Sexual history

Question 1

Principles

Answer 1

Privacy 
Confidentiality 
Sensitive 
Consent
Signposting - “Next, I’m going to move on to discuss your sexual history, some of these questions are quite in-depth and personal. The reason we ask these questions is so that we can accurately assess the risk of sexually transmitted infections. We ask the same questions to everyone, so please don’t take anything personally. If you feel uncomfortable and would prefer not to answer, just let me know.

Question 2

Common presenting complaints in females

Answer 2

Change in vaginal discharge.
Vulval skin problems.
Lower abdominal pain.
Dysuria.
Changes in menstrual cycle or irregular bleeding

Question 3

Common presenting complaints in males

Answer 3

Urethral discharge.
Dysuria.
Genital skin problems.
Testicular swellings or discomfort.
Peri-anal/anal symptoms

Question 4

Vaginal discharge: characteristics

Answer 4

Volume
Colour(e.g. green, yellow or blood-stained)
Consistency(e.g. thickened or watery)
Smell

Question 5

Vaginal discharge: DDx

a) Gonorrhoea/chlamydia
b) BV
c) Trichomonas
d) Thrush (candida)

Answer 5

a) Gonorrhoeaandchlamydiacommonly present with abnormal vaginal discharge.
b) Bacterialvaginosistypically presents with an offensive, fishy-smelling vaginal discharge, without any associated soreness or irritation
c) Trichomonasvaginalistypically presents with yellow-green frothy discharge with associated vaginal itching and irritation.
d) Thrush is generally a cottage cheese discharge

Question 6

Abnormal menstrual bleeding:

a) 2 main types
b) DDx for each

Answer 6

• Post-coital bleeding refers to vaginal bleeding occurring after sexual intercourse.
  DDx: infection (e.g. chlamydia and gonorrhoea),cervical ectropion and cervical cancer.
• Intermenstrual bleeding refers to vaginal bleeding occurring between menstrual periods.
  DDx: infection (e.g. chlamydia and gonorrhoea), malignancy (e.g. cervical or endometrial cancer), uterine fibroids, endometriosis, hormonal contraception (e.g. Mirena coil) and pregnancy

Question 7

Dyspareunia

a) What is it?
b) DDx - superficial, deep

Answer 7

a) Pain during intercourse, not caused by vaginismus or poor lubrication

b) - Superficial: vaginal atrophy, lichen sclerosis, thrush, herpes, vulvodynia, bartholin cyst
- Deep: PID, endometriosis, ovarian cysts, and malignancy.

Question 8

Dysuria: two main differentials

Answer 8

UTI

STI (chlamydia, gonorrhoea, trichomoniasis or herpes)

Question 9

Vulval soreness: differentials

Answer 9

• STI (Bacterial vaginosis, Genital herpes, Chlamydia, Gonorrhoea)
• Thrush
• Vaginal atrophy occurs in post-menopausal women and can lead to itching and bleeding of the vagina
• Lichen sclerosis appears as white patches on the vulva and is associated with itching

Question 10

Genital skin changes: differentials

Answer 10

• Genital herpes – PAINFUL crops of blisters/ulcers (vagina and cervix)
• Syphillis – PAINLESS chancre
• Genital warts – PAINLESS lesions that can be located on the labia, clitoris, urethral meatus, introitus, vagina, cervix, perineum, perianal area and anal canal
• Males - balanitis (diabetes)

Question 11

Systemic symptoms:

a) Abdo pain and fever - DDx (2)
b) Weight loss
c) Rash (palms and soles)
d) Swelling of large joints, conjunctivitis

Answer 11

a) PID, ectopic
b) HIV
c) Syphilis, ?HIV
d) Reiter syndrome secondary to chlamydia/gonorrhoea

Question 12

Menstrual Hx:

Questions to ask

Answer 12

LMP
“When was your last menstrual period?”

Duration:
“How long do your periods typically last?”

Frequency:
“How often do your periods happen?”
“Are they regular and predictable?”

Menstrual blood flow:
“Are your current periods heavier than your usual periods?”
“Have you been flooding through sanitary towels?”
“Have you been passing blood clots larger than a 10p coin?”

Other
“Do you experience a lot of pain during your periods?”
“Are the heavy periods impacting your day to day life?

Question 13

Past gynae history: important points

Answer 13

1. Cervical screening (known previously as the cervical smear): date and result of last cervical screening test
2. Previous gynaecological diagnoses and treatments:
   - HPV vaccination status
   - Ectopic pregnancy
   - Sexually transmitted infections
   - Endometriosis
   - Malignancy (e.g. cervical, endometrial, ovarian)
3. Previous pregnancies
4. Contraception

Question 14

Testicular pain or swelling: differentials

Answer 14

• Epididymo-orchitis, (which is often secondary to chlamydia or gonorrhoea)
• Testicular cancer
• hydrocele
• Torsion (acutely painful)

Question 15

Urethral discharge in males

Answer 15

STI (gonorrhoea or chlamydia)

Question 16

Last sexual contact: questions

Answer 16

1. Timing:
   - when?
   - consensual?
2. Partner:
   - regular partner?
   - partner demographics?
3. Types of sex involved:
   - oral, vaginal, anal
   - receptive/not
4. Contraception:
   - types
   - barriers?
   - missed?

Question 17

HIV risk factors (mnemonic: SHARP)

Answer 17

S - Sexual partner - “Have you ever had a Sexual partner who is known to be HIV positive?”
H - Homosexual - “Have you ever had sex with a bisexual man/engaged in male homosexual activity?”
A - Abroad - “Have you ever had sex with someone abroad, or who was born in a different country?”
R - Recreational drugs - “Have you ever injected drugs?” “Are you aware of any of your previous partners having ever injected drugs?”
P - Prostitution - “Have you ever paid someone for sex, or been paid for sex?”