Sexual Health🤰🏻

Question 1

Ethnicity is one of the risk factors for developing fibroids. What other risk factors does KS have for fibroids and what lifestyle advice would you advise to mitigate these risks?

Answer 1

Risk factors
Age - risk increases with age up until menopause, KS is 32

Obesity - BMI is 29.7 almost >30 which would be obese, excess body fat raises oestrogen levels promoting fibroid growth

Vit D deficiency - 28 nmol/l should be >50 nmol/l

Ethnicity - higher risk in black and Asian women compared with white women. In addition, fibroids are more likely to be symptomatic, occur at an earlier age, be larger, and multiple in these ethnic groups.

Family history - mother had breast cancer at 58 increases risk of fibroids

Lifestyle advice

Weight management - weight loss through diet and physical exercise, can reduce oestrogen production which is essential for fibroid growth
KS could continue her zumba classes more frequently and implement other forms of exercise where possible / swimming

Encourage a diet rich in fruit, veg, whole grains to reduce risk of fibroids, reduce red meat and processed foods

Vitamin D supplement - [loading dose] 40 000 units once weekly for 7 weeks, 4000 units a week / oily fish

Manage stress

Regular cervical screening

Maintain bp within healthy range (history of hypertension)

Reduce alcohol intake

Question 2

What hormones does Microgynon 30 contain and how does it prevent pregnancy?

Answer 2

Contains ethinylestradiol (30 mcg) and levonorgestrel (150 mcg).

Prevents pregnancy by:

Preventing ovulation.

Thickening cervical mucus to block sperm.

Thinning the uterine lining to prevent egg implantation.

Question 3

How should Microgynon 30 be taken?

Answer 3

1 tablet daily at same time for 21 days, followed by a 7-day break (hormone-free interval) before restarting next pack.

Question 4

When does Microgynon 30 provide immediate contraception?

Answer 4

Starting pill 1st–5th day of period: Immediate protection.

After 5th day of period: Use additional contraception for 7 days.

Question 5

What should a patient do if they miss a pill?

Answer 5

If missed by more than 12 hours, use additional contraception and contact their GP.

Question 6

Can Microgynon 30 be used as emergency contraception?

Answer 6

No, it is not an emergency contraceptive and should not be taken after unprotected sex.

Question 7

What are common side effects of Microgynon 30?

Answer 7

Nausea, breast tenderness, headaches, mood swings, and changes in menstrual bleeding.
These often subside after the first few months.

Question 8

What severe side effects require contacting a GP immediately?

Answer 8

Chest pain, shortness of breath, severe headaches, and visual disturbances.

Question 9

What interactions should patients be aware of?

Answer 9

Certain antibiotics and anticonvulsants may interact.
Inform the GP about all medications being taken.

Question 10

What should be done if vomiting occurs after taking Microgynon 30?

Answer 10

Within 3 hours: Take another pill immediately and continue as normal.

After 3 hours: No need to take another pill.

Question 11

What should be done if vomiting occurs after taking Microgynon 30?

Answer 11

Within 3 hours: Take another pill immediately and continue as normal.

After 3 hours: No need to take another pill.

Question 12

How should severe diarrhoea be managed while on Microgynon 30?

Answer 12

Continue taking pills as scheduled.

Use additional contraception during diarrhoea and for 2 days after recovery.

Question 13

What should a patient do if unsure whether to ingest (due to sickness)?

Answer 13

Wait until the next day, then take 2 active pills 12 hours apart, while using additional contraception like condoms.

Question 14

Why are follow-up appointments important for patients on Microgynon 30?

Answer 14

To monitor for side effects and ensure the contraception is effective.

Question 15

If KS missed pills on days 18 to 20 of her cycle and was prescribed Levonelle as emergency contraception what advice would you give her about taking Levonelle, and restarting her Microgynon?

Answer 15

Explaining that Levonelle is an emergency contraceptive pill which can help prevent pregnancy if taken within 72 hours of an unprotected sex by delaying or inhibiting ovulation

Instructing the patient to continue taking Microgynon 30 as scheduled even after taking Levonelle to ensure ongoing contraceptive protection (taking the missed pill as soon as remembering even if it means taking 2 pills in one day). But on the day of the new one don’t take the usual one.

Using an additional form of contraception, such as condoms for the next 7 days to ensure a continued protection as the effectiveness of Microgynon 30 may be temporarily reduced

Advising the patient they may experience irregular bleeding or spotting after taking Levonelle, which is a common side effect and not a cause of concern

Informing the patient that timing of the menstrual cycle may be affected after missing a pill and taking Levonelle through which the next withdrawal bleeding may be different than usual

Summary:

Levonelle is an emergency contraceptive that prevents pregnancy if taken within 72 hours of unprotected sex by delaying or inhibiting ovulation.

Continue taking Microgynon 30 as scheduled, even after taking Levonelle, to maintain contraceptive protection. If a pill is missed, take it as soon as remembered (even if taking 2 pills in one day).

Use additional contraception (e.g., condoms) for the next 7 days as Microgynon 30’s effectiveness may be temporarily reduced.

Irregular bleeding or spotting may occur after taking

Levonelle—this is common and not concerning.
The menstrual cycle timing may change, and the next withdrawal bleed may differ from usual.

Question 16

In case of missing a Combined Hormonal Contraceptive with Ethinylestradiol & Drospirenone (CHC-ED) and taking Levonelle, it is important to provide specific advice for the situation as the following:

Answer 16

Explaining that Levonelle is an emergency contraceptive pill which can help prevent pregnancy if taken within 72 hours of an unprotected sex by delaying or inhibiting ovulation
· Instructing the patient to continue taking (CHC-ED) as scheduled even after taking Levonelle to ensure ongoing contraceptive protection (taking the missed pill as soon as remembering even if it means taking 2 pills in one day)
· Using an additional form of contraception, such as condoms is recommended for the next 7 days to ensure a continued protection

Question 17

In case of missing a Progestin-Only Pill (POP) and taking Levonelle, it is important to provide specific advice for the situation as the following:

Answer 17

Explaining that Levonelle is an emergency contraceptive pill which can help prevent pregnancy if taken within 72 hours of an unprotected sex by delaying or inhibiting ovulation
· Instructing the patient to continue taking (POP) as scheduled even after taking Levonelle to ensure ongoing contraceptive protection (taking the missed pill as soon as remembering even if it means taking 2 pills in one day)
· In case a POP is missed by more than 3 hours, the patient should take the missed pill as soon as remembering then taking the next pill at the regular time
· Using an additional form of contraception, such as condoms is recommended for the next 2 days to enhance a continued protection

Question 18

KS hopes to have a second child in the next few years. Based on her presenting complaint, family history, observations, investigations and family planning intentions, consider the appropriateness of Microgynon 30 as contraceptive for this patient.

Answer 18

Desire for future pregnancy indicating a desire for a reversible contraception
· Menstrual symptoms represented in dysmenorrhoea and heavy irregular bleeding
· Suspected uterine fibroids
· Medical history of asthma ‘not contradicting use of Microgynon 30’
· Being overweight with low vitamin D levels, which should be considered when discussing overall health and potential impacts on contraceptive methods . Obese use with caution.
· Family history of hypertension, diabetes, DVT and breast cancer
Look at dvt risk , family history, obesity
Not appropriate take Tranexamic acid - heavy periods
When stopping micro, may be delay to get pregnant may not be straight away

Question 19

Who’s appropriate for cervical screening (every 3 years)?

Answer 19

25-64 years (65+ risk is reduced)
Not had a total hysterectomy (removed cervix)
Trans man 50+- if cervix every 5 year. Under 50 every 3 years up until 64

Question 20

TY previously had their endometriosis symptoms managed with a GnRH (leuprorelin) and a LARC (levonorgestrel). Explain how these agents helps to reduce the symptoms associated with endometriosis.

Answer 20

Utilise oestrogen dependency of endometrial growth
Anti-oestrogenics to inhibit of endometrial growth
GnRH analogues(Leuprorelin) - gonadotropin releasing hormone: initially stimulate the pituitary gland to releasing luteinizing hormone(LH) and follicle-stimulating hormone(FSH). But it downregulates the pituitary gland with continuous administration, leading to reduced secretion of LH and FSH, and further oestrogen production. Oestrogen can promote endometrial proliferation, thus decreased oestrogen production helps to reduce endometriosis symptoms.

LARC(Levonorgestrel) - long acting reversible contraception: levonorgestrel is a exogenous progestin. It can thicken cervical mucus, oppose endometrial proliferation, thin endometrial lining. LARC can also provide a continuous release of progestin, which helps regulate hormonal fluctuations.
Acts on endometrium (lining of uterus), inhibits endometrial cell growth and thins lining. Reduced glandular activity

Condensing

GnRH Agonist (Leuprorelin)

Location of Action: Hypothalamic-Pituitary-Ovarian Axis.

How it Works:
Overstimulates GnRH receptors in the pituitary gland, causing downregulation of LH and FSH secretion.
Leads to reduced ovarian estrogen production, inducing a hypoestrogenic state.
This shrinks ectopic endometrial tissue and reduces inflammation and pain associated with endometriosis.

LARC (Levonorgestrel)

Location of Action: Uterus (Endometrium).

How it Works:
Released locally from intrauterine devices (IUDs).
Thins the endometrial lining, suppressing growth of ectopic endometrial tissue.
Reduces local inflammation, blood vessel growth, and prostaglandin production, alleviating pain.

Question 21

What lifestyle advice could you suggest to TY to manage the menopausal symptoms they are experiencing?

Answer 21

Current symptoms: low mood, anxiety, vaginal dryness and irritation, sleep disturbance and hot flushes

Hot flushes: regular exercise, weigh loss, wearing lighter clothing/layers of clothing, turning down central heating, sleeping in a cooler room, using fans, reducing stress, and avoiding possible triggers (such as spicy foods, caffeine, smoking, and alcohol).

Sleep disturbances: avoiding exercise late in the day and maintaining a regular bedtime

Low mood and anxiety: adequate sleep, regular physical activity, and relaxation exercises

Vaginal dryness and irritation: avoid tight fitting clothing/underwear, use non perfumed soaps when washing, avoid douching, wear cotton underwear, avoid possible triggers

Advise TY to seek occupational health advice
Manage CVD risk factors.

Question 22

Endometriosis and endometrial tissue responds and grows when exposed to oestrogen. Given their past medical history and family history, outline the risks associated with Oestrogel® for TY.

Answer 22

Oestrogel: hormone replacement therapy for oestrogen deficiency symptoms in postmenopausal women

Risk:
Ovary cancer
Impact on endometrial tissue (proliferates in gi tract eg outside of uterus)

Question 23

Compare the formulation of vaginal rings with the formulation of contraceptive implants.

Answer 23

Contraceptive Implants

small, flexible rods inserted under the skin, usually in the arm, and comprise a biocompatible polymer, such as ethylene vinyl acetate (EVA) or other non-reactive polymers. In the core there is also barium sulphate and magnesium stearate These implants are designed to release synthetic hormones, often a progestin like etonogestrel, over a long period (up to 3-5 years). They generally avoid the specific binding issues seen in silicone elastomer vaginal rings, as implants use non-silicone materials less prone to binding reactions with progestins.

Designed for continuous release of progestins (e.g., etonogestrel) over 3–5 years via non-reactive, biocompatible polymers like EVA.

Advantages:
Stable release without binding issues seen in silicone-based vaginal rings.
Single-progestin formulations reduce drug interaction risks.
Contains additives like barium sulfate and magnesium stearate for functionality.
99% effectiveness

Limitation: Primarily for contraception, unlike dual-function vaginal rings.

Vaginal Rings
3 weeks then 1 week break during menstration. Repeat.
99% effectiveness rate
Made from silicone elastomers that release drugs over time (matrix-type or reservoir-type).
Often combine progestins (e.g., levonorgestrel) with other agents (e.g., Dapiverine for HIV prevention).
Can also contain oestrogen, unlike implants.

Challenges:
Certain progestins (e.g., levonorgestrel) may chemically react with the silicone elastomer, reducing release effectiveness due to platinum-catalyzed hydrolysation.

Question 24

What is the purpose of lactose in a vaginal ring?

Answer 24

Zinc sulphate - moisture control & better release of drug

Magnesium sulphate - reduces LNG reaction & results in better release

Lactose - bulking agent. Stabilises API. Controls release of drug as reduced LNG binding and reactions with hydrodaline groups.

Question 25

Excipients for oestrogen gel

Answer 25

Ethanol: acts as solvent.

Carbonmer: thickener; gives smooth consistent texture. Stabilises formulation

Purified water: acts a solvent to dilute API

Neutralising agents: Trolamine - ph adjuster; balances acidity to match skin ph. Allows effective absorption w/out irritation

Question 26

Clotrimazole cream excipients

Answer 26

Benzyl alcohol - preservative (preventing bacterial contamination), mild local anaesthetic properties (reduce itching/discomfort), solvent (maintain smoothness)

Polysorbate 60 - emulsifier; stabilises oil/water based ingredients and ensure uniform texture/consistency

Cetyl esters wax - emollient & thickener; enhances spreadability. Creates protective skin barrier that locks in moisture

Cetostearyl alcohol - emulsifier & emollient; alcohol contributes to thickness

Octyldodecanol - emollient & skin conditioning agent

Sorbitan monostearate - emulsifier

Purified water - acts a solvent to dilute API

Emulsifiers stabilise oil water emulsion

Question 27

Using the Chlamydia Screening service as an example, describe the patient journey taken and steps when using the service to access screening and treatment.

Answer 27

Patient Awareness: Posters, pamphlets, or direct conversations with pharmacy staff inform patients about the screening program and its benefits.
Self-Referral or Recommendation: Patients may seek screening due to high-risk behavior, symptoms, or recommendations from a partner or healthcare professional.
Private Conversation: Consultations take place in a private room to discuss patient concerns.
Eligibility Evaluation: Pharmacists assess eligibility (e.g., under 25s for the national screening program, risk factors, contraindications).
Consent and Testing:
Consent is obtained, and testing is done via urine or swab samples sent to a third party.
Offered every 3–6 months based on patient risk.
Results and Consultation:
Positive results lead to a consultation for treatment, lifestyle advice, and education.
Pharmacists assist in notifying sexual partners if needed.
Treatment:
First-line: Doxycycline.
Alternative: Azithromycin for patients with allergies.
Follow-Up: Scheduled as needed to confirm infection clearance or address risks of reinfection.