STIs and Contraception

STIs and Contraception

• For
  • prevent pregnancy
  • protect against STIs
  • control periods
  • other medical conditions, e.g. acne, endometriosis, polycystic ovarian syndrome
• Against
  • trying to have a baby
  • religious reasons
  • prefer intercourse without
  • long-term partner
  • peer pressure

• Barrier method
• Male and female condoms
• Only form of protection against STIs
• Perfect use: 98% effective
• Typical use: 82% effective
• Advantages: available for free, no serious side effects, protection from STIs
• Disadvantages: can interrupt intercourse, ineffective if wrong size/fitted incorrectly
• Dental dams available for giving oral sex to vagina

• Oestrogen and progesterone
• Take for 21 days, followed by a 7-day pill-free week ('withdrawal bleed')
• New guidance: can take back-to-back
• 12 hour window
• Perfect use: >99% effective
• Typical use: 91% effective
• Advantages - effective in proper use, pro-menstruation effects, decreased risk of ovarian and endometrial cancers, fertility returns to normal when pill is stopped
• Disadvantages - mood changes, nausea, breast tenderness, weight gain, headaches, user dependent

• The critical time for loss of contraceptive protection is when a pill is omitted at the beginning or end of a cycle, which lengthens the pill-free interval

• If a woman forgets to take a pill, it should be taken as soon as she remembers, and the next one taken at normal time (even if this means taking 2 pills together)

• If a woman misses only one pill, she should take an active pill as soon as she remembers and then resume normal pill-taking. No additional precautions are necessary

• If a woman misses 2 or more pills (especially from the first 7 in a packet), she may not be protected. She should take an active pill as soon as she remembers and then resume normal pill taking. In addition, she must either abstain from sex or use an additional method of contraception such as a condom for the next 7 days. If these 7 days run beyond the end of the packet, the next packet should be started at once, omitting the pill-free interval (or in the case of every day pills, omitting the 7 inactive tablets)
• Emergency contraception is recommended if 2 or more combined oral contraceptive tablets are missed from the first 7 tablets in a packet and unprotected intercourse has occurred since finishing the last packet

• Contains progesterone only
• 'Mini pill'
• Take every day at the same +/- 3-12 hours, no break
• Perfect use: 99% effective
• Typical use: 91% effective
• Advantages: used where combined oral contraceptive pill is contraindicated, not affected by broad spectrum antibiotics
• Disadvantages: spotting, weight gain, headache, mood changes, slightly less effective than the combined oral contraceptive pill

• Progesterone
• Depo-Provera: every 3 months intramuscular
• Noristerat: every 8 weeks intramuscular
• Sayana Press: every 13 weeks subcutaneous
• Perfect use: >99% effective
• Typical use: 94% effective
• Advantages - not user dependent, amenorrhoea
• Disadvantages - weight gain, can take a while for fertility to return to normal

• Progesterone
• Lasts 3 years
• Inserted into inner part of upper arm just under the skin
• >99% effective
• Advantages: not user dependent, rapid return to fertility
• Disadvantages: irregular bleeding, headaches, mood swings, breast tenderness

• Progesterone
• Hormomal coil (Mirena)
• Lasts 3-5 years
• >99% effective
• Advantages: not user dependent, decreased or no periods, rapid return of fertility
• Disadvantages: pain/discomfort on insertion, risk of expulsion, perforation of uterus (<0.5%), risk of infection

• Copper coil
• Lasts 10 years
• >99% effective
• Advantages: not user-dependent, non-hormonal, regular periods
• Disadvantages: heavier, more painful periods, pain, risk of expulsion, perforation of uretus (<0.5%), risk of infection

• Identifying the signs and symptoms of fertility during the menstrual cycle so people are able to plan or avoid pregnancy
  • e.g. requires keeping records of menstruation and avoiding sex or use another method of contraception on 'fertile' days
  • indicators: body temperature, cervical secretions, length of menstrual cycle
  • fertile days = 8-9 in each menstrual cycle
• Perfect use: up to 99% effective
• Typical use: 76% effective
• Advantages: no physical side effects (no hormones), increase awareness of fertility
• Disadvantages: takes 3-6 cycles to learn effectively, have to keep daily records, factors can affect fertility factors, e.g. illness, and must avoid sex or use additional contraception on fertile days

• Permanent method of contraception
• Male: cutting, sealing or tying the vas deferens (the tube that carries sperm from the testicles to the penis)
• Female sterilisation (tubal occlusion) is done by cutting, sealing or blocking the fallopian tubes which carry an egg from the ovary to the uterus
• >99% effective
• Advantages: don't have to worry about contraception again
• Disadvantages: risk of tubes re-joining and becoming fertile, not easily reversed, requires surgery

• Vaginal ring and patch
  • Perfect use: >99% effective
  • Typical use: 91% effective
• Diaphragm/cap with spermicide
  • Perfect use: 94% effective
  • Typical use: 84% effective
• 'Withdrawal'
  • Perfect use: 82% effective
  • Typical use: 71% effective

The morning-after pill

• Levonells (levonorgestrel)
  • Take up to 72 hours after unprotected sex
  • 95% success in 24 hours, 58% success in 72 hours
• ellaOne (ulipristal acetate)
  • Take up to 120 hours after unprotected sex
  • As effective as Levonelle

Intrauterine Device (IUD)

• Inserted up to 5 days after unprotected sex
• Works immediately as contraception
• Can remain in for 10 years

• Since 2012 the number of STIs diagnosed in Wales has increased
  • Possibly due to increased testing
• Young people are disproportionally affected
• High percentage of STI and HIV diagnoses are among men who have sex with men
  • Particularly syphilis and gonorrhoea
• Chlamydia is the most common STI diagnosed in Wales
  • Genital warts second most common
• Partner notification is important

• Chlamydia trachomatis
• Spread through unprotected vaginal, oral or anal sex, sharing unwashed sex toys
• Symptoms in women: bleeding between periods/heavier periods, bleeding after sex, lower abdominal pain, unusual discharge, pain when passing urine
• Symptoms in men: white/cloudy discharge from penis, pain when passing uring, pain in the testicles
• Tests in women: vaginal swab
• Tests in men: urine sample
• Treatment: doxycycline 7 days/azithromycin taken in one dose

• 50% of men and 80% of females will be asymptomatic

• If chlamydia is left untreated, it can cause Pelvic Inflammatory Disease (PID) in women
  • long-term pelvic pain, blocked fallopian tubes, infertility and ectopic pregnancy
  • in men, it can cause testicular infection and decreased fertility

• Neisseria gonorrhoeae
• Spread through unprotected vaginal, oral or anal sex, sharing unwashed sex toys
• Symptoms in women: bleeding between periods/heavier periods, lower abdominal pain, unusual discharge, pain when passing urine
• Symptoms in men: green/yellow discharge from penis, pain when passing urine, pain in the testicles
• Tests in women/men: vaginal/rectal swab
• Tests in men: urine sample
• Treatment: azithromycin + ceftriaxone injection

• Herpes Simplex Virus (HSV2)
• Spread through intimate sexual contact, vaginal, anal or oral sex
• Symptoms: blistering of genitals, leaving open red sores, tinging/burning/itching/pain on urination
• Tests: swab from blister
• Treatment: antiviral medications
  • can be treated but not cured

• Human Papilloma Virus
• Spread by skin-to-skin contact, such as that during vaginal or anal sex, or transferred by sharing sex toys
• Can be spread even if no active warts are seen
• Symptoms: small, fleshy growths that appear on/around the genital area, usually not painful
• Tests: examination of the area
• Treatment: creams or liquids, cryotherapy (frozen off), laser therapy
• The types of HPV that cause visible genital warts (types 6 and 11) do not cause cancer

• Treponema pallidum
• Spread through vaginal, anal, oral sex or by sharing sex toys. Through contact with the ulcers of someone with syphilis
• Symptoms
  • Primary: genital ulcers
  • Secondary: rash on hands and feet, fever, headaches, tiredness
  • Tertiary: if left untreated, can spread to the brain and cause long term damage
• Tests: blood test
• Treatment: benzathine benzylpenicillin or azithromycin

• Trichomonas vaginalis
• Nearly always passed on through unprotected vaginal sex
• Can not get trichomonas from anal or oral sex
• Symptoms: abnormally smelly discharge, soreness, redness, itching, paun when urinating
• Tests: genital swap, urine sample
• Treatment: metronidazole

• Human Immunodeficiency Virus
• Spread through infected blood, semen, vaginal and anal fluids, breast milk
• Symptoms: fever, rash, joint and muscle pain in early stages
  • Late stage: diarrhoea, night sweats, weight loss, recurrent infections
• Tests: blood test
• Treatment:
  • anti-retroviral therapy
  • treatable but not curable
  • undetectable viral load = not transmissable 

• Pthirus pubis
• Spread through skin-to-skin contact
• Symptoms: often visible, itching, irritation, black powdery droppings from lice in underwear
• Tests: examination
• Treatment: topical insecticide

• Not an STI
• Not fully understood
  • Less normal vaginal bacteria, overgrowth of other types of bacteria, change in pH
• Increased risk: perfumed soaps, douching, vaginal deodorant, smoking
• Symptoms: change in vaginal discharge (watery, grey, 'fishy')
• Tests: swab
• Treatment: Metronidazole, creams or gels

• Not an STI
• Candida albicans (yeast fungus)
• Symptoms: itching, soreness, redness around the vagina or *****, unusual white discharge ('cottage cheese'), pain when passing urine
• Tests: examination, swab
• Treatment: antifungals (cream, pessaries, tablets)

• All confidential (unless safeguarding issue)
• GUM clinics (genito-urinary medicine)/Integrated Sexual Health Clinics
  • Abortion services (some), contraception, STI testing and treatments, free condoms, free emergency hormonal contraception, family planning, female health (smears), HIV clinics (some), young peoples' services
• GP
  • Contraception, STI testing
• A & E
  • Emergency contraception
• Pharmacy
  • Emergency hormonal contraception, condoms, pregnancy tests, Chlamydia screening

• Always use a new condom
• Check the expiry date
• Check British Standards Institute kitemark (or CE)
• Push condom to one side of packet, do not use teeth and watch out for sharp nails or jewellery
• Take the condom out of the packet carefully
• Penis must be erect before condom is applied
• The condom should be applied before the penis touched the *****, vagina, rectum or mouth

• With one hand, pinch the end of the condom with the thumb and finger. This is to ensure there is space for the semen to go if *********** happens, so make sure to leave enough room
• With the other hand, put the condom on the tip of the penis and roll it all the way down to the bottom of the penis
• After ***********, pull out carefully, holding onto the bottom of the condom to ensure it does not slip off. Make sure no semen is spilt, and that the condom is not left inside
• Take the condom off when the penis is flaccid. Do not use it again
• Tie a knot in the condom and throw it in the bin