Sexual health: Hot topics Anne Connolly Vice President FSRH
To cover Contraception choices Contraception safety Sexual history taking Relevant tests
We don t do great. 30 50% pregnancies are unplanned One in five pregnancies end in abortion every year >184,500 abortions were performed in 2014 62% of women attending for an abortion were using contraception when they became pregnant Increased risks to mother and pregnancy outcome if inter-pregnancy interval is < 12 months
Doc I want the pill
Contraceptive choices
IUD IUS Implant Injection The Fit and forget methods (LARC)
CHOICE study They chose LARC methods Contraceptive method choices after counselling (N=2,500) 1 Long-acting Shorter-acting 33% 67% LARC=long-acting reversible contraceptive. 1. Secura GM et al. Am J Obstet Gynecol. 2010;203:115.e1 115.e7 2. Mestad et al. Contraception 2011;84:495-8. 69% of 14-17 year-olds chose a LARC with 63% of these choosing an implant 2
Proportion of women, % They liked it after 12 months... Contraceptive CHOICE project 100 90 80 70 60 50 40 87.5 84.0 83.3 30 20 56.5 55.1 49.1 54.2 10 0 Mirena (n=1,809) Cu-IUD (n=434) Implant (n=522) DMPA (n=313) Pills (n=478) Patch (n=99) Ring (n=431) Peipert et al. 2011 LARC Short-acting reversible contraception
.and they work Pill Patch Ring Winner et al. N Eng J Med 2012
Doc I want the pill Vicky is aged 21 She gets headaches Her Mum had migraines with flashing lights and couldn t take the pill She remembers vomiting and having to go home from school with her headaches when she was younger. Can she?
UKMEC 2016 www.fsrh.org It does: Provide guidance on safety of contraceptive methods using numerous medical conditions and patient characteristics. It does not: Address the use of contraceptives for non-contraceptive benefits Consider the efficacy of methods Replace clinical judgment
Definition of categories
Contraceptive risks VTE CVD Others
. Migraine
Cardio-vascular disease
More cardio-vascular disease
Rheumatic diseases
MEDSCAPE
MEDSCAPE
Doc we ve had an accident
This is an opportunity Assessment of pregnancy risk Emergency contraception choices Assessment of STI risk Ongoing contraception
When in the cycle is the risk highest? Max risk
Emergency Contraception IUD EllaOne Levonelle
It hurts Doc Molly is a 45 year old teacher who you have provided primary health care for her and the extended family for many years. She has recently noticed a change in discharge and she is having pain during sex.
Causes of vaginal discharge
Why is taking a sexual history so hard..?
Why is taking a sexual history so hard..? Treat like any other medical enquiry or history A warning shot may make it easier to open discussions. Make no assumptions Ask routine questions Use words that they understand Remember: an embarrassed healthcare professional leads to an embarrassed patient
Sexual history assessment of symptoms What are the symptoms: Discharge Dysuria Bleeding Pain Itching Rash/lumps
Sexual history taking core components Last sexual intercourse (LSI) Partner gender/sites of exposure*/condom use Repeat for other recent partners Women: LMP/contraception/cytology BBV risk history Any safe-guarding concerns? How are they going to get their results?
Sexual history taking BBV risk assessment Current/past use of injecting drugs, personal history or that of partners From/sexual contact with someone from a high risk country MSM or SI with bisexual partner Medical treatment abroad including transfusions SI with HIV positive partner Paid for/been paid for sex History of HIV/hepatitis testing *tattoos
HIV in 2014 Approximately 103,700 people living with HIV Estimated HIV prevalence in the UK 1.9/1000 17% were unaware of their infection and diagnosed late. Most people with HIV who died were diagnosed late. 1/2 new diagnoses probably acquired infection in the UK, 2/3 were MSM
HIV time course
HIV is a long-term condition
I need checking Lauren is bovvered She went to a party on Saturday and her mate said her ex had slept with her ex-best mate who she knew had chlamydia.
Vaginal discharge Infective causes Non STI Bacterial Vaginosis (BV) Candida STI Chlamydia trachomatis Neisseria gonorrhoeae Trichomonas vaginalis Herpes simplex virus (HSV)
STI rates
STIs Chlamydia trachomatis ASYMPTOMATIC in up to 70% women Treatment of lower genital tract infection with azithromicin 1g stat Gonorrhoea ASYMPTOMATIC in 50% women Refer all positives to GUM for treatment due to increasing antibiotic resistance So presence of discharge is not a sensitive indicator of an STI Both can give similar symptoms to candida/bv/tv
Resources
Sexual and reproductive health The planning of the family is important to improve medical, social and psychological outcomes LARC methods are superior Emergency contraception consultations are an opportunity The new UKMEC is published STIs are common and often asymptomatic HIV is important to diagnose early