Sexual health Flashcards
How long is contraception required for after the menopause?
- After last period, contraception required for 2 years in women under 50 and 1 year in women over 50
- HRT not prevent pregnancy
How soon after childbirth does fertility return
Fertility returns after 21 days after giving birth
How effective is lactational amenorrhoea as contraception
98% effective as contraception up to 6m after birth
o Must be fully breastfeeding and amenorrhoeic
Contraception options in breast cancer
o Avoid hormonal contraception
o Choose copper coil or barrier methods
Contraception offers in cervical or endometrial cancer
Avoid mirena coil
Contraception options in Wilson’s disease
Avoid copper coil
Advantages of barrier methods
- Physical barrier to semen entering uterus and causing pregnancy
- Only method that protects against STIs
Examples of barrier methods
Condoms
Diaphragms
Dental dams
Contraindications to COCP
o Uncontrolled hypertension
o Migraine with aura
o History of VTE
o Aged >35, smoking >15 cigarettes per day
o Major surgery with prolonged immobility
o Vascular disease or stroke
o IHD, cardiomyopathy or AF
o Liver cirrhosis and liver tumours
o SLE and antiphospholipid syndrome
o BMI >35 (high risk which outweighs benefits)
Mechanism of COCP
o Preventing ovulation
o Progesterone thickens cervical mucus
o Progesterone inhibits proliferation of endometrium, reducing chance of successful implantation
Breastfeeding and COCP
Avoided in breastfeeding until at least 6 wks
Types of COCP
o Monophasic = same amount of hormone in each pill
1st line = levonorgestel or norethisterone
1st line for premenstrual syndrome = drospirenone
Treatment of acne and hirsutism = dianette, co-cyprindiol
o Multiphasic = varying amounts of hormone to match normal cyclical hormonal changes more closely
Regimes for COCP
o 21 days on 7 days off
o 63 days on and 7 days off
o Continuous use without pill-free period
Side effects and risks of COCP
o Unscheduled bleeding (common in first 3m)
o Breast pain and tenderness
o Mood changes and depression
o Headaches
o Hypertension
o VTE
o Small increased risk of breast and cervical cancer, return to normal 10 years after stopping
o Small increased risk of MI and stroke
Benefits of COCP
o Effective contraception
o Rapid return of fertility after stopping
o Improvement in premenstrual Sx, menorrhagia and dysmenorrhoea
o Reduced risk of endometrial, ovarian and colon cancer
o Reduced risk of benign ovarian cysts
Starting the COCP
o Start within first 5 days on menstrual cycle
o If starting after 5 days, requires extra contraception for 7 days (condoms)
o Ensure pregnancy status negative
Reduces effectiveness of COCP
o Vomiting
o Diarrhoea
o Certain medications (rifampicin)
Surgery and COCP
Stop combine pill 4 wks before major operation
POP and breastfeeding
Safe in breastfeeding and started anytime after birth
Types of POP
o Traditional POP = norgeston or noriday
o Desogestrel-only pill
Contraindications to POP
Active breast cancer
Regime for POP
o Taken continuously
o Traditional POP cannot be delayed by >3hrs
o Desogestrel only pill taken up to 12hrs late and still be effective
Mechanism of POP
o Thickening cervical mucus
o Altering endometrium and making it less accepting of implantation
o Reducing ciliary action in fallopian tubes
o Desogestrel = Inhibiting ovulation
Starting POP
o Up to day 5 of menstrual cycle for immediate protection
o Additional contraception required for 48 hrs
o Take pregnancy test 3wks after last unprotected intercourse
Side effects and risks of POP
o Unscheduled bleeding
o Irregular, prolonged or troublesome bleeding (40%)
o Breast tenderness
o Headaches
o Acne
o Ovarian cysts
o Ectopic pregnancy
o Minimal increased risk of breast cancer, return to normal 10 years after stopping
Reduces effectiveness of POP
Diarrhoea and vomiting
Types of progesterone-only injection
o Depo-Provera (IM)
o Sayana Press (SC)
Regime of POI (depot)
Given at 12-13 wk intervals
Benefits of POI (depot)
o Improves dysmenorrhoea
o Improves endometriosis-related symptoms
o Reduces risk of ovarian and endometrial cancer
o Reduces severity of sickle cell crisis
Side effects of POI (depot)
o Can take 12m for fertility to return after stopping
o Should be stopped before 50 years due to risk of osteoporosis
o Concerns of reduced bone mineral density in <20s
o Irregular bleeding (can be heavier and last longer)
o Weight gain
o Acne
o Reduced libido
o Mood changes
o Headaches
o Flushes
o Hair loss
o Skin reactions at injection sites
o Small increased risk of breast and cervical cancer
Contraindications to POI (depot)
o Active breast cancer
o IHD and stroke
o Unexplained vaginal bleeding
o Severe liver cirrhosis
o Liver cancer
Mechanism of POI (depot)
o Inhibit ovulation = inhibit FSH secretion by pituitary gland, preventing development of follicles in ovaries
o Thickening cervical mucus
o Altering endometrium and making it less accepting of implantation
Starting POI
o Up to day 5 requires no additional protection
o After day 5 requires 7 days of extra contraception before becomes reliably effective
Implant and breastfeeding
Safe in breastfeeding and started any time after birth
Mechanism of the implant
o Slowly releases progestogen into blood
o Lasts for 3 years
o Inhibiting ovulation
o Thickening cervical mucus
o Altering endometrium and making it less accepting of implantation
Benefits of the implant
o Good choice off long-acting reversible contraception in <20s
o Effective and reliable contraception
o Improve dysmenorrhoea
o Make periods lighter or stop all together
o No need to remember to take pills
o No weight gain
o No effect on bone mineral density
o No increase in thrombosis risk
o No restrictions for use in obese patients
Drawbacks of the implant
o Requires minor operation with local anaesthetic
o Worsening of acne
o No protection against STIs
o Cause problematic bleeding
o Implants can be bent or fractured
o Implants can become impalpable or deeply implanted (rare)
Contraindication of implant
o Licensed for ages 18-40
o Active breast cancer
Insertion and removal of implant
o Insert up to day 5 provides immediate protection
o Insertion after day 5 requires 7 days of extra contraception
Bleeding pattern of implant
o 1/3 infrequent bleeding
o 1/4 frequent or prolonged bleeding
o 1/5 have no bleeding
o Rest have normal regular bleeds
o Add COCP if problematic bleedings for 3m
Licenced use for mirena
- Licensed for 5 yrs contraception, 4yrs HRT
o Also used for menorrhagia
Postpartum and mirena
Inserted within 48hrs of birth or >4wks
Mechanism of mirena
o Contains progestogen that is slowly released into uterus
o Thickening cervical mucus
o Altering endometrium and making it less accepting of implantation
o Inhibits ovulation in small number of women
Benefits of mirena
o Fertility returns immediately after removal
o Can make periods lighter or stop
o May improve dysmenorrhoea or pelvic pain related to endometriosis
o No effect on bone mineral density
o No increase in thrombosis risk
o No restrictions for use in obese patients
Drawbacks of mirena
o Procedure required
o Cause spotting or irregular bleeding
o Sometimes pelvic pain
o Not protect against STIs
o Increase risk of ectopic pregnancies
o Increase incidence of ovarian cysts
o Systemic absorption Acne, headaches, breast tenderness
o 5% fall out
Contraindications of mirena
o PID or infection
o Immunosuppression
o Pregnancy
o Unexplained bleeding
o Pelvic cancer
o Uterine cavity distortion (fibroids)
Insertion of mirena
o Screen for chlamydia and gonorrhoea if at increased risk (under 25)
o BP and HR recorded before and after
o Inserted up to day 7 without additional contraception
o NSAIDs help with discomfort
o Woman seen 3-6 wks after insertion to check threads
Risk with insertion of mirena
o Bleeding
o Pain on insertion
o Vasovagal reactions (Dizziness, bradycardia, arrhythmias)
o Uterine perforation (1 in 1000, higher in breastfeeding women)
o PID (in first 20 days)
o Expulsion rate is highest in first 3m
Removal of mirena
Abstain from sex or use condoms for 7 days
Causes of non-visible mirena threads
o Expulsion
o Pregnancy
o Uterine perforation
o Ix: US abdominal and pelvic XR hysteroscopy or laparoscopic surgery
Licencing of copper coil
- Licensed for 5-10 yrs
- Can be used as emergency contraception (inserted up to 5 days after episode of unprotected intercourse)
- Inserted within 48 hrs of birth or >4wks
Mechanism of copper coil
o Contains copper and creates hostile environment for pregnancy
o Alters endometrium and makes it less accepting of implantation
Benefits of copper coil
o Fertility returns immediately after removal
o Reliable contraception
o Inserted at any time of menstrual cycle and effective immediately
o No hormones = safe for women at risk of VTE or history of hormone-related cancers
o Reduce risk of endometrial and cervical cancer
Drawbacks to copper coil
o Procedure required to insert and remove
o Cause heavy or intermenstrual bleedings
o Sometimes pelvic pain
o Not protect against STIs
o Increased risk of ectopic pregnancy
o 5% fall out
Uses of emergency contraception
- Used after episode of unprotected sexual intercourse
o Includes damaged condoms or multiple missed pills
Options for emergency contraception
o Levonorgestrel (within 72hrs)
Prevents or delays ovulation
COCP or POP can be started immediately after taking
Extra contraception required for first 7 days of combined pill or first 2 days of POP
o Ulipristal (within 120 hrs)
Selective progesterone receptor modulator
Delays ovulation
More effective than levonorgestrel
Wait 5 days before starting COCP or POP
Extra contraception required for first 7 days
o Copper coil (within 5 days) = most effective
Effectiveness of oral emergency contraception
o Reduced by BMI, enzyme-inducing drugs or malabsorption
o Earlier taken = more effective
o Unlikely to be effective after ovulation has occurred
Considerations of emergency contraception
o Confidentiality
o STIs
o Future contraception plans
o Safeguarding, rape and abuse
Side effects of levonorgestrel
Nausea and vomiting (within 3 hrs, repeated dose needed)
Spotting and changes to next menstrual period
Diarrhoea
Breast tenderness
Dizziness
Depressed mood
Side effects of ulipristal
Nausea and vomiting
Spotting and changes to next menstrual period
Abdo or pelvic pain
Back pain
Mood changes
Headache
Dizziness
Breast tenderness
Contraindications to ulipristal
Breastfeeding avoided for 1 wk (milk expressed and discarded)
Avoided with severe asthma
Female sterilisation
tubal occlusion
o Laparoscopy under general anaesthesia = elective or during c-section
o Occlusion of tubes using Filshie clips, tubes tied and cut or tubes removed altogether
o Prevents ovum travelling from ovary to uterus
o 99% effective
o Alternative contraception required until next menstrual period
Male sterilisation
vasectomy
o Cutting vas deferens
o Prevents sperm travelling from testes to join ejaculated fluid
o >99% effective
o Local anaesthetic and quick (15-20mins)
o Alternative contraception required for 2m post procedure
o Testing semen (12wks later) to confirm absence of sperm necessary before relied upon for contraception
Causes of bacterial vaginosis
- Gardnerella vaginalis
- Mycoplasma hominis
- Prevotella species
Risk factors for bacterial vaginosis
- Multiple sexual partners (not an STI)
- Excessive vaginal cleaning
- Recent Abx
- Smoking
- Copper coil
Protective factors for bacterial vaginosis
- COCP
- Condoms
Presentation of bacterial vaginosis
- Fishy-smelling watery grey or white vaginal discharge
- Half are asymptomatic
- No itching, irritation or pain
Investigations for bacterial vaginosis
- Speculum = confirm typical discharge
- High vaginal swab (charcoal)
o Clue cells = epithelial cells from cervix with bacteria stuck inside them - Swabs for chlamydia and gonorrhoea
Management of bacterial vaginosis
- Asymptomatic = no treatment, resolve itself
- Metronidazole = 1st line
- Clindamycin = alternative
- Lifestyle advice
Complications of bacterial vaginosis
- STIs = chlamydia, gonorrhoea, HIV
- Pregnancy complications
o Miscarriage
o Preterm delivery
o Premature rupture of membranes
o Chorioamnionitis
o Low birth weight
o Postpartum endometritis
Cause of thrush
Candida albicans
Risk factors for thrush
- Increased oestrogen (pregnancy)
- Poorly controlled diabetes
- Immunosuppression (corticosteroids)
- Broad-spectrum Abx
Presentation of thrush
- Thick, white discharge that doesn’t typically smell (‘cottage cheese’)
- Vulval and vaginal itching, irritation or discomfort
- Erythema
- Fissures
- Oedema
- Pain during sex
- Dysuria
- Excoriation
- Satellite lesions
Investigations for thrush
- Clinical diagnosis
- Testing vaginal pH (<4.5)
- Charcoal swab with microscopy
Management of thrush
- 1st line = Oral antifungal tablets (fluconazole 150mg single dose)
o Contraindicated in pregnancy - 2nd line = Antifungal pessary (clotrimazole)
- Antifungal cream (clotrimazole) inserted into vagina with applicator
- Canesten duo = over the counter
Management of recurrent infection of thrush
> 4 per year
o Check compliance
o Confirm diagnosis with high vaginal swab
o Rule out diabetes with blood glucose test
o Exclude lichen sclerosus
o Induction and maintenance regime >6m with oral or vaginal antifungal (fluconazole) medications = every 3 days for 3 doses and then weekly for 6m
Contraceptive advice for thrush
o Antifungal creams and pessaries damage latex condoms and prevent spermicides from working
o Alternative contraception required for at least 5 days after use
Risk factors for chlamydia
- Age <25
- Sexual partner +ve for chlamydia
- Recent change in sexual partner
- Co-infection with another STI
- Non-barrier contraception or lack of consistent use of barrier contraception
Cause of chlamydia
Chlamydia trachomatis (gram neg bacterium)
Presentation of chlamydia
- Asymptomatic (50% men, 70% women)
- Women
o Pain Dysuria, deep dyspareunia, lower abdo pain, pelvic tenderness
o Abnormal vaginal discharge (mucopurulent)
o Intermenstrual or postcoital bleeding
o Cervicitis and cervical excitation - Men
o Dysuria
o Testicular pain
o Epididymal tenderness
o Mucopurulent discharge
Investigations for chlamydia
- NAAT
o F = vulvo-vaginal swab
o M = first catch urine sample
Management of chlamydia
- Doxycycline 100mg twice daily for 7 days
- Alternative: Azithromycin 1g single dose
- In pregnancy use azithromycin, erythromycin or amoxicillin
- Avoid sexual intercourse and oral sex until completing treatment
- If aged <25, repeat testing is recommended 3 months after treatment
Contact tracing for chlamydia
o Symptomatic Men all contact since and 4 weeks prior to onset of symptoms
o Women and asymptomatic men all partners from last 6 months
Complications for chlamydia
- Chlamydial conjunctivitis
- Salpingitis/endometritis
- PID
- Ectopic pregnancy
- Infertility
- Epididymitis/epididymo-orchitis
- Sexually acquired reactive arthritis
- If pregnant = premature delivery, miscarriage, stillbirth
Cause of genital herpes
Herpes simplex virus 2
Presentation of genital herpes
- May be asymptomatic
- May develop symptoms mnths or yrs after initial infection when latent virus reactivated
- Ulcers or blistering lesions affecting genital area
- Neuropathic type pain (tingling, burning, shooting)
- Flu-like symptoms (fatigue, headaches)
- Dysuria
- Inguinal lymphadenopathy
- Symptoms last 3 wks and appear within 2 wks of infection
- Recurrent episodes usually milder and resolve more quickly
- Sexual contacts including those with cold sores
Investigations for genital herpes
Viral PCR from lesion
Management of genital herpes
- Aciclovir
- Manage symptoms
o Paracetamol
o Topical lidocaine 2% gel (instillagel)
o Cleaning with warm salt water
o Topical Vaseline
o Additional oral fluids
o Wear loose clothing
o Avoid intercourse with symptoms
Complications of genital herpes
Neonatal herpes simplex infection contacted during labour and delivery
Risk factors for gonorrhoea
- Age <25
- Men who have sex with men
- High density urban areas
- Previous gonorrhoea infection
- Multiple sexual partners
Cause of gonorrhoea
Neisseria gonorrhoeae (gram-neg bacterium)
Presentation of gonorrhoea
- Female
o Altered/increased vaginal discharge (thin, watery, green/yellow)
o Dysuria
o Dyspareunia
o Lower abdominal pain
o Rare – intermenstrual/post-coital bleeding - Male
o Mucopurulent/purulent urethral discharge
o Dysuria
o Epididymal tenderness
o Anal pain/discomfort
Investigations for gonorrhoea
NAAT + microscopy and culture
Management of gonorrhoea
- Single dose IM ceftriaxone 1g
- Alternative: oral cefixime + oral azithromycin
- Contact tracing of sexual partners
- Future safe sex advice – abstain from sex until both partners treated
Complications of gonorrhoea
- PID chronic pain, infertility, ectopics
- Epididymo-orchitis
- Prostatitis
- Disseminated gonococcal infection joint pain and skin lesions
- Urethral stricture
Risk factors for HIV
- Unprotected sexual contact – vaginal, anal, oral
- Sharing of injecting equipment
- Medical procedures – blood products, skin grafts, organ donation, artificial insemination
- MSM
- IVDU
- High prevalence areas
- Unprotected sex with someone who lived or travelled in Africa
Presentation of HIV
- 2-6 wks after exposure:
o Fever
o Muscle aches
o Malaise
o Lymphadenopathy
o Maculopapular rash
o Pharyngitis - Next months-years = latent, asymptomatic
- Symptomatic latent
o Weight loss
o High temp
o Diarrhoea
o Frequent minor opportunistic infections
Investigations for HIV
- Fourth-generation test = HIV antibodies and p24 antigen
- Contact tracing
Management of HIV
- Highly active antiretroviral therapy (for life)
Cause of syphilis
Treponema pallidum
Transmission of syphilis
- Oral, vaginal or anal sex (involving direct contact with infected area)
- Vertical transmission (mother to baby)
- IVDU
- Blood transfusion and other transplants
Presentation of syphilis
- Primary (Sx resolve over 3-8wks)
o Painless genital ulcer (chancre)
o Local non-tender lymphadenopathy
o Often not seen in women (lesion may be on cervix) - Secondary (Symptoms resolve 3-12 wks)
o Maculopapular rash on trunk, palms and soles
o Condylomata lata Grey wart-like lesions around genitals and anus
o Low-grade fever, Lymphadenopathy
o Alopecia
o Buccal ‘snail track’ ulcers - Tertiary (many years after initial infection)
o Gummatous lesions (affecting skin, organs, bones)
o Ascending Aortic aneurysms - Neurosyphilis
o Headache
o Altered behaviour
o Dementia
o Tabes dorsalis
o Ocular syphilis
o Paralysis
o Sensory impairment
o Argyll-Robertson pupil (constricted pupil that accommodates when focusing on near object but not react to light)
Investigations of syphilis
- Antibody testing (screening)
- Samples from sights of infection
o Dark field microscopy
o PCR
Management of syphilis
- Single deep IM benzathine benzylpenicillin
- Alternatives = Ceftrixone, Amoxicillin, Doxycycline
- Advise to avoid sexual activity until treated
- Contact tracing
Causes of trichomoniasis
Trichomonas vaginalis (flagellated protozoa)
Presentation of trichomoniasis
- 50% cases asymptomatic
- Vaginal discharge (frothy, yellow-green, fishy smell)
- Itching
- Dysuria
- Dyspareunia
- Balanitis (inflammation of glans penis)
- Strawberry cervix
- Raised vaginal pH
Investigations of trichomoniasis
- Women = high vaginal charcoal swab with microscopy
- Men = urethral swab or first-catch urine
Management of trichomoniasis
Metronidazole
Complications of trichomoniasis
- Contracting HIV (damaging vaginal mucosa)
- Bacterial vaginosis
- Cervical cancer
- PID
- Pregnancy-related complications = pre-term delivery
