risk of breast cancer while using esp with BRACA mutation, small incr in cervical cancer
Why is CHC contraindicated in migraine with aura?
Increases risk of ischaemic stroke
Benefit of CHC in cancer
Reductio in ovarian cancer and endometrial cancer
Benefit can last decades after stopping CHC
Non-contraceptive benefits of CHC
Acne reduction
Less bleeding
Fewer functional ovarian cysts
Improvements with PMS and PCOS
Side effects of CHC
Nausea
Bleeding
Spots
Breast tenderness
Weight gain
Mood swings
Pretty much anything you can think of
Mode of action of desogestrel PO methods
Inhibition of ovulation
Start day 1-5 of period or anytime if reasonably certain not pregnant plus condoms for 7 days (2 days if POP)
Now available OTC
Risk and side effects of POP
Small risk of breast cancer
All similar to COCP plus anything you can think of
Mode of action of depo provera/sayana press
Suppression of FSH
Lowers estradiol
Side effects of depot contraception
Nausea
WG (more likely if <18 or BMI >30)
Bleeding
Spots
Headache
Small incr risk of breast and cervical cancer
Caution in terms of bone health with under 18s and over 50s
How is vasectomy performed and complications?
Local/gen anaesthetic
NO SCALPEL
Comps include: pain, infection, inefficacy, bleeding/haematoma
Failure is usually due to early non compliance and late semen analysis
4 types of female sterilisation
Removal
Band
Clip
Essure
3 main emergency contraceptive methods
Levonorgestrel (levonelle)
- progesterone, 72h afterwards, delays ov, OTC, 60-80% effective
Ulipristal acetate (ella one)
- progesterone receptor mod, 120h afterwards, delays ov, LH surge, OTC, 60-80% effective
IUD
- 5 days after sex or 5 days after ovulation, 99% effective
Describe microbio of neisseria gonnorhoeae
Gm- diplococci
Screen with PCR
Grown on chcocolate agar
Causes urithritis, cervicitis, disseminated disease, PID, pharyngitis, proctitis
Management of gonorrhoea
1G Ceftriaxone IM,
NOT ciprofloxacin 500mg oral unless sensitivity known
2nd line: cefixine 400mg oral + azithromycin 2G
Treatment failure is usually in pharynx infection where there is limited penetration of antibios
Describe clinical pres of chlamydia trachomatis
Increased vaginal discharge, post-coital bleeding, dysuria, dyspareunia, rectal pain
Complications: PID, salpingitis, endometritis, tubal infertility, ectopic pregnancy, perihepatitis, reactive arthritis
Testing and treatment of chlamydia
Test with NAAT
Manage: 100mg BD doxycycline 1 week or azithromycin 1g stat followed by 2 days 50mg
Describe lymphogranuloma venereum
Caused by serovar L2 (and L1/L3)
Presents as outbreaks of chlamydia
Clinical: Painless ulcers and/or haemorrhagic proctitis, pharyngitis, lymphadenopathy (often unilateral)
Anaerobic bacterial causing infections which are not STIs
Gardnerella vaginalis
Prevotells sp.
Mobiluncus sp.
Atopobium sp.
Most commonly causing BV
Test with gram stain
Manage with metronidazole oral/gel or clindamycin cream
Describe pres, testing ad treatment of mycoplasma genitaleum
Pres: PID and urethritis
Not stainable as lacking cell wall, usually NAAT
Treatment: doxycycline/moxyfloxacin
Describe pres/testing of ureaplasma
Sexually transmitted and then becomes part of normal genital flora
Pres: urethritis, epididymitis, prostatitis
Test with PCR or liquid culture for sensitivity
Describe cause of syphilis
Trponema pallidum whichis a spirochate
Sex, blood transfusion, pregnancy
How is syphilis tested for?
PCR from lesion sample
Treponemal serology
- Test 1: treponemal IgG and IgM
- Test 2 if test 1 positive: specific Treponema pallidum assay & RPR (Rapid plasma reagin)/VDRL
Clinical pres of syphilis
Primary: chancre (painless ulcers on genitals)
Secondary: rash incl palms and soles, mucous pathes, condyloma lata, hepatitis, splenomegaly, glomerulonephritis
Latent after 3-12 weeks
Late/tertiary disease: neuro/cardio/gummatous syphilis
Management of syphilis
Benzathine penicillin
OR penicillin relative or doxy or azithromycin or erythromycin
Pres of HSV as STIs
Most asymptomatic
HSV-1 mainly transmitted via oral-to-oral contact => “cold sores”
HSV-2 mainly sexually transmitted => genital herpes with lesions
Complications of HSV
Increases risk of HIV transmission 3x
Severe disease in immunocompromised people
- Frequent recurrences
- HSV-1 – keratitis
- HSV-1 – encephalitis
- HSV-2 - Meningoencephalitis
- Dissemintated infection
Neonatal herpes
Management of HSV
Aciclovir 400mg 3x daily for 5 days
Prevention incl vaccine is much better than treatment
How does HPV present as a sexual health concern?
HPV 16 and 18
=> 70% of cervical cancers
HPV 6 and 11
=> genital warts
Describe Mpox
Causes vesicles similar to HSV, can be severe disease
Outpreaks of pox-like disease, ongoing since May 2022 globally
Smallpox vaccine up to 85% effective in prevention
ARV available for severe disease
How can varicella zoster be differentiated from HSV?
PCR
Complications of varicella zoster
Complications of primary infection:
- Pneumonia
- Encephalitis
- Pregnancy: fetal injury
Complications of recurrent infection:
- Lasting nerve damage
- Visual impairment
Mangaement of varicella zoster
Aciclovir in severe casess
Live attenuated vaccine available
Pres and management of yeast infection
GM pos fungi, mostly candida albicans
Pres: range of infections incl vulvovaginal candidiasis
Manage: topical or systemic antifungals
Pres, testing and management of trichomonas vaginalis
Unicellular protozoa, ST
Pres: Discharge with vulval itching, dysuria, Prostatitis, may cause preterm delivery
Testing: micro from vaginal swab, NAAT, point of care test
Manage: metronidazole 400mg BD and partner notification
Hx urethral symptoms to ask for
Duration of sxs
Colour/amount
Other urinary sxs
Testicular sxs
Systemic sxs
Sexual hx (history of STIs)
Presentation of cystitis
Dysuria
Frequency
Urgency
Nocturia
Haematuria
Suprapubic pain
Systemic
Usually due to gut bacteria
Presentation of urethritis
Dysuria
Discharge
No bladder Sx
Nil systemic
Usually caused by:
Chlamydia
Gonorrhoea
Non-specific urethritis
Presentation of dermatitis
“External dysuria”
Discomfort +/- itch
Rash or ulcers
Usually caused by:
Candidiasis
Trichomoniasis
Herpes simplex
Dermatoses
Investigations for urethritis
Clinical Examination
Urethral swab for Gram stain and microscopy
Urethral swab for gonorrhoea culture and sensitivities
First void urine, Throat and rectal swabs for chlamydia and gonorrhoea NAAT
Blood for syphilis and HIV
Diagnosis of urethritis on microscopy
More than 5 polymorphs on high powered field
Gm- intracellular diplococci = gonnococcal urethritis
None of above = non-gonococcal urethritis
Complications of gonnorhoea
Lower gen tract
- bartholinitis, tysonitis
Upper gen tract
- endomitritis, PID
Disseminated
- skin lesions, septic arthritis
Most common cause of non-specific urtheritis
Chlamydia
Deep dyspareunia suggests?
Upper genital tract infection
Cervical excitation/motion tenderness?
Pain on touch or movement of cervix
Symptomatic sampling of discharge
Cervical microscopy (gram stain)
Vaginal microscopy (gram stain and wet prep) and pH (narrow range)
Amies swab (HVS culture and sensitivity) if recurrent/persistent, unknown cause, preg/PP, PID
When is diag and treatment of PID considered?
sexually active woman who has
- recent onset, lower abdominal pain
- associated with local tenderness on bimanual vaginal examination
- pregnancy excluded
- no other cause for the pain
Presentation of chlamydia
SYMPTOMS
Urethral discharge (milky)
Irregular bleeding (PCB/IMB) (this is red flag)
Abdominal pain
Dysuria
SIGNS
Urethritis
Cervicitis
Epididymo-orchitis
Proctitis (LGV)
Complications of chlamydia
PID
Ectopic pregnancy
Reactive arthritis
Conjunctivitis
Fitz Hugh-Curtis (perihepatitis)
Management of PID
Ceftriaxone 1G IM
Doxycycline 100mg BD x 2 weeks
Metronidazole 400 mg BD x 2 weeks
Management of BV
Reassure
Metronidazole 400mg bd 5/7
Topical clindamycin 2% cream or metronidazole 0.75% gel
pH gels from pharmacy for prevention of recurrence
If persistent cnsider suppressive therapy (metro)
Worsening/recurring advice
Management of candidiasis
Reassure
Clotrimazole 500mg pessary OR Fluconazole 150mg stat
Clotrimazole 1% cream for external symptoms x2 weeks
Worsening/recurring advice
Consider HIV test if recurrent
Why can sex trigger BV?
Semen can incr pH of vagina
Findings of BV on exam
Genital mucosae normal
Film of grey/white homogenous discharge at introitus and around cervix
Normal cervis
RFs for candidiasis
Diabetes mellitus
SGLT2i (Type 2 DM)
Recent antibiotic use
Immunosuppression
How is HSV transmitted?
close contact of oral or genital tract with an individual who is shedding virus
- mouth, anogenital, eyes
virus travels along sensory nerves to dorsal root ganglion and remains inactive
causes symptom distribution in nevrve root, can be asymptomatic
reactivation more often in HSV 2
Presentation of primary HSV
Symptoms:
Pain, dysuria, discharge, painful lymphadenopathy, systemic symptoms, rectal symptoms
Signs:
Erythema, vesicles/ulcers (scab), lymphadenopathy, cervicitis
HSV 1 and 2 often present the same but HSV 2 most likely to be asymptomatic
Symptoms of recurrent HSV
Prodrome (tingling, itching, burning), localised vesicles/ulcers, heal with scab, lasts 5-10 days
Inv for herpes
Swab lesion for HSV 1 and 2 PCR
Recommend a full STI screen (chlamydia, gonorrhoea, syphilis and HIV)
Acquiring primary herpes in last 6 weeks of pregnancy may lead to?
Neonatal herpes
Describe pres of primary syphilis
Incubation 10-90 days
Painless chancre
- mouth, vulval, tip of penis, anal
Resolves in 3-6w without treatment
Describe pres of secondary syphilis
Incubation<2y
Haematogenous and lympathic dissemination causing multi-system disease
Systemic symptoms/fluey:
- low grade fever
- sore throat
- headache
- lymphadenopathy
- rash (esp palms and soles)
- wart like lesions in warm/moist areas (vulva, anus)
Inv for syphilis
Swab from lesion for treponema pallidum PCR
Venous blood for syphilis IgG/IgM (EIA) - serology is not v specific but is best
TPPA is confirmatory, then RPR to monitor disease prog
Consider repeating STI screen if previously not definitive
ST causes of gential lumps
Genital warts (HPV)
Molluscum contagiosum
Monkeypox
Scabies
Non-ST causes of genital lumps
Physiological
Folliculitis
Hydradenitis suppurativa
Seborrhoeic keratoses
Cancers
Bartholin’s abscess
Skin tags
Lichen planus
Pyoderma granuloma
Mnagaement of genital warts
Cryotherapy
Topical podophylotoxin
- Solution (0.5%)
- Cream (0.15%)
Imiquimod
Cataphen
Surgical
- Electrocautery
- Curette
- Debulking
Is HPV persistent?
No not usually
70% DNA negative at 12m and 80% negative at 24m
Persistence more common in immunosuppressed or people who smoke
