ILA3 - sexual health

Question 1

History questions for vaginal discharge

Answer 1

Colour, consistency, volume, smell, duration of symptoms

Question 2

Other questions for a gynae history

Answer 2

Urinary symptoms, systemically unwell, skin changes (swelling, rash), itch, PV bleeding, pain.

Question 3

Sexual history questions

Answer 3

gender of partner/s, contraception used, contact type, high-risk encounter - alcohol & drug use, foreign travel.

Question 4

Menstrual history

Answer 4

last period, regularity, length, dysmenorrhea, post-coital bleed, inter-menstrual bleed. previous terminations/pregnancies.

Question 5

Smear

Answer 5

for abnormal cells indicative of cervical cancer and HPV presence. Over 25yrs, every 3 years.

Question 6

Swabs

Answer 6

High vaginal for bacterial vaginosis and thrush - Microscopy and culture.
Endo-cervical for chlamydia and gonorrhoea - PCR.

Question 7

Normal discharge

Answer 7

clear/white, non-offensive smell. High progesterone at end of cycle = sticky and clear. Low progesterone at beginning = thick and white.

Question 8

Trichomoniasis

Answer 8

pH greater than 4.5, yellow, frothy.
Speculum = Strawberry cervix.
Ix = High vaginal swab.
Rx = metronidazole.

Question 9

Bacteria vaginosis

Answer 9

pH greater than 4.5, thin, grey/white, fishy smell.
Often from excessive cleaning.
Rx = metronidazole. must treat if pregnant as causes premature membrane rupture.

Question 10

Thrush

Answer 10

white, cottage cheese. itchy. painful sex. red inflamed skin. Rx=pessary tablet with clotrimazole or fluconazole tablet.

Question 11

Chlamydia

Answer 11

80% asymptomatic! painful, discharge, frequency and pain on seeing. endo-cervical swab Dx. Rx = azithromycin

Question 12

Gonorrhoea

Answer 12

commonly asymptomatic. muco-prulent discharge. Bleed on contact with cervix, endocervical swab. Rx = ceftriaxome and azithromycin. TEST OF CURE SWAB

Question 13

COCP

Answer 13

Oestrogen and progesterone. Prevent ovulation, thicken cervical mucous so less penetrable to sperm and thin endometrium to reduce implantation. Pros: regular period at end of 3 weeks of pack, reduces ovarian and endometrium cancer, can miss 2 pills and not be pregnant. Cons: increase risk of MI&Stroke, increase breast cancer risk (continues 10yrs after stopping), mood swings, breast tenderness, headache. CI: obesity, migraine + aura, severe liver disease. Efficacy: 92%

Question 14

Progesterone only pill

Answer 14

Thicken cervical mucous so less penetrable to sperm and thin endometrium to reduce implantation. Pros: only 2 days wait until contraception effective, less VTE risk, no breaks in pill taking. Cons: can only miss 1 pill, irregular periods/bleeding. Efficacy: 92%.

Question 15

Depo Injection

Answer 15

Progesterone only. Thicken cervical mucous so less penetrable to sperm and thin endometrium to reduce implantation. Every 12 weeks IM. Pros: effective, easy to remember, no oestrogen so less VTE risk. Cons: delayed return to fertility, put on weight, decreases bone mineral density at faster rate, over 18yrs only. Efficacy: 97%

Question 16

Implant

Answer 16

Progesterone only. Thicken cervical mucous so less penetrable to sperm and thin endometrium to reduce implantation. Pros: good adherence as last for 3 years, no oestrogen so less VTE risk, very effective. Cons: infection risk on insertion and removal, irregular bleeding esp for first year. CI in active breast cancer. Efficacy = 99.5%

Question 17

IUD

Answer 17

Copper coil. Copper makes inhospitable environment for sperm so prevents fertilisation and acts as barrier for implantation also thicken cervical mucous so less penetrable to sperm. Pros: immediate return to fertility, instant contraception, used as emergency contraceptive, effective. Cons: if do get pregnant increase risk of ectopic, no hormones no VTE risk, pain on insertion, heavy bleeds, can be displaced/expelled. Efficacy = 99.2%

Question 18

IUS

Answer 18

Mirena coil with Levonorgestrel. Endometrial atrophy to prevent implantation and thicken cervical mucous so less penetrable to sperm. Pros: no compliance issue, lasts for 3 years, no oestrogen so less VTE risk, effective. Cons: irregular periods, breast tenderness, risk of expulsion/displacement, if get pregnant increase risk fo ectopic. CI in active PID and pelvic TB. Efficacy = 99.9%

Question 19

Condoms

Answer 19

Prevent sperm entering cervix. Pros: stop STI transmission. Cons: latex allergy, not effective as preventing pregnancy, able to tear and split. Efficacy = 85%.

Question 20

Termination of pregnancy GP guides

Answer 20

Before 24weeks gestation and having a child will be detrimental to mum’s psychological health.

Question 21

Risks with teenage pregnancy

Answer 21

premature delivery, low birthweight, higher post-natal depression, higher noenatal mortality, anaemia.

Question 22

Gillick competence

Answer 22

Not just for contraception!!

Capacity to consent to treatment in patient less than 16yrs. Must assess for each new decision.

Question 23

Fraser competence

Answer 23

Only for contraception. Patient must:

1) understand advice.
2) not be persuaded to inform parents/
3) Physical and mental health will suffer if denied contraception.
4) Will begin/continue to engage in sexual activity with or without contraception.
5) patient’s best interests will require Dr to give contraception advise/treatment.

Question 24

Legal aspects of under age sexual activity.

Answer 24

Person under age of 13 is unable to give consent to any sexual activity. Person between 13 and 16 is able to give consent to sexual activity with a person of a similar age and not in a position of power over the child with no evidence of exploitation or abuse.

Question 25

Emergency contraception options

Answer 25

COPPER COIL! 5 day window. Ulipristal = 96hr window, delay ovulation therefore must be able to track cycle and no ovulation for that cycle must have occurred. Levonelle = 72hr window and prevents ovulation again.

Question 26

Contraceptive patch

Answer 26

Patch cycle = first 3 weeks, the patch is worn everyday and needs to be changed each week. 4th week, the patch is not worn and during this time there will be a withdrawal bleed.

Question 27

Criteria for diagnosis of bacteria vaginosis

Answer 27

Amsel's criteria:
Increased thin vaginal discharge.
pH of greater than 4.5
Fishy dour to discharge, esp on adding potassium hydroxide
Clue cells on microscopy