Dyspareunia: definition, assessment, and diagnosis [link]
Dyspareunia: causes [link]
Dyspareunia: treatments [link]
Vaginal discharge: definition, assessment, and diagnosis [link]
Vaginal discharge: causes [link]
Vaginal discharge: investigations and treatment [link]
Sexual health in context [link]
Partner notification [link]
Gonorrhoea: overview [link]
Gonorrhoea: treatment and notification [link]
Chlamydia: overview [link]
Chlamydia: treatment and partner notification [link]
Pelvic inflammatory disease (PID): definition, causes, and diagnosis [link]
Pelvic inflammatory disease (PID): treatment [link]
Hepatitis B (HBV) [link]
Hepatitis C (HCV) [link]
Anogenital warts (benign epithelial skin tumours) [link]
Genital herpes [link]
Genital lumps and ulcers [link]
Human immuno-deficiency virus (HIV) [link]
Post-exposure prophylaxis (PEP) [link]
Sexual dysfunction: history taking and useful prompts [link]
Female sexual arousal disorder [link]
Hypoactive sexual desire disorder [link]
Sexual dysfunction: treatment options [link]
Female orgasmic disorder [link]
Dyspareunia: definition, assessment, and diagnosis
There are two types of dyspareunia:
• Superficial dyspareunia is defined as pain at the onset of penetration or sexual intercourse.
• Deep dyspareunia is defined as pain during and after penetration or sexual intercourse.
It is a common but under-reported symptom, as women do not like to talk about it.
Within women’s health, asking the patient what her worries and concerns are, can often uncover the problem. It should be standard to ask women who you see, if they ‘have any difficulties with sexual intercourse or desire’. This is often a useful tool to determine if there is a problem, as women are often reluctant to bring this up themselves. The patient should not feel hurried and it is important to maintain an understanding, professional atmosphere during the consultation. There are often both physical and psychological factors present. If sexual intercourse has been painful, this can lead to fear and anxiety, lack of lubrication, and then an increase of pain.
• Onset and relationship of pain with women’s life events.
• Relationship of pain to the menstrual cycle.
• Is there any sexual position that worsens or improves the pain?
• What sort of pain is it—burning, tearing, stabbing?
• Does the pain occur on one side more often than the other?
• Does the pain occur in relation to superficial or deep penetration?
• How long has this been a problem?
• Does the pain occur on every episode of intercourse?
• Has it shown any signs of getting better or worse?
• How often approximately do you have sex?
• Effect of the pain on the relationship with your partner?
Sexual history questioning
• Do you look forward to sex?
• When did you last change your sexual partner?
• Any relationship or work problems?
• Have you had the same pain with other partners?
• Did you have any sexual problems when growing up?
• History of recent STIs.
• Attitude to sex and sexuality.
• History of sexual abuse as a child or within current or previous relationships.
General gynaecological questions
In menstrual history, establish whether bleeding irregularities may be interfering with sexual intercourse. Details of reproductive history, including any difficulty conceiving, and elicit previous episodes of endometriosis, cysts, fibroids, and surgery.
• Tact and sensitivity to the woman’s problem is important.
• The examination should be conducted in a quiet clinical room with no unnecessary staff.
• A chaperone is generally needed, regardless of the sex of the examining practitioner.
• Explain that the aim of the examination is to determine if there is any pathology causing the pain.
• If at any time she finds the pain is reproduced, advise that you will stop the examination. This will help her to feel in control.
• Inspect the abdomen for scars of major abdominal or gynaecological surgery.
• Palpate for any masses.
• Assess the mobility of the masses and tenderness.
The examination should include full inspection of the external genitalia and, if possible, try to locate the painful area. The physical examination may be difficult and the woman’s history and attitude to the examination may point to physical or psychological causes.
A particular note should be made of vaginismus when undertaking an examination and, if vaginismus is suspected, a gentle single-finger examination is first undertaken to see if the woman tolerates it. If she tolerates the digital examination, then she should be offered a speculum examination.
Bimanual examination provides useful information in relation to deep dyspareunia.
A physical examination is indicated normally with STI screening and testing. ( See Vaginal discharges: definition, assessment, and diagnosis, p.[link].)
• Need for diagnostic tests depends on the findings.
• Within the history it may become apparent that there are urinary, bowel, and skeletal problems.
• Vulvitis. Caused by infections such as candidiasis, herpes, or genital warts.
• Bartholinitis. An inflammation of the glands that may present as a cyst or an abscess. There can also be pain in the area after surgery to cysts.
• Vulval dermatosis.
• Lichen sclerosis.
• Vestibulitis—this can cause pain in the vestibule.
• Vulvodynia. In vulvodynia there is a constant pain that feels like there are red-hot needles within the vulva. Generally, on examination there are no specific, obvious causes seen. It is thought that it may be brought on by a painful condition, which causes over-sensitivity of the nerve endings.
• Vaginismus. This is the involuntary contraction of the vaginal muscles when penetration is attempted. It is generally linked to psychological dysfunction.
• Vaginitis—infective (as above).
• Imperforate hymen.
• Post-surgery. This can include any vaginal surgery like repairs, hysterectomy, TVT, and perineal stitching after childbirth.
Many of the causes of deep pain are covered in Chronic pelvic pain, (pp.[link]).
• Pelvic endometriosis.
• Ectopic pregnancy.
• Chronic pelvic inflammatory disease.
• Chronic pelvic pain syndrome.
• Ovarian cyst.
• Displaced IUD/IUS.
Treatment of both superficial and deep dyspareunia comprise medical, surgical, and psychosexual management
The treatment of dyspareunia is related to the causes.
• For infective causes, treatment is aimed at treating the cause. With chronic infections this may need to be on a long-term basis.
• Bartholin’s abscesses may need to be drained/marsupialized or treated with antibiotics.
• Vulval dystrophy.
• Vaginismus—this can be treated by behaviour modification and using vaginal dilatation using vaginal trainers. The teaching of how to use trainers needs to be undertaken in a private room, where there has been a therapeutic relationship between the woman and the practitioner. The smallest dilator should be used first, with gradual progression as the patient feels able. It is important to progress like this, as the patient can then overcome her fears and anxieties with the smaller sizes. Partner support and counselling directed towards reassurance and education are important adjuncts to treatment. Women may need to be referred for psychosexual counselling.
• Post-surgery and post-radiotherapy—women may benefit from lubrication, use of local oestrogen creams, and dilators, as above.
• Vulvodynia—can be managed by local hygiene and treating underlying pathology. It can also be helped by having lidocaine 5% ointment to apply prior to intercourse and, in some cases, low dosage of the tricyclic anti-depressant amitriptyline.
• Imperforate hymen—can be surgically incised.
• Granulomata and scar tissue after lower genital tract damage following childbirth may require corrective surgery.
• Dyspareunia associated with female genital cutting may require surgical correction.
With all causes, it is important to discuss with women the psychological impact on their relationship.
Pain can set off a cycle of problems. This can lead to fear in anticipation of sexual intercourse, which leads to decrease in sexual desire, and then decrease in lubrication. This can then move on to avoidance of intercourse and intimacy, and then relationship problems. For this, it is important that there is a sensitive and frank discussion and that the couple is offered relationship or sexual counselling, if needed.
Vaginal discharge: definition, assessment, and diagnosis
Vaginal discharge is a fluid produced by glands in the vaginal wall and cervix that drains through the vagina. Discharge can by physiological or pathological.
Normal vaginal flora (lactobacilli) colonize the vaginal epithelium and may have a role in defence against infection. They maintain the normal vaginal pH between 3.8 and 4.4. The quality and quantity of vaginal discharge will vary during the menstrual cycle; each woman will have her own sense of normality and what is acceptable or excessive for her. Women who have used hormonal contraception may find this differs when they change methods.
An increase in the amount of vaginal discharge, an abnormal odour, or consistency of the fluid can be pointers of an infection or other pathological causes listed in Fig. 8.1.
Vaginal discharge: causes
Causes of vaginal discharge in women of reproductive age1
• Infective non-sexually transmitted.
• Bacterial vaginosis.
• Infective (sexually transmitted).
• Trichomonas vaginalis.
• Chlamydia trachomatis.
• Neisseria gonorrhoeae.
• Foreign bodies (e.g. tampons, condoms).
• Cervical polyps and ectopy.
• Genital tract malignancy.
• Allergic reactions.
Non-sexually transmitted infections
Bacterial vaginosis (BV) is the commonest cause of infective vaginal discharge. BV is characterized by an overgrowth of anaerobic organisms that replace normal lactobacilli, leading to an increase in (pH ≥4.5). Gardnerella vaginalis is commonly found in women with BV, but the presence of Gardnerella alone is insufficient to make a diagnosis of BV. Signs and symptoms are outlined in Table 8.1. BV is associated with a new sexual partner and frequent changes of partner, although can be seen in virgins. Increased rates of BV can occur in certain groups of women, such as black African women, smokers, and lesbians. BV is also associated with pelvic infection after induced abortion and in pregnancy with pre-term delivery and low birth-weight babies.
Table 8.1 Summary of symptoms and signs (including point of care test for vaginal pH) associated with common infective causes of vaginal discharge in women of reproductive age1
Thick white discharge
Scanty to profuse or frothy yellow discharge
Offensive or fishy odour
Vulval itch or soreness
Low abdominal pain
Discharge covering vagina and vestibule. No vulval inflammation
Normal findings or vulval erythema, oedema, fissuring, satellite lesions
Vulvitis and vaginitis. So-called strawberry cervix (uncommon 2%)
POINT OF CARE TEST—VAGINAL pH
1. Adapted from FFPRHC and BASHH Guidance: the management of women of reproductive age attending non-genitourinary medicine settings complaining of vaginal discharge (January 2006).
► Recurrent BV is seen in women who experience prolonged bleeding.
Candida albicans is a vaginal commensal found in 10–20% of asymptomatic women. Acute vulvovaginal candidiasis (VVC) is caused by an overgrowth within the vagina of yeasts—usually C. albicans (80–95% of cases) or C. glabrata (5%). VVC affects about 75% of women at some time during their reproductive life, with 40–50% having two or more episodes. Candidiasis occurs most commonly when the vagina is exposed to oestrogen, especially in women aged 20–30 years and in pregnancy. Antibiotic use and diabetes may precipitate VVC. There is no good evidence that hormonal contraception increases VVC, nor is there evidence that tampons, sanitary towels, or douching cause candidiasis. Signs and symptoms are outlined in Table 8.1.
Sexually transmitted infections
Trichomonas vaginalis is a flagellated protozoan that can cause vaginitis. Women with TV commonly complain of vaginal discharge and dysuria (due to urethral infection). Typical signs and symptoms are given in Table 8.1. Trichomoniasis is less common in affluent countries but reaches high levels (often 10–20%) among poor women in developing countries, as well as among disadvantaged women in affluent countries. Trichomoniasis has been ranked by the WHO as the most prevalent non-viral STI in the world, with an estimated 172 million new cases a year.
Vaginal discharge: investigations and treatment
• Take cervical and urethral sampling for microscopy and culture for gonorrhoea (rectal and oropharyngeal culture is only appropriate if indicated by sexual history).
• Cervical nucleic acid amplification test (NAAT) for chlamydia. If cervical swab not possible, then urine NAAT.
• Microscopy and culture of vaginal discharge for Candida is not always necessary.
• Microscopy of vaginal discharge provides an immediate diagnosis of trichomonas, but, culture is more sensitive.
Non-sexually transmitted infections: treatment
(cure rate: 70–80%):
Metronidazole 2g stat, single dose, or 400–500mg twice a day for 5–7 days.
Avoid alcohol and advise if metallic taste in the mouth.
Avoid stat dose when breast feeding.
Clindamycin 300mg twice a day for 7 days is an alternative.
(cure rate: 70–80%):
Metronidazole gel 0.75% 5g for 5 nights, or clindamycin cream 2% 5g for 7 nights.
► Advise latex barrier methods may be damaged.
All regimens are safe in pregnancy.
Metronidazole 400mg twice a day before and after menstruation, or metronidazole gel 0.75% twice a week for 4–6 months.
Avoid local irritants, no soap, alcohol, and/or perfume products, (shower preferred to (bubble) bath), avoid vaginal douching, and avoid antiseptics. Aqueous cream can be used externally as soap substitute.
(cure rate 80–95%):
Clotrimazole pessaries 500mg single dose, or 200mg for 3 nights, or econazole pessaries 150mg single dose (Ecostatin-1®), or 150mg for 3 nights, or miconazole cream 2% 5g for 10–14 nights. Creams can be applied to vulval and peri-anal areas.
Advise latex barrier methods may be damaged.
Fluconazole capsule 150mg single dose.
Avoid oral regimens in pregnancy, may be teratogenic. Topical treatment may require a longer duration.
Fluconazole 100mg once a week for 6 months, or clotrimazole pessary 500mg once a week for 6 months.
As above for BV, additionally avoid tight fitting clothing, nylon underwear, allow skin to breathe.
Sexually transmitted infections: treatment
(cure rate 95%):
Metronidazole 2g single stat dose, or 400–500mg twice a day for 5–7 days. Metronidazole is not known to present a problem in pregnancy, but avoid stat dose.
Nature of infection (STI), possible complications if not treated (e.g. vestibulitis, cervicitis), partner notification, screening and treatment, recommend screening for other STIs considering window periods, advise no sexual intercourse for 1 week after self and sexual partner(s) have been treated, additional condom use if on COCP.
See Gonorrhoea: overview, p.[link].
See Chlamydia: overview, p.[link].
Sexual health in context
Close links exist between the fields of sexual health and reproductive health as illness/disease/psychological well-being/interventions in one area can impact on others. According to World Health Organization (2005), sexual health encompasses:
• HIV and reproductive tract infections;
• unintended pregnancy and abortion;
• sexual well-being (sexual dysfunction, pleasure)
• violence related to sexuality and gender;
• certain aspects of mental health;
• genital mutilation;
• the effect of physical disabilities and chronic illnesses on sexual health;
Vulnerability to sexual ill health, therefore, goes beyond medical conditions. In the UK, sexual health has a public health function and one of the aims of services is to reduce the increasing burden of STIs and unintended pregnancies by providing a wide range of accessible and high-quality services in a variety of settings, which include general practice, community and voluntary sector sexual and reproductive health clinics, and specialist GUM services
• Taking a good sexual history is a prerequisite to good care.
• An assessment that involves asking relevant questions to acquire the right information to effectively guide examination, testing, and/or referral.
• Find out the most important causes for concern.
• Creates opportunities to appropriately inform and advise patients on risk reduction of STIs and sexual health.
• May identify association with current health problems.
• Some screening services have patient self-management with minimal clinician involvement.
Factors facilitating an effective SH consultation—clinicians should:
• Allow adequate time for the consultation.
• Ensure a confidential environment and emphasize confidentiality.
• Be non-judgmental.
• Avoid embarrassment.
• Be knowledgeable on STIs, at-risk behaviours, tests available, and targeted interventions.
• Have well-developed communication skills: asking sensitive questions, giving information, listening, recognizing verbal and non-verbal cues in patient.
• Be aware of, and use, guidelines on consent (e.g. Fraser guidelines and <16 Department of Health Guidance) Mental Capacity Act and child protection, where appropriate, or acts applicable in your country.
Main elements of a sexual history
Approach to taking a sexual history
• In a comprehensive sexual history, both the clinician and the patient need to avoid embarrassment.
• Framing of questions is important.
• Choice of terminology is crucial.
• Some patients prefer to use common language, others may prefer to discuss the issue in medical terms.
• Social and medical history should always be explored.
• Presenting complaint/reason for testing/presentation at clinic.
• Age—to establish competency/meet service criteria.
• Past STIs—to establish if any symptoms due to recurrent/untreated infection.
• Current/recent antibiotic use/medication—to check for drug interactions/contraindications.
• Sexual partners, gender, last sexual intercourse, condom use, type of sex in last 3–6 months or most recent partners—establishes risk factors for some STIs, sites for sampling, timing of when to test to cover incubation/window period of some infections.
• LMP and contraception—some medications contraindicated/unlicenced for use in pregnancy or interact with hormonal contraception.
• If symptomatic, check if:
• abnormal vaginal discharge;
• genital sores/pain/lumps;
• urinary symptoms;
• lower abdominal pain;
• vulval skin problems.
The 5 Ps
Incorporates all aspects of a good sexual history:
• Prevention of pregnancy.
• Protection from STI.
• Past history of STI.
Planning: specimen collection, diagnosing
• Based on assessment, decide which tests to offer and where to sample, i.e. if includes examination/screening only/referral—important to ensure patients understand what they will be tested for, why, and give consent.
• Discuss any findings with patient and how results will be given.
• Based on risk assessment, raise/discuss safe sex, condom use, as appropriate.
• Partner notification if also being treated for an infection at the time.
The level of detail, depth of information, and relevance of some elements of the sexual history will vary, depending on if patient is having screening only, has symptoms, complexity of any problem, the services offered in that setting and referral pathways.
This is defined as the process of contacting and notifying sexual partners of an individual diagnosed with an STI, that they may be exposed to an infection and need treatment and tests. The aim is to break the chain of infection, i.e. prevent re-infection to the treated individual from an untreated partner, and/or to stop an infection being passed on to new partners.
Main types of partner notification (PN)
This takes place when the patient (referred to as the index patient), with the diagnosis of an infection, is encouraged and helped to inform their sexual partner(s) of the need for treatment and testing. The patient may then decide to do this verbally, send a message, or give a contact slip. The aim is that the patient takes the initiative to inform their sexual partner of the infection and the partner attends in good time for treatment and tests.
Where a patient is unable or unwilling to tell their sexual partner(s), the clinician undertakes to do this (this may be after an agreed period) with the details given by the index patient. The health advisor or clinician is obliged to maintain the confidentiality of the index patient, including the diagnosis, if they do not wish to be identifiable.
The contact slip
Patients with an STI have an option to give or send a contact slip to their partner(s). The purpose is that, hopefully, a contact will respond quickly and attend a recommended clinic. This slip of paper is recognized across sexual health services in the UK and gives key basic information, some of which the clinician completes:
• The clinic where the index patient was treated.
• A national code for the infection.
• The date the index patient was treated.
• The unique number of the patient (not a name).
By using a code for the infection and a number for the patient, the patient’s identity and diagnosis is protected.
In some cases, if the index patient agrees, the name of the infection may be written on the slip.
Contact slips are never given for HIV, more support is needed here compared to other STIs.
Key points when undertaking PN with a patient who has an STI
• Establish understanding of infection, inform and advise.
• Inform of the need to treat, importance of partner treatment.
• Highlight the risks of re-infection if partner untreated and any possible health complications for self and partner or future partners.
• Develop strategies with patient to overcome embarrassment, anger, fear, or other barriers that may prevent them telling partners.
• Establish how they would inform their partner—would they use a contact slip or tell them in person?
• Be objective—listen, explain, challenge any misconceptions, give facts.
• Health promotion—safer sex to prevent/reduce future risks.
Consultation with the contact or partner who presents for treatment
• Check they know what infection they have been in contact with.
• If they bring a slip with a code and are unaware what infection they may have been exposed to, be careful not to break the confidentiality of the index patient by divulging what this means. This is often difficult, as patients would like to know what they are being treated for. You can only offer the treatment and tests unless their own STI tests are subsequently positive for a specific infection.
• Give epidemiological treatment, where needed, and offer/refer for STI screening.
Most STIs are notifiable for advice, screening, and treatment. There are specific issues with HIV partner notification, where the aim is to get as many partners in for counselling and testing rather than break the chain of disease.
www.ssha.info For advice, contact health advisers at your local GUM clinic.
Also known as ‘the clap’ or GC, this infection is caused by a Gram-negative bacterium called Neisseria gonorrhoea and affects mucosal sites, such as the endo-cervix, urethra, pharynx, rectum, and conjunctiva.
At-risk groups in the UK
• Those under the age of 25 years.
• Men who have sex with men.
• Black ethnic groups.
Occurs when infectious fluids come into contact with mucosal surfaces. Risk of transmission from a single episode of sexual intercourse from an infected male to female is 40%. About 30% of babies born to infected mothers develop ophthalmia neonatorum.
Differential diagnosis in women
Difficult to achieve if based on signs and symptoms only. as these mirror other infections as well ( see Table 8.2).
Table 8.2 Gonorrhoea: signs and symptoms
Mucopurulent cervical discharge
Green/yellow urethral discharge and dysuria
+/− contact bleeding of the cervix (up to 50%)
Up to 50% have no signs
Women with pharyngeal and rectal infection are often asymptomatic
Increased or abnormal vaginal discharge (up to 50%)
About 12% of women with urethral infection experience dysuria
Lower abdominal pain (~5%)
• Culture—gold standard test and recommended as the first choice where women are symptomatic or where GC is highly suspected. Sensitivities to antibiotics are also given in lab report.
• Rapid test—microscopy (30–57% sensitive).
• NAAT test—a DNA test for screening, often offered as a combined test with chlamydia screening. A positive result should always be confirmed by taking a sample for culture at the time of treating, as false-positive results have occurred. Also NAAT tests do not give sensitivities to antibiotics.
Sample can be taken from mucosal sites. Use the specified manufacturer’s swab kits for NAAT tests and culture. Some names of NAAT testing kits include Aptima Combo and Probetec.
NAAT tests from women who are asymptomatic can be self-taken, low vaginal swabs.
Storage and transport
Outside GUM, samples for culture should be taken with the specified swab for insertion into an Amies Charcoal or Stuart’s medium. The sample, once taken, should get to the lab within 24h. If samples are kept overnight in the clinic/ward, they should be stored in a fridge ideally at 4°C, but aim to get to the lab as soon as possible next day.
Gonorrhoea: treatment and notification
Depends on site of infection, local antibiotic sensitivities, and national recommendations.
Cephalosporins are currently the first-line treatment, although this differs for pharyngeal infection. Gonococcal antibiotic resistance is becoming an increasing problem, particularly with gonorrhoea that has been acquired abroad, and some quinoline-resistant gonorrhoea has emerged, which responds better to third-generation cephalosporins.
First line is, amoxicillin or ceftriaxone 250mg IM single dose, if allergic to penicillin. Cefixime 400mg orally can be used. Pregnant women should not be treated with tetracyclines or quinolones.
All partners for the last 10 days to 3 months should be notified to have tests and treatment. Points to cover include:
• Nature of the infection, transmission, importance of treatment for herself, and partner treatment.
• Once she is treated, no sex until partner treated and for 1 week after he is treated.
• Check the patient understands the risk to herself and/or partner or future partners if she has an untreated infection and continues to have sex or if re-infection occurs from an untreated partner.
• Discuss how she intends to inform any partners.
• Agree on how to follow up to check treatment-compliance, if relevant, partner treatment, and any risk of re-infection.
• Offer condoms.
What the patient needs to know
• GC is highly infectious and the longer it is left untreated, the more likely it will get passed on to a partner, especially new partners.
• GC can cause complications for women such as PID, which is often quite painful and may affect fertility in the future.
• She must tell her partner or partners to get treated or last known partner, if contactable.
• If she is unable to tell a partner, health advisers in a GUM clinic can help with this.
Caused by the bacterium Chlamydia trachomatis. Sero-variants D-K primarily affect the genital tract.
• Primarily sexually acquired via unprotected vaginal, oral, anal intercourse or genital contact with an infected person.
• Has also been found on nasopharynx and eyes without genital tract infection.
The most common bacterial STI in the UK. In 2006, the highest rates in women were in ages 16–19.
• Change of sexual partner or more than one partner at the same time.
• Under the age of 25.
• Not using barrier method of contraception.
Table 8.3 Chlamydia: signs and symptoms
Contact bleeding on cervical cytology or swab
Unusual vaginal discharge
Mucopurulent cervical discharge
The recommended test is Nucleic Acid Amplification Test (NAAT), a DNA test that is highly sensitive and specific, and can be used on non-invasive specimen samples, such as urine and self-taken low vaginal swabs (currently only the Aptima NAAT is licensed for vulvo-vaginal swabs). The recommended manufacturer’s testing kits should be used and local lab advice sought on sites for specimen collection. Although NAATs are more than 99% specific, false-positive results can occur, particularly in low-prevalence populations.
As a guide:
• If female and asymptomatic—patient can take a low vaginal swab. Urine samples not usually recommended for women, as sensitivity of the NAAT test is reduced compared to swabs
• If female and symptomatic—an endocervical swab should be taken. Men—first-catch urine samples are the recommended specimen.
Chlamydia: treatment and partner notification
First-line treatment is a stat dose of azithromycin (1g) or doxycycline 100mg twice a day for 7 days. Choice of drug is dependent on cost (the latter being cheaper) versus compliance. Both have equal effectiveness in clearing uncomplicated infection and a test of cure is not necessary but, if wanted, should be done 5 weeks after treatment.
Untreated infection can be passed to the baby via the birth canal resulting in pneumonitis and/or eye infection.
Erythromycin is the recommended treatment for pregnant women but is associated with poor tolerance, resulting in patients not completing the course. Test of cure is recommended at 3 weeks for women receiving this treatment. Many sexual health clinics now treat pregnant women with azithromycin, although this is out of licence use (BASSH guidance).
• Risk of PID, if untreated infection.
• Chlamydial perihepatitis.
• Sequalae of chronic PID—ectopic pregnancy.
• Chronic persistent pelvic pain.
• Chlamydial pneumonitis in baby with maternal untreated infection.
• Check understanding of the nature of the infection, treatment, transmission.
• Partner(s) from the last 6 months or last known partner. If last sexual intercourse >6 months, should be contacted for epidemiological treatment and screening.
• Offer a contact slip/establish how partner will be informed.
• Discuss the risk to self, partner, or future partners, if untreated, or risk of re-infection if a partner remains untreated, e.g. PID.
• Advise no sex from treatment to completion, until current sexual partner is treated and for 1 week after.
• Offer condoms and advise on usage.
What to discuss with the patient
• What is chlamydia and how it is transmitted?
• Chlamydia is often asymptomatic, particularly in women, and, although tests are accurate, no test is absolutely so.
• What are the complications of untreated chlamydia?
• The side-effects of treatment and the importance of compliance.
• Interactions between antibiotics and the COCP.
Pelvic inflammatory disease (PID): definition, causes, and diagnosis
The result of an infection in women, ascending from the endocervix or other pelvic organs, causing one or more of the following:
• Tubo-ovarian abscess.
• Pelvic peritonitis.
PID may be acute or chronic, and a patient may present with or without symptoms ( see Table 8.4).
Table 8.4 Clinical features suggestive of PID
Lower abdominal pain
Fever >38 degrees
Guarding/rebound on bimanual examination
Post-coital or inter-menstrual bleeding
Cervical excitation and adnexal tenderness, adnexal mass on bimanual examination
Abnormal vaginal discharge
Mucopurulent discharge on cervix
Irregular vaginal bleeding
• Chlamydia trachomatis (60%).
• N.Gonorrhoea (implicated in 14% of PID cases in a British study).
• Non-sexually transmitted micro-rganisms from the vaginal tract, such as Mycoplasma hominis, anaerobes, E. coli, and staphylococci.
• Descending infections from appendicitis.
• Ascending infections post-procedural, such as insertion of IUD, hysteroscopy.
• Women under age of 25.
• Multiple partners.
• Past history of STIs.
• Termination of pregnancy.
• Insertion of an IUD within the last 3 weeks.
Examination and investigations
• Bimanual examination. Clinical symptoms and signs lack specificity and sensitivity, the positive predictive value of a clinical diagnosis ranges from 65 to 90% compared to laparoscopy.
• Endocervical swabs for chlamydia and GC culture. If either of these tests are positive, this supports the diagnosis of PID; if negative, does not exclude these infections as possible causes, as tests can be negative after infection has ascended. A positive NAAT for gonorrhoea should be confirmed by culture prior to treatment because of high false-positive rates. A high vaginal swab for Trichomonas vaginalis is also recommended but its value in the management of PID is questionable. Bacterial vaginosis has been associated with PID. The presence of clue cells, and leukocytes on microscopy is associated with a 5-fold risk of PID.
• ESR or C reactive protein tests may help in supporting a diagnosis, if either are raised.
• Pregnancy test, if required to rule out ectopic pregnancy.
• Check patient’s temperature.
• Laparoscopy—allows samples to be taken from the fallopian tubes, but there is not enough evidence to support routine use due to:
• High cost.
• Inter-observer variability.
• Intra-observer variability.
• Potential difficulty in diagnosing mild intra-tubal inflammation or endometritis.
• Transvaginal ultrasound scan may help where diagnosis is difficult, but, evidence does not support routine use. Is useful if suspected adnexal or pouch of douglas mass to look for pyosalpinges or tubo-ovarian abscess.
To consider in women presenting with lower abdominal pain:
• Ectopic pregnancy.
• Acute appendicitis.
• Urinary tract infection.
• Torsion of an ovarian cyst.
• Constipation/bowel problems such as irritable bowel syndrome (IBS).
Careful discussion should be based on current evidence and individual patient history.
Pelvic inflammatory disease (PID): treatment
The Royal College of Obstetricians and Gynaecologists (RCOG) recommends a low threshold for empirical treatment. Generally, if cervical motion tenderness +/− adnexal tenderness on bimanual examination, empirical treatment should be given. Do not await the outcome of STI tests.
In mild to moderate PID
Broad-spectrum antibiotic treatment to cover the main likely causes i.e. N.Gonorrhoea, Chlamydia trachomatis +/− anaerobes (treatment for anaerobes is of greater importance in severe PID).
In severe acute PID
Or severe pain and diagnostic doubt on surgical emergency, refer for hospitalization and management.
Treatment in pregnancy
In all cases of suspected PID, a pregnancy test should be undertaken to rule out ectopic pregnancy; erythromycin is the preferred antibiotic.
In an intra-uterine pregnancy, PID is rare, but cervicitis can occur, which is associated with increased maternal and foetal morbidity.
Recommended outpatient treatment regimens for PID
• IM ceftriaxone 250mg single dose + doxycycline 100mg bd for 14 days + metronidazole 400mg bd for 14 days;
• Oral ofloxacin 400mg bd for 14 days + metronidazole 400mg bd for 14 days.
• Partners should be screened, then given empirical treatment for chlamydia, gonorrhoea, and/or other STIs.
• Patient should not have sex until she has completed her treatment and her sexual partners have been treated.
• Where screening for CT and GC is not possible, empirical treatment to cover both infections should be offered to the partner.
Review in 72h to check resolution of symptoms and a bimanual examination and, if improving, thereafter in 2 weeks to check compliance with treatment, response to treatment, abstinence from SI, and to check on partner notification and treatment.
Women with PID and IUD
Current advice from the RCOG and the FSRH is leaving the device in situ in women with mild PID and ensuring review at 72h and in 2 weeks. This sounds sensible and is workable. This also enables a full discussion with the woman regarding her susceptibility to infections within her current sexual relationship.
The British Association for Sexual health and HIV (BASHH) suggest considering removal. It is important to follow local guidelines.
Women with HIV and PID
Antibiotic therapy is the same as for women who are HIV negative, as response tends to be good. If severe symptoms, parenteral therapy may be considered.
Hepatitis B (HBV)
Hepatitis B is a blood-borne virus that causes inflammation of the liver. About 10% of those infected may not clear the virus and remain infectious.
• Injecting drug use with contaminated equipment
• Receiving infected blood or blood products vertical transmission from an infected mother
• Sexual transmission higher in some groups e.g. sex workers, men who have sex with men
• Needle stick/sharps injury
• Practices e.g. tattooing piercing, using infected equipment
• Living in endemic countries
The main route of transmission in UK is via unprotected sex and injecting drug use. Other routes of transmission include: needlestick injuries in health professionals, transfusion of infected blood products, piercing and tattooing with unsterile equipment, living in institutions, and coming from endemic countries.
Symptoms and signs
• Asymptomatic or flu-like symptoms, nausea, fever, unwell, lethargy, +/− pale stools.
• About 30% develop jaundice.
Recommended to check for acute/previous/chronic infection or previous vaccination if hepatitis B suspected or if patient is from a high-risk group and considering vaccination.
• Core antibody (tests for previous infection or natural antibodies).
• Surface antibody (tests for previous vaccination and indicates if a vaccination course or booster is required).
• Surface antigen (if positive suggests current or infection that has not cleared).
• Ig M antibody to Hep B core antigen (to determine if acute or chronic infection).
• Hepatitis B antigen/antibody and Hep B DNA (to determine if high or low infectivity).
• Avoiding and/or minimizing exposure to the risks, e.g. condom use, sterile disposable needles for tattoos.
• Routine screening of transfused blood and blood products.
• Using universal precautions in healthcare settings.
• Vaccination (a course of three injections) for high-risk individuals and all newborn infants:
• persons from endemic areas;
• sex workers;
• alleged sexual assault;
• men who have sex with men and their partners;
• partners and household contacts of hepatitis B carriers;
• injecting drug users and their partners/household contacts;
• those living in institutions, e.g. prisons;
• HIV positive individuals.
• Prevention of vertical transmission from HBsAg and HbeAg positive mothers to newborns—vaccinate newborn.
• Post-exposure prophylaxis—hepatitis B immunoglobulin.
• Preventing transmission in women with liver transplants.
Chronic carriers are those who have not cleared an acute infection naturally after 6 months (the Hep B surface antigen test remains positive). Such persons have no symptoms for many years but are at risk of developing liver cirrhosis and liver cancer. This risk increases in persons who are also HIV positive, on immuno-suppressant drugs, or with chronic renal problems. 90% of babies born to infectious mothers (hep B eAntigen positive) will become chronic carriers unless vaccinated at birth.
Contact tracing testing +/− vaccination
Consider partners or household contacts from the time when the patient remembers having symptoms (2 weeks before the onset of jaundice). This may be difficult for persons coming from endemic countries, where infection may have been acquired vertically or in early childhood.
Lamivudine, adefovir dipivoxil, possibly pegylated interferons in the long term, reduce liver damage and lower risk of liver cancer in patients who respond to treatment.1 Patients are usually managed by a specialist (hepatologist or physician experienced in liver disease).
Patients should be informed of the long-term implications of the condition, advised on alcohol, risk of transmission to partners and household contacts, and prevention measures, such as condom use, getting partners/household contacts tested and vaccinated. No unprotected sexual intercourse should take place until the partner is tested and vaccinated.
Hepatitis C (HCV)
Hepatitis C is a common disease but is often under-diagnosed. Hepatitis C is caused by a blood-borne RNA virus, which, like HBV, can cause inflammation of the liver, but the effects of the infection vary from one individual to the other. There are 11 genotypes of HCV. Genotype 1 is the most common in the UK
• From infected blood transfusions or products prior to 1987.
• Use of, or exposure to, contaminated needles is the major route of transmission in the UK.
• Vertical transmission.
Only 20–40% of women infected will clear the virus naturally. Infection lasting more than 6 months is considered chronic.
There is no vaccine at present to prevent this infection.
• Injecting drugs sharing contaminated needles/equipment.
• Received infected blood transfusions or blood products.
• Dental care or medical care in countries where infection control is poor.
• Regular sexual partner of someone with HCV.
• Tattoos, piercing, other practices involving needles where infection control poor e.g. FGM.
• Accidental exposure to blood where there is a risk of exposure to HCV.
• May take years or decades to develop.
• Most people at the time of transmission are unaware and have no symptoms.
• Some may feel unwell.
• Jaundice is uncommon.
One in five with chronic HCV may eventually develop severe liver damage, which could lead to primary liver cancer or liver failure.
• Antibody test (anti-HCV)—takes up to 3 months for antibodies to become detectable in blood.
• RNA test (HCV RNA):
• If +, suggests unresolved infection.
• If after 6 months it is negative and the anti HCV +, this suggests the infection has cleared but the person may not be immune to further infection.
Prevention in primary care
• Provide hepatitis A and B vaccinations to all those using IV drugs and MSM (men who have sex with men).
• Information on safe sex including condoms.
• Easy convenient access to local needle exchanges or run a needle exchange in the surgery.
• Advice to stop smoking.
• Monitor weight and provide help with weight reduction.
• Discuss alcohol and advise to stop drinking alcohol.
Combined pegylated interferon and ribavirin help to reduce the viral load in about 55% of patients with chronic HCV.
HIV and HCV co-infection
HIV positive patients who also have HCV co-infection and are on HAART, have a 2- to 3-fold increased risk of developing hepatotoxicy. However, the majority of co-infected patients are able to use HAART with careful monitoring (such as ultrasound scans, fibroscan, liver biopsy, blood tests) and are often jointly managed by the HIV physician and local hepatology team.
Nurses have a role in supporting co-infected patients by:
• Discussing safe sex and prevention of transmission to new or long-term partners.
• Advising and referring patients who are planning a pregnancy for specialist advice.
• Advising on avoidance of alcohol and reducing/stopping smoking.
• Helping to cope with side-effects of pegylated interferon drugs, such as weight loss, anorexia, depression, and hair loss by referring appropriately.
• Supporting adherence to HIV medication and treatments.
Anogenital warts (benign epithelial skin tumours)
The double-stranded DNA human papilloma virus—there are several strains associated with genital warts, most common ones are types 6 and 11.
• Mostly sexually through genital to genital skin contact.
• Can occur even if there are no visible warts.
• Increased risk of transmission to a partner if warts are present.
• Poor evidence of transmission from fomites.
• Mother to baby transmission during vaginal delivery possible.
• Most commonly diagnosed viral STI in UK.
• In 2006, there were 47% new diagnoses in GUM clinics in women with highest rates in the 16–19 age group.
• Can appear anywhere in the genital area.
• Perianal lesions common.
• Rarely cause physical discomfort.
• May be itchy, sore, and cause irritation especially around the anus.
• Psychological distress as a result of the disfigurement.
• Occasionally warts can grow so large as to affect urination, defecation, and childbirth.
• Children born to women with cervical and vaginal warts may develop laryngeal and/or genital warts.
• Single or multiple.
• May be flat, fleshy, soft, or keratinized, pigmented, or pedunculated lumps. Size varies, but may increase over time if untreated or if immuno-compromised.
• Usually based on appearance and naked eye examination.
• External genital and speculum examination.
• Biopsy should be considered in secondary care if the lesion is atypical or pigmented.
• Good lighting and clinical diagnostic skills are essential.
Treatment depends on the site, number, size, appearance of warts, and patient preference. The most common treatments for external genital warts are:
• Cryotherapy—clinician applied freezing of individual external warts using liquid nitrogen spray. Often a weekly or twice weekly treatment.
• Podophylotoxin 0.15% cream—patient applied treatment to external warts (except if lesion area is >4cm square). Avoid in pregnancy.
• Imiquimod—an immune response modifier. Suitable for home use. Not licensed in pregnancy.
• Other treatments include clinician applied trichloracetic acid, excision under anaesthetic, electro surgery, and laser treatment. All have limited impact in clearing the virus.
• No treatment is an option.
Cervical warts—may not require colposcopy, unless there is clinical concern or diagnosis is uncertain.
• Most likely in the first 3 months after treatment but varies.
• Warts generally clear within 2 years but may be longer especially if immuno-compromised.
Should check themselves for warts. If in long-term relationship, very likely already exposed to genital HPV. Transmission is more likely when warts are visible. Condoms may not provide complete protection.
Warts can increase in size and proliferate in pregnancy but often disappear once pregnancy is over.
Caesarean section is generally not indicated unless vaginal introitus studded with warts or there are large cervical warts
• Condom use may be beneficial in new relationships.
• Vaccines for preventing high-risk HPV types 16 and 18 now available and a quadrivalent vaccine, which includes protection against low-risk types 6 and 11, is an effective option.
www.bashh.org/guidelines/2007Natguidemgxagw2007.pdf (Accessed Nov 2008.)
Caused by the double-stranded DNA herpes simplex virus (HSV), which is a member of the herpes family. Disease episodes may be primary or recurrent.
• Type 1—causes cold sores on lips and mouth, and usually transfers to the genitalia via oral sex.
• Type 2—confined to genitals only and transmission is via direct genital skin contact, especially mucosal contact. Transmission is even possible if there are no visible sores or ulcers (asymptomatic shedding).
Incidence and prevalence
Incidence rates are highest in the 20–24 age group and prevalence of type 2 infections is 10–30% in developed countries
• Severity of symptoms is determined by primary immunity to HSV.
• Tingling sensation preceding the formation of a blister or vesicle.
• +/− fever, neuralgia.
• Vaginal discharge may reflect vaginal ulcers or cervicitis.
• +/− more severe symptoms such as difficulty passing urine.
• Painful ulcer at the site of the blister or vesicle when it is broken.
• Enlarged and tender inguinal nodes.
• +/− increased vaginal discharge.
• Ulceration usually occurs as multiple small ulcers.
• Behcet’s disease.
• Chancroid (often a single painless ulcer with indurated edges found in primary syphilis).
• Fissure—superficial linear tear in the vulval skin particularly in the folds of the labia and often caused by Candida.
Diagnosis/signs and symptoms
• Clinical appearance based on naked eye examination.
• DNA test with PCR or virus culture of lesion. Swab sample of the fluid from the vesicle or from base of vesicle/ulcer. The sample is inserted in the specific viral medium. The sample has to be kept refrigerated and cold-chain maintained until it reaches the lab.
• Antibody testing is not helpful as it lacks specificity.
• Topical anaesthetic gel helps with localized pain, but, sensitivity can occur.
• Saline bathing.
• Oral antivirals (aciclovir, famciclovir, or valaciclovir) for 5 days can reduce severity and duration of symptoms. These antivirals are most effective if taken within the first 5 days of an outbreak or while new lesions are forming. 5–7 day treatment is best. Longer treatment is required for up to a year if recurrences occur.
• If in a long-term relationship, it is likely the partner has already had exposure to the virus.
• Partners should check themselves for any sores or ulcers.
Management, including type of delivery, depends on gestational age and whether primary/recurrent episode of herpes. Women should be asked at their first antenatal visit if they or their partners had genital herpes in the past. Caesarean section is recommended for all women presenting with primary genital herpes at the time of delivery and/or if infection occurs within 6 weeks of delivery.
The first episode or primary episode is often the most painful and subsequent episodes are more tolerable. Patients learn to recognize prodromal symptoms, such as tingling or itching, in the same area of previous herpetic ulcers and can use antivirals to prevent or reduce an outbreak. Recurrences are more likely in the first year of a primary diagnosis and are more likely with HSV Type 2.
• Patient-initiated antiviral treatment considered for persons who experience <6 outbreaks in a year and can use with onset of symptoms to prevent or reduce an outbreak.
• Prophylactic or suppressive treatment—offered where patient has >6 episodes in a year and antiviral treatment is taken every day with regular follow-up. Long-term treatment with aciclovir can prevent recurrences and is thought to be safe.
Genital lumps and ulcers
• Genital warts (HPV) ( See Anogenital warts, p.[link]).
• Syphilis-related (lumps that resemble genital warts called condylamata lata and present in the secondary stage of syphilis).
• Bartholin’s abscess: a lump may appear on the left or right Bartholin’s gland area, occasionally due to a gonococcal infection, feels warm to touch and may be tender on touch. STI testing is recommended.
• Molluscum contagiosum: caused by the pox virus, not a true STI as commonly found in children but usually sexually acquired in adults. Presents as small round, raised pearly lumps with a dent or core in the middle. Incubation period 3–12 weeks and can be present for up to about 9 months.
• Cysts—usually form under the skin in the area of the Bartholin’s glands; often painless, not raised and may increase or decrease in size. Antibiotics usually not required.
• Other—any lumps that are discoloured, atypical, should be reviewed carefully and consider referral to an appropriate specialist.
Good history taking and clinical examination skills are the key to an accurate diagnosis. History of any previous diagnosis of lumps, of the possible causes, as mentioned below, how long the lump(s) present and any self-treatment help in reaching a correct diagnosis or indicates the need for referral elsewhere.
Patients often describe any breaks in the genital skin as a sore.
Most common types of genital ulcers and the causes
HSV ulcer or lesion
( See Genital herpes, p.[link].)
A sore that presents in primary syphilis infection, usually as a single, painless ulcer with raised, indurated edges. It appears at the site of entry (could be mouth as well) and, depending on the location, may not be noticed by a patient and eventually heals on its own within a week or so. Clinicians should ask about recent travel to or from endemic areas, or sexual activity in high-risk groups, e.g. sex workers. A syphilis blood test that tests for Ig G may be negative in early infections.
Anyone with a suspicious sore should be sent urgently to a GUM clinic, where a sample of fluid from the sore is taken and examined under dark ground microscopy for evidence of treponemes (the parasites that cause syphilis).
Often small, linear, superficial tears in the folds of the labia minora and majora, or posterior fourchette, usually caused by Candida (thrush). Women may complain of burning and soreness. They are often present with other typical signs suggestive of Candida, such as thick vaginal discharge, and vulval itching.
Other less common causes of genital ulceration
• Behcet’s disease—multi-organ disease, where symptoms include painful ulceration in mouth and/or genital area.
• Crohn’s disease.
• Vulval dysplasia and severe dermatitis.
• Good history taking, including a thorough sexual history, is important.
• Note should be made of worsening symptoms and/or systemic symptoms.
• Visual examination with good lighting is an essential aid to diagnosis or may sometimes indicate the need for referral.
Human immuno-deficiency virus (HIV)
A RNA virus that infects protective cells of the immune system, CD4 cells. Over time, these CD4 cells die from continued viral replication and attack. As numbers decline, the person’s immune system becomes compromised. This process often takes place over a number of years.
There is currently no vaccine or cure.
In the UK, HIV is higher in:
• men who have sex with men;
• heterosexuals from migrant black communities, mainly from sub-Saharan Africa;
• injecting drug users sharing needles.
Signs and symptoms
• Primary infection or sero-conversion may involve flu-like symptoms, but not always.
• Such symptoms may occur in the first few weeks after contracting the infection.
• Patient is often asymptomatic afterwards and for many years.
Consent must always be sought.
Where a patient is unable to consent, seek advice from specialists in GUM (genito-urinary medicine), if necessary.
Highly anxious or high-risk patients may need more in-depth counselling—consider referring such patients to GUM specialists or counsellors. General points to cover with someone testing for HIV:
• Reason for testing/benefit of knowing a result.
• Confidentiality of test and what happens with results.
• Window period, if relevant.
• What result are they expecting?
• Limitations of testing and the window period.
• What support would they have if a test was to be positive?
• How will they obtain the result?
• Other concerns—symptoms or high-risk sexual activity, which would require specialist advice, e.g. need for PEP.
• Need full STI screening.
Preventon and risk reduction strategies
• Promoting condom use. There is compelling evidence that in sero-discordant couples, consistent condom use protects the sero-negative partner against infection.
• Post-exposure prophylaxis ( see PEP, p.[link]).
• Partner notification is desirable but not mandatory, and an environment favourable to disclosure must be encouraged.
• Male circumcision may reduce the risk of infection in men but whether it reduces the sexual transmission of HIV from men to women is not known.
Screening tests for HIV
Checks only for antibodies to the HIV virus. The window period (length of time for antibodies to the virus to appear in the blood) is 3 months. A rapid Point of Care screening Test will only test for HIV antibodies but the result can become available within half an hour.
Combined antibody and P24 antigen test
As well as antibodies, this picks up the antigen circulating in the blood and detects early infection, making the window period shorter (on average 6 weeks). Most UK hospital labs now offer a combined antibody and antigen test (check with your local lab).
For both tests a venous blood sample is required.
A person testing positive for HIV should always have a confirmatory test.
Vertical transmission has dramatically reduced in the UK due to the antenatal programme of screening for HIV. An HIV +ve pregnant woman could still take antiretroviral drugs to prevent vertical transmission.
Highly active anti-retroviral drugs (HAART)
These medicines do not cure HIV but help to control viral replication and sustain the immune system. There has been a two-thirds reduction in AIDS-related deaths in the UK as more HIV +ve patients have a better life-expectancy on HAART. The choice of drugs is dependent on viral load, CD4 count, and other illnesses, which may be present at the time. There are side-effects associated with these drugs, which can affect patient compliance. Adherence is important, as viral resistance to drugs can occur if patients do not comply with treatment plans.
Post-exposure prophylaxis (PEP)
A combination of anti-retroviral drugs, which are given to women who are at high risk of exposure to HIV in order to prevent sero-conversion. These are often administered over a period of 4 weeks, with regular follow-up blood tests and reviews usually in a GUM clinic.
PEP for sexual exposure
The detailed risk assessment is based on the type of sexual activity, if the source or contact was from a high-risk group or prevalent area, and if the person was known to be HIV +ve. Such information helps clinicians weigh up the benefits to the patient of taking PEP vs the potentially severe side-effects and whether to recommend PEP or not.
PEP for a sharp injury
The risk of transmission from a single percutaneous exposure is estimated to be 0.3%. This risk increases if a deep injury occurred, or if a visibly blood-stained sharp or hollow-bore needle had just been in an artery or vein, or high-source HIV viral load.
In occupational-related exposure, if the source is known, e.g. a patient, they could be asked to consider an HIV test. The outcome could greatly affect whether someone should take PEP or not.
Timing of PEP
PEP works best if started within 72h (ideally within 24h) from exposure, although may be considered or recommended up to 2 weeks after exposure in someone at very high risk of acquiring HIV. Regular follow-up during the therapy is important to ensure adherence.
Sexual dysfunction: history taking and useful prompts
Disorders of sexual function may be the result of organic disease processes but more commonly they are due to psychological and emotional factors. Sexual problems are brought to medical settings because people do not know where else to go. The medical setting may sometimes not be the correct one, and the nurse’s task may be to assess the problem and refer on appropriately. Without adequate information, the next step will not be clear, so good history taking is crucial.
Taking a comprehensive history of a sexual problem is dependent on both the ease and comfort of the nurse in dealing with this topic, and the willingness of the patient to open up such a sensitive area to that individual. A number of factors need to be taken into account to facilitate this.
• Confidentiality needs to be clarified. The patient may well want to know how confidential her answers will be, how they will be recorded, and what will happen to them.
• Permission giving may be required from the nurse. The patient may be worried about the appropriateness of using explicit sexual language. The nurse should also seek permission before pursuing any line of investigation that the patient may feel uncomfortable with.
• Comfort with the topic is an essential ingredient of effective history taking. Discomfort with the need to be explicit is very common among our patients, as we do not discuss sex frankly in our culture, even when it is going well. It is, therefore, much more difficult when it is going badly. If we as clinicians are embarrassed or uncomfortable, then the difficulty in speaking out is doubled.
• Attitude needs to be open and non-judgemental, as any hint of criticism will close the patient down, and make further history taking very difficult.
• Language may need to be negotiated. Some words can be offensive or unacceptable to some people, or they may not have a word to describe or name something that needs to be explored.
• Taking time is crucial to good history taking in this sensitive subject. Rushing will mean people give inaccurate information, as they are often trying to express something they have never previously put into words.
Guidelines for areas to explore
• History of presenting symptom and its precise features: How long has it been going on? How was it first noticed? How is the patient’s life and her relationship affected by it? What remedies have been tried so far? Has anything made it better/worse?
• What is happening in the patient’s sexual life/relationship/family now?
• Medical history to include medical conditions, e.g. hypertension, depresssion, for which treatments like beta-adrenoceptor blocking drugs and selective serotonin re-uptake inhibitors may have been prescribed.
• Specific factors of relevance are: treatment for subfertility/or control of fertility, lost pregnancies, menstrual history, contraception.
• Sexual history to include: early sexual learning, sex education, childhood development, any interruptions, e.g. illness, loss of close relative, parental divorce, abusive events, trauma.
• Relationship history—first experience with a partner, same sex experiences, development of sexual relating, why relationships came to an end, the place of sex in relationships.
The woman’s views on the reasons why her symptoms are occurring are important, as she will often be right. As sex is a multi-faceted, socio-psychological matter, it is impacted by many factors. These can include cultural and religious influences, life events, family and relationship problems, financial and social pressures, and so on. The successful resolution of a sexual problem needs to take account of whatever other factors may have a bearing on the well-being of the patient.
Many women expect to be referred on for specialist help with a sexual problem, so it is useful to have knowledge of available facilities in your area.
Women very often have a good idea, both of what the problem is and what would be a good way forward. It is wise to ensure they know what the next step may involve before implementing it, however. Many women referred for therapy with a sexual problem have a fear that they will be asked to ‘perform’ for the therapist. In those circumstances they are unlikely to attend!
Female sexual arousal disorder
Sexual arousal in women brings about both physiological and psychological change. When a woman complains of a reduction in these changes, despite appropriate stimulation and a conducive emotional atmosphere, she may be experiencing arousal problems.
However, since a woman can undergo the physiological changes of sexual arousal without being consciously aware of them, she might believe she is experiencing arousal problems, when in fact, she is simply not psychologically/emotionally connecting to her bodily sensations of arousal. In other words, she is blocking her awareness of arousal.
Physiological changes of arousal
• Increase in respiratory rate, pulse, and blood pressure.
• Pelvic engorgement and swelling of the vulva.
• Ballooning and deepening of the interior third of the vaginal barrel.
• Vaginal lubrication.
Psychological changes of arousal
• Sense of excitement, well-being, elation.
• Wish for closeness with the partner.
• Feelings of emotional warmth, pleasure, openness.
For women, the ability to become sexually aroused is bound up with emotional atmosphere and the quality of the relationship with their partner. If the emotional environment is not conducive to the release of those neurotransmitters necessary for arousal to occur, arousal will be inhibited.
Presentation of a sexual arousal problem can be the first symptom of an underlying illness that can be treated. Therefore, accurate diagnosis is crucial. Differential diagnosis must involve careful consideration of both physiological and emotional factors, in order to devise the most appropriate treatment strategy.
The treatment of choice will depend on the cause(s) of the arousal problem, but it is worth bearing in mind that the commonest causes are emotional, in which case personal or relationship counselling is very often the advisable next step.
Where a physiological cause is found, it is likely that there will be a degree of psychological distress to the woman, and possibly to her partner also, and it would be important not to overlook any needs for support in this area. ( See Sexual dysfunction: treatment options, p.[link].)
Physiological causes of sexual arousal disorder
• Inappropriate or insufficient stimulation.
• Neurological disease including multiple sclerosis.
• Vascular disease, such as hypertension, arteriosclerosis.
• Endocrine disorders.
• Any chronic pain condition.
• Drug side-effects.
• Mental illness.
Psychological causes of sexual arousal disorder
• Emotional stress or discomfort for any reason.
• Relationship stresses, inequality, lack of closeness.
• Cultural or religious influences and conditioning.
• Problems with intimacy or commitment.
• Fear of sex, sexual abuse, trauma.
Crowe, M (2005) Overcoming relationship problems. Constable Robinson, London.
Find This Resource
Self help guide for couples in trouble, with useful homework exercises and good examples. Since relationship stress is so frequently a factor in arousal problems, this seems a good place to recommend it.
Hypoactive sexual desire disorder
Definition and classification of female sexual dysfunction (FSD)
Implicit to any discussion about a dysfunction is a consideration of normal functioning. There is much debate about this as satisfaction and fulfillment are more important to women than physiological events.
A classification that has been widely accepted is the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (4th edn) (DSM IV-TR) which covers the physiological events of desire, arousal, and orgasm. Pain is also included.
DSM IV classification of sexual dysfunction
• Hypoactive sexual desire disorder (HSDD).
• Female sexual arousal disorder.
• Female orgasmic disorder.
• Sexual pain disorders—vaginismus and dyspareunia.
Definition of HSDD
HSDD or loss of libido is an absence of, or marked reduction in, a woman’s desire for sex. It can be noticed by changes in frequency of dreams, fantasies, masturbation, and wish for contact with a partner.
• Up to 46% of women in relationships never feel the need for sex.
• 23% of women not in relationship would say they do not experience sexual desire or libido.
• The incidence of loss of libido is, therefore, hard to quantify, but up to 34% of women are dissatisfied with their sexual lives.
Not necessarily a problem
Changes in libido are part of the hormonal and reproductive life of a woman, and could, therefore, be considered normal. If there has been a change that is causing distress to the woman or her partner, then it might become a problem.
Causes of loss of libido
• Hysterectomy and oophorectomy, menopause, pregnancy and childbirth, thyroid imbalance, conditions and drugs that cause hyperprolactinaemia.
• Depression or anxiety, sexual phobia, sexual trauma, sexual abuse, grief and loss, family demands, work stress, insufficient knowledge about sex.
• Unexpressed resentment or anger, violence, infidelity, loss of intimacy, gender issues/inequality.
• Partner’s sexual problem.
• Erection or ejaculation problems in the partner, changes in partner’s sexuality, e.g. addiction, orientation confusion.
• Other sexual problems.
• Fear of sex, fear of pregnancy, avoidance, dyspareunia, vaginismus.
Assessment of HSDD
There are numerous diagnostic tools and validated inventories for sexual dysfunction, which assess various components of the disorder and scales that assess female sexual distress. All have self-reported versions available and take less than half an hour to administer. A full discussion of these inventories is out of the scope of this handbook.
Where there is imbalance, HRT may have a positive effect. Medical treatment of depression or other psychiatric conditions can also be helpful.
This would be indicated where relationship issues are detected, and can be successful using a wide variety of approaches, including psychodynamic cognitive behaviour therapy, systematic therapy, and others.
Help for partner
Where there is a need to resolve or ameliorate a problem in the partner, that can be discussed and advice for further action given.
Management of the underlying sexual problem
If there is pain, phobia, fear, sexual trauma, or sexual abuse underlying the loss of libido, the appropriate help can be offered.
Sexual dysfunction: treatment options
The selection of treatment for sexual problems is dictated by what is revealed in the patient’s history, identification of the sexual health problem, and her choice in discussion with the health professional.
• Surgical removal of hymeneal tag or a rigid hymen, if present. It should be emphasized that this is exceedingly rarely encountered, although sometimes the physical reaction to attempted genital examination can make full evaluation difficult.
• Vaginismus training using vaginal dilators, usually combined with psychological help to reduce fear, and may include biofeedback and anti-anxiety medication, along with counselling.
• Pelvic floor exercises can improve muscle tone and vaginal awareness.
• Modification of reversible causes can be achieved by HRT and/or testosterone after a hysterectomy where indicated by abnormal blood levels. Topical oestrogen may also be beneficial after the menopause.
• Lubricants such as Sylk® and Replens MD® to aid vaginal dryness. Care should be exercised if latex contraceptive products are used, as natural oils can harm the latex.
• Creams and gels recommended for use in vestibulodynia and other vulval pain syndromes, possibly combined with oral medication, such as tricyclic anti-depressants.
• Cognitive restructuring of unrealistic expectations and incorrect beliefs.
• Education of the woman and her partner, since lack of accurate information can give rise to performance pressure and fear of failure.
• Relationship evaluation and couple therapy, by professionals trained in understanding the impact of relationship patterns on sexual expression and function and the methods to resolve these.
• Individual counselling and psychotherapy, where indicated by history of trauma, sexual abuse, childhood influences, co-dependency, addictions.
• Genital examination, if acceptable, can reveal hidden beliefs and emotional blocks in relation to the woman’s self perception, body image, and relationship to her sexuality.
• Sensate focus and self-sensate focus, where the schedule outlined on p.[link] is adapted for a single person.
• Psychosexual therapy/sexual and relationship therapy, which might include both of the above, and attend to couple relationship dynamics, systemic aspects of the couple, and all facets of sexual functioning.
• Agree a ban on intercourse and genital touch until the programme includes these.
• Set up twice-weekly session times to spend on this, increasing from 20 to 60 minutes over 4 weeks.
• Speak during these times only if the touch of the partner is unpleasant or painful, as concentration is important.
• Emphasis is on the personal experience/learning of each partner, not on giving pleasure or aiming for any particular outcome.
Taking plenty of time, each person explores the other’s body, avoiding breasts and genitals, avoiding trying to arouse the other, and concentrating on the physical and emotional feelings experienced in both ‘active’ and ‘passive’ roles. After 2 weeks, 4 sessions, there should be enough familiarity and trust to include breasts, asking for what is preferred, and experimenting with a range of touches, to include oils if liked.
Maintaining the ban on intercourse, genital touching can be included, to explore what types of touch feel pleasurable, to familiarize the couple with each other’s genital responses, and to aid communication about each other’s sexuality. If liked, proceeding to mutual masturbation to orgasm could be included after a few sessions.
Initially maintaining the ban on full intercourse, as before, the couple would experiment with including vaginal penetration and containment without thrusting for a few moments at each session, increasing the movements gradually session by session until full intercourse becomes easy and comfortable.
Female orgasmic disorder
It is the persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase, despite appropriate stimulation and a conducive emotional atmosphere (although some authorities prefer the term pre-orgasmia, if the condition is primary). It may be primary, if the woman has never experienced orgasm in any circumstances, or secondary, in which case, for some reason, she has ceased to have an orgasm. Also, female orgasmic disorder may be situational, where the woman is orgasmic in some situations and not others, e.g. being able to orgasm on her own but not with a partner.
Causes of anorgasmia
These may be physiological, psychological, or anatomical, and whatever the cause, there is likely to be a degree of emotional distress, usually a feeling of not being fully a woman, not measuring up to others, and a sense of shame and inadequacy. The main causes are physiological, psychological and anatomical ( see p. [link] for causes of anorgasmia).
Where there is a lack of accurate and useful information about the normal anatomy and physiology of orgasm, basic sex education is an important part of treatment.
Many women with this problem believe they are the only sufferers, so reassurance that as many as 34% of women have sexual problems and about 10% of women have anorgasmia can be helpful.
This would include learning to masturbate to orgasm, possibly using aids (see below), practising Kegel’s pelvic floor exercises to strengthen the pubbococcygeal muscles, sensate focus programme either for the woman alone or with a partner, experimenting with lubricants.
Sex toys and vibrators can be very helpful in this condition. Main’s operated devices are more effective for women who have never achieved orgasm
Vielle orgasm enhancers are latex finger cots with protuberances to increase stimulation to the clitoris.
Causes of anorgasmia
• Any disease that affects the nervous system or the blood supply to the genital area.
• Hormonal imbalance, particularly hyperprolacitinaemia, menopause, thyroid imbalance.
• Any drug treatment that affects the nervous system, particularly SSRIs.
• Genital surgery where the nerve supply may have been implicated.
• Fear of intimacy/commitment/need to control.
• Relationship stresses.
• Fear of sex.
• Past sexual trauma.
• Insufficient or inappropriate stimulation.
• Poor pelvic fit between partners can cause orgasm difficulty with intercourse, simply because the male pelvis does not press the woman’s vulva at the correct angle for her.
• Weakening of pelvic floor causing reduced intravaginal sensitivity.
Heiman, J, LoPiccolo, J (1988) Becoming orgasmic: a sexual growth programme for women. Piatkus Books, London.
Find This Resource
Useful self-help guide for women, a bit old-fashioned but it does not sensationalize and is very sound.
Komisaruk, B, Beyer-Flores, C and Whipple, B (2007) The science of orgasm. Johns Hopkins University Press Baltimore.
Find This Resource
Interesting for clinicians as it gives overview covering many aspects and approaches to this wide subject.