Womens sexual and reproductive health

Topics: STIs, Contraception, Abortion, Endometriosis, PCOS, Ectopic pregnancy

Name the bacterial STIs

Chlamydia, Gonorrhoea, Syphilis, Trichomoniasis

Name the viral STIs

HSV (Herpes simplex virus ), HPV (Human papilloma virus), HIV (Human immunodeficiency virus)

What are the symptoms of Chlamydia ?

Often a symptomatic however symptoms include, purulent vaginal discharge, post coital bleeding, lower abdominal pain, mucopurulent cervicitis

What is the treatment for chlamydia ?

Antibiotic treatment; doxycycline (unsafe during pregnancy), erythromycin, amoxicillin

Symptoms of Gonorrhoea?

Increased and abdominal pain, dysuria, intermenstrual bleeding, Menorrhagia

What are the implications of Gonorrhoea during pregnancy/birth

Gonorrhoeae can be transmitted to the newborn via maternal genital tract during birth with a transmission rate 30-50%. Manifests as gonoccocal ophthalmia neonatorum & and can cause blindness

What is the treatment for Gonorrhoea

Treated with penicillin & probenecid

What are the disease stages of Syphilis

Primary 10-90 days post exposure, secondary 2 weeks- 6 months after exposure, latent 2 years after exposure, tertiary 3 years or more after exposure with neurological and vascular involvement

Describe characteristics of primary syphilis

painless genital sore (chancre), lymphadenopathy (lymph node enlargement) 3-6 weeks post exposure

Describe characteristics of secondary syphilis

Involvement of lymph nodes, generalised rash and warts

How does syphilis impact pregnancy?

Syphilis can pass through the placenta and is associatd with; spontaneous abortion, stillbirth/neonatal death, LBW, PROM, chorioamnionitis, premature birth, postpartum endometritis (inflammation/infection of uterine lining)

What is Trichomoniasis and what are some symptoms

Is a protozoan (single cell organism). symptoms include green vaginal discharge, dysuria, vulval itching and offensive odour, dysparaunia, strawberry cervix

Treatment for Trichomoniasis ?

Metrondiazole (Flaygl)

What is type 2 HSV

Is herpes simplex virus and is genital/anal lesions. Its a viral infection which can be transmitted to newborns

How does HSV type 2 present?

Tingling pain, genital blisters, dysuria & retention, anorectal spasm, vaginal discharge and lymphadenopathy

What is the treatment for genital herpes ?

Treatment is symptomatic not curative. Primary infection treatment and recurrent infection treatment uses antiviral therapy

What is HPV ?

Human papilloma virus has over 20 different types that can infect the genital area with a 60% infection rate in sexually active adults

How is HPV/genital warts treated

Antiproliferative agents (inhibit cell division) as well as ablative methods (laser, cryotherapy) and immune response enhancements (imiquinod cream)

What are barrier methods of contraception?

• Male condoms

• Female condoms where ring sits behind the pubic bone, diaphragms (dome shaped rubber cap with flexible rim)

What are the differences between the 3 types of contraceptive pills

• Monophasic pills: same does of oestrogen and progesterone for 21 days

• Biphasic pills: same dose of oestrogen but higher progesterone in second half of cycle

• Triphasic: oestrogen altered mid cycle, progesterone increases in 2 stages

How do hormonal contraceptives work?

Suppress ovulation through inhibition of hypothalamic-pituitary-ovarian feedback system, thicken cervical mucus to inhibit sperm penetration and create a sub-optimal endometrium

How does the hormonal contraceptive pill work?

Uses 21 active pills and a 7 day break from hormone pills, withdrawal from hormones causes an artificial menstural period and brief return of pituitary activity.

When is the hormonal pill contraindicated

• DVT

• Strokes & myocardial infarctions,

• hypertension

• cancer risks

• hepatic tumors

• gall bladder disease

What is the mini pill?

A 28 day progesterone only pill which changes cervical mucus and makes it harder for sperm to penetrate. Can be used in combination with breastfeeding

What are advantages and disadvantages of the injectable contraceptive?

• Advantages: long acting and given 12 weekly, used when compliance is a concern, able to be used with intelectually disabled people and historical drug use.

• Disadvantage: Irreversible, delayed fertility (up to 12 months) after resuming, can produce menstural irregularities

What are contraceptive devices and how do they work?

• Implanon: sub dermal rod whch is inserted under the skin of the arm and gives a continous release of progesterone over 3 years

• Intrauterine devide: Plastic device with progesterone thats inserted through the cervix and sits inside the uterus

How is male sterilisation and female sterilisation achieved

• Male: vasectomy whereby cutting or blocking of both vas deferens occurs

• Female: tubal occlusion is the surgical blocking of fallopian tubes and is permanent

What are the legalities of abortion in Australia?

• All states permit abortion up to 22 weeks of gestation

• After this, a review of the reason for abortion must occur and requires 2 doctors and a psychologist

What is medical vs surgical abortion?

• Medical: can be performed until 9 weeks of gestation and involves taking oral medication and results in cramping, bleeding and miscarriage

• Surgical: performed under a GA through suction currette and after 9 weeks

What is endometriosis?

• An oestrogen dependent inflammatory condition

• Endometrial epithelium and stroma are present outside uterine cavity and walls

• up to 20% of women

What is the pathophysiology of endometriosis?

• endometriotic implants respond cyclically to ovarian hormone production (similarly to uterine lining)

• Proliferative under oestrogenic stimulation

• When Oestrogen and progesterone levels decline, implants breakdown and results in inflammatory response (causing pain & fibrosis)

• 
  

What are the classifications of endometriosis and the characteristics associated?

• Mild: normal function of fallopian tubes and ovaries uncompromised

• Severe: extensive adhesive formation formation & altered function of affected organ

What are the symptoms of endometriosis:

• Dysmenorrhoea: cyclic pelvic pain & increased blood and menstural debris

• Dyspareunia: pain during sex

• Dyschezia:

Explain the diagnosis and managment of endometriosis ?

• Suspect endometriosis if; presence of triad pelvic pain, tender adnexal mass, tender nodule in uterosacral ligament

• Perform laparoscopy / laparotomy: biopsy + history = definitive diagnosis

• Management depends on the extent of the disease but can include medical and surgical intervention

• 
  

What is the medical management of Endometriosis

• Cyclic dysmenorrhoea is treated with NSAIDS and COCP (oral contraceptive pill)

• Non-cyclic dysmenorrhoea is treated through 1st line: short term NSAIDS or depo-provera, 2nd line GnRH agonist, higher dose progestins, danazol

What are the 4 types of FGM

• Type 1: Clitoridectomy: total or partial removal of the clitoris and surrounding skin

• Type 2: Excision: The partial or total removal of clitoris plus removal of labia minora

• Type 3: Infibulation: cutting and repositioning of the labia minora and labia majora, often including stitching to leave only a small gap

• Type 4: This covers all other harmful procedures like pricking, piercing, incising, scraping of the clitoris and genital area

What are some of the immediate implications of FGM

• severe pain

• excessive bleeding and haemorrhage

• fever

• genital tissue swelling

• fever

• infection

• urinary problems

• wound healing

• injury to surrounding tissue

• shock

• death

What are some long term complications of FGM

• Urinary problems (painful urination, UTI)

• Vaginal complications (BV and other infection, itching, discharge)

• Sexual dysfunction

• Increased risk of childbirth complications

• psychological problems

What is the estimated extent of FGM

it is estimated 200 million girls and women alive today have undergone some form of FGM

What are the two categories for surgical management of endometriosis

• Conservative: electrocautery, laser, excision of endo

• Radical: Destruction of peritoneal implants

How does PCOS manifest

• irregular menses, weight gain, acne, multiple ovarian cysts, alopecia

How is PCOS treated

Normally through a number of means:

• Education and counselling

• Lifestyle interventions

• Metformin (for insulin resistance)

• COCP

• Management of acne

what are some implications of PCOS on women of reproductive age

• sub fertility

• gestational diabetes

• insulin resistance

• obesity

What is an ectopic pregnancy

• Occurs in 1-2% of pregnancoes where a fertilised ovum implants outside the uterus

• Most frequent implantation sites are fallopian tubes, cervix and c/s scar

What are some risk factors for an ectopic pregnancy

• over 35 years of age

• cigarette smoking

• fallopian tube pathology

• infertility

• pelvic inflammatory disease

• pregnancy with an IUD insitu

• previous ectopic pregnancies

• previous fallopian tube surgeries

What are some signs of an ectopic pregnancy

• bleeding early in pregnancy

• slower rate of increase in HCG hormone

• lower abdominal pain

• collapse

How is an ectopic pregnancy diagnosed ?

• sequential beta hcg test

• trans vaginal US (exludes intrauterine pregnancy)

• patient hx

What is the treatment of an ectopic pregnancy

• surgical removal of ectopic pregnancy

• Intramuscular methotrexate: cytotoxic mediction which can interupt rapid division of of cells and then reabsorbed by body

How can medical methotrexate treatment be determined as succesful?

• levels of HCG wll decline

What is a blighted ovum?

• AKA anembryonic pregnancy where a fertilized egg implants in uterus but is reabsorbed. The gestational sac and placenta continue to grow but a miscarriage is caused in the first trimester