Sexual Health

Question 1

Emergency contraception 1

• Miss S asks to speak to you, the pharmacist
• She would like a supply of the ‘morning-after pill’
• The community pharmacy you are working in does not provide a PGD service for EHC
• What questions should you ask?

Answer 1

• Who is it for?
• Age?
• When did UPSI take place?
• Does she use any form of contraception?
• Timing of the last menstrual period?
• Is there any possibility she might already be pregnant?
• Is she breastfeeding?
• Has she taken EHC since her last period?
• Any history of allergy to contraceptive or lactose?

Question 2

Questions continued

EHC

Answer 2

• What medications is she taking?- include prescription, OTC and herbal
  
  • Enzyme inducing drugs e.g. CBZ, phenytoin, phenobarbital, topiramate, rifampicin, STW
  • Ciclosporin
  • Oral glucocosteroids
  • Drugs that raise gastric pH
  • Progesterone

Question 3

Questions continued

PMH & BMI

Answer 3

• PMH
  
  • A condition that might affect absorption e.g. vomiting, diarrhoea, conditions such as chron’s
  • Liver problems
  • Any condition that alerts you to women having one of conditions treated with a drug on the previous slide
• BMI
  
  • Do not need to ask, can do by observation

Question 4

Emergency contraception 2

• She tells you the request is for himself, she is alone and appears calm
• She is 19 years old, had UPSI in the early hours of this morning, she relies on condoms (fell off), is not on any other medication, has no significant PMH and is not feeling sick
• She has regular periods and there was nothing unusual about her last period which finished 8 days ago
• She has not taken EHC this cycle, she looks slim
• Recommendations?

Answer 4

• Inform her that the most effective form of EC is a copper inter-uterine device (Cu-IUD) which can be left in for on-going contraception, but you will have to refer her to have it fitted by a trained health professional
• Miss S says she will make an appointment tommorow
• The FSRH recommends that even if referring for Cu-ICD, ECH should be given at the same time as referral in case Cu-ICD can’t be inserted or the women changes her mind, you also recommend EHC

Question 5

What EHC will you recommend and what advice should you give

Question 6

EHC choices

Answer 6

• Ella-One (UPA-EC) is more effective than Levonelle One Step (LNG-EC)
• But within license for LNG-EC (Within 96hrs of UPSI)
• License for UPA-EC is within 120 hrs of UPSI
• As an OTC sale, she may be influenced by the cost

Question 7

Emergency contraception

Advice

Answer 7

• Take ASAP- single dose
• If vomit within 3 hours need a repeat dose
• Prevents ovulation
• Can make next period early or late. Pregnancy test if in doubt
• If late by >7 days, very light or very heavy, lower abdo pain, see medical advice
• A barrier method needs to be used until the next period (with UPA majority of women will still ovulate later in the cycle)
• Seek regular contraception and protection against STI (NOTE: Condom use in history)

Question 8

Emergency contraception 4

Answer 8

• If Miss S had told you she was taking CBZ, you would have to refer her
• What emergency contraceptive treatment can be used

Question 9

EHC 4- enzyme inducing drug

Answer 9

• FSRH recommend for women taking liver enzyme-inducing drugs, EC should be with Cu-ICD
• If this is refused, then outside of its product license but recommended by FSRH guidelines, double the dose of LNG can be given i.e. 3mg (2 x 1.5mg tabs)

Question 10

EHC 5- advanced sale

Question 11

Missed contraceptive pill query

Answer 11

• You are working in a community pharmacy
• The phone rings and Mrs T asks to speak to you, the pharmacist
• She tells you that she has realised that she has missed a dose of her contraceptive pill and asks you for your advice
• What is the first question you should ask her
  *

Question 12

Missed contraceptive pill query

Question 13

Sexually transmitted infections (STIs)

Answer 13

• Reported by publich health england in June 2019, states that number of STIs diagnosed in england increased by 5% in 2018 compared to 2017
• Chlamydia diagnosis Up 6%
• Gonnorrhoea diagnosis up 26%, with highest levels since 1978
• Genital herpes diagnoses up 3%
• Syphilis diagnoses up 5%, with highest levels since WWII
• Increase in diagnosis of chlamydia and gonorrhoea in over 65s

Question 14

Chlamydia

Answer 14

• Bacterium chlamydia trachomatis found in sexual fluids so passed by sexual contact, but it can also be passed from mother to baby during birth
• Commenest STI, most common in 15-24 yr olds
• Suggest this age group check annually
• If sexually active, or more frequently, if changing partners

Question 15

Chlamydia symptoms

Answer 15

• 50% of women and 25% of men have NO symptoms
• Symptoms may appear within a couple of weeks after infection, sometimes months, but can be latent
• WOMEN: unusual vaginal discharge, pain when urinating, bleeding between periods, heavier periods, breakthrough bleeding on contraception, pain during sex, lower ab pain
• MEN: White cloudy or watery discharge from the tip of the penis, Pain or burning sensation when urinating, testicular pain or swelling

Question 16

Chlamydia

Why is it important

Answer 16

• Infertility
• Chronic pain
• If unaware or infection, transmit to sexual partner
• WOMEN: PID, ectopic pregnancy, blocked fallopian tubes, long-term pelvic pain, early miscarriage and premature birth, Reiter’s syndrome
• MEN: Painful inflammation of the testicular, Reiter’s syndrome

Question 17

Chlamydia: GUM clinic

Why is this important

Answer 17

• Testing for other STIs
• Contact tracing

Question 18

Chlamydia- treatment

Answer 18

• First line: Doxycycline 100mg PO, BD for 7/7
• If tolerant or pregnant
  
  • Azithromycin 1g PO as single dose, then 500mg daily for 2/7 OR
  • Erythromycin 500mg PO BD for 10-14/7

Question 19

Chlamydia: Advice re-treatment

Answer 19

• Need to avoid sexual activity for 7 days after antibiotics
• For doxycycline, take with water whilst sitting or standing, with food; avoid exposure to sunlight or sun lamps
• Repeat test 3-6 months after completing treatment
• If develop symptoms, return for further Ix
• Use of condoms
• Annual test; more often if change partners
• Reassurance Miss S that service is confidential

Question 20

Gonorrhoea: symptoms

Answer 20

• MEN
  
  • 80-90% have mucopurulent urethral discharge and 50% have dysuria; occasionally testicular/epididymal pain
  • Within 2-5 days of exposure
• WOMEN
  
  • 50% increased/altered vaginal discharge; 25% lower ab pain, 10-12% dysuria
  • Within 10 days of exposure
• Pharyngeal- 90% no symptoms; 10% sore throat/tonsillitis
• Rectal- anal discharge/pain/discomfort

Question 21

Gonorrhoea: Testing and Ab resistance

Answer 21

• Caused by G-ve Neisseria Gonorrhoeae
• Test- NAAT (Nucleic Acid Amplification Test) no earlier than 3 days after sexual contact with an infected person
• Men- urine sample; women- vulvovaginal swab
• If NAAT is positive, the culture for antimicrobial sensitivity
• In England, resistance to first-line oral treatment (i.e. ciprofloxacin) is currently 36.4%
• In Jan 2019, UK reports of resistant strains to both ceftriaxone and azithromycin
• Worldwide, cases resistant to all known antibiotics

Question 22

Gonorrhoea: treatment

Answer 22

• If antimicrobial sensitivity not known
  
  • Ceftriaxone 1g IM stat
• If bacterium is known to be sensitive to ciprofloxacin
  
  • Ciprofloxacin 500mg PO STAT
• Other regimens
  
  • Cefixime 400mg PO STAT and Azithromycin 2g PO stat
  • Gentamicin 240mg IM stat and Azithromycin 2g PO stat
  • Spectinomycin 2g IM stat and Azithromycin 2g PO stat

Question 23

Genital herpes

Answer 23

• Herpes Simplex Virus
• Maybe HSV1 or HSV2
• In the UK, HSV1 slightly more common
• Can be subclinical for years- 80% of people with HSV are unaware they are infected
• Virus latent in local sensory ganglia, periodically reactivating- role of triggers
• HSV1- usual cause of oral herpes simplex. Transmitted by oral-genital intercourse
• HSV2- transmitted via vaginal or anal intercourse
• Can also transmit the infection from lesions at other sites, e.g. herpetic whitlow on finger or skin lesions
• Transmission most likely to occur when lesions are present, but virus can be shed asymptomatically especially in the first 12 months after infection
• Swab viral culture or polymerase chain reaction (PCR)

Question 24

Genital herpes

Answer 24

• NO CURE
• Chronic infection- some people have frequent outbreaks whilst other remain asymptomatic
• Recurrent episodes 4 times more frequent with HSV2 than 1
• Recurrence rate declines with time
• Lesions (Bilateral for first episode only)
• On external genitalia- red, blistering and ulceration- Painful
• In women, can also find in vagina and cervix
• Complications

Question 25

Genital herpes- 1st episode treatment

Answer 25

• 1st episode
  
  • Within 5 days of start of episode or new lesions forming
• 1st line
  
  • Aciclovir 400mg TDS PO for 5 days OR Aciclovir 200mg 5 times a day PO for 5 days
• 2nd line
  
  • Valaciclovir 500mg BD PO for 5-10 days
  • Famciclovir 250mg TDS PO for 5-10 days

Question 26

Genital herpes: recurrent attacks

Answer 26

• Shorter courses of antivirals
• E.g. Aciclovir 800mg TDS for 2 days
• May provide as self-initiated treatment
• If having >6 attacks per year, consider suppressive antiviral therapy, e.g. aciclovir 400mg BD or TDS PO for minimum 1 yr, then stop and assess re-occurence

Question 27

Genital herpes: Self care

Answer 27

• Clean affected area with plain or salt water
• If micturition is painful, apply vaseline or topic anaesthetic
• Increase fluid intake to make urine more dilute
• Urinate into a bath or with water flowing over the area
• Avoid wearing tight clothes around area of lesions
• Take pain relief
• Avoid sharing towels and flannels
• No SI until all lesions have cleared