Oxford Handbook of General Practice (4 edn)
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Assessment of sexual health
Good communication skills are particularly important for clinicians when discussing sexual health problems and may improve health outcomes. Ensure a comfortable, private, and confidential environment.
General assessment
Objectives are to:
Establish a constructive relationship with the patient to enable patient and doctor to communicate effectively and serve as the basis for any subsequent therapeutic relationship
Determine whether the patient has a sexual health problem and, if so, what that is
Find out (where possible) what caused that problem
Assess the patient’s emotions and attitudes towards the problem. Be aware of signs of anxiety/distress. Recognize non-verbal cues
Establish how it might be treated
History
Use open questions at the start becoming directive when necessary—clarify, reflect, facilitate, listen. Ask about:
Presenting complaint
Chronological account and concerns. If appropriate, ask about:
Vaginal or urethral discharge
Dysuria/other urinary symptoms
Dyspareunia—pain on intercourse (
p. 714)
Erectile dysfunction— p. 776
Genital skin problems—soreness, itching, ulceration, warts
Perianal/anal symptoms
Other symptoms, e.g. pelvic/abdominal/groin pain, deformity of the penis, haematospermia (blood in the ejaculate), retrograde ejaculation
Past medical history
Similar symptoms—for suspected sexually transmitted infections (STIs), ask about previous STI, date of diagnosis, and treatment
Obstetric history for women
Urological problems and treatments or pelvic surgery
Chronic medical problems—endocrine; cardiovascular; DM
Medical treatment abroad—in certain countries, may be associated with ↑ HIV/hepatitis risk
HIV testing/hepatitis B vaccination history
Drugs
Prescription drugs, e.g. drugs associated with erectile dysfunction
Illicit drugs—may be associated with erectile dysfunction, and history of injecting drug misuse is associated with ↑ hepatitis/HIV risk
Allergies
Sexual history
Current sexual partner (person with whom the patient had last sexual intercourse) and other recent sexual partners—if appropriate, ask about:
Nature of relationship with partner—long-term partner; casual partner who could/could not be traced; paid-for partner
Gender of partner
Nature of intercourse—oral, vaginal, anal
Contraception? Method used. Does the patient use a condom (male or female) regularly and consistently? Did it remain in place and intact?
For women, establish date of LMP, cycle length, and regularity
Symptoms in partner?
For suspected STI, ask about all partners within the previous 3mo or incubation period of the suspected infection (if longer). If no partners are reported, note the last time the patient had sexual intercourse.
Social history
Smoker?
Alcohol consumption
Travel abroad—if suspected STI, ask whether the patient had sexual intercourse abroad other than with their travelling partner, and with whom
Attitudes and beliefs
How does the patient see the problem?
What does he/she think is wrong?
How does he/she think his/her partner views the situation?
What does the patient want you to do about it?
Examination
Examine the external genitalia and perianal area. Check groins for lymphadenopathy if STI is suspected. For women, perform pelvic and vaginal speculum examination. Consider digital rectal examination if indicated.
Explain the need for, and offer a suitably medically qualified chaperone for the examination of all patients. Record if a chaperone is declined.
Action
Summarize the history back to the patient and give an opportunity for the patient to fill in any gaps
Check that the patient has no other concerns
Draw up a problem list and outline a management plan. Further investigations and interventions are guided by the findings on history and examination—so a good history and examination is essential
Set a review date
Genital ulcers
Causes: genital herpes; primary syphilis; Behçet’s syndrome. If history of foreign travel, partner from abroad, or doubt about diagnosis refer to GUM clinic.
Further information
BASHH Sexual history taking (2012) 
www.bashh.org
Patient information about sexual health
Family Planning Association (FPA) www.fpa.org.uk
Department of Health Sexual Health Line 
0800 567 123 (24h); Sexwise (for under 19s) 0800 28 29 30
Vaginal discharge
All women have some vaginal discharge. Physiological discharge varies considerably and is affected by the menstrual cycle.
Before ovulation—mucus is clearer, wetter, stretchy, and slippery
After ovulation—mucus is thicker and stickier
Causes of ‘abnormal’ discharge
5 causes account for 95% cases:
Excessive normal secretions
Bacterial vaginosis (BV)
Candida albicans
Cervicitis (gonococcal, chlamydial, or herpetic)
Trichomonas vaginalis (TV)
Rarer causes
Cervical ectropion/polyp; IUCD/IUS; chemical vaginitis (avoid perfumed or disinfectant bath additives and vaginal douches); foreign body (e.g. retained tampon—remove and treat with metronidazole 400mg tds for 7d); genital tract tumour; fistula.
History
Ask about:
Symptoms Vaginal discharge (itchy, offensive, colour, duration), vulval soreness and irritation, lower abdominal pain, dyspareunia, heavy periods, intermenstrual bleeding, fever, vulval pain
Sexual history Recent sexual contact with new partner, multiple partners, presence of symptoms in partner, worries about STIs
Medical history Pregnancy, diabetes mellitus, recent antibiotics
Attempts at self-medication
Examination
Always offer examination if:
High risk for STI—age <25y; new sexual partner or >1 sexual partner in the past year; diagnosis of STI in the past 12mo
Upper reproductive tract symptoms—abnormal bleeding (heavy, post-coital ± intermenstrual); pelvic/abdominal pain; deep dyspareunia; fever
Pregnant, postpartum, or after miscarriage/termination
After instrumentation (e.g. insertion of IUS/IUCD, after colposcopy)
Recurrent infection or failed treatment
Requesting examination/STI testing
Do an abdominal, bimanual pelvic, and vaginal speculum examination. Look for tenderness on lower abdominal or bimanual palpation, cervical erosion/contact bleeding, discharge, foreign bodies, warts, or ulcers.
Investigation
Check pH of secretions with narrow-range pH paper. If >4.5, BV or TV is likely; pH is 4.5 with physiological discharge and candida infection. Other investigations to consider:
High vaginal swab for M,C&S—only if symptoms/signs and/or pH consistent with specific diagnosis; the patient is pregnant, postpartum, or after miscarriage/termination; after instrumentation; or if there is recurrent infection/treatment has failed
Endocervical swabs for gonorrhoea and chlamydia
Viral swab if herpes is suspected (if not available, refer to GUM)
Opportunistic cervical smear if indicated ( p. 728)
Self-taken vulvovaginal swab if examination is declined
Management
Treat the cause. If unclear refer to GUM or gynaecology.
Sexually transmitted infections
p. 738
Bacterial vaginosis (BV)
Vaginal flora is changed from Lactobacillus species to anaerobes. Not sexually transmitted. Affects 10–40% of premenopausal women—about half are asymptomatic. Associated with:
↑ risk of preterm delivery (and ↓ risk if treated)
Development of PID and endometritis following abortion or birth
Infection post-hysterectomy
Presentation
Grey/white, thin, fishy-smelling, offensive discharge with no vulval soreness. On examination, the cervix looks normal; pH of secretions is >4.5. HVS for M,C&S may confirm diagnosis but treat without swab if no examination is carried out, or pH is >4.5 and typical clinical picture.
ManagementG
Without treatment, 50% remit spontaneously. Cure rate with all methods is ~85%. There is no benefit from treating the woman’s partner. Treatment:
Metronidazole 400mg bd for 5–7d or 2g single dose
Clindamycin 2% cream 5g nocte pv for 1wk
Recurrent infection—
suppressive therapy using metronidazole 400mg bd for 6d to cover each period, metronidazole 0.75% gel 2x/wk pv for 4–6mo, lactic acid gel alternate nights for >1mo, and pv probiotics are all but robust evidence of effectiveness is lacking
Candidiasis (thrush)
Fungal infection—~20% of patients are asymptomatic. Predisposing factors include:
Cushing’s or Addison’s disease
Broad-spectrum antibiotics
Radiotherapy/chemotherapy
Immunosuppression
Steroid treatment
Vaginal trauma
DM
Pregnancy
Presentation
Well, pruritus vulvae, superficial dyspareunia, and/or thick, creamy, non-offensive discharge. Examination: discharge (cottage cheese) and sore vulva which may be cracked/fissured. Investigation is usually unnecessary. Confirm diagnosis if infection persists or recurs by sending a swab from the anterior fornix for M,C&S.
ManagementG
Only treat if symptomatic. Sexual transmission is minimal; there is no benefit from treating the partner unless overt infection:
Try clotrimazole pessaries—cure rate ~90%
Alternative is oral fluconazole 150mg stat, repeated after 3d if severe infection. Contraindicated in pregnancy or lactation—83% cure rate
Recurrent infectionG
Advise loose, cotton underwear and avoidance of soaps, perfumes, or disinfectants in the bath. Consider vulval emollients to treat associated dermatitis. If ≥4 documented episodes (≥2 confirmed with microbiology) in a year, treat with fluconazole 150mg every 3d x3, then 150mg weekly for 6mo.
Further information
FSRH Management of vaginal discharge in non-genito-urinary medicine settings (2012) www.fsrh.org
BASHH www.bashh.org
Management of bacterial vaginosis (2012)
Management of vulvovaginal candidiasis (2007)
Sexually transmitted infection
GPs are frequently presented with symptoms/signs either presented directly or found incidentally (e.g. when doing a cervical smear) that may indicate sexually transmitted infection (STI). The easiest (and often best) option is to refer suspected cases to a genito-urinary medicine (GUM) clinic. Sometimes the patient is reluctant to go and 40% referrals never attend, so it is still necessary for GPs to know how to prevent, diagnose, and treat STI themselves.
Contact tracing
Best done by GUM clinics. If a patient refuses to go, then provide him/her with a letter to give to contacts stating the disease he/she has been in contact with, treatment given, and suggesting contacts visit their local GUM clinic promptly.
Use of GUM clinics
In general, refer patients:
Who require contact tracing
If counselling is needed, e.g. first attack of HSV, HIV
If diagnosis is still unclear after investigation
For confirmation of diagnosis, e.g. HSV
If specialist treatment is required, e.g. treatment of genital warts
Prevention of STIs
NICE recommends:
Identification of high-risk patients opportunistically in general practice, e.g. at new patient checks, when attending for travel advice
One-to-one discussions with those at ↑ risk of STIs lasting 15–20min, structured on the basis of behaviour change theories to ↓ risk-taking
High-risk groups
Include patients with STIs; men who have had sex with other men; people who have come from/visited areas of high HIV prevalence; substance/alcohol misuse; early onset of sexual activity; unprotected sex; and frequent change of/multiple partners.
Young people from vulnerable groups
(e.g. from disadvantaged backgrounds; in/leaving local authority care; low educational attainment). Should be offered one-to-one sessions aimed at educating them about sexual health and contraception.
Chlamydia screening
A screening programme for the under 25s is currently in operation in the UK ( p. 740).
Vaccination
A vaccine targeting the most common forms of HPV causing cervical cancer is now available in the UK. The target population is girls aged 12–14y before they become sexually active ( p. 749), but potentially any sexually active woman could benefit.
Prevention of HIV
p. 744
Vaginal discharge
p. 736
Acute pelvic inflammatory disease (PID)
May be asymptomatic. Peak age 15–25y. >10% develop tubal infertility after 1 episode; 50% after 3 episodes. Risk of ectopic pregnancy ↑ x10 after a single episode. Only 70% of those with acute PID clinically have diagnosis confirmed on laparoscopy. Most cases of PID are associated with STI—usually chlamydia (50%) or gonorrhoea. In 20% no cause is found.
History
Fever >38°C and malaise
Acute pelvic pain (usually bilateral) and deep dyspareunia
Dysuria
Abnormal vaginal bleeding—heavier periods, intermenstrual and/or post-coital bleeding
Purulent vaginal discharge
Examination
Pyrexia, bilateral lower abdominal tenderness, vaginal discharge, cervical excitation, and adnexal tenderness.
Investigations
Consider swabs (HVS and endocervical swab for M,C&S and chlamydia/gonorrhoea screen) and blood tests (FBC—may show leucocytosis; ↑ ESR/CRP).
ManagementG
Admit if very unwell, pregnant, or if ectopic pregnancy or other acute surgical emergency cannot be excluded. Otherwise:
Advise rest and sexual abstinence; provide analgesia
Treat with ofloxacin 400mg bd and metronidazole 400mg bd for 14d; alternative is ceftriaxone 500mg IM as a single dose, followed by oral doxycycline 100mg bd and oral metronidazole 400mg bd for 14d
If the patient has an IUCD consider removal, but only if symptoms are severe. If removed advise re alternative contraception and emergency contraception if sexual intercourse <7d ago
Arrange contact tracing via GUM clinic
If no improvement after 48h, admit; if slow recovery, consider referral for laparoscopy to exclude abscess formation
Chronic PID
Caused by inadequately treated acute PID. Presents with pelvic pain, dysmenorrhoea, dyspareunia (1 in 5) ± menorrhagia. Examination: lower abdominal/pelvic tenderness, cervical excitation ± adnexal mass. Screen for chlamydia and gonorrhoea. A −ve result does not exclude diagnosis. If chronic pelvic pain with no obvious cause, refer to gynaecology. Once diagnosis is confirmed treatment options include long-term antibiotics or surgery.
Urethritis
Inflammation of the male urethra. Multifactorial condition primarily sexually acquired. Mucopurulent cervicitis is the female equivalent. Characterized by discharge and/or dysuria although may be asymptomatic (found when a swab is taken following contact tracing). Treat the cause. Classified by the organisms grown:
Gonococcal urethritis
N. gonorrhoeae is identified on urethral swab. Treat as for gonorrhoea ( p. 740).
Non-gonococcal urethritis
Most common organisms identified are: chlamydia (30–50%); Ureaplasma (10%); Mycoplasma genitalium (10%); Trichomonas vaginalis (1–17%). In 20–30% no organism is isolated. First-line treatment is with azithromycin 1g stat. If persistent/recurrent symptoms, treat with azithromycin 500mg stat, then 250mg od for 4d and metronidazole 400mg bd for 5d.
Further information
NICE Preventing sexually transmitted infections and reducing under-18 conceptions (2007) 
www.nice.org.uk
BASHH www.bashh.org
UK National Guidelines on safer sex advice (2012)
Management of pelvic inflammatory disease (2011)
Management of non-gonococcal urethritis (2008)
Chlamydia, gonorrhoea, and trichomonas
A single individual may have >1 STI simultaneously.
Chlamydia
Major cause of pelvic pain and infertility in women.
Screening
Chlamydia is a preventable cause of infertility, ectopic pregnancy, and pelvic inflammatory disease. Screening using urine testing or self-taken swabs ↓ prevalence and incidence of pelvic inflammatory diseaseS. Screening programmes aimed at young people <25y are in operation throughout the UK. Self-test kits are available through GP surgeries, sexual health/contraception clinics, and community venues (e.g. schools).
Presentation in men
Usually asymptomatic. May have urethritis. Send urethral swab or first-catch urine sample for nucleic acid amplification testing (NAAT) to confirm diagnosis.
Presentation in women
History >70% are asymptomatic. Symptoms: vaginal discharge (30%); post-coital or intermenstrual bleeding; pelvic inflammatory disease (10–30%—
p. 738); dysuria
Examination Mucopurulent cervicitis; hyperaemia and oedema of the cervix ± contact bleeding; tender adnexae; cervical excitation
Investigation Send endocervical (if symptoms) or self-taken vulvovaginal swab (if asymptomatic) for NAAT to confirm diagnosis
If ♂ or ♀ and exposed to potential infection <2wk previously, repeat test >2wk after exposure.
Management
Doxycycline 100mg bd for 1wk or erythromycin 500mg qds for 14d; azithromycin 1g stat po is an alternative which ensures compliance
During pregnancy/breastfeeding use erythromycin 500mg qds for 2wk
Consider supplying home-testing kits to patients at high risk of STIs
Presentation in neonates Conjunctivitis, pneumonia, otitis media, pharyngitis—1 in 3 affected mothers have affected babies. Seek specialist advice if suspected.
Gonorrhoea
Transmission: ♂—1 in 5 exposures; ♀—1 in 2 exposures.
Presentation in men
Depends on site of infection:
Urethral infection (<10% are asymptomatic). Urethral discharge (80%); dysuria (50%) 2–5d after exposure; prostatitis; urethral stricture
Rectal infection (usually asymptomatic). Anal discharge (12%); anal/perianal pain or discomfort (7%)
Pharyngeal infection (>90% asymptomatic)
If asymptomatic—send first-catch urine sample for NAAT; if symptomatic send urethral ± rectal ± pharyngeal swabs (as appropriate) for NAAT and M,C&S to confirm diagnosis.
Presentation in women
Infection may be asymptomatic (50%) or cause vaginal discharge (50%), lower abdominal pain; dysuria but not frequency (25%); abnormal vaginal bleeding; pelvic inflammatory disease; abscess of Bartholin’s gland; miscarriage; or preterm labour. Rectal and pharyngeal infections are usually asymptomatic.
If asymptomatic—send self-taken vulvovaginal swab for NAAT
If symptomatic—send endocervical swab ± rectal ± pharyngeal swab (as appropriate) for NAAT and M,C&S to confirm diagnosis
ManagementG
Ceftriaxone 500mg IM as a single dose + azithromycin 1g stat po
Refer to GUM for contact tracing
If persisting symptoms/signs after treatment, test for cure with swabs sent for M,C&S >72h after completion of therapy
If asymptomatic following treatment, test for cure 2wk after treatment completion with NAAT, followed by culture if NAAT-positive
If persistent infection, seek specialist advice
Trichomonas vaginalis (TV)
Presentation in neonates Ophthalmia neonatorum. Purulent discharge from the eyes of an infant <21d old. Send swabs for NAAT and M,C&S. If confirmed, seek immediate specialist advice.
Presentation in men
15–50% are asymptomatic. Symptoms: dysuria, urethral discharge. Take urethral swab and first-void urine for culture.
Presentation in women
10–50% are asymptomatic. Symptoms:
Vaginal discharge (25%)—mucopurulent yellow-white, smelly discharge; may be frothy
Vulvovaginal soreness/itching
Abdominal pain
Dysuria
Examination shows typical discharge, vaginal inflammation, and strawberry cervix. Check pH of secretions with narrow-range pH paper. If pH >4.5, TV is a possibility; send HVS from the posterior fornix at the time of speculum examination for M,C&S. Sensitivity of HVS is low for TV, so if HVS is −ve, consider GUM referral for wet microscopy ± culture and contact tracing. TV may rarely be detected on cervical smear.
ManagementG
Advise patients to avoid sexual intercounse until they and their partner(s) have completed treatment and follow-up
Metronidazole po (400mg bd for 5–7d or 2g stat)—tinidazole 2g stat is an alternative
Consider referral to GUM clinic for contact tracing
Resistant TV—try higher dose metronidazole: 400mg tds po + 1g od pr for 7d, or metronidazole 2g od for 3–5d. High-dose tinidazole 2g bd for 2wk ± topical vaginal tinidazole is an alternative
Further information
BASHH www.bashh.org
Management of Chlamydia trachomatis genital tract infection (2006)
UK national guideline on gonorrhoea testing (2012)
Management of gonorrhoea in adults (2011)
Management of Trichomonas vaginalis infection (2007)
National Chlamydia Screening Programme (NCSP) www.chlamydiascreening.nhs.uk
Hepatitis B and C
Hepatitis B (HBV)
Common. Endemic in much of Asia and the Far East. The virus has 3 major structural antigens: surface antigen (HBsAg), core antigen (HBcAg), and e antigen (HBeAg). Spread is via infected blood, sexual intercourse, from mother to newborn baby, or via human bites. Incubation period is 6–23wk (average 17wk).
High-risk groups
Patients who are/have:
Injecting drug users
Many sexual partners
Adopted children from high/intermediate-risk countries
Foster parents
Close family contacts of a case/carrier
Receiving regular blood/blood products and their carers
Chronic renal/liver disease
Prison inmates
At risk due to occupation e.g. healthcare workers
Staff/residents of residential accommodation for individuals with mental handicap
Travelling to high/intermediate-risk areas
Babies born to mothers who are chronic carriers of hepatitis B or have had acute hepatitis B in pregnancy
Presentation
May be asymptomatic or present with fever, malaise, fatigue, arthralgia, urticaria, pale stools, dark urine, and/or jaundice.
Investigation
LFTs (hepatic jaundice—↑ bilirubin, ↑ ALT/AST, ↑ alkaline phosphatase), hepatitis serology (see Figure 22.1).
HBsAg Present from 1–6mo post-exposure. If present >6mo after the acute episode defines carrier status
HBeAg Present from 6wk–3mo after acute illness. Indicates high infectivity
Anti-HBs Antibodies appear >10mo after infection; imply immunity
Hepatitis B serology
Management
In all cases advise patients to avoid alcohol. Refer for specialist advice. Treatment is supportive for acute illness. Chronic hepatitis is treated with interferon and lamivudine with varying success.
Prognosis
~85% recover fully; 10% develop carrier status; 5–10% develop chronic hepatitis—may lead to cirrhosis and/or liver carcinoma. Fulminant hepatitis and death are rare (<1%).
Prevention
Advise patients re ‘safe sex’. Immunize high-risk groups. Give passive immunization with human immunoglobulin to non-immune, high-risk contacts of infected patients.
Hepatitis immunization of injecting drug misusers
If not already infected/immune or close contact of someone already infected, use a rapid regime—immunization at 0, 7, and 21d and booster after 12mo.
Hepatitis C (HCV)
Common. Spread is usually via contact with infected blood (causing post-transfusion hepatitis) but can pass from mother to baby. Not easily spread through sexual contact. In 10% no source of infection is found. Incubation is 2–25wk (mean 8wk).
Risk factors
Blood transfusion; healthcare work; IV drug abuse; haemodialysis; infant of infected mother (5% risk); multiple sexual partners.
Presentation and management
As for HBV. Anti-HCV antibody is detectable 3–4mo post-infection. Refer for expert advice. Avoid alcohol. 50% develop chronic infection; 5% cirrhosis; and 15% of those hepatoma.
Further information
BASHH Management of viral hepatidides (2008) www.bashh.org
HPA Hepatitis A, B, and C www.hpa.org.uk
Department of Health The Green Book www.dh.gov.uk/greenbook
Information for patients
British Liver Trust 
0800 652 7330 www.britishlivertrust.org.uk
HIV infection: prevention and testing
Human immunodeficiency virus (HIV) is a retrovirus infecting T-helper cells bearing the CD4 receptor. Worldwide, the HIV epidemic continues, but prophylaxis and treatment are improving prognosis in developed countries where treatment is available. It is estimated that ~1 in 3 of those infected in the UK are unaware of their diagnosis.
Transmission
~1 in 1,000 exposures. Mode of transmission may be:
Sexual (60–70%)—heterosexual intercourse in 54%
IV drug abuse (2%)
Mother → child (1.5%)
Infected blood products
Accidental (e.g. needle stick injuries)
HIV antibodies can take 3mo to develop after HIV infection, so HIV tests may miss those infected in the early stages of their disease. Consider repeating if infection may have occurred <3mo prior to testing. If in doubt, arrange a second test 3mo after the first.
Prevention of HIV infection
Promotion of safe sex and ↓ IV drug abuse and needle sharing
Refer to GUM for post-exposure prophylaxis if sexual contact <72h previously with an HIV-infected individual (or high-risk individual)
Screening blood donors
Prevention of transmission from mother to child—risk can be ↓ to <1% with antiretroviral treatment (given to the mother antenatally, during delivery, and to the neonate for first 6wk), elective Caesarean section, and advising against breastfeeding
Trials of HIV vaccines are in advanced stages
Accidental exposure
(e.g. needle stick injury). Significant exposure if:
The source is HIV +ve
The material is blood/another infectious body fluid (semen, amniotic fluid, genital secretions, CSF), and
Exposure is caused by inoculation (risk of transmission 1 in 300) or by a splash onto a mucus membrane (risk of transmission 1 in 3,000)
Immediate action Irrigate the site of exposure with running water; establish history of HIV infection and (if possible) obtain a blood sample from the source and victim. Refer to A&E immediately for HIV post-exposure prophylaxis. Treatment is with 3 antiretroviral drugs for 4wk.
Who should be offered a test?
Universal HIV testing (offered to everyone)
Everyone attending GUM/sexual health clinics
Women registering for antenatal care
Women attending for termination of pregnancy
Everyone diagnosed with TB, hepatitis B/C, or lymphoma
If prevalence of HIV in the local population is >2/1,000, all those registering in general practice, and all general medical admissions
High-risk patients
If HIV is part of the differential diagnosis of the presenting condition
If diagnosed with another STI
Sexual partners of those known to be HIV +ve
Men who have sex with other men and any female sexual partners
History of injecting drug misuse
People originating from or current/former sexual partner from a country with high HIV prevalence (>1%, e.g. sub-Saharan Africa, India)
Offer repeat testing if:
HIV −ve, but possible exposure has occurred within the 3mo window period or since testing
Men who have sex with men or injecting drug user—offer >1x/y
Women who refuse an HIV test at antenatal booking—offer testing again, then a third time at 36wk
Index conditions
In which HIV is part of the differential diagnosis:
Respiratory TB, pneumocystis, aspergillosis, bacterial pneumonia, lung cancer
Neurology cerebral toxoplasmosis; cerebral lymphoma; cryptococcal meningitis; progressive multifocal or other leucoencephalopathy; aseptic meningitis/encephalitis; cerebral abscess; SOL; Guillain–Barré syndrome; transverse myelitis; peripheral neuropathy; dementia
Dermatology Kaposi’s sarcoma; severe/recalcitrant seborrhoeic dermatitis or psoriasis; multidermatomal/recurrent herpes zoster
GI Persistent cryptosporidiosis; chronic diarrhoea; hepatitis B/C; Salmonella, Shigella, or Campylobacter infection; oral candidiasis/hairy leukoplakia
Sexual health STI; cervical cancer; CIN 2/3; VIN; seminoma
Haematology Unexplained blood dyscrasia, e.g. thrombocytopenia, neutropenia, lymphopenia; unexplained lymphadenopathy; lymphoma (Hodgkin’s or non-Hodgkin’s); anal cancer (or intraepithelial dysplasia)
Ophthalmology CMV retinitis/other infective retinal disease; unexplained retinopathy
Other PUO; weight ↓; chronic parotitis/parotid cysts; head/neck cancer; mononucleosis-like syndrome (primary HIV)
Giving the result
If the result is negative
Consider whether the patient needs a follow-up test in 3mo. Provide health promotion information about minimizing risk of HIV infection in future.
If the result is positive
Give the result early in the consultation.
Explain the result and its implications for the patient and their partner
Emphasize the positive aspects of knowing the diagnosis
Try to arrange specialist referral before the patient attends so that the patient can be given a time and date for specialist follow-up
Give the patient time to talk through feelings and fears
Talk about support available, e.g. friends/family; support organizations
Provide literature about HIV and patient support organizations
Arrange follow-up to maintain the link with primary care
Further information
BASHH www.bashh.org
National guidelines on HIV testing (2008)
Post-exposure prophylaxis for HIV following sexual exposure (2011)
RCOG Management of HIV in pregnancy (2010) www.rcog.org.uk
Information and support for patients with HIV and carers
HIV infection: clinical disease
Primary HIV
Half have no symptoms. Possible symptoms:
Mononucleosis-like picture of fever, fatigue, myalgia/arthralgia ± lymphadenopathy. Consider as a differential diagnosis of glandular fever
Blotchy rash affecting the trunk, and orogenital/perianal ulceration
Rarely acute neurological symptoms (aseptic meningitis, transverse myelitis, encephalitis) or diarrhoea
FBC may show atypical lymphocytes
Rarely, CD4 count drops acutely and conditions associated with immunosuppression, e.g. oral candidiasis or shingles, may occur
If you think a patient has primary HIV infection, seek urgent advice from a specialist. HIV tests can be negative <3mo after infection.
Progression
Duration/severity of HIV infection is reflected by the CD4 count which ↓ as infection progresses. If CD4 count is <200 cells/mm3, patients have acquired immune deficiency syndrome (AIDS) and are at risk from opportunistic infection (e.g. pneumococcal, TB, CMV, Pneumocystis, toxoplasmosis, cryptosporidial diarrhoea) and AIDS-associated malignancies (e.g. Kaposi’s sarcoma, lymphoma)—see Table 22.1.
| CD4 count cells/mm3 | Risk of opportunistic infection | Risk of HIV-associated tumours |
|---|---|---|
>500 | Minimal/none | Very small ↑ risk |
200–500 | Little risk unless falling rapidly, except TB | Small ↑ risk |
<200 | ↑ risk of serious opportunistic infection, e.g. • Pneumocystis pneumonia • Toxoplasmosis • Oesophageal candidiasis | Increasing risk |
<100 | Additional risk of: • Mycobacterium avium intracellulare • Cytomegalovirus | High risk and increasingly aggressive disease |
| CD4 count cells/mm3 | Risk of opportunistic infection | Risk of HIV-associated tumours |
|---|---|---|
>500 | Minimal/none | Very small ↑ risk |
200–500 | Little risk unless falling rapidly, except TB | Small ↑ risk |
<200 | ↑ risk of serious opportunistic infection, e.g. • Pneumocystis pneumonia • Toxoplasmosis • Oesophageal candidiasis | Increasing risk |
<100 | Additional risk of: • Mycobacterium avium intracellulare • Cytomegalovirus | High risk and increasingly aggressive disease |
Kaposi’s sarcoma
Purple papules or plaques on skin or mucosa of any organ. Metastasizes to lymph nodes. If suspected refer for expert help:
Endemic—occurs in central Africa. Peripheral lesions, good response to chemotherapy
Associated with AIDS or transplant—commonly skin or pulmonary lesions; lymphatic obstruction predisposes to cellulitis
M.K. Kaposi (1837–1902)—Hungarian dermatologist.
Management
Specialist management is always needed.
Antiretroviral drugs
5 main groups:
Entry inhibitors
Integrase inhibitors
Nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs)
Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
Protease inhibitors
Choice of drugs is a specialist decision. A combination is usual (highly active antiretrovirus therapy or HAART regime). Adherence to therapy is essential to avoid resistance. The aim is to ↓ viral load to an undetectable level in <6mo. Response to treatment is measured with viral load, CD4 count, and CD4 percentage. Treatment failure requires switching or increasing therapy. Do not stop or change the dose of antiretroviral drugs without taking specialist advice.
Drug interactions
are common. Record antiretrovirals on GP system medication charts (even though prescriptions are usually issued by specialist centres). Check drug interactions at: www.hiv-druginteractions.org
Prophylaxis against opportunistic infections
Prophylactic antibiotics are used to prevent Pneumocystis, toxoplasmosis, and Mycobacterium avium for patients with low CD4 counts.
Psychological support
Due to the stigma attached to HIV infection, patients and carers often lack the support offered by the community for most other serious illness.
Immunizations
Inactivated vaccines—can be used safely; offer annual influenza vaccination, pneumococcal vaccination, hepatitis B testing and vaccination if seronegative, and hepatitis A vaccine if at risk
Live vaccines (e.g oral typhoid, BCG) are generally contraindicated but give varicella (for all) and MMR (if ♀ of child-bearing age) if seronegative and CD4 count >200mm3
CVD prevention
HIV is associated with ↑ risk of CVD. Check risk before, then 3–6mo after starting antiretrovirals and annually thereafter (every 5y from 40y if not taking antiretrovirals). Provide lifestyle advice ( p. 242), and treat hyperlipidaemia if 10y CVD risk >20%.
Sexual health
Advise to use condoms with water-based lubricant for all vaginal/anal sex and condoms/dams for oral sex—even if both partners are HIV +ve (as prevents transmission of drug-resistant strains).
Contraception
Efficacy of hormonal contraception is ↓ by antiretrovirals. Consider Depo-Provera® or IUS/IUCD. Advise condoms in addition to contraception. If emergency contraception is needed, first-line is an IUD; if using levonorgestrel, provide a double (3mg) dose.
Cervical screening
Women with HIV have ↑ risk of HPV and cervical cancer. Annual cervical screening is recommended.
Pregnancy
p. 811
Palliative care
p. 1028
Death
If HIV has contributed to death, this must be recorded on the death certificate.
Further information
Medical Foundation for AIDS and Sexual Health HIV in primary care (2011) www.medfash.org.uk
Information and support for patients with HIV and carers
Other sexually transmitted infections
Genital herpes
HSV is transmitted by direct contact with lesions. Lesions may appear anywhere on the skin or mucosa but are most frequent around the mouth, on the lips, conjunctiva, cornea, and genitalia.
Presentation of primary infection
May be asymptomatic. If symptomatic, history and examination are diagnostic in 90% cases. Presents with multiple painful genital ulcers on a red background ± inguinal lymph nodes <1wk after sexual contact. Lesions crust over then heal. Untreated lasts 3–4wk. Complications: urinary retention, aseptic meningitis.
Management
Refer to GUM if diagnosis is uncertain and for contact tracing
Treat with aciclovir if presents within the first 5d of symptoms starting and while new lesions are still forming (↓ duration, symptoms, and complications)
Analgesia, ice packs, and salt baths may help. 5% lidocaine ointment gives symptom relief but use with caution as may cause sensitization
Advice—barrier methods of contraception (risk of transmission in monogamous relationships is 10%/y)
If pregnant obtain specialist advice
Recurrent infection
Reactivation of latent virus. Less severe than primary infection. Neonatal transmission rates are low (<3%)—elective Caesarean section for those with active recurrences at term is controversial. Consider suppressive therapy if 6 attacks/y, e.g. aciclovir 400mg bd. If breakthrough occurs, ↑ dose of antiviral, e.g. aciclovir 400mg tds.
Neonatal infection Presents at age 5–21d with vesicular lesions around the presenting part or rarely systemic infection. Usually babies of women with no history of genital HSV. Refer as a paediatric emergency.
Genital warts
Caused by human papillomavirus (HPV). Usually sexually transmitted, and >25% have concomitant STIs. Disease may be clinical (found on examination) or subclinical (changes associated with infection detected on smear). In women CIN ( p. 726) is related to infection with HPV types 16 and 18, but 90% of genital warts are caused by HPV types 6 or 11.
Presentation in women
Often asymptomatic but may be associated with itching or vaginal discharge. Warts are usually seen on the vulva or introitus. Warts enlarge during pregnancy.
Presentation in men
Warts are usually found on the penis or perianally.
Management of clinical warts
Treatment does not eradicate the virus but removes lesions. Barrier contraception is needed for at least 3mo after the warts are gone. Treatment options in primary care:
Podophyllotoxin Suitable for home treatment of unkeratinized genital warts and licensed for a 4wk course. Avoid in pregnancy. Apply 2x/d for 3d, followed by a 4d rest. This cycle is repeated 4–5x. Side effects: soreness/ulceration of the genital skin—advise to discontinue treatment
Imiquimod Can be used at home for keratinized or non-keratinized warts. Avoid in pregnancy. Apply 3x/wk. On each occasion wash off 6–10h later. Continue for up to 16wk. Avoid unprotected intercourse after application. Can weaken latex condoms
Alternatives
(usually in specialist settings)–trichloroacetic acid, excision, cryotherapy, electrosurgery.
Human papillomavirus (HPV) vaccination HPV vaccines are aimed at preventing infection with strains causing cervical cancer. Currently vaccines target strains 6, 11, 16, and 18, which account for ~70% of HPV-related cancer cases and 90% of genital warts. Vaccination in the UK is targeted at girls aged 12–14y. Cervical screening in adulthood is still necessary as the vaccine does not protect against all strains causing cervical cancer.
Pubic lice
Pubic (or crab) lice are similar to head lice and may be sexually transmitted. All hairy areas (including eyelashes, eyebrows, pubic and axillary hair) can be affected. Treatment options are:
Malathion 0.5%—apply to dry hair; wash out after 12h
Permethrin 1% cream rinse—apply to damp hair; wash out after 10min
Phenothrin 0.2%—apply to dry hair; wash out after 2h
Carbaryl 0.5–1% (unlicensed)—apply to dry hair; wash out after 12h
Repeat treatment after 3–7d
Scabies
p. 639
Syphilis
Caused by Treponema pallidum. Rare in the UK but incidence is increasing. Incubation: 9–90d. If suspected, send blood for VDRL, TPHA or treponemal antibody absorption depending on local policy. In all confirmed cases refer for specialist care. Contact tracing is essential.
4 stages
Primary syphilis Chancre at the site of contact
Secondary syphilis 4–8wk after chancre—systemic symptoms: fever, malaise, generalized lymphadenopathy, anal papules (conylomata lata), rash (trunk, palms, soles), buccal snail track ulcers, alopecia
Tertiary syphilis 2–20y after initial infection—gummas (granulomas) in connective tissue e.g. testicular gumma
Quarternary syphilis Cardiovascular or neurological complications.
Further information
BASHH www.bashh.org
Management of genital herpes (2007)
Management of Phthirus pubis (2007)
Management of scabies (2007)
Management of syphilis (2008)
Management of genital warts (2007)
Health Protection Agency (HPA) www.hpa.org.uk
Information for patients
Family Planning Association (FPA) 
0845 122 8690 (0845 122 8687 in Northern Ireland) 
www.fpa.org.uk
Herpes Association 0845 123 2305 www.herpes.org.uk
Summary of contraceptive methods
80% women receive contraceptive advice and treatment through their GP. A sexually active woman has an 85% chance of becoming pregnant in <1y without contraception, and ~1 in 3 pregnancies are unplanned.
Contraceptive services
Provided as an Additional Service; opting out results in a 2.4% ↓ in global sum. IUDs may be fitted as a National Enhanced Service; payment is available for fitting and annual review.
Choice of method
See Table 22.2. Consider: a woman’s personal preference; age; lifestyle/cultural aspects; medical history; and risk of STI. 
Prescriptions for contraceptives are free of charge for all women in the UK).
| Method of contraception | % unintended pregnancies* | Advantages | Disadvantages |
|---|---|---|---|
Sterilization (♂) | 0.05 (1:2,000) | No contraindications Single procedure | Difficult to reverse Post-operative complications |
Sterilization (♀) | 0.5 (1:200) | No contraindications Single procedure | Requires GA and rarely results in laparotomy Post-operative complications Difficult to reverse ↑ risk ectopic pregnancy |
Nexplanon® (single capsule upper arm) | 0.05 | Lasts 3y Immediately reversible | Needs training to insert and remove Wound infection and/or scarring Can cause irregular bleeding Progestogenic side effects |
Progestogen-containing intrauterine system (IUS) (e.g. Mirena®) | 0.1 | Lasts 5y↓ bleeding, ectopic pregnancy risk, dysmenorrhoea Endometrial protection | May cause erratic bleeding Progestogenic side effects Problems with insertion or retrieval |
Combined contraceptive pill/patch/ring | 0.3 (9) | Regular cycle and lighter periods↓ dysmenorhoea Cycle control | Compliance Side effects ↑ risk breast cancer, thromboembolism |
Progestogen-only pill (POP) | 0.3 (8) | Few side effects and contraindications | Compliance Irregular bleeding Progestogenic side effects |
Intrauterine contraceptive device (IUCD) | 0.6 (0.8) | Lasts ≥5y No systemic effects | Heavy periods Problems with insertion or retrieval No protection from pelvic inflammatory disease or ectopic pregnancy |
Injectable progestogen (e.g. Depo-Provera®) | 0.3 (3) | Avoids pill-taking ↓ bleeding and can help PMS ↓ risk of ectopic pregnancy, endometrial cancer | Menstrual irregularity Weight gain Unpredictable return of fertility ↑ risk of osteoporosis |
Barrier methods (condoms, diaphragm) | 2 (32) | Barrier to transmission of STIs | User-dependent Allergy |
Natural methods | 1 (27) | No contraindications or side effects | Teaching required High failure rate |
| Method of contraception | % unintended pregnancies* | Advantages | Disadvantages |
|---|---|---|---|
Sterilization (♂) | 0.05 (1:2,000) | No contraindications Single procedure | Difficult to reverse Post-operative complications |
Sterilization (♀) | 0.5 (1:200) | No contraindications Single procedure | Requires GA and rarely results in laparotomy Post-operative complications Difficult to reverse ↑ risk ectopic pregnancy |
Nexplanon® (single capsule upper arm) | 0.05 | Lasts 3y Immediately reversible | Needs training to insert and remove Wound infection and/or scarring Can cause irregular bleeding Progestogenic side effects |
Progestogen-containing intrauterine system (IUS) (e.g. Mirena®) | 0.1 | Lasts 5y↓ bleeding, ectopic pregnancy risk, dysmenorrhoea Endometrial protection | May cause erratic bleeding Progestogenic side effects Problems with insertion or retrieval |
Combined contraceptive pill/patch/ring | 0.3 (9) | Regular cycle and lighter periods↓ dysmenorhoea Cycle control | Compliance Side effects ↑ risk breast cancer, thromboembolism |
Progestogen-only pill (POP) | 0.3 (8) | Few side effects and contraindications | Compliance Irregular bleeding Progestogenic side effects |
Intrauterine contraceptive device (IUCD) | 0.6 (0.8) | Lasts ≥5y No systemic effects | Heavy periods Problems with insertion or retrieval No protection from pelvic inflammatory disease or ectopic pregnancy |
Injectable progestogen (e.g. Depo-Provera®) | 0.3 (3) | Avoids pill-taking ↓ bleeding and can help PMS ↓ risk of ectopic pregnancy, endometrial cancer | Menstrual irregularity Weight gain Unpredictable return of fertility ↑ risk of osteoporosis |
Barrier methods (condoms, diaphragm) | 2 (32) | Barrier to transmission of STIs | User-dependent Allergy |
Natural methods | 1 (27) | No contraindications or side effects | Teaching required High failure rate |
Failure rates stated are with perfect use. Rates in brackets are with typical use.
Before providing contraception
Provide information to enable the woman to choose a method and use it effectively. Exclude pregnancy. A woman is probably not pregnant if she:
Has been using a reliable method of contraception correctly
Has not had unprotected sexual intercourse (UPSI) since her last period, or
Is <7d after the start of a normal period; <4wk postpartum, <7d post-termination or miscarriage; or is fully breastfeeding, amenorrhoeic, and <6mo postpartum
If in doubt, do a pregnancy test ≥3wk after the last UPSI
Can be inserted ≤120h (5d) after UPSI. >99% effective. Progestogen-containing IUCDs are not suitable for this purpose.
1.5mg po stat. Licensed ≤72h (3d) after UPSI but effective for 96h (4d). Can be used more than once if >1 episode of UPSI in a single cycle. Available OTC and on prescription. There is no evidence that treatment with levonorgestrel harms the fetus if pregnant.
(ulipristal acetate 30mg stat) Can be used ≤120h (5d) after UPSI. Only use 1x/cycle.
Vomiting <3h after taking oral emergency contraception—give a replacement dose or offer a copper IUCD
Enzyme-inducing drugs (e.g. anti-epileptics, St John’s wort) Efficacy of oral emergency contraception may be ↓. Consider a copper IUCD or ↑ dose of levonorgestrel to 3mg (unlicensed)
Provide advice about ongoing contraception and prevention of STI. Advise to return if abdominal pain, next period is overdue or abnormally light/heavy, or if needs further contraceptive advice.
Sexually transmitted infections
Discuss prevention of STIs with all women when providing contraception. Advise high-risk groups to use barrier methods in addition to hormonal methods of contraception.
Further information
FSRH Emergency contraception (2012) www.fsrh.org
Combined hormonal contraception
Contraceptives containing an oestrogen and progestogen are available as:
Combined oral contraceptive pills (COC)
Contraceptive patches (Evra®), and
Vaginal contraceptive rings (NuvaRing®)
COC pill
Most COC come in packets of 21 pills. The woman takes the entire packet starting on the first day of her cycle and then has a 7d ‘pill-free’ break before starting the next packet. Pills vary by:
Oestrogen type
Most COCs contain ethinylestradiol; alternatives are estradiol valerate (Qlaira®) or mestranol (Norinyl-1®).
Oestrogen content
Low-strength preparations (20 microgram ethinylestradiol). Use if risk factors for circulatory disease or if oestrogenic side effects
Standard-strength preparations (30–35 microgram ethinylestradiol or 50 microgram mestranol). Use for most women
Phased preparations Dose of oestrogen/progestogen varies through the cycle. Try for women who have bleeding problems with monophasic products
Everyday (ED) preparations Taken continuously. Can help women who find it difficult to remember to start a new packet
Progestogen type
COC pills containing:
Levonorgestrel and norethisterone Suitable for most women. Choose for first-time COC pill users
Desogestrel, norgestimate, dienogest, drosperidone, and gestodene Consider if side effects, e.g. acne, headache, depression, weight ↑, breast symptoms, breakthrough bleeding. Desogestrel/gestodene may be associated with ↑ clotting risk
Cyproterone acetate (co-cyprindiol)—Licensed for treatment of acne, not for contraception, but does provide contraception. Use for 3–4mo after resolution of symptoms. Associated with 4x ↑ risk of venous thromboembolism compared to COC containing levonorgestrel
Contraceptive patch (Evra®)
20 microgram ethinylestradiol and norelgestromin in a transdermal patch. Alternative if compliance with daily pill-taking is problematic. Apply patch on day 1 of the cycle; change patch on days 8 and 15; remove third patch on day 22 and then apply new patch after a 7d ‘patch-free’ interval to start the subsequent cycle.
Contraceptive vaginal ring
15 micrograms/24h ethinylestradiol and etonogestrel. Alternative low-dose preparation. Insert ring into vagina on day 1 of cycle and leave in for 3wk; remove ring on day 22; subsequent courses repeated after 7d ring-free interval.
Reasons not to prescribe combined contraception
See Box 22.1.
Venous disease
Avoid if sclerosing treatment for varicose veins or if history of current/past venous thromboembolism (VTE)
Risk factors for VTE (use with caution if 1; avoid if >1):
Age ≥35y—avoid if ≥50y
Smoker or <1y after smoking cessation—avoid if ≥35y and if smoking ≥15 cigarettes/d
BMI ≥30kg/m2—avoid if BMI ≥35kg/m2
Family history of VTE in first-degree relative <45y—avoid if known prothrombotic coagulation abnormality, e.g. Factor V Leiden, antiphospholipid antibodies, lupus anticoagulant
Immobility—avoid if bed-bound or leg in plaster cast
History of superficial thrombophlebitis
Arterial disease
Avoid if valvular/congenital heart disease with history of complications (e.g. pulmonary hypertension, AF, SBE) or if history of CVD including stroke/TIA, IHD, peripheral vascular disease, hypertensive retinopathy
Risk factors for CVD (use with caution if 1; avoid if >1):
Age ≥35y—avoid if ≥50y
Smoker—avoid if smoking ≥40 cigarettes/d
BMI ≥30kg/m2—avoid if BMI ≥35kg/m2
Family history of arterial disease in first-degree relative <45y—avoid if atherogenic lipid profile
DM—avoid if vascular, renal, neurological, or eye complications
Hypertension with BP >140/90mmHg—avoid if >160/95mmHg
Migraine without aura—avoid if migraine with aura within 5y, attacks treated with ergot derivatives, or severe migraine lasting >72h
Liver disease Avoid if active/flare of viral hepatitis, liver tumour, or severe cirrhosis or if active gall bladder disease; seek specialist advice if history of contraceptive-associated cholestasis.
Cancer Avoid if current breast cancer; take specialist advice if no suitable alternative and past history of breast cancer, but no evidence of disease for >5y or known gene mutation for breast cancer (e.g. BRCA1).
Pregnancy-related issues Avoid if history in pregnancy of pruritus, cholestatic jaundice, chorea, or pemphigoid gestationis; or if postpartum and breastfeeding (p. 837).
Others Avoid if acute porphyria or haemolytic uraemic syndrome.
Investigate any undiagnosed vaginal bleeding before starting combined hormonal contraception.
Based on UK Medical Eligibility Criteria (UKMEC) 3 (theoretical or proven risks usually outweigh advantages) and 4 (unacceptable health risk) and BNF guidance (7.3.1).
Further information
FRSH www.fsrh.org
Combined hormonal contraception (2012)
UK Medical Eligibility Criteria for contraceptive use (2009)
Before starting combined contraception
Take a history—medical, sexual health, medications, and lifestyle
Consider asking for specialist haematology advice about thrombophilia screening if FH of DVT/PE in a first-degree relative aged <45y or multiple family members, and/or check cholesterol/triglycerides if FH of arterial disease in a first-degree relative <45y, or multiple family members
Check BP
Education—discuss side effects/risks of combined contraception (see Table 22.3), STIs, cervical smears, smoking, control of weight. Give both verbal and written directions on use
| Risks | Benefits |
|---|---|
Venous thromboembolism (risk ↑ x2 but absolute risk is still very low) Ischaemic stroke—small ↑ risk Breast and cervical—any ↑ in risk is small and disappears <10y after combined contraception is stopped Mood changes (but no ↑ in depression) | Improvement in acne ↓ in menstrual pain and bleeding ↓ in menopausal symptoms ↓ risk of ovarian, bowel, and endometrial cancer that persists after combined contraception has stopped No evidence of weight ↑ |
| Risks | Benefits |
|---|---|
Venous thromboembolism (risk ↑ x2 but absolute risk is still very low) Ischaemic stroke—small ↑ risk Breast and cervical—any ↑ in risk is small and disappears <10y after combined contraception is stopped Mood changes (but no ↑ in depression) | Improvement in acne ↓ in menstrual pain and bleeding ↓ in menopausal symptoms ↓ risk of ovarian, bowel, and endometrial cancer that persists after combined contraception has stopped No evidence of weight ↑ |
Starting combined contraception
Contraceptive effect starts immediately if started:
Day 1–5 of the cycle (day 1 only for estradiol valerate/dienogest pill)
At the end of the third week postpartum
<5d after miscarriage/TOP at <20wk gestation (day 1 only for estradiol valerate/dienogest pill)
Changing COC pill variety or to patch or ring—start the new pill/patch/ring omitting the 7d break (or ‘inactive’ tablets if taking ED preparation)
Changing from contraceptive implant, injectable progestogen, or desogestrel-only POP—start at any time until repeat injection due, implant due for removal, or last desogestrel pill taken
In all other cases and at all other times use additional contraception for the first 7d (9d if using estradiol valerate/dienogest pill).
Extended dosingG
Continuous dosing is an alternative approach to combined hormonal contraceptive administration that does not ↓ contraceptive efficacy. Several (unlicensed) regimes are in common use:
Short pill-free interval Replacement of 7d break with 4d break
Tricycling 3 cycles taken continuously back-to-back followed by a 7d break, i.e. 3x 21 monophasic COC, 3x rings, or 9x patches
Extended use Continuous use of monophasic COC, ring, or patch until breakthrough bleeding for 3–4d, followed by a 4d or 7d break
Follow-up
3mo after starting or changing a combined contraceptive—earlier if complications. Once established, review every 6–12mo. At follow-up, assess risk factors and side effects; give health education, e.g. smoking cessation advice, benefits of long-acting reversible contraception, information about STIs; check BP.
Missed doses
COC pills (except Qlaira®)—see Figure 22.2; Qlaira® and contraceptive patches or rings—see BNF 7.3.1 and/or product literature.
Advice for patients regarding missed COC pills
Reasons to stop CHC immediately (pending investigation if needed):
Sudden severe chest pain (even if not radiating to left arm)
Sudden breathlessness (or cough with bloodstained sputum)
Unexplained swelling or severe pain in calf of one leg
Acute abdominal pain
Serious neurological effects including:
Unusual severe, prolonged headache especially if first time or getting progressively worse
Sudden dysphasia, partial or complete loss of vision, disturbance of hearing, or other perceptual disorders
Bad fainting attack or unexplained collapse
First unexplained epileptic seizure
Weakness, motor disturbances, or numbness affecting one side or one part of body
Hepatitis, jaundice, liver enlargement
BP >160/95mmHg
Prolonged immobility after surgery or leg injury
Detection of a risk factor/contraindication (
p. 753)
Short-term side effects
Usually resolve within 2–3 cycles.
Relative oestrogen excess
Breast tenderness (3.6%); nausea (1.5%); dizziness; cyclical weight ↑; bloating; vaginal discharge without infection. Use a more progestogen-dominant pill.
Relative progestogen excess
Mood swings (3.9%); PMT; dry vagina; sustained weight ↑; ↓ libido; lassitude; acne. Use a more oestrogen-dominant pill.
Headache
Affects 2.9% of women taking the combined contraceptive. Ask women to report ↑ in headache frequency or onset of focal symptoms when taking any combined contraceptive. If new focal symptoms, discontinue immediately and, if not typical of migraine aura and lasts >1h, admit. If headaches continue consider switching brand/alternative method of contraception.
Breakthrough bleeding
Most common in the first few months of combined contraceptive use—after 6 cycles affects 1.1% women (spotting affects 3.3% women). If no vomiting/diarrhoea and no missed pills, breakthrough bleeding does not indicate ↓ efficacy. If symptoms suggest other pathology (e.g. abdominal or pelvic pain, post-coital bleeding) or breakthrough bleeding persists >3mo:
Check compliance—any missed pills? Breakthrough bleeding may start 2–3d after a missed pill; any diarrhoea/vomiting
Check for gynaecological causes—exclude STI (especially chlamydia); examine cervix; check smear is up to date and take smear if overdue; exclude pregnancy; consider referral for ultrasound, hysteroscopy + endometrial sampling if >45y or other risk factors for endometrial cancer
↑ oestrogen content of COC pill if on low-dose preparation. If problem persists, change progestogen. If still persists ↑ progestogen and/or try phased preparation.
Long-term risks/benefits
Acne and CHC
In general acne improves when using CHC. If it fails to improve, consider switching to a brand containing a less androgenic progestogen (e.g. desogestrel, drosperidone) or one with a higher oestrogen content. Co-pyrindiol use is associated with higher risk of thromboembolism; if using for contraception as well as acne control, switch to an alternative CHC 3–4mo after symptoms have resolved.
Hepatic-enzyme-inducing drugs
Combined contraceptives may interact with hepatic-enzyme-inducing drugs leading to ↓ efficacy, e.g.:
Anti-infective agents—rifamycins (rifampicin, rifabutin), griseofulvin, antivirals (e.g. nelfinavir, nevirapine, ritonavir)
St John’s wort
Anticonvulsants—phenytoin, carbamazepine, oxcarbazepine, phenobarbital, primidone, topiramate, modafinil
Short course (<7d) of enzyme-inducing drug
Advise additional barrier contraception whilst taking the enzyme-inducing drug and for 4wk after stopping it. Omit pill/patch-free week or inactive tablets if using an ‘ED’ preparation.
Longer course of enzyme-inducing drug
For rifampicin or rifabutin, advise alternative method of contraception, e.g. intrauterine device. For other enzyme-inducing drugs, consider ↑ the dose to ≥50 micrograms ethinylestradiol (maximum 70 micrograms) and shorten pill/patch/ring-free interval to 4d; alternatively advise another unaffected method of contraception, e.g. intrauterine device.
There is no evidence that broad-spectrum antibiotics (e.g. amoxicillin) ↓ efficacy of combined contraceptives. Additional contraceptive precautions are no longer recommended.
Anticonvulsants that do not affect pill efficacy
Sodium valproate
Lamotrigine—but seizure frequency may ↑ when combined contraception and lamotrigine are used together and side effects of lamotrigine may be ↑ when combined contraception is stopped
Interaction with ulipristal acetate (UPA)
UPA blocks the action of progesterone and so ↓ effectiveness of combined contraceptives. Advise additional contraception for 14d after using UPA when taking combined contraceptives (16d if taking estradiol valerate/dienogest pills).
Diarrhoea and vomiting
Does not affect the contraceptive patch or ring. If a woman vomits <2h after taking a COC pill or has very severe diarrhoea, assume the COC pill has not been absorbed and treat as a missed pill ( p. 755).
Surgery
Combined contraceptives should be discontinued and alternative contraceptive arrangements made (e.g. depo-injection, barrier methods) 4wk before major elective surgery, all surgery to the legs or surgery which involves prolonged immobilization of a lower limb. Restart the combined contraceptive on the first day of the next period occurring ≥2wk after full mobilization.
Women taking combined contraceptives are at ↑ risk of DVT during travel involving long periods of immobility (>3h). Advise women:
To drink plenty of non-alcoholic fluids
To keep their legs moving whilst sitting, or walk up and down the aisle
Graduated compression hosiery is available for purchase OTC and does ↓ risk of DVT.
Further information
Family Planning Association (FPA) 0845 122 8690 (0845 122 8687 in Northern Ireland) www.fpa.org.uk
FSRH www.fsrh.org
Missed pill recommendations (2011)
Combined hormonal contraception (2012)
BNF Section 7.3.1 www.bnf.org
Progestogen-only contraceptives
Progestogen-only contraceptives thicken cervical mucus, ↓ endometrial receptivity, and inhibit ovulation. They ↓ risk of pelvic infection and can be used when oestrogen is contraindicated.
Current breast cancer—may be used with specialist advice if disease-free for >5y and no other suitable method of contraception
Trophoblastic disease—seek specialist advice if unsure
Liver disease—active viral hepatitis; severe decompensated cirrhosis, or liver tumour (benign or malignant)
If new symptoms/diagnosis of ischaemic heart disease, stroke/TIA, or migraine with aura when taking progestogen-only contraception
Avoid if SLE with antiphospholipid antibodies (or if unknown)
Investigate any undiagnosed vaginal bleeding before starting progestogen-only contraception.
Progestogen-releasing intrauterine system (Mirena®)
p. 762
Progestogen-only pill (POP or ‘mini-pill’)
(BNF 7.3.2.1.) Oral POPs are a suitable alternative for women for whom oestrogen-containing pills are contraindicated:
Older women
Heavy smokers
Women with past history/predisposition to venous thromboembolism
Patients with hypertension, valvular heart disease, DM, or migraine
Breast-feeding women <6mo postpartum Delay until ≥3wk postpartum to avoid risk of heavy bleeding
Choice of POP
5 brands are currently available in the UK:
Etynodiol 500 micrograms—Femulen®
Norethisterone 350 micrograms—Micronor® or Noriday®
Levonorgestrel 30 micrograms—Norgeston®
Desogestrel 75 micrograms—Cerazette® or Nacrez®—use if compliance problems (12h window before ‘missed pill’), history of ectopic pregnancy or ovarian cysts (desogestrol POPs have a stronger ovarian suppressive effect than other POPs), and/or weight >70kg
Side effects
Higher failure rate than COC pills
Menstrual irregularities—oligomenorrhoea, menorrhagia, amenorrhoea—examine to exclude a pathological cause ± do a pregnancy test. Menstrual irregularities tend to resolve with long-term use. If necessary, consider changing progestogen or ↑ to 2 pills/d (unlicensed)
↑ risk of ectopic pregnancy. If a patient presents with abdominal pain treat as an ectopic pregnancy ( p. 816) until proven otherwise
Others—nausea and vomiting; headache; dizziness; breast discomfort; depression; skin disorders; disturbance of appetite; weight changes; changes in libido
Long-term—small ↑ risk breast cancer; risk reverts to normal <10y after stopping the POP
Starting the POP
No previous hormonal contraception Start on day 1–5 of the cycle—no additional contraception needed; if starting any other time, use additional contraception/abstain from sexual intercourse for 2d (9d if started after emergency contraception using ulipristal acetate)
Changing from COC Start the day following completion of COC without a break (omitting ‘inactive’ pills if ED preparation)—no additional contraception needed
Changing from IUD If POP started ≥2d before removal of copper IUD or at the time of IUS removal—no additional contraception; if started at the time of copper IUD removal, advise abstinence/barrier contraception for 7d prior to removal and for 2d afterwards
After childbirth Start any time >3wk postpartum (↑ risk of bleeding earlier). Does not affect lactation. No additional contraception needed
Directions for taking the POP
Take 1 tablet every day with no pill-free breaks. Take each tablet at the same time each day—if delayed >3h (>12h for desogestrel POP) treat as missed pill.
Missed pills
If a pill is missed or delayed >3h (>12h for desogestrel POP), continue taking the POP at the usual time and use additional barrier methods for 2d.
Give emergency contraception if ≥1 POPs have been missed or taken >3h late (>12h late for desogestrel POP) and unprotected sexual intercourse has occurred in the 2d following this.
Diarrhoea/vomiting
Continue taking the POP but use an additional barrier method during the episode and for 2d afterwards.
Interactions with other drugs
Efficacy of POPs is not affected by antibacterials that do not induce liver enzymes. Efficacy is ↓ by enzyme-inducing drugs ( p. 756)—advise women to use an additional barrier method or alternative contraceptive method during treatment and for >4wk afterwards. Advise an alternative method of contraception if taking long-term hepatic-enzyme-inducing drugs.
Follow-up
Review 3mo after starting the POP or changing from CHC—earlier if complications. Once established, review every 6–12mo—assess risk factors and side effects; give health education, e.g. smoking cessation advice, information about STIs, information about long-acting reversible contraception; check BP.
Injectable progestogens
(BNF 7.3.2.2) Useful if oestrogen-containing preparations are contraindicated or compliance is a problem. Failure rate is <4/1,000 women over 2y.
Advantages
Can be used to age 50y if no other risk factors for osteoporosis
↓ ectopic pregnancy, functional ovarian cysts, and sickle cell crises
↓ risk of endometrial cancer. Provides endometrial protection as part of HRT regime (unlicensed)
May alleviate premenstrual syndrome and ↓ menorrhagia
Disadvantages
Relatively contraindicated if DM with complications or multiple risk factors for CVD
May ↓ bone density in first 2–3y of use. Consider DEXA scan in older women if result would influence choice
Can mask natural menopause
May be a delay in return of fertility of up to 1y on stopping
Can cause menstrual disturbance—if troublesome give next injection early (8–11wk after the previous injection for Depo) or add oestrogen if no contraindications
Other side effects, e.g. weight ↑ (up to 2–3kg), mood swings, acne
Depo-Provera®
Medroxyprogesterone acetate 150mg/mL.
Give 1x 1mL by deep IM injection into the buttock/lateral thigh or deltoid up to day 5 of the cycle. Do not rub the injection site afterwards
If given for first time after day 5, check the woman is not pregnant and provide and advise an additional method for 7d
Postpartum: delay until >6wk after childbirth—if not breastfeeding, first dose can be given <5d after childbirth but may cause heavy bleeding
Repeat every 12wk. If interval is >12wk and 5d—see Table 22.4
| Timing of Depo- Provera® | Has unprotected sex occurred? | Can the injection be given? | Is emergency contraception needed? | Are condoms or abstinence advised? | Should a pregnancy test be done? |
|---|---|---|---|---|---|
Up to 12wk and 5d since date of previous injection | N/A | Yes | No | No | No |
No | Yes | No | Yes—for the next 14d* | No | |
Yes—but only in the last 3d | Yes—or give desogestrel 75 micrograms for 21d | Yes | Yes—for the next 14d* | Yes—21d later | |
Yes—but only in the last 3–5d | Yes—or give desogestrel 75 micrograms for 21d | Yes—offer copper IUD | No | Yes—21d later | |
When an injection is overdue | Yes—>5d ago | No | No | Yes—for 21d until a pregnancy test is confirmed negative and for a further 14d* after giving Depo injection | Yes—at initial presentation and 21d later |
| Timing of Depo- Provera® | Has unprotected sex occurred? | Can the injection be given? | Is emergency contraception needed? | Are condoms or abstinence advised? | Should a pregnancy test be done? |
|---|---|---|---|---|---|
Up to 12wk and 5d since date of previous injection | N/A | Yes | No | No | No |
No | Yes | No | Yes—for the next 14d* | No | |
Yes—but only in the last 3d | Yes—or give desogestrel 75 micrograms for 21d | Yes | Yes—for the next 14d* | Yes—21d later | |
Yes—but only in the last 3–5d | Yes—or give desogestrel 75 micrograms for 21d | Yes—offer copper IUD | No | Yes—21d later | |
When an injection is overdue | Yes—>5d ago | No | No | Yes—for 21d until a pregnancy test is confirmed negative and for a further 14d* after giving Depo injection | Yes—at initial presentation and 21d later |
WHO/FSRH recommendations state that injections of Depo-Provera® can be given up to 14wk and Noristerat® can be given up to 10wk after the previous injection without the need for additional barrier contraception. These guidelines also state that, when needed, additional contraception is only necessary for 7d.
CSM advice about Depo-Provera® In all women, weigh benefits of use for >2y against risks
In women with risk factors for osteoporosis, consider a method of contraception other than Depo-Provera®
In adolescents, Depo-Provera® should only be used only when other methods of contraception are inappropriate
Noristerat®
Norethisterone enantate 200mg/mL. Warm first then give 1x 1mL by deep IM injection into the gluteal muscle before day 6 of the cycle or immediately after childbirth (avoid breastfeeding if baby has jaundice requiring treatment). Do not rub the injection site afterwards.
May be repeated once only after 8wk. Unlicensed if repeated further.
Interactions
Effectiveness is not ↓ by antibacterials that do not induce liver enzymes. Effectiveness of Noristerat® (but not Depo-Provera®) is ↓ by enzyme-inducing drugs—advise additional contraception whilst taking these drugs and for 4wk after stopping or alternative method.
Progestogen implant
(see BNF 7.3.2.2) Nexplanon® is the only implant currently available in the UK. It is a radio-opaque flexible rod (40mm × 2mm) containing 68mg of etonogestrel that is inserted subdermally into the lower surface of the upper arm on day 1–5 of the cycle. If inserted after day 5, check not pregnant and use an additional method for 7d.
Advantages
Lasts 3y and, once inserted, no compliance required; can be used for women at risk of ectopic pregnancy; no effect on bone density; once removed, fertility returns immediately to normal.
Disadvantages
A minor operation is needed for insertion/removal. Special training is needed, and complications of minor surgery can occur (e.g. infection, scarring). ↓ efficacy with liver enzyme-inducing drugs—advise additional method for duration of treatment and 4wk afterwards or alternative contraception if enzyme-inducing drugs are being used long-term. Cannot be used as part of a HRT regime. May cause menstrual disturbances—exclude other causes. Treat with oestrogen (Marvelon® contains the same progestogen), additional progestogen, or NSAID. Other side effects include acne, mood swings, breast tenderness, change in libido—treat symptoms as needed.
Further information
NICE Long-acting reversible contraception (2005) www.nice.org.uk
FSRH www.fsrh.org
Progestogen-only pills (2009)
Progestogen-only injectable contraception (2009)
Progestogen-only implants (2008)
Nexplanon® (2010)
Patient information
Family Planning Association (FPA) 0845 122 8690 (0845 122 8687 in Northern Ireland) www.fpa.org.uk
Intrauterine devices
Intrauterine contraceptive device (IUCD)
(BNF 7.3.4) Plastic carrier wound with copper wire/fitted with copper bands. Suitable for:
Older parous women
As second-line contraception in young nulliparous women, or
For emergency contraception
Acts by inhibiting fertilization, sperm penetration of the cervical mucus, and implantation. Pregnancy rate with IUCDs containing 380mm2 copper is <20/1,000 over 5y.
Intrauterine system (IUS)
(BNF 7.3.2.3) The progestogen-only intrauterine system (Mirena®) releases levonorgestrel 20 microgram/24h directly into the uterine cavity. It acts by preventing endometrial proliferation, thickening of cervical mucus, and suppression of ovulation (some women and some cycles). Licensed uses include:
Contraception—particularly suitable for women with heavy periods
Primary menorrhagia—menstrual bleeding is ↓ significantly in 3–6mo
Prevention of endometrial hyperplasia during oestrogen therapy
Emergency contraception
p. 750
Choice of devices
See Table 22.5
| Device | Licence | Uterine length |
|---|---|---|
Flexi-T 300® | 5y | >5cm |
FlexiT +380® | 5y | >6cm |
GyneFix® | 5y | Any |
Load 375® | 5y | >7cm |
Mini TT 380 Slimline® | 5y | >5cm |
Multiload Cu375® | 5y | 6–9cm |
Multi-Safe 375® | 5y | 6–9cm |
Nova-T 380® | 5y | 6.5–9cm |
Neo-SafeT380® | 5y | 6.5–9cm |
T-Safe Cu380A Quickload® | 10y | 6.5–9cm |
TT 380 Slimline® | 10y | 6.5–9cm |
UT 380 Short or Standard® | 5y | Short—5–7cm Standard—6.5–9cm |
Mirena® | 5y* | >6.5cm |
| Device | Licence | Uterine length |
|---|---|---|
Flexi-T 300® | 5y | >5cm |
FlexiT +380® | 5y | >6cm |
GyneFix® | 5y | Any |
Load 375® | 5y | >7cm |
Mini TT 380 Slimline® | 5y | >5cm |
Multiload Cu375® | 5y | 6–9cm |
Multi-Safe 375® | 5y | 6–9cm |
Nova-T 380® | 5y | 6.5–9cm |
Neo-SafeT380® | 5y | 6.5–9cm |
T-Safe Cu380A Quickload® | 10y | 6.5–9cm |
TT 380 Slimline® | 10y | 6.5–9cm |
UT 380 Short or Standard® | 5y | Short—5–7cm Standard—6.5–9cm |
Mirena® | 5y* | >6.5cm |
4y if being used for prevention of endometrial hyperplasia
Contraindications
IUCD only
Allergy to copper; Wilson’s disease; heavy/painful periods.
IUCD and IUS
Pregnancy or <4wk postpartum
Current or high risk of STI or pelvic inflammatory disease (includes severe immunosuppression)—a woman should not have an IUCD/IUS fitted <3mo after treatment of a pelvic infection. Following treatment of STI suitability depends on ongoing risk
Undiagnosed uterine bleeding
Distorted uterine cavity
Endometrial, ovarian or cervical cancer, or trophoblastic disease
Anticoagulation—caution—use another method if possible
Advantages
IUCD only
No systemic side effects; does not mask the menopause; if fitted in a woman of >40y can remain in the uterus until menopause (unlicensed).
IUS only
↓ menorrhagia/dysmenorrhoea
↓ risk of pelvic inflammatory disease—particularly younger age groups
↓ risk of ectopic pregnancy compared to the IUCD
If 45y and amenorrhoeic, can be left in situ for 7y for contraception (unlicensed)—change after 4y if using IUS for endometrial protection
IUCD and IUS
Long-lasting and can be used until the menopause
Once fitted, no compliance is needed
Easily and immediately reversible by removal
Can be used for women who are breastfeeding, obese, or have concurrent illness—migraine, venous thromboembolism, DM, cardiovascular disease (or ↑ risk of cardiovascular disease), or women taking long-term hepatic-enzyme-inducing drugs (e.g. anticonvulsants, antivirals)
Can be used for HIV +ve women—but screen for STIs first and advise condom use
Disadvantages and problems
IUCD only
Ectopic pregnancy Risk (0.02/100 women years) is higher than if using a hormonal contraceptive method. If pregnancy occurs, there is a 1 in 20 risk of ectopic pregnancy—consider in any woman who has IUCD and develops abdominal pain
↑ dysmenorrhoea/menorrhagia Most common reason for discontinuation. Exclude infection and malposition. Exclude other gynaecological causes. Treat with NSAID or tranexamic acid or consider changing to the IUS
IUS only
Progestogenic side effects:
Changes in pattern/duration of menstrual bleeding (spotting/prolonged bleeding) are common—warn women prior to insertion. Bleeding usually becomes light/absent within 3–6mo of insertion
Mastalgia, mood changes, change in libido—usually resolve in <6mo
Ovarian cysts—usually resolve spontaneously; monitor with USS
Cannot be used for emergency contraception
IUCD and IUS
Fitting and removal Requires specialist training and can be uncomfortable for the woman
Expulsion/malposition—Risk of expulsion is ~1 in 20. Usually occurs <3mo after insertion—teach women to feel for threads after each period. If threads cannot be felt advise other contraception until checked by a health professional (see Figure 22.3)
Perforation of the uterus Risk <1 in 1,000
Pelvic inflammatory disease ↑ risk of infection <21d after insertion. Related to existing carriage of STIs. It is good practice to screen for STIs (especially chlamydia) and treat infection prior to insertion
Actinomyces-like organisms (ALOs) on cervical smear Assess to exclude pelvic infection. If no signs of pelvic infection, offer choice to leave device in situ or change it. If symptomatic discuss antibiotic treatment with microbiology and refer to GUM/gynaecology for further management
Intrauterine pregnancy Confirm intrauterine pregnancy with USS. Remove device at <12wk gestation whether or not the woman intends to continue the pregnancy. If pregnancy is >12wk or no threads are visible, refer to obstetrics/gynaecology
Insertion
Special training is required. The Faculty of Sexual and Reproductive Healthcare runs a training scheme ( 020 7724 5669 www.fsrh.org). Accreditation must be updated every 5y. IUS/IUCDs may be inserted:
<7d after onset of menstruation—tail end of a period is the optimum time; heaviest days of a period are best avoided
At any other time in the cycle—if replacement of IUS/IUCD. If first device, and not in the first 7d of the cycle, ensure not pregnant and advise additional method for 7d
Immediately after TOP/miscarriage or >4wk postpartum (unlicensed <6wk postpartum), irrespective of the mode of deliveryN
Always consider pre-screening for STI (especially chlamydia) ± antibiotic prophylaxis, e.g. azithromycin 1g stat, prior to insertion. Advise women to contact a doctor if any sustained pain is experienced in the first 3wk after insertion
Cervical shock Rare complication of IUD insertion. Presents with pallor, sweating, and bradycardia. Immediately tip the woman head down with legs raised. If symptoms/bradycardia persist, give 0.6mg atropine IV.
Women with epilepsy ↑ risk of seizure at the time of cervical dilation—ensure emergency drugs are available.
Follow-up
Review after first period then annually. Ask about periods, pelvic pain, vaginal discharge, and discomfort to partner. Perform pelvic examination to check threads.
Removal
If pregnancy is desired—remove at any time
If pregnancy is not desired—remove after establishing a hormonal method or use barrier methods/abstinence for ≥7d prior to removal. If urgent removal is necessary, provide emergency contraception if mid cycle and intercourse has occurred in the previous 7d ( p. 750)
Menopause—remove after 1y amenorrhoea if aged >50y or after 2y amenorrhoea if aged <50y. If there is difficulty removing the device, try again after a 5d course of oestrogen (e.g. Premarin® 1.25mg od po)
Further information
FSRH Intrauterine contraception (2007) www.fsrh.org
NICE Long-acting reversible contraception (2005) www.nice.org.uk
Patient information
Family Planning Association (FPA) 0845 122 8690 (0845 122 8687 in Northern Ireland) www.fpa.org.uk
Other contraceptive methods
Sterilization
There are no absolute contraindications to sterilization of men or women, provided that:
They make the request themselves
They are of sound mind, and
They are not acting under external duress
If there is any question of a person not having the mental capacity to consent to a procedure that will permanently remove their fertility, seek advice from your medical defence organization.
Method
Women Laparoscopic tubal occlusion with clips or rings (usually done under GA as a day case) or hysteroscopic sterilization with intratubal implants (usually done under LA or sedation as a day case)
Men Vasectomy. Usually done under LA as a day case
Pre-referral counselling
Alternative long-term contraceptive methods (include sterilization of partner as an alternative)
Reversibility—sterilization is intended to be permanent; reversal is only 50–60% successful
Failure rate—1 in 200 for ♀; 1 in 2,000 for ♂
↑ risk of ectopic pregnancy after tubal occlusion
Risk of operative complications
Effect on long-term health—no proven long-term risks
Need for contraception before and after operation
Women: other contraception until first post-procedure period
Men: other contraception until 2 consecutive semen analyses, 2–4wk apart and ≥8wk after the procedure shows azoospermia
All counselling should be supported by impartial written information.
Take additional care when counselling:
People of <30y
People without children
People taking decisions during pregnancy
People taking decisions in reaction to a loss of relationship
People at risk of coercion by their partner, family, or health or social welfare professionals
Coitus interruptus
Penis is withdrawn prior to ejaculation.
Avoidance of intercourse during times of fertility
3 methods of estimating time of ovulation are used:
Urine testing—a commercial kit (Persona®) is available to buy
Temperature—taken orally in the morning before drinking/getting up (thermometer is available on NHS prescription). ↑ 0.2–0.4°C indicates progesterone release from the corpus luteum. Unprotected intercourse can take place from day 3 of the ↑ until the next period
Mucus texture (Billing’s method). Texture of vaginal secretions is felt between finger and thumb daily. Prior to ovulation the mucus becomes profuse and slippery, then abruptly changes to being thicker and more tacky. No unprotected intercourse from the day the mucus becomes more profuse until 3d after it becomes tacky. Patients with cycles > or <28d must vary timings
Vaginal diaphragms
(BNF 7.3.4) Latex or silicone and flat metal spring, coiled metal rim, or arcing spring diaphragms are available. Motivation is crucial. Fitting must be performed by a doctor or nurse trained to fit diaphragms. After fitting, a woman should practise inserting, wearing, checking the diaphragm is over the cervix, and removing the diaphragm for >1wk using another form of contraception. Some vegetable/mineral oil-based lubricants (e.g. petroleum jelly (Vaseline®), baby oil) can damage caps. Water-based lubricants are safe (e.g. KY Jelly®).
Spermicides (2 × 2cm strips applied to the upper surface) must always be used in combination with diaphragms and reapplied without removal if in situ >3h before sex takes place. The diaphragm must be left in situ for ≥6h (maximum 30h) after intercourse.
Follow-up
Check fit and comfort after ~1wk, and discuss again the routine for use, especially the importance of spermicide. See after 3mo and then annually, but more frequently if there are difficulties, if there is a weight change of >4kg, if the woman has a baby, or after pelvic surgery. Prescribe a new diaphragm yearly.
Cervical caps
(BNF 7.3.4) Silicone. Attach by suction. Otherwise used in the same way as a diaphragm. The inside of the cap should be filled one-third full of spermicide. Useful for women with poor muscle tone, absent retropubic ledge, or recurrent cystitis when using a diaphragm.
Spermicides to use in combination with caps or condoms
(BNF 7.3.3) Nonoxinol ‘9’ 2% gel (Gygel®) is the only preparation currently available in the UK.
Condoms
Give protection against STIs. Male and female versions.
A new condom should be applied for each episode of sexual intercourse (or if applied incorrectly) and only one should be used at a time; male and female condoms should not be used simultaneously
Advise about emergency contraception in the event of an accident
Some lubricants/topical vaginal preparations ↓ effectiveness, e.g. petroleum jelly (Vaseline®), baby oil, and oil-based vaginal/rectal preparations; water-based lubricants are safe (e.g. KY Jelly®)
Dams
Are not a contraceptive but protect against STIs. Thin film that provides a barrier between the mouth/cervico-vaginal secretions or between the mouth and anus.
Further information
FSRH www.fsrh.org
Barrier methods for contraception and STI prevention (2012)
Sterilization (2013)
Patient information
Family Planning Association (FPA) 0845 122 8690 www.fpa.org.uk
Fertility UK www.fertilityuk.org
Teenagers and women over 40
Contraception for the under 16s
Sexual health problems
One in three have sexual intercourse under the age of 16y. Those who have intercourse early are at ↑ risk of early pregnancy and STI. Worries about sexuality can add to the pressure for some. Sensitive support, clear guidance, and accurate information about contraception, sexuality, and STI are helpful. Remember to offer chlamydia screening ( p. 740) to the under 25s.
Safeguarding
( p. 924) Sexual intercourse with a child under the age of 13y is rape and must be reported to the authorities.
Providing contraception to the under 16s
In the UK, a doctor is allowed to give contraceptive advice and treatment to a girl aged <16y without parental consent if it is in her best interest that contraceptive advice/treatment is given and she:
Is sufficiently mature to understand the moral, social, and emotional implications of treatment
Cannot be persuaded to inform her parents
Is likely to begin/continue, intercourse with or without contraception
Is likely to suffer if no contraceptive advice or treatment is given
Confidentiality and consent
Choice of contraceptive method
Condoms Most commonly used contraception for adolescents. Relatively high failure rate—suggest their use in addition to another form of contraception to help prevent STIs
Long-acting reversible contraception (LARC) Offer IUCD, progestogen implant, injectables, or intrauterine system to all teenagers. Provides high levels of protection against pregnancy with no need for ongoing compliance once fitted/administered. The CSM advises that medroxyprogesterone acetate (Depo-Provera®) should only be used when other methods of contraception are inappropriate as it may ↑ osteoporosis risk (use alternative if other risk factors and try not to use >2y), menstrual irregularity, and ↑ weight
Combined hormonal contraception (pill, patch, or vaginal ring) Suitable method of contraception for the under 16s. Poor compliance can be a problem and leads to a relatively high failure rate
Progestogen-only pill (POP) Suitable for teenagers but has the same compliance problems as combined hormonal contraception and is associated with menstrual irregularity. Useful if the teenager does not want long-acting contraception and CHC is contraindicated
‘Morning after pill’ (levonorgestrel 1.5mg <72h or ulipristal acetate 30mg <120h after unprotected intercourse). Not suitable as regular contraception, but valuable in preventing unwanted pregnancy. Provide information on availability and make it easy for teenagers to get urgent same-day appointments to obtain a prescription
Do’s and don’ts
Don’t insist on vaginal examination unless it is necessary
Do discuss the merits of delaying sexual intercourse until older
Do stress the need for protection against sexually transmitted infection
If prescribing combined hormonal contraception for acne, dysmenorrhoea or cycle control, do explain its use for contraception too
Do consider ‘quick-starting’ contraception when the young person is seen rather than waiting for the next cycle
Information and support for teenagers
Brook Advisory Service 0808 802 1234 www.brook.org.uk
Sexwise For under 19s 0800 28 29 30
Teenage Health Freak www.teenagehealthfreak.org
Contraception for women >40y
Choice of contraceptive method
Combined hormonal contraception Non-smokers with no risk factors for CVD or breast cancer can use combined hormonal contraception until 50y. Consider a lower oestrogen preparation (20 micrograms ethinylestradiol). Improves menstrual and menopausal symptoms and protects bone density. Women experiencing menopausal symptoms may wish to try an extended regime ( p. 754)
Progestogen-only pill Can be continued to 55y and can be used as the progestogen component of HRT, but three POPs daily are needed for endometrial protection (unlicensed and no data for desogestrel). Does not interfere with FSH levels
Injectable progestogen Can be used up to 50y in women not at risk of osteoporosis (CSM advises benefits of using injectable medroxyprogesterone acetate for >2y should be evaluated against risks of ↓ bone density). May cause menstrual irregularity
Progestogen implant Cannot be used as part of HRT regime
IUS (Mirena®) Improves menorrhagia. Licensed for endometrial protection (can be used as part of an HRT regime). If 45y and amenorrhoeic, can be left in situ for 7y for contraception (unlicensed); change after 4y if using IUS for endometrial protection
IUCD Copper intrauterine devices fitted in women >40y may remain in the uterus until post-menopause
Stopping contraception after the menopause
Non-hormonal methods After 2y amenorrhoea if <50y; after 1y amenorrhoea if ≥50y
Combined hormonal or injectable progestogen Use to 50y, then switch to alternative method of contraception
Implant, POP, or IUS Continue to 50y; if ≥50y and amenorrhoeic, continue to 55y or check FSH—if FSH >30iu/L, repeat after 6wk and if second FSH >30iu/L stop contraception after 1y of amenorrhoea; if ≥50y and not amenorrhoeic, consider investigating abnormal bleeding and continue >55y until amenorrhoeic for 1y
Further information
Family Planning Association (FPA) 0845 122 8690 (0845 122 8687 in Northern Ireland) www.fpa.org.uk
FSRH www.fsrh.org
Contraception for women aged over 40 years (2010)
Contraceptive choices for young people (2010)
UK Medical Eligibility Criteria for contraceptive use (2009)
Termination of pregnancy
The earlier in pregnancy a termination of pregnancy is performed, the lower the risk of complications. General practice is often the first stage of the referral procedure—have arrangements which minimize delay
Termination of pregnancy (TOP), especially for ‘social’ reasons, is a difficult ethical area for many GPs. Whatever your views, be sympathetic and if not prepared to refer yourself, arrange for the patient to see someone who will do so as soon as possible
Confirm pregnancy if unsure. Assess dates by bimanual palpation or arrange dating USS
Counselling—unbiased counselling to allow a woman to reach a decision she feels is right for her—this is an important decision she will have to live with for the rest of her life. Why does she want a termination? Has she considered alternatives? Does her partner/do her parents know? What are their views?
Ideally the woman should be given some time once she has all the information to make her decision (e.g. follow-up in a few days). Offer a let-out clause—she can always change her mind right up until the time of the procedure, and you will support her whatever decision she makes
Consider signing form HSA1 (remember to include your qualifications)
Discuss contraception after TOP (ideally do this before TOP so it can be started immediately after)
Arrange follow-up after the procedure
Legal constraints
The 1967 and 1990 Human Fertilization/Embryology Acts govern termination of pregnancy in the UK. Termination is allowed at <24wk gestation if termination:
↓ risk to the woman’s life
↓ risk to the mother’s physical/mental health (90% TOPs are carried out under this clause)
↓ risk to the physical/mental health of the mother’s existing children
The baby is at serious risk of being physically or mentally handicapped
There is no upper time limit if there is:
Real risk to the mother’s life
Risk of grave, permanent injury to the mother’s physical or mental health, or
The baby would be born seriously physically or mentally handicapped
Terminations of pregnancy (TOPs) >24wk can only be carried out in NHS hospitals. 99% TOPs take place <20wk. Those taking place >20wk are usually performed when fetal abnormality is found on USS (or amniocentesis) or if pregnancy is concealed in the very young.
Seek medicolegal advice from your medical indemnity organization if the patient is <16y or has a cognitive deficit that might impair ability to consent to referral and/or treatment.
Procedure
Medical Oral mifepristone followed by oral and/or vaginal prostaglandin (usually misoprostol)
Surgical Suction termination <15wk; dilatation and evacuation >15wk
Complications
Infection
Haemorrhage
Uterine perforation
Cervical trauma
Failed procedure and ongoing pregnancy
Psychological sequelae
There is no association between TOP and subsequent infertility or miscarriage/preterm delivery.
Follow-up
In many areas post-procedure follow-up is undertaken by the GP. Worrying symptoms are: excessive blood loss, pain, and/or high temperature. Assess, consider the possibility of infection and treat if reasonably well; admit if the patient is unwell.
Check anti-D has been given if needed ( p. 820) and chosen method of contraception has been started.
Contraception post-termination or miscarriage <24wk
Combined pill/patch/ring, POP, progestogen injection/implant Start on the day of surgical or second part of medical termination. No additional method required. If started >5d after termination (day 1 only for estradiol valerate/dienogest pill) an additional method is required for 2d (POP), 7d (combined pill/patch/ring or progestogen injection/implant) or 9d (estradiol valerate/dienogest pill)
IUCD or IUS Insert at time of surgical or second part of a medical abortion. No additional method required. Otherwise delay insertion to 4wk post-abortion—use another method in the interim
Teenage pregnancy
The UK has the highest teenage pregnancy rate in western Europe. Not all are unplanned. Pregnant teenagers need information and non-judgemental support to help them to reach a decision whether or not to continue with the pregnancy.
Further information
RCOG The care of women requesting induced abortion (2004) 
www.rcog.org.uk
Information/support for women about unplanned pregnancy
Family Planning Association (FPA) 
0845 122 8690 (0845 122 8687 in Northern Ireland) www.fpa.org.uk
Marie Stopes International 0845 300 8090 www.mariestopes.org.uk
British Pregnancy Advisory Service (BPAS) 0845 730 40 30 www.bpas.org
Brook Advisory Centres (patients <25y only) 0808 802 1234 www.brook.org.uk
Antenatal results and choices (ARC) Supports parents faced with termination for fetal abnormality 0845 077 2290 www.arc-uk.org
Infertility
Failure to conceive after 1y of regular unprotected sexual intercourse in the absence of known reproductive pathology. Affects ~1 in 5 couples.
Pregnancy rates
The normal rate of pregnancy in the first year is 20–25% per cycle. 84% of couples conceive after 1y of unprotected intercourse (17 in every 20 couples); 92% conceive after 2y (19 of every 20 couples); after 3y, the pregnancy rate is still ~25%/y.
Causes of infertility
Ovulatory dysfunction ~30%
Pelvic disease ~20%
Male factor ~20%
Unknown ~30%
Initial approach
Most couples tend to present at about 1y. Where possible, see the couple together. This shows mutual commitment and initiates ongoing, couple-centred management.
Couple
Ask about:
Length of time trying to conceive
Frequency of and/or difficulties with sexual intercourse, e.g. psychosexual problems, physical disability—includes excessive travelling which may limit optimal coital timing and indirectly affect fertility
Women
Ask about:
Previous pregnancies—children, miscarriages, same/different partner?
Menstrual cycle—length of cycle (normal cycle is 21–35d duration), changes in cervical mucus through the cycle, ovulatory discomfort?
Past gynaecological history—cervical smears, previous pelvic surgery, STI/pelvic inflammatory disease, PCOS
Past medical history—systemic or debilitating disease, e.g. thyroid dysfunction, DM, inflammatory bowel disease, anorexia nervosa
Drug history—chemotherapy, phenothiazines, cannabis, NSAIDs
Lifestyle—occupation (exposure to pesticides?), smoking, alcohol, excessive exercise, stress
Men
Ask about:
Previous children, same/different partner?
PMH—mumps, other testicular disease, STI
Any systemic or debilitating diseases?
Drug history—sulfasalazine, nitrofurantoin, tetracycline, cimetidine, ketoconazole, colchicine, allopurinol, α-blockers, tricyclic antidepressants, MAOI, phenothiazines, propranolol, chemotherapy, anabolic steroids, cannabis, cocaine
Social history—occupation (exposure to pesticides, X-rays, solvents, paints, chemicals from smelting or welding), smoking, alcohol, excess exercise, stress, social or occupational factors which might cause testicular hyperthermia
Adverse factors
Age (♀ only—fertility ↓ significantly from mid-30s), BMI <19 (♀ only) or >29 (♂ and ♀), smoking (↓ fertility by about one-third), excess alcohol (♂ only), excess caffeine (>2 cups of coffee/d—♀ only).
Examination
Consider pelvic/genital examination.
GP investigations
Perform investigations if no pregnancy after a year of trying to conceive—sooner if aged >35y.
Female
Rubella status
Chlamydia serology—indicator of possible tubal disease
Mid-luteal progesterone—check on day 21 of the menstrual cycle for a woman with a 28d cycle; adjust timing if longer/shorter cycle. Can only be accurately interpreted after the next period as aims to ‘catch’ the progesterone peak 7d before the next period. Normal value (>30nmol/L) signifies ovulation
FSH/LH—check on day 1–5 of the menstrual cycle
Consider TFTs if symptoms/signs of thyroid disease, or prolactin if galactorrhoea or any suggestion of pituitary tumour
Male
Sperm problems affect ~1 in 5 couples. Semen analysis is important even if the man already has children. If the first test is abnormal, advise loose trousers and underwear and repeat after 3mo—or as soon as possible if grossly abnormal. 
Abnormal sperm do not fertilize ova.
Instructions for producing a semen sample for analysis
No sex for 2d beforehand and ≤7d since last sex (may affect motility). Masturbate into labelled sterile pot without use of condoms/gels. Keep the sample warm (e.g. inside pocket), and deliver to the laboratory within 2h. Handover directly to a member of laboratory staff if possible.
Referral
Local protocols vary and exclusions may apply. Generally refer after 18mo of failure to conceive despite regular intercourse. Refer sooner if abnormal history, examination, or investigations, e.g.:
Female age >35y; amenorrhoea/oligomenorrhoea; PCOS; previous pelvic inflammatory disease or STI
Male Previous genital pathology or urogenital surgery; varicocele; significant systemic illness; persistent abnormality on semen analysis
Possible treatments GPs may need to continue to prescribe
Clomifene—ovarian stimulation, treatment for oligospermia
Tamoxifen—may be prescribed to women intolerant of clomifene
Metformin—used as an adjunct to clomifene in overweight ladies with polycystic ovarian syndrome who fail to respond to clomifene alone
Others, e.g. gonadotrophins, dopamine agonists (e.g. bromocriptine)
Counselling
Consider early referral for specialist counselling. Access is through national support groups and at local specialist fertility centres. Useful contacts:
British Infertility Counselling Association www.bica.net
British Fertility Society www.britishfertilitysociety.org.uk
Further information
NICE Fertility: Assessment and treatment of people with fertility problems (2004) www.nice.org.uk
Advice and information for patients
Infertilitynetwork UK 0800 008 7464 www.infertilitynetworkuk.com
Sexual problems
Sexual problems may have a physical or psychological basis but all develop a psychological aspect in time. Both partners have a problem in ~30% cases. Be supportive—your response will determine whether the patient receives appropriate help.
Assessment
History of the problem What is the problem? If new, when did it start? Why consult now? What outcome does the patient want? Is the patient complaining or is his/her partner?
Sexual history Details of sex education; attitude towards sex; past history of sexual problems (or lack of problems)
Medical history Chronic disease; psychiatric problems; current medication
Social history and recent life events
Examination Genitalia for abnormalities or tenderness—helpful but do not insist as it may scare the patient away
Always consider psychological aspects
Poor self-image; anger or resentment—relationship/financial difficulties, children, parents, work stress; ignorance or misunderstanding; shame, embarrassment, or guilt—view that sexuality is ‘bad’, sexual abuse; anxiety/fear about sex—fear of closeness, vulnerability, letting go, and failure.
Lack of sexual interest
Usually needs specialist help. Often there are underlying psychological difficulties which may relate specifically to sex, e.g. previous child abuse, or a general psychological disorder. Women frequently lose interest around the menopause or after operations (especially mastectomy or hysterectomy) or if their partner’s performance repeatedly leads to frustration (e.g. impotence). Both sexes lose interest if depressed or after traumatic events.
Vaginismus
Usually apparent at vaginal examination—severe spasm of the vaginal muscles and adduction of thighs. May be detected incidentally when undertaking routine procedures, e.g. cervical smear. Try to find the root cause. Common causes:
Fear of the unknown
Local pain
Past history of rape, abuse, or severe emotional trauma
Defence mechanism against growing up
Management
Treat any underlying medical disorder causing pain. Desensitize by encouraging the woman to examine herself, and also encourage the partner to be confident enough to insert a finger into the vagina. If no success, refer.
Orgasmic problems in women
Consider:
Physical reasons
Drugs—major tranquillizers, antidepressants
Neurological disease
Pelvic surgery—recognized complication of hysterectomy
Psychological reasons
Women who have never achieved an orgasm May have psychological reasons. Give ‘permission’ for the woman to investigate her body’s own responses further by masturbation or vibrator. When she has learned how to relax, encourage her to tell her partner and incorporate caressing into their usual lovemaking
Women who have lost the ability to achieve orgasm May need specialist help, especially about current relationship or loss of self-image
Dyspareunia
p. 714
Erectile dysfunction
p. 776
Premature ejaculation
Ejaculation sooner than either partner wishes. With practice men can learn to delay ejaculation. The stop/start technique may be effective: when during caressing or intercourse, a man feels he is close to climax he should stop being stimulated and relax for 30 seconds; stimulation can then recommence until he is close to climax again, when the relaxation is repeated. If this fails, the woman should squeeze the penis at the base of the glans between finger and thumb during relaxation phases. Consider referral for sex therapy if no improvement.
Delayed ejaculation
May be a sign of long-standing sexual inhibition. Often patients can ejaculate by masturbation but not intravaginally. Explore anxiety and guilt feelings. Use a strategy like that for psychogenic erectile dysfunction ( p. 778). If that fails, refer for psychosexual counselling.
Retrograde ejaculation
Semen passes into the bladder rather than the urethra—complication of TURP or bladder neck incision. May also occur as a result of spinal injury or DM. The patient can usually achieve an orgasm but there is no ejaculate or the volume of the ejaculate is ↓. Urine may be cloudy after having sex. Confirm diagnosis with urine microscopy (excess sperm in urine). Unless infertility is a problem, no treatment is required.
Haematospermia
Blood in the ejaculate. Common causes include urogenital infection and minor urethral trauma, but often no cause is found. If persistent, underlying pathology is more likely. Ask about other symptoms, e.g. discharge, pain, dysuria. Examine the external genitalia and perform DRE to assess the prostate. Check MSU and semen analysis ± urethral swab (including chlamydia) if any urethral discharge/high risk of STI. Check PSA and urine cytology if patient is aged >40y. If persists and no cause is found, refer to urology.
Further information about specialist doctors/therapists
College of Sexual and Relationship Therapists 020 8543 2707 www.cosrt.org.uk
Institute of Psychosexual Medicine www.ipm.org.uk
Information for patients
Brown P, Faulder C (
Erectile dysfunction
50% men aged 40–70y experience inability to obtain/maintain sufficient rigidity of the penis to allow satisfactory sexual performance; 90% are too embarrassed to seek help—always ask. Incidence ↑ with age.
Organic causes
(80%)
Cardiovascular CHD ↑ incidence x4—more likely to have multi-vessel than single-vessel coronary artery disease; peripheral vascular disease; hypertension—incidence ↑ x2
DM incidence ↑ x3. >35% of diabetic men have erectile dysfunction. May be the presenting feature of DM
Neurological, e.g. pelvic surgery, spinal injury, multiple sclerosis
Side effects of prescription drugs Consider changing medication if onset of erectile dysfunction is within 2–4wk of initiation of drug therapy e.g. thiazides
Smoking (incidence ↑ x2), alcohol, or drug abuse
Peyronie’s disease ( p. 464)
Testosterone deficiency or hyperprolactinaemia
Psychogenic causes
Performance anxiety
Depression or stress
Relationship failure
Fear of intimacy
Drugs causing erectile dysfunction
Antihypertensives
Antidepressants (e.g. SSRIs)
Major tranquillizers
Anti-androgens
Finasteride
Cimetidine
History
Ensure the presenting problem is erectile dysfunction and not other sexual difficulties; identify risk factors and distinguish psychogenic from organic causes (see Table 22.6). Many with organic erectile dysfunction develop a psychogenic component which perpetuates symptoms.
| Psychogenic origin | Organic origin | |
|---|---|---|
Onset sudden or gradual? | Sudden onset | Gradual onset |
Consistent loss of erections? | Inconsistent response | Consistent failure |
Does the patient ever wake up with an erection? | Early-morning erections | Loss of early-morning erections |
Does the patient want to have intercourse? | Relationship problems | Normal libido |
Age? | Usually <60y | Usually >60y |
| Psychogenic origin | Organic origin | |
|---|---|---|
Onset sudden or gradual? | Sudden onset | Gradual onset |
Consistent loss of erections? | Inconsistent response | Consistent failure |
Does the patient ever wake up with an erection? | Early-morning erections | Loss of early-morning erections |
Does the patient want to have intercourse? | Relationship problems | Normal libido |
Age? | Usually <60y | Usually >60y |
Examination and investigation
CVD and DM—check BP, peripheral pulses, and blood for fasting lipid profile and glucose
Psychological distress—consider depression/anxiety screening
Testosterone insufficiency—genitals (small/absent), breasts ↑, ↓ beard (↓ frequency of shaving). If suspected, check serum testosterone, sex hormone binding globulin, free androgen index, FSH/LH ± prolactin
Andropause/male menopause From ~30y, testosterone levels ↓ by ~10% every decade. At the same time, sex hormone binding globulin (SHBG) level ↑, which ↓ the amount of bioavailable testosterone further. Andropause is associated with low bioavailable testosterone levels; ~30% of men in their 50s develop symptoms.
↓ sex drive, emotional, psychological, and behavioural changes, ↓ muscle mass and muscle strength, ↑ upper and central body fat, osteoporosis and back pain, ↑ cardiovascular risk.
If suspected, check total testosterone and SHBG ± FSH/LH and prolactin. If hypogonadism is confirmed, refer for specialist management with testosterone replacement.
GP management
Advice on lifestyle—↓ smoking and alcohol. Weight loss and ↑ exercise for obese, underactive patients improves both sexual function and cardiovascular health
Discuss pros and cons of available drug treatment. Phosphodiesterase type 5 inhibitors (PDE5s) are the mainstays of treatment—titrate dose to effect (most people with DM need the maximum dose); warn the patient he may need 8 attempts before a satisfactory erection occurs; side effects include headache, flushing, and acid reflux
Review progress—adjust dosage, consider other treatment options (intraurethral/intracavernosal alprostadil, vacuum devices) or treatment for psychosexual problems, and/or referral
| Treatment | Notes |
|---|---|
Oral drugs | |
Phosphodiesterase type 5 inhibitors, e.g. sildenafilS | Effective for 70%. Use prn before intercourse (see Table 22.8). Only use 1x/d. Avoid if patient has unstable angina, recent stroke, or MI. Do not give a nitrate within 24h of use |
Apomorphine | 2–3mg prn 20min before sexual activity |
YohimbineS | Herbal remedy available OTC. 10–30mg od is effective May cause insomnia |
Local drug treatments | |
Intraurethral or intracavernosal alprostadil | Intraurethral preparation is effective for 40% and intracavernosal preparation for 80% patients. Used prn. Requires some manual dexterity. Takes ~10min to work. Penile pain is common. Prolonged erection and priapism results in ~1%. Advise patients to seek medical help if erection >4h |
Mechanical devices | |
Vacuum devices | 80% effective. The penis is placed in the device and air withdrawn mechanically sucking blood into the penis. Erection is maintained by placing a constriction band around the base of the penis |
Penile prosthesis | Last resort. Inflatable or rigid. Major complication is infection |
Others | |
Androgen supplements | Ineffective unless documented hypogonadism. Only use with specialist advice. Exclude prostatic cancer and significant CVD first, and check PSA and haematocrit at 3,6 and 12mo after initiation of treatment, then annually thereafter |
Psychotherapy | Effective for some. Time-consuming and expensive but may avert the need for drugs and give permanent resolution |
| Treatment | Notes |
|---|---|
Oral drugs | |
Phosphodiesterase type 5 inhibitors, e.g. sildenafilS | Effective for 70%. Use prn before intercourse (see Table 22.8). Only use 1x/d. Avoid if patient has unstable angina, recent stroke, or MI. Do not give a nitrate within 24h of use |
Apomorphine | 2–3mg prn 20min before sexual activity |
YohimbineS | Herbal remedy available OTC. 10–30mg od is effective May cause insomnia |
Local drug treatments | |
Intraurethral or intracavernosal alprostadil | Intraurethral preparation is effective for 40% and intracavernosal preparation for 80% patients. Used prn. Requires some manual dexterity. Takes ~10min to work. Penile pain is common. Prolonged erection and priapism results in ~1%. Advise patients to seek medical help if erection >4h |
Mechanical devices | |
Vacuum devices | 80% effective. The penis is placed in the device and air withdrawn mechanically sucking blood into the penis. Erection is maintained by placing a constriction band around the base of the penis |
Penile prosthesis | Last resort. Inflatable or rigid. Major complication is infection |
Others | |
Androgen supplements | Ineffective unless documented hypogonadism. Only use with specialist advice. Exclude prostatic cancer and significant CVD first, and check PSA and haematocrit at 3,6 and 12mo after initiation of treatment, then annually thereafter |
Psychotherapy | Effective for some. Time-consuming and expensive but may avert the need for drugs and give permanent resolution |
Algorithm for management of erectile dysfunction
Referral
Options:
Urologist If the patient has never had an erection, has a severe vascular problem, lack of success with treatment in general practice, or severe psychological distress due to erectile dysfunction
Endocrinologist Hormone abnormalities (e.g. ↓ androgen, ↑ prolactin)—treatment does not always restore potency
Psychiatrist/psychosexual counsellor Age <40y and no evidence of organic cause; psychosexual problem
Psychogenic erectile dysfunction
Treatment in general practice is appropriate for couples who do not wish to be referred.
See the couple together
Recommend a manual, e.g. ‘Treat Yourself to Sex’ (P. Brown and C. Faulder, Penguin, 1989. ISBN: 0140110186)
Forbid sexual intercourse
Explain that stroking should progress slowly from non-genital to genital—if anxiety occurs, go back one step
Progress until erection is achieved
Give permission for intercourse (if not already achieved)
If unsuccessful, refer to a psychosexual counsellor
All men >25y with erectile dysfunction should be screened for DM, cardiac risk factors, and signs/symptoms of vascular disease.
NHS prescriptions for erectile dysfunction are available only for men:
Treated for prostate cancer; with kidney failure, spinal cord injury, DM, MS, spina bifida, Parkinson’s disease, polio, severe pelvic injury, or who have had radical pelvic surgery or a prostatectomy
Already receiving drug treatment for impotence on 14.9.98
Through specialist services for men suffering severe distress due to erectile dysfunction
Endorse NHS prescriptions with the letters ‘SLS’. A consultation is currently underway to lift NHS prescribing restrictions.
| Drug | Onset of action in min (peak action) | Duration of action in h | Doses |
|---|---|---|---|
Sildenafil | 20–30 (60) | 4–6 | 25–50–100mg |
Tadalafil | 60–120 (120) | 36–48 | 10–20mg* |
Vardenafil | 20–30 (60) | 4–6 | 5–10–20mg |
| Drug | Onset of action in min (peak action) | Duration of action in h | Doses |
|---|---|---|---|
Sildenafil | 20–30 (60) | 4–6 | 25–50–100mg |
Tadalafil | 60–120 (120) | 36–48 | 10–20mg* |
Vardenafil | 20–30 (60) | 4–6 | 5–10–20mg |
For patients who anticipate sexual activity ≥2x/wk, 2.5–5mg od can be used instead.
Figure 22.4 and Table 22.8 are reproduced from British Heart Foundation Factfile: Drugs for erectile dysfunction (6/2005) available from www.bhf.org.uk
Further information
British Society for Sexual Medicine Guidelines for the management of erectile dysfunction (2007) www.bssm.org.uk
