Emergency Contraception

For our third GUM episode Dr Katie Boog once again joins us this time going through emergency contraception

Here is our #TakeVisually for this episode:

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Here are her notes, which Katie again kindly shared:

When do you need to think about emergency contraception?

Every sexually active female who is not on contraception or where contraception may have failed

What do you mean where contraception may have failed?

Condom not used/ condom accident

Missed COCP (≥2 pills)

Late POP (>36 hours for Desogestrel, 27 for traditional)

Late Depo >14w since last injection

Impalpable implant or > 3 yrs

IUD expulsion, lost threads

Whilst taking liver enzyme inducers and for 28 days after

What types of emergency contraception are there?

Levonorgestrel or Levonelle (LNG) - oral

Ulipristal acetate or ellaOne (UPA) - oral

Copper Coil (cuIUD)

How do they work?

LNG - works until LH surge begins

UPA - works until LH peaks (midcycle)

cuIUD - no effect on ovulation, prevents implantation 

How effective are they?

Oral - Depends when they are taken

cuIUD >99.9% at any time

 When can they be used?

LNG lic 72, used 120, efficacy decreases with time

UPA – 120 hours

cuIUD 5 days after first UPSI, 5 days after ovulation

How do you know when someone has ovulated?

Cycle – 14

Why are there different time options for the copper coil?

Preventing implantation

<5 days from fertilisation = no implantation

Are there any side effects?

Oral – Nausea/vomiting; 2 hour rule; spotting; delayed/early menses

cuIUD – painful fit, heavy/painful/prolonged menses

What would make you choose one oral method over the other?

UPA most effective mid cycle

UPA more effective between 72-120 hours

UPA – can’t use if progestogen in last 7/7

UPA – can’t quickstart

UPA not suitable if taking glucocorticoids for asthma

UPA and breastfeeding – discard 7/7

OK so for example, you see a lady who is not using contraception and she had unprotected sex 2 days ago.  What do you need to know?

Is she at risk of pregnancy?  Assume: partner is male, no condom used, not on contraception.

When was her last period?

Does she know how long her cycle is?

OK so her last period was 7 days ago and they come every 30 days like clockwork.

OK so she is day 7 of a 30 day cycle.  Her expected date of ovulation would therefore be day 16.  So she is eligible for all types of EC

cuIUD – could be fitted up to day 21 for her (5 days after ovulation)

EllaOne can be given up to 5 days after UPSI.  She has not yet ovulated.  But what does she want to start on for contraception?  She will have to wait 5 days

LNG – pre-ovulation, licensed up to 72 hours, could then quickstart new method

Discuss her options, PT in 3 weeks

What about if she was day 18 of her cycle and she had had unprotected sex every day and she had had emergency pills 3 times this month?

Day 18 of a 30 day cycle. 

Earliest day of ovulation would have been day 16. 

Oral methods ineffective after ovulation. 

She could have a coil fitted up to day 21 (5 days after ovulation) this would cover her for all sex that cycle

But couldn’t she already be pregnant from all the sex she had earlier that month?

No

Pregnancy starts at implantation

Implantation is not until >5 days after fertilisation

Earliest possible day of fertilisation was day of ovulation

We are within 5 days of ovulation

Vaginal Discharge

In our second ‘GUM’ special Dr Katie Boog talks us through vaginal discharge.

For more information don’t forget to check out the BASHH website.

Katie once again was kind to share her notes for this episode with us:

What causes vaginal discharge?

Discharge is normal:  Lubrication, Cervical mucus changes with hormones – contraception, cycle, age

We only worry if it changes

What type of changes?

Change in colour e.g. from clear/white to yellow/green/blood stained

Change in consistency/volume

Change in smell

Associated with itch or pain

Does a change in discharge mean an STI?

Can do but not always.

Changes can be due to:

Infection (STI or not), washing practices, foreign bodies (retained tampon, condom), growths (degen fibroids, malignancy), fistulae

Chlamydia and gonorrhoea usually asymptomatic in women

More likely to be thrush or BV

BV is most common cause of abnormal discharge

The history and examination will give you a lot of clues as to the most likely cause, often able to treat on the day rather than wait for the results

So what features in the history help you decide?

Smell – likely to be BV or TV

BV – thin, white/grey. Smelly, not sore or itchy.  Worse after sex and after period

TV – Smelly, itchy, may have dysuria. Can be thick or thin. Classically frothy and yellow but only <1/3rd

Itchy – likely to be TV or thrush

Thrush – thick, white, lumpy, itchy, sore (vulva, vagina or both), may have dysuria and dyspareunia

Increased discharge and abdo pain or deep dyspareunia – might be STI/PID

Gonorrhoea – might be yellow/green discharge most women are asymptomatic

Blood stained discharge – STI (cervicitis), PO contraception, cervical cancer

Also look at risk factors

What are the risk factors?

Chlamydia/gonorrhoea: new sexual partner, under 25

TV: new partner

BV: douching, smoking, black ethnicity, new partner, receptive cunnilingus (though not STI)

Thrush: diabetes, pregnancy, perfumed products, synthetic clothing

How should we examine/what tests should we do?

Examine vulva: signs of discharge, inflammation, excoriations, fissures, ulcers

VV swab for CT/NG

Speculum:

-          Look for a foreign body

-          Assess for vaginitis

-          Review cervix for cervicitis/abnormalities/growth/strawberry cervix  (rarely HSV lesions)

-          High vaginal swab for BV/thrush/TV (microscopy or MC&S)

-          Endocervical for microscopy and MC&S if suspect gonorrhoea

Bimanual if suspect PID

How do we diagnose and manage the infections?

Thrush:

Diagnosis:

-          High vaginal swab (ant fornix)

-          wet film or gram stain microscopy, hyphae and spores

-          MC&S (charcoal swab or plate)

Advice:

-          Not an STI, partner does not need notified or treated

-          Avoid tight fitting clothing, irritants

-          Wash with an emollient/soap substitute

Treat with an azole: oral (fluconazole, stat dose, CI in pregnancy) or vaginal (pessary or cream)

Sometimes need clotrimazole/hydrocortisone (external)

BV:

Diagnosis:

Microscopy (wet film or gram stain) – clue cells

PH >4.5

Charcoal swab

Advice:

-          Partner does not need treated

-          Essentially an imbalance in vaginal bacteria

-          Stop douching/excessive washing. Wash only with water and no internal washing

-          Treat with oral metronidazole, metronidazole gel (0.75% 5/7), clindamycin cream (2% 7/7)

-          No ETOH with metro +48 hours

TV:

Diagnosis:

High vaginal swab – post fornix, mobile trichomonads seen on wet prep, TV PCR if available, some POCTs available, culture

Advice:

-          Screen for other STIs

-          Sexual contacts from the last 4 weeks should be treated (+ screen for other STIs)

-          No sex until 7/7 both treated

-          Metronidazole (first line) or Tinidazole

-          Advice re ETOH

Chlamydia:

Most common bacterial STI

No immediate test, cannot be cultured

VV swab for NAAT testing (not endocervical)

Positive test:

-          Advise STI

-          Partner notification and testing/treatment

-          Doxycycline 7/7 (no longer azithro due to MG) – CI in preg: erythro 7/7

-          No sex until both partners treated

-          Regular screening, safe sex, can get again (more episodes = increase likelihood of longterm sequelae eg infertility, chronic pelvic pain)

Gonorrhoea:

VV NAAT test

Culture (cervix/urethra) if suspected and before rx due to resistance

Gram stain: gram neg intracellular diplococci

Advice:

-          STI, partner notification and testing/treatment

-          No sex until both partners treated

-          Ensure cultured before rx

-          Treatment: changing due to resistance, check BASHH

-          TOC 2/52

Sexual History Taking

Dr Katie Boog, ST6 in Community Sexual and Reproductive Health joined the pod to talk us through how to take a Sexual History with some top tips along the way.

Here are her notes for the episode which she kindly shared:

What is different about a sexual history compared to a normal medical history?

Asking about sexual partners and sexual practices is not routine/Embarrassing for patient/Out of our comfort zone

It can be difficult to bring up, outside of the sexual health clinic setting

What do we need to know?

All the usual things: PC, history of PC, medical/surgical history, medications/allergies, gynae history for women, social history PLUS the sexual history – who have they been having sex with, what type of sex, when etc

Why do you need to know about medical history?

Sexually transmitted infections can present outwith the genitals e.g. syphilis, scabies

Medical conditions can present on the genitals – e.g. psoriasis, lichen planus, diabetes

Side effects from meds can affect genitals e.g. rash or dryness

And aside from their partners, what social history do you need to know?

General health promotion advice

Drugs/alcohol and risk taking/interactions

Smoking and BV/warts

So what exactly do you ask for the sexual history?

When they last had sex –window periods, PEP, EC

Who they had sex with: gender, relationship/casual, how long they’ve been having sex with them – assessing risk, partner notification

What type of sex – which orifices to swab, assessing risk

Giving/receiving top/bottom anal/oral/ano-oral

Was there a condom used, did it break etc

Does this person have any symptoms/known infection

Then repeat for other partners, 3-6 months

Then we do a blood-borne virus screen

How do you ask those questions?

Avoid assumptions!

"You're married, so no other partners, right?"

"Your partners are all male, yes?"

"And you just have normal sex?"

"Have you had any other sexual partners in the last 3 months?"

"Are your partners male, female, or both?/Do you have sex with men, women, or both?”

"Do you have vaginal sex? Oral sex? Anal sex? All three?"

"Was this partner regular, casual, or a one-off?"

“Do you use condoms sometimes, always, never?”

What do you ask about in the blood borne virus screen?

MSM

Injected drugs/Chemsex

Paid for sex/Been paid for sex

Had sex with someone who is not from the UK

Medical procedures/blood transfusions abroad

Tattoos/piercings in non-professional place

Coercive sex

Identify risk factors for HIV and hepatitis

Any top tips?

Use a warning shot/explain why you are asking

Language – make sure you both understand

Confidentiality – room/ward, relatives, interpreters

Practice your poker face

And here is the #TakeVisually for this episode:

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