Cervical Screening and STI

Question 1

Vaginal Discharge Hx

Answer 1

Colour
Consistency 
Blood 
Duration
Timing
Cyclical / constant 
Odour
Previous Hx, sexual and menstrual hx

Question 2

DDx

Answer 2

Infective (non STI) - bacterial vaginosis, candida
Infective (STI) - chlamydia, gonorrhoea, trichomonas, herpes simplex virus

Non-infective - foreign bodies, cervical polyps and ectopy, genital tract malignancy, fistulae

Question 3

CIN

Answer 3

Appear white when stained with acetic acid.
1 - no tx needed, often return to normal
2 and 3 - may be removed

Question 4

Dyskariosis

Answer 4

NOT a histological dx
Merely a description of how abnormal the cells on the surface of the cervix appear

Low grade
High grade - moderate or severe

Question 5

HPV testing

Answer 5

HPV triage: borderline or mild dyskariosis - test for HPV - if negative returned to routine call

HPV test of cure: all women who are treated for CIN will have a test for HPV 6 months following their treatment - if negative no more follow up and returned to routine call, if positive then colposcopy

Question 6

HPV vaccination

Answer 6

Introduced in September 2008 for girls 12-13 years

Cervarix - 16 and 18
Gardasil - 16, 18, 6 and 11

2012 - swapped to Gardasil

Question 7

Bacterial Vaginosis (NOT AN STI)

Answer 7

Most common cause of abnormal vaginal discharge in women of reproductive age

Offensive, fishy smelling vaginal discharge, without soreness or irritation

O/E - usually a thin layer of white discharge covering vaginal wall

Common organisms - Gardnerella vaginalis, Prevotella spp, Mycoplasma hominis and more (they increase pH)

Question 8

Bacterial Vaginosis RF

Answer 8

Sexual activity, new sexual partner, other STIs, ethnicity, IUCD, vaginal douching, bubble baths, receptive oral sex, smoking

Protective factors - COCP, condoms, circumcised partner

Question 9

Dx

Answer 9

Can be difficult therefor can be empirical:
Typical symptoms and signs
Not at increased risk of STI (including being < 25)
Not postnatal / post miscarriage / post gynae surgery
Not pregnant
Not recently had tx for BV
No signs of alternative cause (fever, bleeding, pain, itch)
Raised pH if paper available to measure

Question 10

Tx

Answer 10

Oral metronidazole 400-500 mg bd for 5-7 days. Tx of choice. May be used in pregnancy.

Oral metronidazole 2g stat (avoid in pregnancy)
Metronidazole vaginal gel
Oral clindamycin / clindamycin vaginal gel

Complications - endometritis, PID, increased risk of acquiring STIs, late miscarriage, preterm delivery, premature rupture of membranes, low birth weight, postpartum endometritis

Question 11

Chlamydia

Answer 11

Most common STI in the UK - often asymptomatic

Females - vaginal discharge, dysuria, abdo pain, fever, intermenstrual and postcoital bleeding, deep dyspareunia

Males - urethritis with dysuria and urethral discharge / epididymo-orchitis presenting as unilateral testicular pain and swelling

Question 12

Signs (chlamydia)

Answer 12

Women - inflamed cervix (‘cobblestone’) with contact bleeding, mucopurulent discharge, abdo tenderness, adnexal tenderness, cervical excitation

Men - epididymal tenderness, mucoid / mucopurulent discharge, perineal fullness due to prostatitis

Question 13

Chlamydia Tx

Answer 13

Screening for other STIs, partner notification
Abx: Doxycycline 100mg bd 7 days (CI in pregnancy) / single dose of 1g azithromycin

Pregnancy: 1g azithromycin stat / erythromycin 500mg qds for 7 days or bd for 14 days (nausea can result in compliance issues) - TEST OF CURE IN 3 WEEKS