Possible Causes of Hepatitis in a Middle-Aged Man

Although hepatitis can be caused by various viruses, the likelihood of acute infection decreases with age. In the case of cytomegalovirus (CMV) and Epstein-Barr virus (EBV), these viruses are typically encountered before the age of 55, making acute infection less probable. While hepatitis A is a possibility, it is unlikely without a history of travel. Although hepatitis C can be transmitted sexually, its prevalence among men who have sex with men is lower than that of hepatitis B. Additionally, hepatitis B is more easily transmitted through sexual contact, making it a more probable diagnosis. It is important to note that there is a 5-10% chance of becoming a chronic carrier of hepatitis B.

Emergency Contraception for Patients on Liver Enzyme-Inducing Drugs

When a patient is on liver enzyme-inducing drugs or has had a copper intrauterine device (IUD) inserted in the last 28 days, the copper IUD is recommended as first-line emergency contraception. However, if the patient declines this option, a higher dose of levonorgestrel (3mg) is recommended as second-line. Common drugs that induce liver enzymes include antiretrovirals, carbamazepine, phenytoin, rifampicin, and St John’s wort. It is important to note that ulipristal is not suitable for women on liver enzyme-inducing drugs, according to NICE guidelines. It is crucial for healthcare providers to be aware of these recommendations and provide appropriate emergency contraception options for patients on liver enzyme-inducing drugs.

Patients with erectile dysfunction can now receive an unlimited amount of generic sildenafil through NHS prescriptions. Previously, only patients with specific medical causes of erectile dysfunction were eligible for sildenafil prescriptions, and the medication was limited to four tablets per month under the Selected List System (SLS) scheme of the Drug Tariff. However, these restrictions have been lifted, and NICE guidance now recommends that GPs assess monthly quantities on an individual basis. Despite this, some patients are still being limited to four tablets a month due to outdated prescribing habits. It should be noted that the British National Formulary (BNF) recommends using sildenafil a maximum of once daily.

Erectile dysfunction (ED) is a condition where a man is unable to achieve or maintain an erection that is sufficient for sexual performance. It is not a disease but a symptom that can be caused by organic, psychogenic, or mixed factors. It is important to differentiate between the causes of ED, with factors such as a gradual onset of symptoms and lack of tumescence favoring an organic cause, while sudden onset of symptoms and decreased libido favoring a psychogenic cause. Risk factors for ED include cardiovascular disease, alcohol use, and certain medications.

To assess for ED, it is recommended to measure lipid and fasting glucose serum levels to calculate cardiovascular risk. Free testosterone should also be measured in the morning, and if low or borderline, further assessment may be needed. PDE-5 inhibitors, such as sildenafil, are the first-line treatment for ED and should be prescribed to all patients regardless of the cause. Vacuum erection devices can be used as an alternative for those who cannot or will not take PDE-5 inhibitors. Referral to urology may be appropriate for young men who have always had difficulty achieving an erection, and those who cycle for more than three hours per week should be advised to stop.

Condoms in General Practice

Condoms cannot be prescribed in general practice in the UK, but local Clinical Commissioning Groups (CCGs) may have other arrangements for condom supplies. It is important to note that condoms pre-lubricated with spermicide are not recommended as they may increase the risk of HIV transmission. However, condoms in general do help prevent HIV transmission. It is also important to understand that condoms are not as effective at preventing pregnancy as hormonal and intrauterine methods. Condoms are typically made of either latex or polyurethane, and individuals with a latex allergy should stick to polyurethane condoms.

Syphilis, Lymphogranuloma venereum (LGV), and donovanosis (granuloma inguinal) can all lead to the development of genital ulcers that are not accompanied by pain. However, in the case of the patient who has recently changed sexual partners and is not experiencing any other symptoms, herpes simplex is the more probable cause of the painful genital ulcers. Behcets may also cause painful genital ulcers.

Understanding STI Ulcers

Genital ulcers are a common symptom of several sexually transmitted infections (STIs). One of the most well-known causes is the herpes simplex virus (HSV) type 2, which can cause severe primary attacks with fever and subsequent attacks with multiple painful ulcers. Syphilis, caused by the spirochaete Treponema pallidum, has primary, secondary, and tertiary stages, with a painless ulcer (chancre) appearing in the primary stage. Chancroid, a tropical disease caused by Haemophilus ducreyi, causes painful genital ulcers with a sharply defined, ragged, undermined border and unilateral, painful inguinal lymph node enlargement. Lymphogranuloma venereum (LGV), caused by Chlamydia trachomatis, has three stages, with the first stage showing a small painless pustule that later forms an ulcer, followed by painful inguinal lymphadenopathy in the second stage and proctocolitis in the third stage. LGV is treated with doxycycline. Other causes of genital ulcers include Behcet’s disease, carcinoma, and granuloma inguinale (previously called Calymmatobacterium granulomatis). Understanding the different causes of STI ulcers is crucial in diagnosing and treating these infections.

When to Get Tested for Chlamydia

Chlamydia is a common sexually transmitted infection that often doesn’t show any symptoms. Therefore, it is important to get tested regularly if you are sexually active. The recommended time to get tested for chlamydia is at presentation and then again two weeks after a possible exposure. This is because it can take up to two weeks for the infection to show up on a test. If symptoms do develop, testing should be done immediately. It is also recommended to get tested again at six weeks and three months after a possible exposure to ensure that the infection has been fully treated. Remember, early detection and treatment of chlamydia is crucial for preventing long-term health complications.

Chlamydia is the most common sexually transmitted infection in the UK caused by Chlamydia trachomatis. It is often asymptomatic but can cause cervicitis and dysuria in women and urethral discharge and dysuria in men. Complications include epididymitis, pelvic inflammatory disease, and infertility. Testing is done through nuclear acid amplification tests (NAATs) on urine or swab samples. Screening is recommended for sexually active individuals aged 15-24 years. Doxycycline is the first-line treatment, but azithromycin may be used if contraindicated. Partners should be notified and treated.

Diagnosis and Management of PID Following IUCD Insertion

The most probable diagnosis in cases of pelvic inflammatory disease (PID) is following the insertion of an intrauterine contraceptive device (IUCD). To support the diagnosis, swabs should be taken, although negative results do not necessarily rule out PID if there are clinical indications.

Expert opinions differ on whether to remove the IUCD at the time of presentation. However, if symptoms persist after 72 hours, the IUCD should be removed. Proper diagnosis and management of PID following IUCD insertion are crucial to prevent complications and ensure the patient’s well-being.

Contraception and Major Surgery

Major surgery, which includes surgery lasting more than 30 minutes, all lower limb surgeries, and surgeries resulting in prolonged immobilization of a lower limb, requires special consideration for patients who are using combined hormonal contraceptives. To avoid potential complications, patients should be offered alternative contraception options four weeks prior to their operation. Once the patient is fully mobilizing, typically two weeks after the surgery, they can resume their combined hormonal contraceptive.

It is important to note that patients who are unable to stop their combined hormonal contraceptive prior to surgery should not resume use until they are fully mobilizing. This information is crucial for healthcare providers to communicate to their patients to ensure safe and effective contraception management during and after major surgery. By following these guidelines, patients can avoid potential complications and continue to receive the contraceptive care they need.

Tuberculosis Treatment and Pregnancy

When treating tuberculosis in women who are of childbearing age or pregnant, it is important to consider the potential effects of the medication on contraception and fetal development. Rifampicin, a commonly used medication for tuberculosis, can accelerate the metabolism of oral contraceptives, making them less effective. Therefore, patients should be advised to use alternative forms of contraception while taking rifampicin.

If a pregnant woman develops tuberculosis, standard treatment with rifampicin, isoniazid, pyrazinamide, and ethambutol should be given. However, streptomycin should be avoided as it may be ototoxic to the fetus. Quinolones, such as ciprofloxacin, should also be avoided during pregnancy as they have been shown to cause arthropathy in animal studies.

Overall, it is important to carefully consider the potential risks and benefits of tuberculosis treatment in pregnant women and to provide appropriate counseling and monitoring throughout the course of treatment.

Syphilis on the Rise Among Men Who Have Sex with Men

There has been a recent increase in syphilis cases, particularly among men who have sex with men. Confirming the diagnosis requires multiple tests and thorough contact tracing, making it important to refer cases to a specialist center. Testing for HIV is also recommended, as the two conditions are often associated. While serology can be conducted in a primary care setting if syphilis is suspected, secondary syphilis can present with a range of different rashes, including a non-itchy macular-papular rash that often affects the palms and soles.

Timing and Options for Emergency Contraception

When it comes to emergency contraception, timing is crucial. If ovulation can be estimated, an IUD can be inserted up to five days after the expected date of ovulation. On the other hand, levonorgestrel can be taken beyond the recommended 72-hour window, but its effectiveness may be reduced. It can also be repeated within the same menstrual cycle. In cases where condoms are the only form of contraception, additional levonorgestrel may be prescribed. However, it’s important to note that pharmacists will not sell levonorgestrel to males. By understanding the timing and options for emergency contraception, individuals can make informed decisions about their reproductive health.

Referral and Treatment for Reduced Serum Testosterone

Patients with low levels of serum testosterone should be referred to secondary care for further investigation and treatment. This may involve consulting with an endocrinologist, urologist, or andrologist, depending on the area. Testosterone replacement therapy can be administered through topical testogel or intramuscular nebido, but it requires counseling and monitoring by secondary care before initiation. Ongoing monitoring may include checking the full blood count, lipids, and prostate-specific antigen levels. Since the test has already been repeated, there is little benefit in repeating it again in four weeks.

Trichomonas Vaginalis Infection

Trichomonas vaginalis is a protozoan that can cause malodorous frothy discharge in some individuals, but many are asymptomatic. The organism can be seen under microscopic examination of vaginal secretions in saline, where trophozoites with three flagella can be observed moving. In some cases, a ‘strawberry cervix’ with punctuate mucosal haemorrhages may be present. Treatment for trichomonas infection is typically metronidazole 400 mg BD for seven days.

If an asymptomatic patient initially tests negative for HIV, it is recommended to offer a repeat test at 12 weeks to confidently exclude the diagnosis. The preferred test for HIV is the combined HIV test for HIV-1 and HIV-2 antibodies and p24 antigen. It is important to note that although most cases of HIV infection can be detected by 4 weeks, a repeat test at 12 weeks is still recommended.

HIV seroconversion is a process where the body develops antibodies against the virus. This process is symptomatic in 60-80% of patients and usually presents as a glandular fever type illness. The severity of symptoms is associated with a poorer long-term prognosis. The symptoms typically occur 3-12 weeks after infection and include a sore throat, lymphadenopathy, malaise, myalgia, arthralgia, diarrhea, maculopapular rash, mouth ulcers, and rarely meningoencephalitis.

Diagnosing HIV involves testing for HIV antibodies, which may not be present in early infection. However, most people develop antibodies to HIV at 4-6 weeks, and 99% do so by 3 months. The diagnosis usually involves both a screening ELISA test and a confirmatory Western Blot Assay. Additionally, a p24 antigen test can be used to detect a viral core protein that appears early in the blood as the viral RNA levels rise. Combination tests that test for both HIV p24 antigen and HIV antibody are now standard for the diagnosis and screening of HIV. If the combined test is positive, it should be repeated to confirm the diagnosis. Some centers may also test the viral load (HIV RNA levels) if HIV is suspected at the same time. Testing for HIV in asymptomatic patients should be done at 4 weeks after possible exposure, and after an initial negative result, a repeat test should be offered at 12 weeks.

Contraceptive Options for Young People: Guidelines and Considerations

When it comes to providing contraception to young people, there are legal and ethical issues that need to be considered. In the UK, the age of consent for sexual activity is 16 years, but practitioners may provide advice and contraception if they feel that the young person is competent. The Fraser Guidelines are used to assess competence, and practitioners must ensure that the young person understands their advice, cannot be persuaded to inform their parents, is likely to have sex with or without contraception, and needs contraception for their physical or mental health.

Young people should also be advised to have STI tests 2 and 12 weeks after an incident of unprotected sexual intercourse. When it comes to choosing a contraceptive method, long-acting reversible contraceptive methods (LARCs) are often recommended as young people may be less reliable in remembering to take medication. However, there are concerns about the effect of progesterone-only injections on bone mineral density, and the UKMEC category of the IUS and IUD is 2 for women under the age of 20 years, meaning they may not be the best choice. The progesterone-only implant (Nexplanon) is therefore the LARC of choice for young people.

In summary, providing contraception to young people requires careful consideration of legal and ethical issues, as well as the individual’s needs and preferences. STI testing and LARCs may be particularly important for this age group, but the potential risks and benefits of each method should be discussed with the young person to ensure they make an informed decision.

Fraser Guidelines for Young People’s Competence to Consent to Contraceptive Advice or Treatment

The Fraser guidelines provide a framework for healthcare professionals to determine whether a young person is competent to consent to contraceptive advice or treatment.

According to the guidelines, a young person is considered competent if they understand the doctor’s advice, cannot be persuaded to inform their parents or allow the doctor to inform the parents, are likely to start or continue having sexual intercourse with or without contraceptive treatment, their physical or mental health (or both) are likely to deteriorate if contraceptive advice/treatment is not given, and their best interests require the doctor to give advice/treatment without parental consent.

It is important to follow these guidelines as failure to provide contraceptive advice or treatment can put young people at risk of physical and mental harm, including unwanted pregnancies. In the UK, statistics suggest that about 30-40% of young people have had sexual intercourse by the time they are 16. Therefore, it is crucial for healthcare professionals to assess young people’s competence to consent to contraceptive advice or treatment and provide appropriate care.

Erectile dysfunction (ED) is often caused by beta-blockers like bisoprolol, which are commonly prescribed to patients who have had a previous myocardial infarction (MI). While amlodipine can also cause ED, it is less common than bisoprolol. Isosorbide mononitrate doesn’t typically cause ED, but patients taking it should avoid taking sildenafil at the same time due to the risk of hypotension. Mirtazapine is a less common cause of sexual dysfunction, and sertraline is generally the preferred antidepressant for post-MI patients.

Erectile dysfunction (ED) is a condition where a man is unable to achieve or maintain an erection that is sufficient for sexual performance. It is not a disease but a symptom that can be caused by organic, psychogenic, or mixed factors. It is important to differentiate between the causes of ED, with factors such as a gradual onset of symptoms and lack of tumescence favoring an organic cause, while sudden onset of symptoms and decreased libido favoring a psychogenic cause. Risk factors for ED include cardiovascular disease, alcohol use, and certain medications.

To assess for ED, it is recommended to measure lipid and fasting glucose serum levels to calculate cardiovascular risk. Free testosterone should also be measured in the morning, and if low or borderline, further assessment may be needed. PDE-5 inhibitors, such as sildenafil, are the first-line treatment for ED and should be prescribed to all patients regardless of the cause. Vacuum erection devices can be used as an alternative for those who cannot or will not take PDE-5 inhibitors. Referral to urology may be appropriate for young men who have always had difficulty achieving an erection, and those who cycle for more than three hours per week should be advised to stop.

Methotrexate and Contraception

Methotrexate is a commonly used treatment for rheumatological conditions and ectopic pregnancy, but it is also teratogenic. The British National Formulary (BNF) advises that effective contraception should be used during and for at least six months after treatment in both men and women. However, there is limited evidence on the exact safe timing of conception after methotrexate treatment. If a woman becomes pregnant within three months of taking methotrexate, she should receive close follow-up and targeted assessment for fetal malformations.

In an exam setting, it is expected that the Royal College of General Practitioners (RCGP) would follow the BNF and Summary of Product Characteristics (SPC) in any questions about prescribing. However, the Faculty of Sexual and Reproductive Healthcare (FSRH) has conflicting recommendations, stating that effective contraception should be used during and for at least three months after treatment due to the teratogenic effects of methotrexate.

Overall, it is unlikely that you will be tested on this learning point, but if you are, the reference will be clearly stated in the question. It is important to follow the guidelines provided by the BNF and SPC, but the additional information from the FSRH can provide a more balanced perspective.

FSH Testing and Contraception in Perimenopausal Women

Current guidance from the Faculty for Sexual and Reproductive Healthcare advises that FSH levels can be measured in perimenopausal women using progestogen-only methods of contraception, but this should be limited to women over the age of 50. For women taking the progestogen-only pill, it is recommended to stop at age 55 when natural loss of fertility can be assumed for most women. However, if a woman over 50 with amenorrhoea wishes to stop before age 55, FSH levels can be checked. If the FSH level is above 30 IU/L, the contraception can be discontinued after one more year. If the FSH level is in the premenopausal range, the method should be continued, and the FSH level should be checked again after one year.

NICE NG23 recommends diagnosing perimenopause based on vasomotor symptoms and irregular periods, menopause in women who have not had a period for at least 12 months and are not using hormonal contraception, and menopause based on symptoms in women without a uterus. It is important to note that measuring serum hormone levels in perimenopausal women can be complex, and discontinuing contraception should generally be restricted to women over the age of 50, as they are more likely to be menopausal. Overall, FSH testing can be a helpful tool in determining when to discontinue contraception in perimenopausal women.

Contraception Contraindications and Cautions

Contraception questions are commonly featured in the MRCGP exam, and it is essential to have a good understanding of the contraindications and cautions listed in the British National Formulary (BNF). In the BNF, unexplained uterine bleeding is listed as a contraindication, while the other items mentioned in the history are listed as cautions. It is important to note that there are other contraindications not mentioned in the history, such as pregnancy, current sexually transmitted infection, current pelvic inflammatory disease, and distorted uterine cavity. Familiarizing oneself with these contraindications and cautions is crucial in providing safe and effective contraception to patients.

Chlamydia: A Common and Often Asymptomatic STD

Chlamydia is a prevalent sexually transmitted disease that often goes unnoticed due to its asymptomatic nature. In fact, 75% of women and 25% of men with Chlamydia show no symptoms, making it difficult to detect and treat. However, this disease can have serious consequences, including infertility.

In men, the main symptoms of Chlamydia include clear, white, or yellow discharge from the urethra, dysuria, and tingling or itching sensations. It is important to note that Chlamydia often co-occurs with Gonorrhoea, and patients should be treated for both if Gonorrhoea is suspected. Failure to treat both infections can result in the return of symptoms and potential complications. Therefore, it is crucial to practice safe sex and get tested regularly to prevent the spread of Chlamydia and other STDs.

Erectile dysfunction is a side-effect that is considered uncommon for amlodipine and ramipril, according to the BNF. However, SSRIs are a frequent cause of sexual dysfunction, making them the most probable medication to result in ED.

Erectile dysfunction (ED) is a condition where a man is unable to achieve or maintain an erection that is sufficient for sexual performance. It is not a disease but a symptom that can be caused by organic, psychogenic, or mixed factors. It is important to differentiate between the causes of ED, with factors such as a gradual onset of symptoms and lack of tumescence favoring an organic cause, while sudden onset of symptoms and decreased libido favoring a psychogenic cause. Risk factors for ED include cardiovascular disease, alcohol use, and certain medications.

To assess for ED, it is recommended to measure lipid and fasting glucose serum levels to calculate cardiovascular risk. Free testosterone should also be measured in the morning, and if low or borderline, further assessment may be needed. PDE-5 inhibitors, such as sildenafil, are the first-line treatment for ED and should be prescribed to all patients regardless of the cause. Vacuum erection devices can be used as an alternative for those who cannot or will not take PDE-5 inhibitors. Referral to urology may be appropriate for young men who have always had difficulty achieving an erection, and those who cycle for more than three hours per week should be advised to stop.

In this scenario, it is important to prioritize confidentiality and empathy.

It is crucial to treat the patient with respect and care, regardless of whether she is willing to disclose the names of her previous partners. Refusing to treat her or threatening to disclose her information to her parents is unethical and unacceptable.

Instead, it is important to have an open and non-judgmental conversation with the patient to understand her concerns and reasons for not disclosing her partners. This approach may help to build trust and alleviate her fears.

On the other hand, simply providing her with a tablet of azithromycin to give to her partner is not a recommended solution. This approach doesn’t address the underlying issues and may not effectively prevent the spread of the infection.

Female Sterilisation as a Permanent Contraception Method

Female sterilisation is a safe and effective method of permanent contraception that can be performed immediately after childbirth or as a delayed interval procedure. The two common techniques for sterilisation are partial salpingectomy and tubal occlusion. However, before opting for female sterilisation, women should be informed about all methods of contraception, including vasectomy. The discussion should be open, transparent, and non-pressurised. It is important to note that some long-acting reversible contraceptive methods are as, or more, effective than female sterilisation and may provide non-contraceptive benefits such as improving menorrhagia with levonorgestrel intrauterine device use. Therefore, women should be fully informed about all their options before making a decision about permanent contraception.

Prostatitis and STIs: A Possible Link

The history of a recent lads’ holiday to Spain has raised concerns about the possibility of a sexually transmitted infection (STI) causing prostatitis. Two common STIs, Chlamydia trachomatis and Neisseria gonorrhoeae, are known to cause prostatitis. If a sexual cause is suspected, it is important to refer the patient to a genitourinary medicine (GUM) clinic for appropriate contact tracing and screening for other STIs. This will help to identify any potential sources of infection and prevent the spread of STIs. It is important to be aware of the link between prostatitis and STIs, and to take appropriate measures to protect oneself from infection.

Transgender males who are on testosterone therapy should be aware that this treatment doesn’t prevent pregnancy. In the event that a patient becomes pregnant, testosterone therapy is not recommended as it can have harmful effects on the developing fetus. Instead, emergency contraception should be prescribed and the patient should be advised against continuing testosterone therapy during pregnancy. It is important to note that emergency contraception is still safe for patients on testosterone therapy. While discussing the risk of sexually transmitted infections is important, it is not a substitute for effective contraception. While a future pregnancy test may be necessary, the immediate priority is to provide emergency contraception. It is also important to note that testosterone therapy is not a form of emergency contraception and that other options, such as a copper intrauterine device or specific medications, should be considered.

Contraceptive and Sexual Health Guidance for Transgender and Non-Binary Individuals

The Faculty of Sexual & Reproductive Healthcare has released guidance on contraceptive choices and sexual health for transgender and non-binary individuals. The guidance emphasizes the importance of sensitive communication and offering options that consider personal preferences, co-morbidities, and current medications or therapies. For those engaging in vaginal sex, condoms and dental dams are recommended to prevent sexually transmitted infections. Cervical screening and HPV vaccinations should also be offered. Those at risk of HIV transmission should be advised of pre-exposure prophylaxis and post-exposure prophylaxis.

For individuals assigned female at birth with a uterus, testosterone therapy doesn’t provide protection against pregnancy, and oestrogen-containing regimens are not recommended as they can antagonize the effect of testosterone therapy. Progesterone-only contraceptives are considered safe, and non-hormonal intrauterine devices may also suspend menstruation. Emergency contraception may be required following unprotected vaginal intercourse, and either oral formulation or the non-hormonal intrauterine device may be considered.

In patients assigned male at birth, hormone therapy may reduce or cease sperm production, but the variability of its effects means it cannot be relied upon as a method of contraception. Condoms are recommended for those engaging in vaginal sex to avoid the risk of pregnancy. The guidance stresses the importance of offering individuals options that take into account their personal circumstances and preferences.

If a patient was assigned male at birth and is undergoing treatment with oestradiol, GNRH analogs, finasteride or cyproterone, there may be a decrease or cessation of sperm production. However, this cannot be considered a reliable method of contraception. In the case of a trans female patient, who was assigned male at birth, hormonal treatments cannot be relied upon for contraception. There is a possibility of her female partner becoming pregnant, and therefore, barrier methods are recommended. Hormonal contraceptives are not suitable for this patient, and the copper IUD is not an option as she doesn’t have a uterus.

Contraceptive and Sexual Health Guidance for Transgender and Non-Binary Individuals

The Faculty of Sexual & Reproductive Healthcare has released guidance on contraceptive choices and sexual health for transgender and non-binary individuals. The guidance emphasizes the importance of sensitive communication and offering options that consider personal preferences, co-morbidities, and current medications or therapies. For those engaging in vaginal sex, condoms and dental dams are recommended to prevent sexually transmitted infections. Cervical screening and HPV vaccinations should also be offered. Those at risk of HIV transmission should be advised of pre-exposure prophylaxis and post-exposure prophylaxis.

For individuals assigned female at birth with a uterus, testosterone therapy doesn’t provide protection against pregnancy, and oestrogen-containing regimens are not recommended as they can antagonize the effect of testosterone therapy. Progesterone-only contraceptives are considered safe, and non-hormonal intrauterine devices may also suspend menstruation. Emergency contraception may be required following unprotected vaginal intercourse, and either oral formulation or the non-hormonal intrauterine device may be considered.

In patients assigned male at birth, hormone therapy may reduce or cease sperm production, but the variability of its effects means it cannot be relied upon as a method of contraception. Condoms are recommended for those engaging in vaginal sex to avoid the risk of pregnancy. The guidance stresses the importance of offering individuals options that take into account their personal circumstances and preferences.

Contraception Options for Postnatal Women

The postnatal period is a crucial time for women to consider their contraception options. The key factors to consider are the time since delivery and whether the woman is breastfeeding or not. Progestogen-only implants, injectables, and pills can be initiated immediately after delivery or any time after childbirth. However, for women considering combined hormonal contraception, an assessment of their venous thromboembolism risk is necessary. If risk factors are present, they should wait six weeks before starting. Women without additional risk factors should wait 21 days postpartum before starting. Intrauterine contraceptives can be safely inserted immediately after birth or within 48 hours after uncomplicated delivery, but after 48 hours, insertion should be delayed until 28 days after childbirth. It is important for women to discuss their options with their healthcare provider to determine the best choice for their individual needs.

IUS and Menopause: Understanding the Connection

Her symptoms are unlikely to be caused by the IUS and may be related to ovulation, which is common in up to 75% of patients with an IUS. This doesn’t affect the effectiveness of the contraceptive. It’s important to note that amenorrhea is not a reliable indicator of menopause in patients on oestrogen and/or progesterone-containing contraception. Therefore, ongoing contraception is necessary.

For patients aged 45 years or older with an IUS fitted, the device can be maintained until aged 55 years if they are amenorrheic. At this point, menopause can be assumed to have occurred. If a patient wishes to confirm menopause, FSH levels can be checked. If both levels are >30IU/L 6 weeks apart, contraception can be stopped after 12 months.

Understanding the connection between IUS and menopause is crucial for patients and healthcare providers. By following the guidelines and recommendations, patients can make informed decisions about their contraceptive options and overall health.

The Importance of Proper Condom Use

The use of condoms is crucial in reducing the risk of venereal infections, especially in controlling the spread of HIV. However, occasional failures may occur due to defective sheaths, not wearing them in the earlier phases of coitus, or slipping from the penis after ejaculation. It is also important to note that spermicides should not be used with latex condoms as they do not offer additional contraceptive efficacy. Moreover, certain topical, vaginal, and rectal preparations can destroy the integrity of latex condoms, rendering them ineffective. For instance, baby oil can destroy 90% of a latex condom’s strength within 15 minutes. Therefore, it is essential to be aware of the potential interaction between latex condoms and certain topical preparations, such as dalacin and clotrimazole. Professor John Guillebaud’s book Contraception: Your Questions Answered provides a more exhaustive list of preparations that should be avoided and are regarded as unsafe to use with latex condoms. Proper condom use is crucial in protecting oneself and one’s partner from sexually transmitted infections and unwanted pregnancies.

In 2014, sildenafil was removed from the list of restricted medications and can now be prescribed without limitations.

Phosphodiesterase type V inhibitors are medications used to treat erectile dysfunction and pulmonary hypertension. They work by increasing cGMP, which leads to relaxation of smooth muscles in blood vessels supplying the corpus cavernosum. The most well-known PDE5 inhibitor is sildenafil, also known as Viagra, which is taken about an hour before sexual activity. Other examples include tadalafil (Cialis) and vardenafil (Levitra), which have longer-lasting effects and can be taken regularly. However, these medications have contraindications, such as not being safe for patients taking nitrates or those with hypotension. They can also cause side effects such as visual disturbances, blue discolouration, and headaches. It is important to consult with a healthcare provider before taking PDE5 inhibitors.

Guidance on Timing of Depot Injection and Pregnancy Testing

When it comes to administering depot medroxyprogesterone acetate injections, it is important to consider the timing of the previous injection and the possibility of pregnancy. If the timing of the previous injection is unknown, it is recommended to repeat the injection as long as it is reasonably certain that the woman is not pregnant. This can be determined if there are no signs or symptoms of pregnancy and if the woman meets certain criteria, such as not having had sexual intercourse since the last normal menses or using a reliable method of contraception correctly and consistently.

If a woman has had sexual intercourse within the past three weeks, a pregnancy test should be performed no sooner than three weeks since the last episode of unprotected sexual intercourse and should be negative before administering the injection. However, if the woman’s last menstrual period was within seven days, it is considered reasonably certain that she is not pregnant and the injection can be given without a pregnancy test.

It is important to advise the woman to avoid intercourse or use a barrier method of contraception for seven days after the injection. By following these guidelines, healthcare professionals can ensure the safety and effectiveness of depot medroxyprogesterone acetate injections.

Emergency Contraception for Naomi

Naomi has presented more than 72 hours after unprotected sexual intercourse (UPSI), making Levonelle ineffective. Additionally, she is taking a proton pump inhibitor (PPI) which can reduce the effectiveness of ulipristal acetate. Therefore, the most appropriate management for her is the emergency intrauterine device (IUD), which is the most effective emergency contraceptive and provides ongoing contraceptive cover. It is important to note that progesterone-containing contraception should be delayed until after 5/7 after ellaone (ulipristal acetate) to reduce the risk of it being less effective as an emergency contraceptive.

The most appropriate screening test for asymptomatic males to detect chlamydia is a urine test. This is preferred over blood serology, urethral swab, or semen sample as it is less invasive and has similar sensitivity to urethral swab. It is important to note that Chlamydia infection can often be asymptomatic, so screening is still recommended even in the absence of symptoms.

Chlamydia is the most common sexually transmitted infection in the UK caused by Chlamydia trachomatis. It is often asymptomatic but can cause cervicitis and dysuria in women and urethral discharge and dysuria in men. Complications include epididymitis, pelvic inflammatory disease, and infertility. Testing is done through nuclear acid amplification tests (NAATs) on urine or swab samples. Screening is recommended for sexually active individuals aged 15-24 years. Doxycycline is the first-line treatment, but azithromycin may be used if contraindicated. Partners should be notified and treated.

Oral Candidiasis and Immune System Defects

Oral candidiasis, also known as thrush, is a fungal infection that can occur in the mouth and throat. While it can affect anyone, it should always raise suspicion of an underlying defect of the immune system in young healthy individuals. Further investigation is necessary to determine the cause of the infection.

In London, men who have sex with men have a high rate of HIV, with some estimates as high as 15%. Therefore, HIV infection is the most likely diagnosis for oral candidiasis in this population. It is important to consider this possibility and test for HIV to ensure proper treatment and management.

In addition to oral candidiasis, a weakened immune system can also lead to other health issues. For example, HIV infection is a predisposing factor for deep vein thrombosis (DVT), a blood clot that forms in a deep vein, typically in the leg. Recurrent attacks of shingles in a young person may also be a result of a weakened immune system. Therefore, it is important to investigate the underlying cause of these conditions to ensure proper treatment and management.

The patient is suffering from nonspecific balanitis and should be treated with a combination of hydrocortisone and antifungal cream. This treatment may help improve the condition, and if it fails, it can provide diagnostic clues to the underlying cause. Betamethasone dipropionate is not necessary for this condition, but it may be appropriate for more severe conditions like lichen sclerosis. Clotrimazole cream alone may not be effective in relieving the irritation, and hydrocortisone cream alone may not treat a potential fungal cause. Mupirocin is not useful in this situation as it is an antibacterial product used for gram-positive skin infections like impetigo.

Understanding Balanitis: Causes, Assessment, and Treatment

Balanitis is a condition characterized by inflammation of the glans penis and sometimes extending to the underside of the foreskin. It can be caused by a variety of factors, including bacterial and candidal infections, autoimmune conditions, and poor hygiene. Proper assessment of balanitis involves taking a thorough history and conducting a physical examination to determine the cause and severity of the condition. In most cases, diagnosis is made clinically based on the history and examination, but in some cases, a swab or biopsy may be necessary to confirm the diagnosis.

Treatment of balanitis involves a combination of general and specific measures. General treatment includes gentle saline washes and proper hygiene practices, while specific treatment depends on the underlying cause of the condition. For example, candidiasis is treated with topical clotrimazole, while bacterial balanitis may be treated with oral antibiotics. Dermatitis and circinate balanitis are managed with mild potency topical corticosteroids, while lichen sclerosus and plasma cell balanitis of Zoon may require high potency topical steroids or circumcision.

Understanding the causes, assessment, and treatment of balanitis is important for both children and adults who may be affected by this condition. By taking proper hygiene measures and seeking appropriate medical treatment, individuals with balanitis can manage their symptoms and prevent complications.

Contraindication of Sildenafil with Nitrates

Sildenafil should not be taken by patients who are also taking nitrates or nitrate derivatives such as nicorandil. If a patient is taking nitrates, they should stop taking them during the period when they are using sildenafil. This is because the combination of sildenafil and nitrates can cause a dangerous drop in blood pressure, which can lead to serious health complications. It is important for patients to inform their healthcare provider of all medications they are taking before starting sildenafil to avoid any potential contraindications.

Men with sickle cell disease should be prescribed PDE-5 inhibitors with caution due to their increased risk of priapism, a painful and persistent erection that requires urgent medical attention. Similarly, individuals with a predisposition to priapism, such as those with multiple myeloma or leukemia, should also use these medications with caution. While PDE-5 inhibitors may be used in men with Peyronie’s disease or other anatomical abnormalities of the penis, caution should still be exercised. It is important to note that diabetes doesn’t increase the risk of priapism, but it is a risk factor for erectile dysfunction.

Phosphodiesterase type V inhibitors are medications used to treat erectile dysfunction and pulmonary hypertension. They work by increasing cGMP, which leads to relaxation of smooth muscles in blood vessels supplying the corpus cavernosum. The most well-known PDE5 inhibitor is sildenafil, also known as Viagra, which is taken about an hour before sexual activity. Other examples include tadalafil (Cialis) and vardenafil (Levitra), which have longer-lasting effects and can be taken regularly. However, these medications have contraindications, such as not being safe for patients taking nitrates or those with hypotension. They can also cause side effects such as visual disturbances, blue discolouration, and headaches. It is important to consult with a healthcare provider before taking PDE5 inhibitors.

Hormonal Contraception and Breast Health

When a woman is being investigated for a breast mass, continuation of combined hormonal contraception is considered safe and is classified as UKMEC 2. Similarly, a family history of breast cancer is not a contraindication to oestrogen-containing contraception, unless the patient is a known BRCA1/BRCA2 carrier, which is classified as UKMEC 3. However, for women aged 40 years and above, combined hormonal contraception is classified as UKMEC 2, and they can continue until their investigations are complete. On the other hand, the use of an intrauterine system (IUS) is contraindicated in patients currently being treated for breast cancer. It is important to consider these guidelines when making decisions about hormonal contraception and breast health.

Approaching a Question on Gonorrhoea Treatment

When faced with a question on gonorrhoea treatment, it is important to exercise judgement and use examination technique to narrow down the options. For instance, if a patient is asking for treatment and has a history of non-compliance with previous follow up, referring them to gynaecology and taking a swab may not be useful if they are refusing referral to a genito-urinary medicine (GUM) clinic.

In such a scenario, the three treatment options left are the focus. While it is important to have some understanding of the guidance, even if one is unfamiliar with the individual drugs and doses, knowing that the current first line recommendation involves IM Ceftriaxone as a single dose can help narrow down the choices. This approach is useful in the actual AKT examination, where one may not know everything, but can increase their chances of success by logically narrowing down the options.