Sexual health Flashcards
Contact tracing
- conditions required for
Required for: - Chlamydia - Gonorrhoea - Trichomonas - Syphilis - Urethritis - PID (including pathogen unidentified) - Epididymo-orchitis (if STI related) Not required for genital warts or herpes
Automatic lab-notifiable infections:
- HIV - Syphilis - Gonorrhoea
Clinical features of herpes
Signs tend to develop within 3-7 days of skin-to-skin contact with an infected person (range 2-20 days)
First outbreak is usually the most painful, may last longer than later outbreaks
Other signs:
- Fever
- Muscle aches
- Headaches, which may be severe
- Vaginal discharge or painful urination
- Swollen and tender lymph nodes in the groin
Women are more severely affected than men
Virus is shed from the infected area for a median of 11 days
Systemic and local symptoms last 2-3 weeks if untreated
- Oral Rx reduces the duration and intensity of symptoms
HSV incidence
Up to 23% of adults have HSV-2 antibodies
Prior HSV-1 means HSV-2 is less likely to be symptomatic
Treatment of HSV non-pregnant
Valaciclovir 500mg BD for 7 days
Aciclovir 400mg TDS for 7 days
All first episodes should be treated regardless of timing of onset of symptoms
Treat before waiting for HSV PCR results
Episodic treatment: Valaciclovir 500mg BD for 3 days
Suppressive: Valaciclovir 500mg OD
- Reduces recurrences by 70-80%
Chlamydia - what is it?
and clinical features
Chlamydia trachomatis
Obligate intracellular bacterium infects columnar and transitional epithelium
70% of females asymptomatic
- c.f. 50% of males
Reiters syndrome
- Urethritis, arthritis and conjunctivitis
- Triggered by chlamydia
Risk of ectopic pregnancy
- No increased risk after single episode
- RR 11 after three episodes of chlamydia
Treatment of chlamydia
Treat immediately if high index of suspicion
Azithromycin 1g po stat for asymptomatic urogenital infection
Doxycycline 100mg po BD for 7 days
- Not in pregnancy
Pregnancy and chlamydia
Conflicting results in prospective studies looking at impact on pregnancy
Neonates born to women with untreated chlamydia:
- 50-60% will become colonised
- up to 50% will develop conjunctivitis or chlamydia pneumonitis
Test of cure recommended in 3 weeks following completion of antibiotics
gonorrhoea
- what is it?
Neisseria gonorrhoeae
Gram negative diplococci
Infects the epithelium of the genitourinary tract, rectum, pharynx and eye
Acute infection can –> bacteraemia and disseminated disease (~1% of cases)
Bacteria can invade bloodstream and infects the skin, synovia and joints
Almost 40% are co-infected with chlamydia
Clinical features of gonorrhoea
Frequently asymptomatic In >50% of women
In males, usually symptomatic with urethritis >95%
Diagnose with NAAT swab
- High sensitivity
Endocervical swab useful for anti-microbial susceptibility testing
Treatment of gonorrhoea
Ceftriaxone 500mg IM stat PLUS azithromycin 1g po stat
Dual therapy is recommended to delay anti-microbial resistance to gonorrhoea
Pregnancy and gonorrhoea
Increased risk of:
- Preterm ROM - Preterm birth - Low birthweight
Increased risk of PP fever
Risk of postpartum infection which can be severe
- Gonococcal ophthalmia neonatorum occurs in ~30% of exposed babies
- Pharyngeal infection carries a higher risk of disseminated gonococcal infection
- Disseminated infection - rare (<1%)
Trichomoniasis
- what is it?
Trichomonas vaginalis
Flagellated Protozoal infection
Co-infection with other STIs common
- 60-80% have co-existent BV
Incubation period: 4-28 days
10-15% of females asymptomatic
Treatment of trichomonas
> 90% effective
Metronidazole 2g po STAT
Treatment in pregnancy and breastfeeding: metronidazole 400mg BD for 7 days
Complications of trich
Increased risk of PP or post-STOP infections
Increases the risk of HIV acquisition and transmission
Increases the risk of PID in women with HIV
Associated with:
- Preterm birth
- Low birthweight
- Premature ROM
Little neonatal morbidity is associated with maternal T. vaginalis
Risk factors of PID
Age <30 Recent change in sexual contact Multiple sexual contacts Previous STI Vaginal 'douching' - 'Cleaning' the vagina by squirting water or vinegar >3x in 1 month --> 300% increase risk in PID Smoking Low SES Recent IUCD insertion (within 4 weeks) Lack of barrier contraception Sex during or just after menstruation Recent uterine instrumentation or unplanned pregnancy
Complications of PID
TOA
Chronic pelvic pain
Ectopic pregnancy and tubal factor infertility
- Risk of ectopic pregnancy and infertility increases 6x after episode of PID, and further 17x after 2 episodes
Perihepatitis (Fitz-Hugh Curtis syndrome)
- RUQ pain
- Aminotransferases are usually normal or only slightly elevated
- 10% of women with acute PID
PID severe if:
Acute abdomen Pregnant - Rare in the absence of septic miscarriage Fever, vomiting, or systemically unwell Intolerant of oral therapy Clinical failure at review
Treatment of PID
- IUD
- Antibiotics
- Pregnancy
High index of suspicion and low threshold for treatment
- Short delays can markedly increase the risk of subsequent complications
- Negative swabs do not exclude PID
Evidence suggests PID treatment outcomes are not affected by the presence of an IUD
Consider removal if:
- No improvement after 48-72h
- Removal requested by patient
- Actinomyces-like organisms on smear and has pelvic pain
Delay removal until ~24h into antibiotic therapy and consider ECP if unprotected sex in previous 7 days
Ceftriaxone 500mg IM stat + doxycycline 100mg po BD for 2 weeks + metronidazole 400mg po BD for 2 weeks
Alternative:
Ceftriaxone 500mg IM stat + azithromycin 1g po stat and repeat in 1 week if poor compliance likely
Pregnancy:
Ceftriaxone 500mg IM stat + azithromycin 1g stat and 1 week later + metronidazole 400mg po BD for 2 weeks
Severe:
- Cefoxitin 2g IV q6h or Cefuroxime 1.5g IV q8h
+ metronidazole + doxycycline
Follow up of PID
Review 1 week after completion of treatment to ensure resolution (GP)
No sex for 1 week following treatment
Outpatient management
- If no significant improvement in 72h, refer to hospital
- Further f/u at 2-4 weeks to assess:
○ Response to treatment
○ Reiterate importance of screening for STIs
○ Check compliance
pH of physiological discharge
what’s in a healthy vagina?
Fluctuating and dynamic
pH 3.8-4.5
lactobacilli predominant organisms
Signs of BV
and typical organisms
Often asymptomatic
Thin watery discharge
Symptoms more noticeable following menstruation or intercourse
No lactobacilli present - Normally an acid producing bacteria
Typical organisms:
- Gardnerella
- Mobiluncus species (present in 50-70%)
- Mycoplasma hominus (present in 60-70%)
-Prevotella species
- pretostreptococcus
Amsel’s criteria
3 out of 4 to diagnose BV:
- Offensive vaginal discharge
- Vaginal pH >4.5 (alkaline)
- Positive amine ("whiff") test with KOH
- Clue cells on microscopy of wet film
Recurrent BV treatment
Longer term Metronidazole gel twice weekly for 16 weeks after initial 10 days of treatment
Treat partner
Suppressive clindamycin cream - can lead to secondary fungal infections
Identify triggers - E.g. douching
Attempts to colonise with exogenous Lactobacillus crispatus
Pregnancy
and BV
15% of pregnant women have BV - Most are asymptomatic Associated with: - Preterm rupture of membranes - Preterm birth - Low birthweight - Postpartum infection Increased risk of complications the earlier in pregnancy the condition occurs Cochrane review found overall treatment does not reduce complications compared to no treatment or placebo
Candida incidence
Vaginal candida colonisation 10-20% asymptomatic women
Pregnancy 20-40%
90% Candida albicans
Recurrent vulvovaginal candida
4+ episodes in 12 months (proven microbiologically on 2+ episodes)
<5% of women
Fluconazole 150mg for 3 doses at 3 day intervals
- Follow with 100-150mg weekly for 6 months
Review contraception - linked to increased oestrogen
Exclude underlying medical comorbidity
LARC use
14.3% of women of reproductive age globally use IUC
LARC uptake in Au and NZ lags behind other similar countries
Advantages to LARC
Less chance of unintended pregnancy compared to user-dependent methods
Most effective, reversible methods available
High rates of user satisfaction
High continuation rates
Few contraindications
‘Fit and forget’ methods that do not require daily adherence
Require fewer visits to health care providers
Cost effective
Suitable for women of all ages including young nulliparous women
Safe for nulliparous or parous women and adolescents
Do not affect fertility after removal
Some methods have non-contraceptive benefits, e.g. reduced HMB and pain for Mirena
Barriers to use of LARC
Lack of accurate knowledge among providers and women about LARC methods
Insufficient training in insertion and removal, and management of complications
Lack of appropriate remuneration for these procedures in GP (Au)
Misperceptions about the risks of infection and infertility, concerns about potential side effects
Lack of information designed for specific audiences
- E.g. low literacy, low income, culturally and linguistically diverse backgrounds
Pearl index
the number of contraceptive failures per 100 women-years of exposure
typical and perfect use failure rate
- Mirena
- Cu IUD
LNG-IUS: 0.20% for both
CuIUD: 0.8%
Hormone and dose of Mirena
Mechanism of action
52mg levonorgesterel
Releases daily intrauterine dose of 20 mcg/24h
Causes endometrial changes, including atrophy
Thickens cervical mucus preventing sperm penetration
Prevents or delays ovulation in some users
Inhibits sperm migration to the upper genital tract
Inhibits ovum transport
Prevents implantation
