Sexual Health

Consent, Gender of partners, when was last sexual contact, the type of sex involved, what contraception used, other sexual partners in last 3 months

Safeguard for DV, sexual abuse.
Partner place of origin, nature of the relationship

Initial seroconversion may involve a flu-like illness occuring within a few weeks of infection. It may be ASx until condition progresses to immunodeficiency

Unprotected anal, vaginal, oral sexual activity.

Vertical transmission at any stage of pregnancy / birth / breastfeeding

Mucous membrane, blood, open would exposure to infected blood / bodily fluids.

NOT THROUGH SALIVA

Kaposi’s sarcoma, Pneumocystitis jirovecii pneumonia, neuro-complications [toxoplasmosis, primary CNS lymphoma, TB], generalised neurological diseases [encephalitis, cryptococcus, progressive multifocal leukoencephalopathy, AIDs dementia complex]

CMV infection, candidiasis, lymphomas

caused by HHV-7, presents as purple papules on skin / mucosa. Can ulcerate later. Respiratory involvement may cause massive haemoptysis and pleural effusion

Treat via radiotherapy and resection

headache, confusion, drowsiness. Will see single OR multiple ring enhancing lesions + mass effect

Manage via sulfadiazine and pyrimethamine

Associated with EBV. Will see a single or multiple homogenous enhancing lesion

Treat via steroids, chemotherapy, surgery

most common fungal infection of CNS. Will see headache, fever, malaise, n / v, seizures, focal neurological deficit.

high opening pressure, raised protein, decreased glucose, normal lymphocytes, India ink test +ve

diarrhoea

Cryptosporidium + other protozoa [most common]: may see red cysts on modified Ziehl-Nielsen stain

CMV

Mycobacterium avium intracellulare: atypical bacteria seen in CD4 < 50. Will see fever, sweats, abdo pain and deranged LFTs. Managed via rifabutin, ethambutol and clarithromycin

Giardia

oral thrush [secondary to candida albicans], shingles [secondary to HZV], hairy leukoplakia [secondary to EBV], kaposi sarcoma

aspergillosis, oesophageal candidiasis, cryptococcal meningitis, primary CNS lymphoma

cryptosporidiosis. cerebral toxoplasmosis, progressive multifocal leukoencephalopathy, pneumocystis jirovecii pneumonia, HIV dementia

CMV retinitis, mycobacterium avium intracellulare infection

most common cause of oesophagitis in px with HIV, generally CD4 < 100. Will present with dysphagia and odynophagia

Treat with Fluconazole + Itraconazole

may occur as a consequence of treatment or virus itself. HIV-associated nephropathy [HIVAN] accounts for up to 10% of ESRF.

Will see massive proteinuria [nephrotic], normal / large kidneys, focal segmental glomerulosclerosis, raised urea and creatinine

Px may present with HIV seroconversion sx: sore throat, lymphadenopathy, malaise / myalgia / arthralgia, diarrhoea, maculopapular rash, mouth ulcers

1st line test is HIV antibody and antigen [4th generation test with p24 test]. 45 days window test

HIV antibody can also be tested via enzyme linked immunosorbent assays [ELISAS]

HIV RNA testing is not routine but is useful for neonatal HIV infection and screening blood donors

done via CD4 cell counts. HIV destroys CD4 cells, so the lower the count, the higher the risk of opportunistic infections. <200 is high risk

Can also test for viral load via HIV RNA per ml of blood. This is to see if the HIV is undetectable or not

Conservative: CVS RF monitoring = offer statin, yearly cervical smears, up to date vaccines like HPV / hep B / C, use condoms to prevent transmission

Medical: Combination of antiretroviral therapy [ART]. Usually 2 nucleoside reverse transcriptase inhibitors and a protease inhibitor

Aim is for a normal CD4 count and an undetectable viral load

Prophylactic co-trimoxazole is given to all HIV +ve px with a CD4 < 200

if viral load is under 50: normal vaginal delivery

if viral load is above 50, consider pre-labour caesarean section.

If viral load is above 400, pre-labour C section is recommended

Can also give IV zidovudine if viral load is high

caution as HIV can be transmitted whilst breastfeeding.

If viral load is undetectable, can attempy with close monitoring by HIV team

used after exposure to reduce risk of transmission, <72hr window of opportunity.

ART: emtricitabine / tenofovir and raltegravir for 28 days

Receptive oral / anal / vaginal intercourse with known HIV +ve partner

Occupational exposure [sharps / splash] from HIV +ve

Needle sharers with HIV +ve

Consists of Emtricitabine / tenofovir and works by preventing HIV from multiplying in T cells

Indicated in MSM / trans women with condomless sex in last 6 months or ongoing. Basically anyone with condomless sex with HIV +ve person. Unless their partner is on ART for more than 6 months and their plasma viral load is < 200

HIV +ve already

pill every day for consistent HIV protection

for an event: 2 pills 2-24hrs before anal sex and then one pill at 24hrs and 48hrs

nausea, headache, GI disturbance [these settle within 2 weeks]

reduced creatinine clearance and small decreases in bone density can be seen

at 2 weeks, 1 month and then 3 months, then every 3 months

Check for SEs, FBC / U&Es, LFTs

1 dose done at 12-13yr olds to protect against HPV strains 16, 18 and 6, 11

99% cervical cancer

anal, vaginal, mouth, throat cancer

genital warts

to GBMSM

if under 25yrs old, offer 1 dose

if between 25-40yrs old, offer 2 dose

offer 3 doses for those who are immunosuppressed or those known to be HIV +ve

An overgrowth of anaerobic bacteria in the vagina, causing a loss of the lactobacillic “friendly bacteria” in the vagina. This can increase the risk of women developing STIs

Most common cause is Gardnerella Vaginalis.

multiple sexual partners, excessive vaginal cleaning [douching, vaginal washes, use of cleaning products], recent ABx, smoking, copper coil

Fishy smelling, watery grey / white vaginal discharge.

Usually no itching, pain, irritation: if so, think alternative diagnosis or concurring infection

Lactobacilli produces lactic acid which brings down the pH. BV leads to a loss of lactobacilli, so there is a rise in pH > 4.5

test vaginal pH with a swab and pH paper: will see pH > 4.5

Standard charcoal vaginal swab for microscopy to see “clue cells”. These are epithelial cells from the cervix that have bacteria stuck inside them

need 3 of the 4:
thin white homogenous discharge
clue cells
ph > 4.5
+ve fishy smell after adding potassium hydroxide

Oral metronidazole for 5-7 days

Clindamycin is an alternative

warn px to not drink alcohol whilst on metronidazole. The interaction of the two can cause a disulfiram-like reaction with N / V

STI from a parasite / protozoa

ASx in 50%.

Can see offensive, yellow / green, frothy discharge. Itching, dysuria, dyspareunia, balanitis may be seen

Cervix examination can show a “strawberry cervix”

vaginal pH > 4.5
Motile trophozoites seen under microscopy with a standard charcoal swab. Use urethral swab / first catch urine for men

GUM referral for diagnosis, Tx and contact tracing

Oral metronidazole for 5-7 days

vaginal infection with the yeast of candida albicans. May colonise the vagina without causing sx before progessing to infection when the right environment occurs such as pregnancy OR after px has had broad spectum ABx that alter the vaginal flora

raised oestrogen, poorly controlled diabetes, immunosuppression, broad spectrum ABx

“Cottage cheese” discharge but no smell. Will see vulval / vaginal itching and discomfort

Severe infection can lead to: erythema, fissure, oedema, dyspareunia, dysuria, excoriation

if diagnosis is unclear, can do a swab. pH will be < 4.5. Will see pink structures under microscopy

1st line: oral fluconazole 150mg

Co-trimazole 500mg can be given as an intravaginal pessary if oral is CI

if vulval sx: consider topical imidazole in addition to above Tx

warn px that antifungal creams / pessaries can damage latex condoms AND prevent spermicides from working.

So alternative contraceptive is needed for at least 5 days

4 or more episodes per year.

Check compliance with previous Tx. Confirm diagnosis via microscopy and use blood glucose test to exclude diabetes.

Consider induction maintenance regime

induction: oral fluconazole every 3 days for 3 doses

Maintenance: oral flucoazole weekly for 6 months

chlamydia trachomatis infection, it is a gram -ve bacteria. Most common STI in the UK

screens every sexually active person under 25yrs of age for chlamydia annually OR when they change partner.

If a +ve test, retest in 3 months after Tx to see if they have contracted chlamydia again

young, sexually active, multiple partners

charcoal swab to send for microscopy, culture and sensitivites.

NAAT testing for chlamydia and gonorrhoea. Uses vulvovaginal / endocervical / first catch urine sample swabs

should be carried out 2 WEEKS after possible exposure. NAAT testing with vulvovaginal swab or first catch urine in men

conservative: abstain from sex for 7 days of Tx of all partners to reduce risk of re-infection. Refer to GUM for contact tracing. Safeguard px, advise condom use

Medical: doxycycline 100mg BD for 7 days

if CI like pregnancy: use azithromycin 1g STAT then 500mg OD for 2 days

occurs around the site of chlamydia infections usually in MSM.

3 stages: painless ulcers first, then lymphadenitis and finally inflammation leading to prostitis, anal pain / discharge, change in bowel habit and tenesmus

give doxycycline BD for 21 days

chlamydia of eye usually when genital fluid comes in contact with eye. Will see chronic erythema, irritation and discharge

young, sexually active, multiple partners, previous STIs like chlamydia / HIV

neiserria gonorrhoea [gram -ve diplococcus]

transmission via contact with mucous secretions from infected areas

Females: odourless purulent discharge, dysuria, pelvic pain

Males: odourless purulent discharge, dysuria, epididymo-orchitis

NAAT testing with endocervical / vulvovaginal / urethral swab / first catch urine sample. Can also get rectal and pharyngeal swabs if relevant

Charcoal endocervical swab is taken to investigate any resistance to ABx

Conservative: refer to GUM for testing and contact tracing. Abstain from sex for 7 days of Tx for all partners. Safeguard and advice patients ways to prevent future infection

Medical: IM ceftriaxone 1g if sensitivities are not known. If they are known, can use oral ciprofloxacin 500mg.

test of cure with NAAT testing or cultures to see if px is +ve

seen in untreated gonorrhoea that spreads to the skin / joints. will see:

non-specific skin lesions, migratory polyarthritis, tenosynovitis, dermatitis

emergency: can coincide with sepsis and result in the perforation of the eye and blindness

bacteria that causes non-gonococcal urethritis. It is an STI

urethritis, epididymitis, cervicitis, endometritis, PID, reactive arthritis, preterm delivery in pregnancy, tube infertility

NAAT testing, microscopy to look a leucocyte count levels

Doxycycline 100mg BDS / 7 days + Azithromycin 1g STAT then 500mg OD / 2days

can use moxifloxacin as an alternative in complicated cases

important to check every +ve sample for macrolide resistance AND perform a “test of cure” after Tx in every +ve px

inflammation and infection of the female pelvis [uterus, fallopian tubes, ovaries], caused by infection spreading through the cervix

usually an STI: chlamydia trachomatis, neisseria gonorrhoea, mycoplasma genitalium, gardnerella vaginalis, haemophilus influenzae, e.coli

not using barrier contraceptives, multiple sexual partners, younger age, existing STIs, previous PID, IUD

pelvic / abdominal pain, abnormal vaginal discharge / bleeding, dyspareunia, fever, dysuria

o / e: pelvic tenderness, cervical motion tenderness, cervicitis, purulent discharge

systemic sx: fever and sepsis signs

vaginal swab for STI, pregnancy test to exclude ectopic

Bloods for ESR / CRP inflammatory markers

Microscopy + NAAT testing

Test for HIV / syphilis

refer to GUM for management and contact tracing.

Usually start ABx empirically before swab results to avoid delays so that means giving ceftriaxone, doxycycline and metronidazole

treponem pallidum or an STI.

Transmitted via oral / vaginal / anal sex, vertical transmission, IV drug use, blood transfusions

painless ulcer [chancra] at site of infection + local lymphadenopathy

systemic fever / lymphadenopathy

maculopapular rash on trunk / soles / palms. Condylomata lata [grey wart lesions], snail track ulcers, alopecia, oral lesions

occurs after secondary stage where the px becomes ASx despite being infected. Occurs within 2 years for early latent and after 2yrs in late latent syphilis

occurs many years after initial infection, gummatous lesion, aortic aneurysms, neurosyphilis, Argyll-Robertson pupil

headache, altered behaviour, dementia, tabes dorsalis, Argyll-Robertson pupil, paralysis, sensory impairment

when pupil does not constrict to light but accomodates

blunted upper incisor teeth [Hutchinsons], Rhagades [scars on mouth / lips], keratitis, deafness, saddle nose

Rapid plasma reactin [non-treponemal test] can be used to see antibody response to syphilis antigen. Can give false negatives due to TB, SLE, HIV, malaria, pregnancy

Treponemal tests like TPHA are specific to syphilis

consistent with active syphilis infection

false +ve syphilis

consistent with successfully treated syphilis

Refer to GUM, STI screening, contact tracing, advice and safeguarding

1 dose of deep IM benzathine benzylpenicillin. Monitor response via non-treponemal test, high the number, the more active the syphilis infection

fever, rash tachycardia seen after first dose of ABx. No wheeze or hypotension seen compared to anaphylaxis

give antipyretics if needed, usually no tx is needed

by two strains of HSV in humans: HSV 1 and 2.

PAINFUL genital ulceration with associated with dysuria and pruritus. There may be systemic sx like fever, malaise and headache due to the primary infection of herpes

Tender inguinal lymphadenopathy

urinary retention may occur

NAAT testing

HSV serology is useful when there is recurrent genital ulceration of unknown cause to exclude herpes

conservative: saline bathing, analgesia, topical anaesthetics like lidocaine

ORAL ACICLOVIR

elective C-section is advised if primary attack of herpes occurs at 28 weeks gestation onwards

if pregnant with recurrent herpes, suppressive therapy and advise that the risk of transmission to the baby is low

tropical disease caused by haemophilus ducreyi, causing painful genital ulcers associated with unilateral, painful inguinal lymph node enlargement with pus underneath

usually clinical. Culture of H. ducreyi is difficult and time-consuming

PCR can be done for more rapid diagnosis

pain relief

ceftriaxone, azithromycin, ciprofloxacin

HPV 6, 11

small [2-5mm] fleshy protuberances which are slightly pigmented

pruritus and bleeding

1st line: topical podophyllum for multiple, non-keratinised warts

Cryotherapy for solitary keratinised warts

2nd line: imiquimod cream

very effective, lasts for 3 years, no need for further action and fertility return to normal after removing

painful insertion / removal, there may be scarring / insertion site problems, unpredictable bleeding and hormonal SEs

very effective, lasts 3-6yrs, no further action needed, fewer or no periods

minor medical procedure to insert / perforation, expulsion, infection risk. ectopic pregnancy risk

risk of light vaginal bleeding for 3-6months after insertion

very effective, lasts 5-10yrs, no further action needed

heavy periods, risk of vaginal bleeding for 3-6 months after insertion, risk of perforation / infection / expulsion as it is a medical procedure to insert

High chance to stop periods and does not need to take everyday

hormonal SEs, procedure is done every 3 months, there is a delay of up to a year to returning to fertility, erratic bleeding, weight gain and reduced bone density

easy to use, controlled by user, may help with premenstrual sx and painful / heavier periods

have to remember to take pill

easy to use, controlled by user, improves irregular bleeding, helps with premenstrual sx and heavy painful periods

decreases risk of endometrial / ovarian / colon cancer, protects against PID

stroke risk, hormonal SEs, VTEs, CVD, breast cancer

obesity increases the risk of VTE if the px takes COCp. If their BMI is 35 or above, it is UKMEC3. If between 30-34, then it is UKMEC 2

they cannot have oral contraception due to lack of efficacy, including emergency contraception

continued up to 50yrs before switching to non-hormonal or progesterone only method

condoms, diaphragms / cervical caps, dental dams

silicone caps over the cervix to prevent semen from entering. fitted before having sex and leave in place for at least 6hrs after sex.

Should be used with spermicide gel to further reduce the risk of pregnancy

these are used during oral sex to provide a barrier between the mouth and vulva / vagina / anus

used to prevent the spread of STIs, HIV, pubic lice

prevent ovulation via -ve feedback on the hypothalamus and pit gland

Progesterone also thickens the cervical mucus to maintain the endometrial lining

monophasic has the same amount of hormone in each pill whilst multiphasic has varying amounts of hormone to match the normal cyclical hormone changes more closely

21 days on, 7 days off
63 days on, 7 days off
continous use, no pill free period

unscheduled bleeding is common in the first 3 months and should settle with time
Breast pain and tenderness
Mood changes / depression
Headaches
HPTN

increased VTE and breast / cervical cancer risk

small increased risk of MI and stroke

over 35yrs AND smoking less than 15 cigarettes a day
BMI > 35
FHx of VTE
controlled HPTN
immobility [wheel chair use]
carrier of BRCA1 /2 gene
current gallbladder disease

Uncontrolled HPTN [> 160 / 100]
Migraine with aura
VTE Hx
over 35 yrs AND more than 15 cigs a day
major surgery w/ prolonged immobility
vascular disease / stroke
ischaemic heart disease
liver cirrhosis / tumours
SLE and antiphospholipid syndrome

no other protection is needed

otherwise, extra contraception is needed for the first 7 days of consistent pill use before they are protected

they need to have extra contraception for 7 days before they are protected UNLESS they are switching from desogestrel which doesnt need additional management

if 1 pill is missed, take the last pill even if it means doubling up and then go back to normal

if 2 or more pills missed: do the same BUT use additional contraception until pill has been taken for 7 days in a row

use emergency contraception if she has had unprotected sex during this period

finish the pack and start the new pack the next day. NO pill free interval

only take precaution for enzyme inducing ABx like rifampicin

recommended to stop COCp for 4 weeks before a major operation or any procedure that requires the LL immobilised

Evra patch is the only one licensed in UK and lasts for 4 weeks. Patch is worn everyday and changed weekly. Same rules and concerns as the pill

Norgestor. Cannot be delayed by more than 3hrs or it is considered a missed pill

works by thickening the cervical mucus to make it less accepting of implantation

can be taken up to 12hrs late and still effective, afterwards it is a “missed” pill

inhibits ovulation, thickens cervical mucus and reduces ciliary action in fallopian tubes

if done in day 1-5, protected immediately

otherwise, can start whenever but needs 48hrs to be effective so need additional contraception for 48hrs

can switch between POPs without any extra contraception

IF COCp is taken for more than 7 days, can switch immediately without any additional contraception

IF on days 1-2 of the hormone free period following a full pack of COCp, they can switch immediately

if they have had unprotected sex in the days of the hormone free period, they need additional contraception for the first 48hrs of taking POP

unpredictable bleeding pattern than often settles after 3 months
breast tenderness
headaches
acne

ovarian cysts, small risk of ectopic pregnancy due to reduced ciliary action in the tubes
minimal increase risk of breast cancer that returns to normal 10yrs after stopping

take pill as soon as possible even if they need to double up AND need additional contraception for the next 48rs

Emergency contraception if they have had unprotected sex during this period

diarrhoea and vomiting episodes are treated as missed pills

a flexible plastic rod inserted under LA in the upper arm beneath the skin where it slowly releases progestogen into systemic circulation

inhibits ovulation, thickens cervical mucus and alters endometrium

if inserted in day 1-5 of cycle: immediate protection

if inserted after day 5: need 7 days of extra contraception

they can become impalpable / deeply implanted or fractured. IF so, need extra contraception until palpable. Need specialist referral and guidance to remove the implant. Nexplanon has barium sulphate inside to make it visible on Xray.

very rarely can travel through blood vessels, so if unable to find, might need to consider a CXR

recommend COCp in addition to implant for 3 months when problematic bleeding occurs to help settle bleeding

devices inserted into uterus to providde contraception. A form of Long acting reversible contraception [LARC].

Cu-IUD. makes a hostile environment for pregnancy as Cu is toxic to ovum and sperm. Lasts for 5-10 yrs

contains progestrogen that is slowly released into uterus and is effective after 7 days UNLESS inserted in the first 1-7 days of the cycle. Mirena coil is an example

PID / infection, immunosuppression, pregnancy, unexplained bleeding, pelvic cancer, uterine cavity distortion like fibroids

need screening for STIs for women at high risk of STI.

Need a bimanual + speculum and device system insertion with HR / BP monitored before and after the procedure

there may be temporary crampy period type pain after insertion. NSAIDs can be given to help

check up on 3-6 weeks after insertion, to check the threads

bleeding, pain on insertion, vasovagal reactions [bradycardia, dizziness], uterine perforation, PID. expulsion rate is highest in the first 3 months

if unable to see threads, need to exclude: expulsion, pregnancy and uterine perforation

Extra contraception is required until coil is located. Locate via US / AXR and pelvic XR. Hysteroscopy or laparoscopic surgery may be required depending on coil location

known as a depot medroxyprogesterone acetate [DMPA]. Given at 12-13 week intervals as an IM / SC injection. Can take up to 12 months for fertility to return after stopping the injection

if done on day 1-5, immediate protection

started after day 5 of the cycle, requires 7 days of extra contraception

changes to bleeding, weight gain, osteoporosis, acne, reduced libido and mood changes, headaches, flushes, alopecia, skin reactions at injection site

ischaemic heart disase / stroke
unexplained vaginal bleeding
severe liver cirrhosis
liver cancer

active breast cancer

any women over 45yrs due to osteoporosis concerns

Levonorgestrel: must be taken within 72hrs of unprotected sexual intercourse [UPSI], can give after this but warn px of the reduced efficacy. Give 1.5mg dose or double this is BMI is above 26 or over 70kg

Ulipristal or EllaOne: 30mg oral dose. Tell px if they use hormonal contraception, they should restart after 5 days due to reduced efficacy, use barrier methods instead. Warn px with severe asthma

Copper IUD is the most effective method and should be offered to all women if they meet the criteria. Must be inserted within 5 days of UPSI OR can be fitted up to 5 days after likely ovulation date

tubal occlusion via laparascopy under GA, using Filshie clips. Alternative contraception is required until the next menstrual period as an ovum may have already reached the uterus during the cycle

vasectomy is the cutting / tying of the vas deferens, preventing sperm travelling from the testes to join ejaculated fluid. Done under LA. Need alternative contracpetion for 2 months after the procedure

generally recommend to use condoms or barrier methods

COCp is UKMEC3 for basically all anti-epileptics and if it is taken, it should contain a minimum of 30 micrograms of ethinylestradiol

HRT is alone not enough so recommend POP as long as HRT has a progestogen component

if unsure, talk to senior or medical defense organisation

if 18 or above, full autonomy
16-17yr olds also

if under 13, trigger child protection measures

judges whether the understanding / intelligence of the child is sufficient to consent to Tx

done via safeguarding, ask questions, check if child understands implications