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STIs &Contraception
26 June 2025, Dr Milena Nossen,
Dr Sophia HwaiLearningOutcomes
● Sexually transmitted infections: Diagnosis, treatment, prevention
● HIV/AIDS: Testing, management, and ART
● Hepatitis B and C: Screening, diagnosis, and management
● Contraception: Emergency, hormonal, IUD, sterilization
● Adverse effects of contraception
● Patient counselling for STI prevention and contraception Question 1
A 25-year-old woman who is 16 weeks pregnant presents to her GP with mild lower
abdominal discomfort and increased vaginal discharge. She denies any urinary symptoms. A
high vaginal swab is taken, and nucleic acid amplification tests (NAATs) return positive for
Chlamydia trachomatis. She reports no known drug allergies.
Which is the most appropriate antibiotic to prescribe?
A. Azithromycin 1g stat dose
B. Doxycycline 100mg twice daily for 7 days
C. Erythromycin 500mg four times daily for 7 days
D. Amoxicillin 500mg three times daily for 7 days
E. Ciprofloxacin 500mg twice daily for 7 days Question 1
A 25-year-old woman who is 16 weeks pregnant presents to her GP with mild lower
abdominal discomfort and increased vaginal discharge. She denies any urinary symptoms. A
high vaginal swab is taken, and nucleic acid amplification tests (NAATs) return positive for
Chlamydia trachomatis. She reports no known drug allergies.
Which is the most appropriate antibiotic to prescribe?
A. Azithromycin 1g stat dose
B. Doxycycline 100mg twice daily for 7 days
C. Erythromycin 500mg four times daily for 7 days
D. Amoxicillin 500mg three times daily for 7 days
E. Ciprofloxacin 500mg twice daily for 7 daysChlamydiaChlamydia-Symptoms
Asymptomatic (70% women, 50% men)
Urethral: dysuria, urethral discharge (often white),
epididymitis
Vaginal: dysuria, PV discharge, PV bleeding, PID
Rectal: asymptomatic or proctitis (discharge, bleeding,
pain)
Oral: asymptomaticChlamydia-Testing
Men: first-void urine (NAAT)
Woman: vulvovaginal swab (NAAT)
Window period 2 weeks
Gram-stained dry slide (urethral discharge)
->shows non-gonococcal urethritisChlamydia-Treatment
Doxycycline 100mg BD for 7 days
2ndline azithromycin, erythromycin, amoxicillin
Counselling, partner notification
Men: 4 weeks before symptoms
Women/ asymptomatic men: 6 months
Abstain from sex for 7 days
No TOC needed if 1 line treatment
Test will remain +ve for 6 weeksQuestion 2
A 29-year-old man presents at the sexual health clinic with a 2-day history of green,
penile discharge and dysuria. He is otherwise well, has no significant medical
history and does not take any medications. He is sexually active and has had 5
female partners in the last 3 months, for which he uses condoms sporadically. His
last encounter was 7 days ago. Examination is significant for erythema around the
urethral meatus and green discharge on the tip of the penis.
What is the most likely diagnosis?
A. Chlamydia
B. Gonorrhoea
C. Urinary tract infection
D. Urethritis
E. SyphilisQuestion 2
A 29-year-old man presents at the sexual health clinic with a 2-day history of green,
penile discharge and dysuria. He is otherwise well, has no significant medical
history and does not take any medications. He is sexually active and has had 5
female partners in the last 3 months, for which he uses condoms sporadically. His
last encounter was 7 days ago. Examination is significant for erythema around the
urethral meatus and green discharge on the tip of the penis.
What is the most likely diagnosis?
A. Chlamydia
B. Gonorrhoea
C. Urinary tract infection
D. Urethritis
E. SyphilisGonorrhoeaGonorrhoea–Symptoms
Urethral: dysuria, urethral discharge
Vaginal: PV discharge, PV bleeding
Rectal: asymptomatic or proctitis (discharge, bleeding, pain)
Oral: asymptomatic
Disseminated infection
Tenosynovitis, migratory polyarthritis, dermatitis
Septic arthritis, endocarditis, perihepatitisGonorrhoea-Testing
Men: first-void urine (NAAT)
Women: vulvovaginal swab (NAAT)
Window period 2 weeks
Gram-stained dry slide (urethral
discharge)
->might show gram-negative intracellular
diplococci Gonorrhoea-Treatment
1. Send culture from infection site (urethral, endocervical, rectal, oral
swab)
2. Ceftriaxone 1g IM stat OR ciprofloxacin 500mg PO stat (if
sensitivities known)
a) 2nd line: oral cefixime 400mg STAT + oral azithromycin 2g
STAT
3. Partner notification, counselling
4. Abstain from sex for 7 days
5. TOC after 2 weeks Question 3
A 28-year-old man presents to his GP with a 2-week history of fever, sore throat, and a
non-itchy maculopapular rash on his trunk and limbs. He returned from a backpacking
trip across Southeast Asia four weeks ago. He also reports malaise, myalgia, and mouth
ulcers. On examination, he has cervical lymphadenopathy. Blood tests are unremarkable.
What is the most likely diagnosis?
A. Infectious mononucleosis (glandular fever)
B. Secondary syphilis
C. HIV seroconversion illness
D. Dengue fever
E. Streptococcal pharyngitis Question 3
A 28-year-old man presents to his GP with a 2-week history of fever, sore throat, and a
non-itchy maculopapular rash on his trunk and limbs. He returned from a backpacking
trip across Southeast Asia four weeks ago. He also reports malaise, myalgia, and mouth
ulcers. On examination, he has cervical lymphadenopathy. Blood tests are unremarkable.
What is the most likely diagnosis?
A. Infectious mononucleosis (glandular fever)
B. Secondary syphilis
C. HIV seroconversion illness
D. Dengue fever
E. Streptococcal pharyngitisHIVHIV-Transmission
via body fluids – blood, semen,
vaginal fluid, rectal fluid, breast milk
During sex, mother-to-child, blood
exposure (needlestick, transfusion)HIV-Symptoms
Incubation period 2 - 4 weeks on average
60-80% symptomatic
○ sore throat
○ lymphadenopathy
○ malaise, myalgia, arthralgia
○ diarrhoea
○ maculopapular rash
○ mouth ulcers
○ rarely meningoencephalitisHIV-Testing
Who to test?
○ Symptomatic patients
○ Patients taking PrEP
○ HIV contacts, SA victims
○ Everyone who consents to it in sexual
health
○ Opt-out testing in EDs since 2022
○ Routine in pregnancy / blood donations
○ BASHH condition indicator, eg Kaposi
sarcoma
Window period 4 generation tests: 45 days
HIV 1/2 Antibody and HIV p24 Antigen testing
HIV RNA viral load – particularly in acute infection and
infants <18 monthsHIV-Treatment
1. Partner notification & counselling
2. Refer to HIV clinic
3. Baseline testing
1. Health checks – FBC, U&Es, LFTs,
lipids, HbA1c
2. HIV – resistance, viral load, CD4
count etc.
4. Commence ART immediately
1. 2x NRTI + INI, PI or NNRTI
5. f/u in HIV clinic regularly Question 4
A 25-year-old woman presents to her general practitioner with a painless genital ulcer that
appeared one week ago. She reports a new sexual partner and inconsistent use of barrier
contraception. On examination, there is a single, firm, non-tender ulcer on her labia majora
and non-tender inguinal lymphadenopathy. Serological testing shows a positive
treponemal-specific enzyme immunoassay (TP-EIA) test.
What is the most appropriate next investigation to confirm active syphilis infection?
A. Repeat the treponemal-specific TP-EIA test
B. Order a non-treponemal test (e.g., VDRL)
C. Arrange HIV serology testing
D. Perform dark-field microscopy on the lesion
E. Request PCR testing for Treponema pallidum DNA Question 4
A 25-year-old woman presents to her general practitioner with a painless genital ulcer that
appeared one week ago. She reports a new sexual partner and inconsistent use of barrier
contraception. On examination, there is a single, firm, non-tender ulcer on her labia majora
and non-tender inguinal lymphadenopathy. Serological testing shows a positive
treponemal-specific enzyme immunoassay (TP-EIA) test.
What is the most appropriate next investigation to confirm active syphilis infection?
A. Repeat the treponemal-specific TP-EIA test
B. Order a non-treponemal test (e.g., VDRL)
C. Arrange HIV serology testing
D. Perform dark-field microscopy on the lesion
E. Request PCR testing for Treponema pallidum DNASyphilisSyphilis
Primary (9 -90 days) Secondary (6 weeks – 6 months) Tertiary (20+ years)
Chancre Fevers, lymphadenopathy Cardiovascular
Local, non-tender lymphadenopathy Rash on trunk, palms, soles Neurological
Buccal, ‘snail track’ ulcers Gummatous
Condylomata lataSyphilis-testing
Non-treponemal tests
o E.g. RPR, VDRL Non-treponemal Treponemal Interpretation
o Not specific – false positives positive negative Active syphilis
o Pregnancy, SLE, TB, HIV, infection
malaria, leprosy
o Becomes –ve after treatment positive negative False positive
syphilis
Treponemal-specific tests
negative positive Treated syphilis
o e.g. TP-EIA, TPHA
o More expensive but specific for
syphilis
o Remains +ve Question 5
A 35-year-old man attends the GP clinic for a routine health check. He is asymptomatic and
has no significant past medical history. He mentions he is planning to travel abroad for
work and wants to ensure his vaccinations are up to date. Blood tests reveal the following
Hepatitis B serology results:
- HBsAg: positive
- Anti-HBc IgM: negative
- Anti-HBc IgG: positive
- Anti-HBs: negative
Which of the following is the most likely interpretation of his Hepatitis B serology results?
A. He has acute Hepatitis B infection.
B. He is chronically infected with Hepatitis B.
C. He is immune to Hepatitis B due to vaccination.
D. He is immune to Hepatitis B due to past infection.
E. He has resolved a past Hepatitis B infection and is a carrier. Question 5
A 35-year-old man attends the GP clinic for a routine health check. He is asymptomatic and
has no significant past medical history. He mentions he is planning to travel abroad for
work and wants to ensure his vaccinations are up to date. Blood tests reveal the following
Hepatitis B serology results:
- HBsAg: positive
- Anti-HBc IgM: negative
- Anti-HBc IgG: positive
- Anti-HBs: negative
Which of the following is the most likely interpretation of his Hepatitis B serology results?
A. He has acute Hepatitis B infection.
B. He is chronically infected with Hepatitis B.
C. He is immune to Hepatitis B due to vaccination.
D. He is immune to Hepatitis B due to past infection.
E. He has resolved a past Hepatitis B infection and is a carrier.HepatitisHepatitis B
Spread via blood/ other fluids HBsAg: indicates current infection – either acute or
Incubation period 6-20 weeks chronic (if > 6months)
Fever, jaundice, deranged LFTs HbeAg – marker of replication, infectivity
Management: 1 pegylated interferon-alpha
or other antivirals Anti-HBc IgM: in acute infection
Complications: chronic hepatitis, liver failure, Anti-HBc IgG: in chronic infection (persists
hepatocellular carcinoma, >6months)
glomerulonephritis, polyarteritis nodosa,
cryoglobulinaemia Anti-HBs: indicates immunity by vaccination OR
Vaccine routinely given in babies and high exposure – negative in chronic infection
risk groupsHepatitis
Hepatitis C Hepatitis D
Transmission via blood, <5% risk while Via blood and fluids, requires hepatitis B surface
intercourse antigen
Incubation period 6-9 weeks Either co-infection or superinfection
30% symptomatic (jaundice, LFTs, fatigue, Treatment: interferon
arthralgia) No vaccine available – but hep B vaccine is
Complications: 55-85% develop chronic effectively protection
hepatitis C
Arthritis, arthralgia, Sjogren’s, cirrhosis,
hepatocellular ca, cryoglobulinameia,
glomerulonephritis
No vaccine availableHepatitis
Hepatitis A Hepatitis E
Faecal-oral spread Faecal-oral spread
Incubation period 2-4 weeks 3-8 weeks
Self-limiting, usually harmless Similar disease to hepatitis A
Flu-like symptoms, RUQ pain, tender Severe disease, 20% mortality in pregnant
hepatomegaly, jaundice, deranged LFTs women
Vaccine only given to at risk groups (high Vaccine in development
risk areas, MSM, IV drug users, chronic
liver disease) Question 6
A 25-year-old woman presents to the sexual health clinic complaining of painful
genital sores. She reports that over the past three days she has developed
multiple small ulcers on her vulva, which are very painful. She also reports
dysuria (painful urination).
She is sexually active and has had two new sexual partners in the last six months.
On examination, there are multiple small, shallow ulcers on her labia majora and
minora, with surrounding erythema. There is no inguinal lymphadenopathy. She
is otherwise well, but feels a bit under the weather.
What is the most likely diagnosis?
A. Genital herpes simplex virus infection
B. Primary syphilis
C. Chancroid
D. Lymphogranuloma venereum
E. Behçet’s disease Question 6
A 25-year-old woman presents to the sexual health clinic complaining of painful
genital sores. She reports that over the past three days she has developed
multiple small ulcers on her vulva, which are very painful. She also reports
dysuria (painful urination).
She is sexually active and has had two new sexual partners in the last six months.
On examination, there are multiple small, shallow ulcers on her labia majora and
minora, with surrounding erythema. There is no inguinal lymphadenopathy. She
is otherwise well, but feels a bit under the weather.
What is the most likely diagnosis?
A. Genital herpes simplex virus infection
B. Primary syphilis
C. Chancroid
D. Lymphogranuloma venereum
E. Behçet’s diseaseGenital HerpesGenital herpes simplex-symptoms
Prodrome – flu-like symptoms, tingling/itching/burning
sensation
Small, painful blisters or ulcers in genital area
Dysuria/ difficulty opening bowels
Tender lymphadenopathy
Will resolve on their own after several days to weeks Genital herpes simplex-management
In pregnancy:
1. HSV 1/2 swab
2. Treat clinically – 5-day course
400mg acyclovir TDS Known diagnosis or 1 /2st ndtrimester
o Consider regular aciclovir until
3. Saline bathing, analgesia, topical
anaesthetics delivery 22 (if risks for premature)
or 32 and offer vaginal delivery
4. Patient education
3 trimester
o Consider aciclovir until delivery.
Consider c-section, especially if
within 6 weeks of deliveryContraception Question 7
A 23-year-old woman presents to the clinic, requesting for emergency
contraception. She had sex with her regular partner 101 hrs ago, but the
condom broke.
She is currently on day 21 of a 28-day cycle. She has not had any other UPSIs in
this current cycle.
She does not have any medical conditions and takes no regular medications.
Her BP is 117/78 and she weighs 68kg. She is not keen for an invasive
procedures but agrees to try hormonal contraception.
Which of the following options is most suitable?
A. Levonorgestrel today and commence POP today
B. Levonorgestrel today and start POP after 5 days
C. Ulipristal today and commence POP after 5 days
D. Ulipristal today and commence POP today
E. Advise that oral EC are unlikely to be effective if taken after ovulation Question 7
A 23-year-old woman presents to the clinic, requesting for emergency
contraception. She had sex with her regular partner 101 hrs ago, but the
condom broke.
She is currently on day 21 of a 28-day cycle. She has not had any other UPSIs in
this current cycle.
She does not have any medical conditions and takes no regular medications.
Her BP is 117/78 and she weighs 68kg. She is not keen for an invasive
procedures but agrees to try hormonal contraception.
Which of the following options is most suitable?
A. Levonorgestrel today and commence POP today
B. Levonorgestrel today and start POP after 5 days
C. Ulipristal today and commence POP after 5 days
D. Ulipristal today and commence POP today
E. Advise that oral EC are unlikely to be effective if taken after ovulationEmergency
ContraceptionEmergencyContraception
Copper IUD Ulipristal (EllaOne) Levonorgestrel
Most effective – 99% Selective progesterone receptor Inhibits ovulation & inhibits
modulator – inhibits ovulation
implantation
Inserted up to 5 days after UPSI or 5
days post likely ovulation date Up to 120 hours post UPSI Up to 72 hours – efficacy decreases
with time
Can be used for long-term Can be used multiple times in same
contraception cycle Can be used multiple times in same
Reduces hormonal contraception cycle
effectiveness – wait 5 days
Does not affect hormonal
Caution in severe asthma/ enzyme contraception
inducers
Double dose if BMI > 26 or weight >
Delay breastfeeding for 1 week 70kg or enzyme inducerEmergencyContraception
Copper IUD Ulipristal (EllaOne) Levonorgestrel
Most effective – 99% Selective progesterone receptor Inhibits ovulation & inhibits
modulator – inhibits ovulation
implantation
Inserted up to 5 days after UPSI or 5
days post likely ovulation date Up to 120 hours post UPSI Up to 72 hours – efficacy decreases
with time
Can be used for long-term Can be used multiple times in same
contraception cycle Can be used multiple times in same
Reduces hormonal contraception cycle
effectiveness – wait 5 days
Does not affect hormonal
Caution in severe asthma/ enzyme contraception
inducers
Double dose if BMI > 26 or weight >
Delay breastfeeding for 1 week 70kg or enzyme inducerEmergencyContraception
Copper IUD Ulipristal (EllaOne) Levonorgestrel
Most effective – 99% Selective progesterone receptor Inhibits ovulation & inhibits
modulator – inhibits ovulation
implantation
Inserted up to 5 days after UPSI or 5
days post likely ovulation date Up to 120 hours post UPSI Up to 72 hours – efficacy decreases
with time
Can be used for long-term Can be used multiple times in same
contraception cycle Can be used multiple times in same
Reduces hormonal contraception cycle
effectiveness – wait 5 days
Does not affect hormonal
Caution in severe asthma/ enzyme contraception
inducers
Double dose if BMI > 26 or weight >
Delay breastfeeding for 1 week 70kg or enzyme inducerEmergencyContraception
Column textEmergencyContraception
Column text Question 8
A 28-year-old woman attends your GP practice for a routine follow-up 6
weeks after insertion of a copper intrauterine device (IUD). She reports that
she has not felt the threads recently and is concerned about whether the
device is still in place. She has not experienced any abdominal pain, vaginal
bleeding, or signs of infection.
On examination, you are unable to visualise the IUD threads on speculum
examination. A pregnancy test is negative.
What is the most appropriate next step in management?
A. Reassure her and advise to check for threads again in one month
B. Arrange a pelvic ultrasound scan to locate the IUD
C. Insert a new IUD immediately
D. Advise use of barrier contraception and review in three months
E. Refer for abdominal and pelvic X-ray to locate the IUD Question 8
A 28-year-old woman attends your GP practice for a routine follow-up 6
weeks after insertion of a copper intrauterine device (IUD). She reports that
she has not felt the threads recently and is concerned about whether the
device is still in place. She has not experienced any abdominal pain, vaginal
bleeding, or signs of infection.
On examination, you are unable to visualise the IUD threads on speculum
examination. A pregnancy test is negative.
What is the most appropriate next step in management?
A. Reassure her and advise to check for threads again in one month
B. Arrange a pelvic ultrasound scan to locate the IUD
C. Insert a new IUD immediately
D. Advise use of barrier contraception and review in three months
E. Refer for abdominal and pelvic X-ray to locate the IUDIUD/ IUSIntra-uterine device
IUD IUS
Releases cupper ions -> decreased Levonorgestrel -> prevents
sperm motility and survival endometrial proliferation and causes
cervical mucus thickening
For 5 or 10 years For 3,5 or 8 years
Immediately effective Effective after 7 days
Side effects: heavier, longer, more
painful periods Side effects: initial irregular bleeding,
later lighter, less painful periods or
amenorrhoea
Complications: uterine perforation
(0.2%), ectopic pregnancies,
infection, risk of expulsion 1 in 20Intra-uterine device
IUD IUS
Releases cupper ions -> decreased Levonorgestrel -> prevents
sperm motility and survival endometrial proliferation and causes
cervical mucus thickening
For 5 or 10 years For 3,5 or 8 years
Immediately effective Effective after 7 days
Side effects: heavier, longer, more
painful periods Side effects: initial irregular bleeding,
later lighter, less painful periods or
amenorrhoea
Complications: uterine perforation
(0.2%), ectopic pregnancies,
infection, risk of expulsion 1 in 20 Question 9
A 32-year-old woman comes to the contraception, requesting for a repeat of her usual form of
contraception, Depo-Provera. She has been on the depot injection for 1 year and her last dose
was 15 weeks and 2 days ago. She has been amenorrhoeic since commencing the injections.
She had unprotected sex at 13+3 and at 14+4 weeks after her last dose.
Her PMH is significant for epilepsy, for which she takes lamotrigine.
What is the best course of action on this appointment?
A. Administer the depot injection today, no further action required
B. Book another appointment for 3 weeks time and offer bridging contraception with POP
C. Book another appointment for 3 weeks time and advise to abstain from sex until then
D. Administer the depot injection today and provide emergency contraception
E. Perform a urinary pregnancy test and administer the depot injection if it is negative Question 9
A 32-year-old woman comes to the contraception, requesting for a repeat of her usual form
of contraception, Depo-Provera. She has been on the depot injection for 1 year and her last
dose was 15 weeks and 2 days ago. She has been amenorrhoeic since commencing the
injections. She had unprotected sex at 13+3 and at 14+4 weeks after her last dose.
Her PMH is significant for epilepsy, for which she takes lamotrigine.
What is the best course of action on this appointment?
A. Administer the depot injection today, no further action required
B. Book another appointment for 3 weeks time and offer bridging contraception with POP
C. Book another appointment for 3 weeks time and advise to abstain from sex until
then
D. Administer the depot injection today and provide emergency contraception
E. Perform a urinary pregnancy test and administer the depot injection if it is negativeDepot injectionDepot injection
Medroxyprogesterone acetate
MOA: Inhibits ovulation, thickens cervical mucus
Administration: every 12-13 weeks, effective for 14
weeks
Side effects: amenorrhoea, irregular bleeding, weight
gain, delayed return to fertility, increased risk of
osteoporosis
Contraindications: breast cancer
Cautions: high BMI, osteoporosis Question 10
A 27-year-old woman is looking to start on contraception. She has read up on the
different options and would like to try the combined oral contraceptive pill.
Which of the following is the strongest contraindication to her starting the COCP?
A. PMHx of ovarian cancer
B. Blood pressure on visit 135/87
C. Mother had a PE aged 52
D. History of migraine with aura, 5 years ago
E. 5 weeks post-partum and breastfeeding Question 10
A 27-year-old woman is looking to start on contraception. She has read up on the
different options and would like to try the combined oral contraceptive pill.
Which of the following is the strongest contraindication to her starting the COCP?
A. PMHx of ovarian cancer
B. Blood pressure on visit 135/87
C. Mother had a PE aged 52
D. History of migraine with aura, 5 years ago
E. 5 weeks post-partum and breastfeedingCombined oral
contraceptive pillCombined oral contraceptive pill
Contains oestrogen/ progesterone
MOA: inhibits ovulation
Taken daily for 21 days, followed by 7 days break
Advantages: makes periods regular, lighter, less painful. Reduced risk of ovarian,
endometrial and colorectal cancer. May benefit ovarian cysts, benign breast disease,
acne vulgaris, PID
Disadvantages: user-dependent, increased risk of VTE, stroke, breast, cervical cancer
Temporary side effects: headache, nausea, breast tendernessCombined oral contraceptive pill
Contraindications:
UKMEC 3
BMI >35, immobility, FHx of VTEs <45yrs, >35
yrs & smoking <15
UKMEC 4
Migraine with aura, hx of VTE, breastfeeding
<6weeks, >35 yrs & smoking >15 SEEYOUNEXT
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