GUM Flashcards
GUM History Taking
- Steps
Sexual History Taking
- Steps
- Concerns and expectations
- Check identity/pronouns
- PMC
- Drug history
- chemsex - If uterus
- Gynae/smear/HPV vaccine
- Menstrual
- Contraception
- Pregnancies - Social Hx
- Sexual History
- Chemsex - BBI risk (blood born)
HPV vaccine
- Valency
- Age
- Years introduced
HPV
- Vaccine
1. Now quadra-valent
2. Was bi-valent - Age
3. 12-13 - Years introduced
4. 2008 onwards
GUM
- Presenting complaint AFAB
GUM AFAB
- Presenting complaint
- Vaginal discharge
- Lumps/ulcers
- IMB/PCB
- Dyspareunia (deep/superficial)
- Urinary symptoms
- Abdo pain
- STI contact
- contraception - Rectal symptoms
- Sexual assault
- Asymptomatic screens
GUM AMAB
- Presenting complaint
GUM AMAB
- Presenting complaint
- Urethral discharge
- Urinary symptoms
- Lumps/ulcers
- Testicular pain/swelling
- Rectal symptoms
- Sexual dysfunction
- Asymptomatic screens
GUM
- Sexual history
GUM
- Sexual history
- STI Hx
- Last sex episode
- Male/female/trans
- Regular or casual contact
- Duration of sexual relationship
- Sexual activity
- use of barriers - Type of sex
- MSM (active/passive) - Partner details/contact tracing
GUM
- BBI risk factors
GUM
- BBI risk factors
- IVDU
- MSM/Anal sex
- Swingers
- Partners
- High risk countries - Paid-for sex
- Blood products
- 1985 or abroad - Tattoos/piercings
GUM
- Examination principles
GUM
- Examination principles
- Explain rationale
- Consent
- offer to stop at any point - Chaperone
- Document even if declined - Privacy for dressing/undressing
- Expose only area needed
GUM
- Male examination
GUM
- Male examination
- Palpate inguinal region
- lymphadenopathy - Inspect pubic area and scrotum
- Inspect penis
- retract foreskin (eg thrush) - Palpate scrotum
- symmetry of size, firmness,
- swelling/cyst/hydrocele - MSM
- Peri-anal
- Proctoscope
GUM AMAB
- Symptomatic investigations
GUM
- Symptomatic investigations
- Urethral smear
- GC or NSU (non-specific)
- GC culture (gonorrhoea) - First pass urine
- GC/CT dual Naats - Bloods
- HIV/syphilis
- Hep B/C - Rectal/pharyngeal swab/culture
- MSM
- “Triple site testing” - Other swabs
- MC&S/Candida/Herpes - Urine dip
GUM AFAB
- Examination
GUM AFAB
- Examination
- Lithotomy position
- Inspect and palpate inguinal region
- Lymphadenopathy - Inspect pubic area
- labia majora/minora
- perianal areas - Speculum exam
- Bimanual exam (PID - CMT cervical movement tenderness)
- Abdominal pain
- Deep dyspareunia
Speculum examination
- Technique
Speculum examination
- Technique
- Lubricant and warmed
- Insert using dominant hand
- Part labia with non-dominant hand
- Slowly insert
- open blades to visualize the cervix
Bimanual examination
- Technique
Bimanual examination
- Technique
- Gloved right hand
- separate labia - Index and middle finger
- insert into vagina and palpate cervix - Left hand
- palpates uterus and adnexa
GUM
- Symptomatic afab investigations
GUM
- Symptomatic afab investigations
- TV, BV, Candida
- High vaginal loop swab for MC & pH - Chlamydia and gonorrhoea
- Vulvovaginal swab ‘dual NAAT’
- May offer triple site testing - Bloods
- HIV/Syphilis
- Hep B/C - History dependant
- TV - High vaginal charcoal/PCR
- Gonorrhoea - endocervical
- Herpes simplex - PCR
- Pregnancy test (?PID)
GUM - Asymptomatic screening
- Afab
GUM - Asymptomatic screening
- Afab
- Self- vulvo-vaginal swab
- Dual NAAT chlamydia - Serology
- STS, HIV - Pregnancy test/Urinalysis
Partner notification
- Definition
Partner notification
- Definition
- Contacting and advising
- Those at high risk of
- STI/HIV
- encouraged to attend
GUM - Partner notification
- Securing co-operation
GUM - Partner notification
- Securing co-operation
- Voluntary
- Non-judgement and supportive
- Emphasize patient choice
- Confidentiality
- Risk of re-infection
- Partner at risk from infections
- Risk of transmission
GUM
- Identifying partner’s at risk
GUM
- Identifying partner’s at risk
- Look-back period
- infection specific - Memory prompts can help recall
- Document details to track progress
- Safer sex advice
GUM
- HIV non-notification
GUM
- HIV non-notification
- In ‘x’ time, if you have not notified, we will
Genital Warts
- Latin name
- Pathology
Genital Warts
- Latin name
1. Condyloma acuminata - Pathology
- HPV manifestation
Condyloma acuminata
- Commonest
- High risk
Condyloma acuminata
- Commonest (90%)
- Types 6, 11 - 16 & 19
-High risk
HPV types
- Hands
- Face
- Genital/laryngeal
- CIN
- Head and Neck Ca
HPV types
- Hands
2, 4, 26, 27 - Face
2 - Genital/laryngeal
6,11 - CIN
16,18 - Head and Neck Ca
18
HPV
- Pathophysiology
HPV
- Pathophysiology
- Basal layer invaded
- Latent phase
- Dormancy - Viral DNA, capsids
- Wart formation
HPV
- Infectivity rate
- Incubation
- Prevention
HPV
- Infectivity rate
1. 60% (sexual contact)
- Incubation
2. 2. weeks to 8 months
3. 3 Months average - Prevention
4. Condoms do NOT prevent skin contact
Gential warts
- Presentations
Gential warts
- Presentations
- Usually asymptomatic and painless
- Noticed after sexual contact aqcuiring them
- Itching or sore
- Peri-anal common
- Internal lesions
- Bleeding from urethra, anus, cervix
- Distorsion of urine flow - Pscyhological distress
- Site of trauma
- Warm or moist conditions
- Multifocal infection
- Ano-genital
Condyloma acuminata (Warts)
- Clinical appearance
Condyloma acuminata (Warts)
- Clinical appearance
- Solitary or often multiple
- Can be
- Broad based
- Pedunculated
- Pigmented - Warm, moist, non-hairy skin
- soft
- non keratinised - On hariry skin
- firm and keratinised
Condyloma acuminata (warts)
- Female follow up
Condyloma acuminata (warts)
- Female follow up
- Sepculum exam
- Colposcopy
- if internal warts - Proctoscopy
- if rectal bleeding
Condyloma acuminata (warts)
- Common differentials
- Other things to consider
Condyloma acuminata (warts)
- Common differentials
1. Fordyce spots
2. Pearly papules
3. Skin tags
4. Follicles
5. Tyson’s glands
6. Vestibular papillosis
7. Haemangiokeratoma
8. Sebaceous cysts - Other things to consider
1. Conylomata lata (syphilis)
2. VIN, PIN, SCC
3. Molluscum contagiosum
Buscheke-Lowenstein
- Pathology
Buscheke-Lowenstein
- Pathology
1. Giant condyloma accuminata - HPV
- Higher rate of malignant transformation
Condyloma acuminata
- Mx
Condyloma acuminata (Warts)
- Mx
- Screen for STIs
- Reassure
- Cosmetic rather than immune
- cryoRx
- Podophyllotoxin
- antimitotic - Immune modifiers
- Imiquimod cream - Catephen
- Green tea leaf extract - Surgery
Condyloma accuminata
- Patient applied therapy
Condyloma accuminata
- Patient applied therapy
- Softer warts
- 4 weeks to 16 weeks
- Include:
- Podophyllotoxin
- Imiquimod
- Catephen
Genital warts
- Threshold to refer
Genital warts
- Threshold to refer
- Suspicious/uncertain/internal
- Recalcitrant lesions (consider HIV)
- Cervical lesions
- Meatal warts
- Immunosuppressed
- Pregnant
- Children/young
- Elderly
- High risk
HPV
- Quadravelent vaccine
HPV
- Quadravelent vaccine
- 6&11
- 16&18
Genital warts in pregnancy
- Vertical transmission
- Management
Genital warts in pregnancy
- Vertical transmission
- Very low risk - Management
- Watch and wait
- Cryoablation
- Surgical if extreme
HIV
- Replication
HIV
- Replication
- Uses reverse transcriptase
- Generates proviral DNA from RNA
HIV Presentation
- Asymptomatic
- Early infection
- Advanced HIV
HIV Presentation
- Asymptomatic
0. screening - Early infection
1. Seroconversion symptoms
2. TB
3. Blood dyscrasias
4. Lymphomas - Advanced HIV
- PCP
- Cryptococcal meningitis
- Malignancies/pathology
- KC
HIV Seroconversion illness
- Mx
HIV Seroconversion illness
- Mx
- Early treatment
- TasP (treatment as prevention) - Risk behaviour modification
- PN
HIV
- Testing
HIV
- Testing
- EIA
- 4th Generation combo assay
- Detects antibodies
- Detects P24 antigen
- 45 day window - Immunoblot in lab
- other antigens - PCR
- Viral load measure
HIV
- Testing in Sero-conversion
HIV
- Testing in Sero-conversion
- False negatives possible
- Test and repeat over time - Viral load
- help diagnose before antibodies (45 day window) - Pro-viral DNA
- considered in some circumstances - PrEP and PEPSE
- Delayed or unusual seroconversion
HIV
- Monitoring tests
HIV
- Monitoring tests
- CD4 count
- Viral load
- HIV resistance testing
- Patient health
- FBC, U&E, LFT, Bone, Physical, Fundoscopy, Urine dip - Infection screening
- STIs/BBIs
- TB
- OI
HIV
- TasP
HIV
- TasP
- Treatment as prevention
- Valid if VL<50 for 6mo
HIV
- PrEP
- PEPSE
HIV
- PrEP
1. High risk eligible patients
2. Truvada daily or ‘event based’
3. At least 86% successful
- PEPSE
1. Within 72 hours of exposure
2. Truvada and Raltegravir for 28 days
HIV
- Treatment
HIV Treatment
- Triple Anti-retroviral
- Typically 2 NRTI + 3rd agent
- Many one pill OD
- Monitored 6 monthly
- viral load
- regular blood tests
HIV
- Drug classes
HIV
- Drug classes
- NRTI
- Nucleoside reverse transcriptase inhibitors
eg. Tenofovir, abacovir, emtricitabin, lamivudine - NNRTI
eg. Efavirenz, doravarine - Protease inhibitors
- co-prescribed with a booster
eg. Darunavir pulus Ritonovir - Integrase inhibitors
- eg. Raltegravir, bictegravir
Hepatitis C
- Virus
- Transmission
Hepatitis C
- Virus
1. RNA
2. Flaviviridae family - Transmission
1. Parenteral
2. Vertical (5% risk)
3. Sexual transmission (very low) - UP AI
- Fisting, rimming, chemsex IV ‘slamming’
Hepatitis C
- Symptoms
- Incubation
- Progression
Hepatitis C
- Symptoms
1. Icteric hepatitis
2. Chronic hepatitis - Incubation
1. 6 wks (4-20)
2. 90% positive serology at 3/12 - Progression
1. 80% progress to chronic
2. 30% to Cirrhosis
3. Hepatocellular carcinoma
Hep C
- Testing
Hep C
- Testing
- Anti-HCV
- CUrrent or past infection
- 4-10 weeks after exposure
- Some detect HCV-Ag - HCV RNA
- Current vs past infection - Hep C genotyping
- guides treatment
Hep C
- Mx
Hep C
- Mx
- Curable
- Liver function
- hepatology involvement - DAAs
- Direct acting antivirals
- eg. Harvoni
Hepatitis B
- Virus
- Transmission
Hepatitis B
- Virus
1. DNA virus - Transmission
1. Parenteral
2. Vertical
3. Sexual - Rimming, multiple partners
Hep B
- Presentation
Hep B
- Presentation
- Children
- no Sx - Incubation for 40-160 days
- Acute phase
- Similar to Hep A
- Prodrome/icteric phase
Hep B
- Complications
Hep B
- Complications
- Acute liver failure/mortality
<1% - Chronic
- 5-10% of symptomatic cases
- Higher in HIV, immunosuppressed, LD - 90% of infants will progress to chronic unless treated quickly
Hep B Prevention
- Pregnancy
- Sexual contacts
- Household contacts
Hep B Prevention
- Pregnancy
1. Antivirals in high load
2. Vaccination of neonate
3. HBIG if HR - Sexual contacts
1. Vaccinate
2. HBIG if recent (<7 days)
3. Condoms until immune - Household contacts
1. Vaccination
2. Do not share razors/toothbrushes
Hepatitis B Serology
- Interpretation
Hepatitis B Serology
- Interpretation
- Surface antigen
- Hep B activity - Core antibody?
- Hep B exposure - Surface antibody
- Immunity
Hep B
- Management
Hep B
- Management
- Notify
- Self-limiting acute infection
- Hepatology referral for persistent
- STI/BBI screening
- Vaccinate against Hep A
- Treatment options
- Peg interferon alpha 2a
- Antivirals (Entecavir, tenofovir)
Genital sores
- Infective causes
Genital sores
- Common infectious causes
- Candida
- Herpes simplex
- Herpes zoster
- Syphilis
- Tropical diseases
- LGV
- Granuloma inguinale - Chancroid
Genital soreness
- Non-infective causes
Genital soreness
- Non-infective causes
- Trauma
- physical/chemical - Dermatological
- Drug reactions
- Bechets
- Apthosis
- Lichen planus
- Pemphigus - Malignancy
Herpes simplex
- Incubation period
- Stages of primary attack
Herpes simplex
- Incubation period
1. 3-14 days - Stages of primary attack
1. Tingling and itching
2. Fluid filled blisters
3. Burst, painful sores
4. Scabbing, itching, cracking
HSV
- Tests
HSV Tests
- Immediate
1. PCR - Delayed
1. Full STI screen
2. Syphilis serology
3. HIV antibody test
HSV 1 vs HSV 2
- Location
- Seropositivity
- Recurrence in year 1
HSV 1 vs HSV 2
- Location
- Orofacial vs genital - Seropositivity
- 80% vs 7% - Recurrence in year 1
- 1 vs 4
HSV
- Management
HSV Management
- Supportive
1. Rest
2. Analgesia (eg lidocaine 5%)
3. Saline washing - Medical
1. Antivirals - in systemic infection
eg. Aciclovir 400mg TDS 5/7
Herpes simplex
- Complications
Herpes simplex
- Complications
- Urinary retention
- Adhesions
- Meningism
- Recurrence/emotional distress
HSV
- Pregnancy
1. Recurrence
2. Trimesters
HSV
- Pregnancy
- If recurrent - low risk
- If third trimester, caesarian
Syphilis diagnosis
- Lesions
- Blood
Syphilis diagnosis
- Lesions
1. Dark ground microscopy
2. Treponemal PCR - Blood
1. EIA - Treponemal enzyme immunoassay
2. TPPA - Treponema pallidum particle agglutination assay
3. RPR - Rapid plasma reagin test
Syphilis
- Natural history
Syphilis
- Natural history
- Infectious
1. Primary
2. Secondary
3a. Early Latent period (<2y) - Non-infectious
3b. Late latent (>2y)
4. Tertiary
Syphilis
- Mx
Syphilis
- Mx
- Benzathine Penicillin
- IM - Once weekly when infectious
- Thrice weekly in late latent
- CVS and gummatous syphilis
MPox
- Virus
- Symptoms
MPox
- Virus
1. Zoonotic disease
2. Monkeypox virus - Symptoms
1. Rash - face and body
- Palms and soles
- Anorectal symptoms
PID
- Complications
PID
- Complications
- Ectopic
- Infertility
- Tubo-ovarian abscess
- Chronic pelvic pain
- Fitz-Hugh-Curtis
- Peri-hepatitis
- CT PID
PID
- Locations
PID
- Locations
- Cervicitis
- Endometritis
- Salpingitis
- Intra-abdominal
PID
- Infections
PID
- Infections
-STIs
1. Chlamydia
2. Gonorrhoea
3. Mycoplasma genitalium
Non-STIs
1. Anaerobes
2. Gardnerella vaginalis
3. Vaginal flora
- Poly-microbial
PID
- Symptoms
PID
- Symptoms
- Abdo pain
- bilateral and lower - Deep dyspareunia
- Discharge
- ICB/HMB - Dysmenorrhoea
- Purulent dischrge
- Fever, rigors, chills, night sweats
PID
- Signs
PID
- Signs
- Abdo tenderness
- bilateral lower - Uterine/adnexal tenderness
- Cervical motion tenderness
- Adnexal mass
- abscess - Muco-purulent vaginal discharge
- Cervicitis/contact bleeding
- Pyrexia
- Peritonitis
- Fitz-Hugh-Curtis
PID
- Differentials
PID
- Differentials
- Gynae
1. Ectopic
2. Ovarian cyst (torsion, rupture, haemorrhage)
3. Endometriosis - UTI
1. Cystitis - GI
1. IBD
2. Appendicitis
3. IBS
PID
- Ix
PID
- Ix
- Swabs
- Gonorrhoea, chlamydia, trichomonas vaginalis, mycoplasma genitalium
- Confirmation, not exclusion - Urine Dip/MSU
- Exclude urinary tract - Pregnancy
- Microscopy
- Discharge - TUS
- If uncertainty, severity - Laparoscopy
- In severe cases with uncertainty
PID
- Empirical treatment
PID
- Empirical treatment
- Low threshold
- Sexually active
- New onset lower bilateral abdo pain
- Tenderness - Condition
- Pregnancy excluded
- No other cause of pain
PID
- Outpatient treatment
PID
- Outpatient treatment
- Stat IM Ceftriaxone (gonorrhoea)
+Doxycycline PO (chlamydia)
+ Metronidazole PO (anaerobes) - Mycoplasma:
Moxifloxacin OD PO - Analgesia
- Rest
- Abstinence
- self and partner treated
PID
- Outpatient follow-up
PID
- Outpatient follow-up
- 72hrs
- Consider removing IUC
- Consider IV abx - 2-4 weeks
- Symptom resolution
- Abx compliance
- Screening of contacts
PID
- Inpatient indications
PID
- Inpatient indications
- Nausea, vomiting, high fever
- Peritonitic
- Pregnant
- Unresponsive to po abx
- Uncertain diagnosis
PID
- Inpatient abx
PID
- Inpatient abx
- IM Ceftriaxone
+ IV doxycycline
-> PO Met and PO Doxy - IV clindamycin
+ IV gentamicin
-> PO Clinda and PO Met
Vaginal discharge
- Questions
Vaginal discharge
- Questions
- Colour, blood
- Consistency, odour
3.Itch/soreness
4. IMB/PCB
- Dyspareunia
- Rash/lesions
Vaginal secretion
- Vaginal
- Cervical
Vaginal secretion
- Vaginal
1. Candidiasis
2. Trichomoniasis
3. Gardnerella-associated
4. Bacteria (FB)
5. Postmenopausal vaginitis - Cervical
1. Gonorrhoea
2. Non-specific
3. Herpes
4. Ectopy
5. Neoplasm eg. polyp
Vaginal discharge
- High VS
- Vulvlovaginal
- Endocervical
- Other
Vaginal discharge
- High vaginal swab
1. Culture - T. vaginalis
- Candida
2. Wet mount
3. Gram stain - Vulvlovaginal
1. NAAT - N.gonorrhoeae
- C. trachomatis
- Endocervical
1. Gonorrhoea culture - Other
1. Other organisms
2. HSV PCR cervix
Candidiasis
- Epidemiology
- Risk Factors
Candidiasis
- Epidemiology
1. 75% lifetime risk for women - Risk Factors
1. Immunosuppression
2. High oestrogen - pregnnacy
- luteal phase
- COCs
- ABx
- DM
- Mucosal breakdown
- sex, dermatitis - Atopy
- Recurrent candidiasis
Candida
- Tests
Candida
- Tests
- Clinical
- Normal pH
- Infection - Samples
- Vaginal Wall
+/- vulval swab - Gram staining
- 60% sensitive
- 90% albicans/5% glabrata
Candida
- Mx
Candida
- Mx
- Antifungal
- Fluconazole
- Clotrimazole
+/- Hydrocortisone 1% - Recurrent
- >4 episodes per year
- Induction then maintenance
- Fluconazole every 72 hours then weekly
- Fluconazole weekly
BV
- Epidemiology
- Precipitants
BV
- Epidemiology
1. Most common discharge in child-bearing age - Precipitants
1. Unprotected sex
2. Receptive oral
3. Douching
4. Menstruation
BV
- Diagnosis
BV
- Diagnosis
- Hay-Ison criteria
- Posterior fornix gram - Amsel (3 of:)
- Characterisitc discharge
- Wet mount epithelial ‘clue’ cells
- Raised pH
- KOH “whiff test”
BV
- Mx
BV
- Mx
- Metronidazole
- BD 5/7 - Avoid precipitants
Trichomonas
- Sx
Trichomonas
- Discharge
1. Off-white, blood-staining
2. Putrid, frothy
- Itch/soreness
- Strawberry cervix
- contact bleedin
Trichomonas
- Ix
Trichomonas
- Posterior fornix sample
- Vulvo-vaginal swab
- self-taken - First void urine in men
- urethra swab
- centrifuged - Wet mount
- 70% sensitive compared to culture
Trichomonas
- Mx
Trichomonas
- Mx
- Metronidazole
- 400mg BD 7/7
Male urethral discharge
- Investigations
Male urethral discharge
- Investigations
- Exam
- Gram stain
- urethra smear - Gonorrhoea culture
- Urine NAAT
- NG and CT - Considere
- Micro of urine threads
- TV - wet smear
- MSU
- HSV PCR
Gonorrhoea
- Dx
Gonorrhoea
- Dx
- Microscopy
- Urethral/cervical - NAAT
- >95% sensitivity - Culture
- After NAAT, for treatment
Gonorrhoea
- Mx
Gonorrhoea
- Mx
- Ceftriaxone
- Susc not known - Cipro
- Susc known - Allergy
- Discuss with GUM
Non-specific Urethritis
- NSU
- Common agents
Non-specific Urethritis
- NSU
- STI pathogens
- CT
- Mycoplasma genitalium
- Ureaplasma urealyticum
- TV
- HSV
- HPV
Non specific urethritis
- Non STI
Non specific urethritis
- Non STI
- Infective
1. UTI
2. Adenovirus
3. Candida - Non-infective
1. Drugs
2. Alcohol
3. Trauma/FB
Chlamydia
- Mx
Chlamydia
- Mx
- Doxy
- BD 7/7 - Azithro/erythro
Mycoplasma genitalium
- Microscopic appearance
- Presentation
Mycoplasma genitalium
- Microscopic appearance
1. Flask shaped
2. Small gram +ve - Presentation
1. Urethritis, epididymitis, proctitis
2. PID, mucopurulent cervicitis
Mycoplasma genitalium
- Dx
Mycoplasma genitalium
- Dx
- First void urine
- Swab
- Self-taken vaginal
- Anal - NAATs
- detect resistance
Mycoplasma genitalium
- Mx
Mycoplasma genitalium
- Mx
- ABx (no cell wall)
1. Doxy 7/7 + Azithro 4/7
2. Moxifloxacin 7-10/7 - PID/Epididymitis
1. Moxifloxacin 14/7
POP
- Active ingredients?
- Cerazette
- Micronor
- Noriday
- Norgeston
POP
- Active ingredients?
- Cerazette
- Desogestrel - Micronor & Noriday
- Norethisterone - Norgeston
- Levonorgestrel
LARC contraception
- Routes
LARC contraception
- Routes
- Injections
- Implants
- Devices/systems
LARC contraception
- Injectables (POIC)
Progestogen-only Injectable
- Depo Provera (IM)
- 12 wk - Sayana Press (SC)
- 13wk
LARC contraception
- LNG-IUS
Levonorgestrel-releasing IUS (LNG IUS)
- Mirena
- Kyleena
- Jaydess
- Levosert
Lactational Amenorrhea Method
- Effectiveness
Lactational Amenorrhea Method
- Effectiveness
- 98% if all of:
- Fully breastfeeding
- No periods
- <6 mo postpartum
IUD vs IUS
- Fertilisation or implantation?
IUD vs IUS
- Fertilisation or implantation?
- IUD
- Prevents fertilisation - IUS
- Prevents implantation
COCP vs POP
- Missed pills
- Clots
- Periods
- Acne
COCP vs POP
- Missed pills
1. Daily for POP (12hrs) - Clots
2. Increased in COCP - Periods
3. Lighter in COCP - Changes in POP
- Acne
4. Can improve with COCP
1 Missed Pill?
1 Missed Pill?
- Take the missed pill
- Continue as normal
2 -7 missed pills
- Week 1
- Week 2
- Week 3
2 or more missed pills
- Week 1
1. Emergency contraception
2. Take last pill missed
3. 7 days contraception
4. Continue as normal - Week 2
1. Take last missed pill
2. Extra contraception
3. Continue as normal - Week 3
1. Take last missed pill
2. Skip break (dummy or pill-free)
8 or more missed pills
- COCP
8 or more missed pills
- COCP
- Preg test
- Emergency contraception
LARC
- Injection ADRs
LARC
- Injection ADRs
- Bleeding
- Erratic then amenorrhoea - Weight gain
- Fertility
- 1 year in delay
LARC
- Implant brand
- Length of activity
- Return of fertility
LARC
- Implant brand
1. Nexplanon - Etonogestrel
- Length of activity
2. 3 years
3. Rapid return of fertility
Contraception
- EC methods
Contraception
- EC methods
- LNG
3 days - UPA
5 days - IUD
5 days (UPSI or ovulation)
Emergency contraception
- Physiology
- Failure
Emergency contraception
- Physiology
1. Delays ovulation - Failure
2. After ovulation
