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Just realized that whole time I was speaking, I was on mute. So, hello, everyone. Thanks for joining. Sorry for being a little bit late. It was just a bit late getting back from work. Um I'm just uploading the slides as we speak and we'll get started soon, but I'll give people a bit more time to log in. Yeah, thanks for joining again. So, yeah, thanks again for joining. I can see one or two more people joining. It looks like it's not such a big session today. Um That's ok. Hopefully you guys will benefit from it as well. And I suppose if any, you know anyone who was interested in coming, but just couldn't make it today, then we'll obviously upload um the slides and the recording. So just bear with me just while these slidess are loading. But yeah, we'll, we'll get started very shortly. Yes, I know. R um It's just that I don't want to get to the point where um we reach the limit of the slide if that makes sense. Cos the first two are just some quick intro ones. So I'll just wait for just some, another minute or so. Just for like one or two more slides to slow and we can probably get cracking. Ok. I might give it a go anyway. But apologies if we end up having to wait for some slight load, but it should load as we speak. So I'll start presenting now. Okie Doke. So, yes. So today the topic is sexual health. So I'm Vicky, uh, a doctor at Eastbourne Hospital and I'm basically here to just teach everything. Um, well, not everything. Some of the main bits that I thought were quite useful to cover under sexual health, um, for finals or for whatever stage you're at. Really, um, it's quite a, I think, high yield topic and also I think tends to be some of the more straightforward questions in exams. So I think really good to have nailed this, have this topic nailed down. So, just a quick intro about who we are. So, um, the overall organization is called Metic Teaching and, um, the final series as part of the sort of Thursday 15 series, we roughly sticked about, um, 10 to 15 minutes of MC Qs. But to be honest, in this session, actually, what I'm gonna do is we'll do the M CQ, then we'll go straight into the answer and then so on and so on. I've got about eight MC Qs. So hopefully it shouldn't take too long. Um, and then I'll go over some of the explanations for the answers. Um, as we go along as well. And yeah, so join in for, on Thursdays for more topics. We have some on Tuesday as well coming up, we're kind of nearing the end of the series. So by like mid June, we'll probably finish then also you'll probably have all finish your exams as well by then. So just in time. So in terms of what we're gonna cover here, um, I, yeah, the actual MLA section for sexual health is not a huge uh section. Um, but to be honest, actually, I think a lot of it overlaps with the Gynae stuff as well. Um, and the infectious diseases part, but I'm just sort of mainly focusing on the sexual health element of that, but there is definitely overlap. Um, so today I'm mainly gonna cover on uh sort of vaginal and urethral discharge differentials, er, investigations and management, a little bit of post, post quoted bleeding and some emergency contraception and postpartum contraception stuff. So all very high yield, um, useful information to know for your exams. Um, so let's get straight to it. So if you want to grab a pen and paper or just write on your phone and I'll give you about a minute um, to read the question and write down your answer and then I'll ask you for what you put down first before I let you know what the answer is. Ok. So starting off with question one minute starts now. Okie Doke. That's been about a minute. So, does everyone wanna put, what they think is the answer in the chart? Any others? So, this question was actually, um, based on, uh, in fact all these questions I've really tried to base on what came up in my, um, exams. Yes. I wish I was organized enough to have made poll before this. So, I'm really sorry. I think it'll probably distract me trying to make a poll right now. Um, but if no one wants to pop it in the chat, that's fine, we'll just go straight. Oh gosh, r are very helpful. Um I mean, yeah, feel free to be clear. It's fine. No problem. Um I will anyway, just move on to the answers for this one then. So, um, the answer is the first void urine sample. Um So I suppose it's just this. Oh, yes, thank you. OK. People wanna, I mean, you already know the answer. Um So the reason why I put this question in is because, um, I think it's just very important to have a good handle on what tests to do basically for different presentations. And actually in this history here, it's really, really difficult to tell, um, what actually is going on here. Um, without some further, I think investigation results like some microscopy or something cos it, you know, could be, um, chlamydia could be gonorrhea, could be all sorts of different things. Um, but actually the, I suppose single most useful test in this case would be the first void urine sample out of all of these. Um You would still do some of these as well as well as um the urine sample, not saying the others are wrong. Um But yeah, out of all these options here, you'd yeah, that would be the one you'd prioritize in order to help diagnose the cause of discharge. Um And obviously a swab would still be useful. Um And that would obviously be more of your testing for like gonorrhea and other bits. So, yeah, and then I made, so this is what I had in my notes as well. So I suppose if you try and make a summary table yourself for when you do certain tests for different types of presentations. So I suppose the standard S ti screening will test for chlamydia and gonorrhea. Uh and that you will get from a first world urine sample as in the case in this question here and they send that off for NTS testing or if it's a woman, you would send a vulvovaginal swab. Um And then you can also do HIV and syphilis serology. Although in this case, I think the presentation that he had was less likely to be those things, but you would still do all the other bits and Bobs as well. Um And then depending on other um bits of the demographic history, you're gonna do further testing. So, um in men who have sex with men, you would do the three site testing. So in addition to the urine, the rectum and the pharynx, um and then you can also do hepatitis B and C serology screening. Um And then there's a whole bunch of other different um yeah, types of microscopy or viral PCR tests that you can do when you're thinking of more specific infections that you want to test for. Um So you just need to be a bit more, have a bit more history to sort of guide you as to why you're doing those tests for something like trichomonas. For example, you wouldn't typically screen for that unless you had a suspicion of it. But yeah, most of the testing will be for chlamydia and gonorrhea and the standard ST I testing. Okey doke. So moving on to the second question. So yeah, maybe I'll have a go then at making the poll. If that works, I'll let, I'll give you a minute whilst you're um thinking of the answer here. Very kind of you, Ria, don't worry. I think actually I can probably do them whilst you guys are uh thinking of the question answer. So, um, don't worry. Thank you, Doctor Okie Doke. I think that's been about a minute there. So I will, I've queued something but for some reason it's not coming up. Let me see. Ok, I think I'm done. Ok, pop your answers in anyone else wanna also? Ok. I've got one at the moment. Ok, we've got two anymore for anymore. Ok. We're getting the trend here. So, yeah, well done the right diagnosis here. Um, oh, we had a late entrant there with E That's ok. Um, so I suppose, uh, let's go through this question then. So this is a 27 year old female five day history of vaginal discharge. That could be so many different things. Um, so I suppose I was trying to be a bit leading here with some of the clues here, but they have to give you something in the exams as well. So an offensive smell, no pain or itchiness has a new sexual partner. Um but sort of to deter you from more of the um S ti route. She's been using condoms. Um And on speculum examination, you get this description of a thick, thin, oh, sorry, not thick, thin gray watery um discharge and the ph as well as the clue. So that's 5.5 0.0. Sorry. And I think so I put a lot of images actually in my questions because that is how they tend to ask a lot of the um sexual health questions I remember in my exam. Um There was yeah, lots of images actually in the gynae sexual health section. So I think definitely something to include in your vision is um Yeah, looking at how things how these um infections look under the microscope. Uh So yes, if you'd revised this already you would know that. Yes. So those, that image there shows what we call clue cells. Um And I've got some slides later on to show the difference between what normal vaginal flora looks like compared to when um someone's experiencing bacterial vaginosis. Um So yes, well done to those who answered. Thank you. Um And I suppose just before we go into the specifics of uh bacterial vaginosis, um it's good to just make sure you have a good framework in mind of thinking of differentials because um in this case, obviously, there was a lot of clues there to try and get, get you to think of BV. Um But always remember to sort of have a broad range of differentials in your mind and different clues and different aspects of the history are gonna just lead you down um certain different routes, but just remember there's infective and non infective causes. Um and then within the infective causes. Um There's, yeah, non S TI which is what BV is, but still an infection there is S ti sort of more in the vaginal area. So that's like trichomonas and then more endocervical urethral is chlamydia and gonorrhea. Um Yeah, so just have that bear that in mind. So just going to the specifics of BV. Um So it's like I said, a non sexually transmitted infection of the lower genital tract and the reason why it happens um is because if there's a disturbance basically to the normal flora, it leads to decreased number of the lactobacilli. Um, and they're actually the type of organisms that keep the bacteria ph, sort of less than 4.5. Um, but when the population of lactobacilli is reduced, er, it means that other types of um bacteria are able to grow other organisms and then um the PH therefore increases as well. So commonly you can find things like um, oh gosh, I'm really bad at pronouncing these GG nella um anaerobes and mycoplasmas as well. They tend to be quite common in BB. Um Yes. So clinical features wise this is important. So, like I was saying, you know, you might not get something as obvious as like a fishy smell but uh they might just say, yeah, offensive smell, um, usually is not associated with itching or irritation and the description of the discharge is usually a thin watery gray vaginal discharge. Um And some of those risk factors here just make you more likely to get BV. So, yeah, new sexual partner use of the IUD presence of an ST I use of, you know, scented soaps, er, recent antibiotic use in smoking are some, um, and in terms of the investigations you're gonna do, um, so you're gonna do a high vaginal smear and you're gonna check under the, you know, the microscope, what you can see. So you'll be able to see clue cells. I've got slides coming up just to uh accentuate this point. Um You're gonna see a reduced number of lactobacilli in an absence of pus cells. Um So there's, there's something called the AML criteria here. Um So yeah, basically, if you remember all these key features here, you can be pretty certain that you've got BV, especially in an M CQ. Um Yeah, I suppose it also could come up in Roy as well if they present, you know, if it's part of an examination as well. Um So yeah, here's a slide just to show the difference between the, so the normal er flora is on your um left of the screen. Um So you can see here. Yeah, there's normal squamous epithelial cells like lots of lactobacilli around. Um Yes, sorry. Yes, I think that's the right thing. Yeah. And then in the next one to the right, you can see that there are clue cells present. So um there's a distinct lack of lactobacilli. Um and you can see that actually there's a lot of these like clue cells basically around um with all the Yeah, so it's basically, yeah, no lactobacilli and then the clu cells are present there as well. Um So yeah, that's basically gonna help you diagnose BV. Um and in terms of management, er so most commonly you take metroNIDAZOLE, um this can be taken orally or as a gel. Um and just basically provide some advice about um you know, not using certain products like scented shower gels and you may consider removing IUD if it is contributing to that, it tends to actually reoccur quite a few times. Um But yeah, hopefully that treatment should, uh you know, treat it and sometimes you may not even need treatment for it. It will just sort of resolve on its own if it's asymptomatic. Okie Doke. So, moving on to the next question. So I'll give you a minute to have a think about this. So I think that's your minute up. So let me just pop the pull up. So what did everyone put for this? Any other responses? Give me another few seconds. No. Oh We've got a little bit of a split here and I wonder actually because there is, there may be some sort of mixed information out there. Um But yeah, so let's go through this question there. So the answer is Ceftrixone and let's so I haven't actually given you much information in this um you know, stem um apart from maybe the green vaginal discharge makes you think less likely to be something like chlamydia. But you never know. Um And actually the main thing I was trying to get you to focus on in this question was, yeah, looking at that slide because I'm pretty sure this exact image came up in my exam. Um So just make sure to have, yeah, all these sort of um S ti s and non infect, non S ti sorry infections um memorized in your head what they look like on the slide. Um So we'll go through. Um So, yeah, this basically, this slide here shows the classic um gram negative like coffee shaped, coffee bean shaped sorry diplo um organisms there. So indicative of Neera gonorrhea and I've got a labeled slide a bit further on as well. So you can just look at it in a bit more detail. And so the treatment for gonorrhea is 1 g of im cefTRIAXone. Um So metroNIDAZOLE, metroNIDAZOLE, as we just studied, there was, would be used to treat bacterial vaginosis. Ciprofloxacin used to be the treatment of choice for gonorrhea. Um, but I think as there's been increasing resistance to it, cefTRIAXone is recommended. So you can look at these guidelines. Er, there's an organization called Bash and I've got the, um, I'll have the link at the end and, yeah, so just have a look in there. But I think it's ceftrixone uh, rather than Ciprofloxacin. Nitro is for lower uti S as you know, and benzylpenicillin used to treat syphilis. So that's how you'd narrow it down. Um So just a bit more detail about gonorrhea. So it is a sexually transmitted infection caused by the gram negative bacteria. No gonorrhea, it's one of the most common. Um, bacterial ST is um more common in people under the age of 25 and with, uh, in men who have sex with men and it's treated uh, sorry, transmitted through um unprotected vaginal oral anal sex and can also be transmitted vertically from mother to child. Um So yeah, like I said, some of those risk factors that include the age range um and living in high density urban areas. Previous infection gonorrhea, sometimes it can lay dormant there for a while or you just may not have symptoms from it and having multiple sexual partners as well. Um So in females, the typical symptoms are sort of increased vaginal discharge. It can be a range of appearances. So sometimes I think just making diagnosis based on the appearance can be quite tricky. And that's why I think they have to give you some other piece of information um to help you make that diagnosis, which is why I gave you that microscopy um slide there. Um So yeah, dysuria, dya lower abdominal pain, um maybe some postcoital bleeding or intermenstrual bleeding, sorry. And in terms of what you're actually gonna see, so you're gonna see discharge, it can be like I said, a range of different, you know, colors and um yeah, and you might get some pelvic tenderness as well if it's gone to the stage of where it's maybe causing um pelvic inflammatory disease as well. And in males similar, um you're just gonna get, yeah, obviously discharge coming from the urethra instead, you will also get symptoms of dysuria. Um you may get tenderness around the epididymis. Um But, and then if you have a rectal infection as well you may not actually know about this and to be honest, in both males, females as well, you, you may not, you know, you just may not have symptoms. Um but otherwise you may also get discharged from the anus and anal pain and discomfort. Um So yeah, this is the slide I was talking about which just has a bit more. Um Yeah, labels basically on it to just tell you what we're looking at here in terms of the slide. Um So yeah, you can see the diplo I labeled there. Um And yeah, so that just helps you basically diagnose us from the slide. So, in terms of how you're actually gonna test for it, um So sort of similar to what we were saying in the first question there. So females, endocervical vaginal swab um and that you can do your nap testing and you're also gonna take another swab for microscopy and culture for males. It's the first pass urine. Um Then you're also gonna take a urethral metal swab for microscopy culture. Um And if needs be as well, the throat rectum or even eye um if indicated in terms of management, like I said, uh so it's intramuscular ceftrixone 1 g, you should also be screening for other STIs s especially chlamydia. So that's why the sort of s ti testing that we're talking about just covers both of them because they're so, um you know, interlinked, you could have both. It's really hard to tell the difference. Um Unless you, yeah, physically sometimes see the slide and even then something you know, could be coexisting. Um And also, yeah, you should encourage previous sexual partners to, you know, to, to basically to get in touch with them and advise them to be screened. Um or sexual health clinics as well offer the service to try and maybe keep certain people anonymous as well. And you know, it's called contact tracing as well. Um And then after treatment, you should do a test of cure um at least 14 days after completing the treatment. So, and actually that reminds me of another point as well. So you may actually not test positive from on for gonorrhea if the um encounter, sexual encounter happened less than two weeks ago. So sometimes, yeah, you're gonna have to wait a little bit longer for it to test positive. So you may still actually have gonorrhea but it just won't come up on the test as well. And yeah, just important to remember the complications. So uh pelvic inflammatory disease is, is one of those if it's left sort of untreated. So that's why even, yeah, if you're asymptomatic for a while, um and you having different sexual partners, they may just offer you screening anyway, even if you're not getting symptoms. Um Yeah, epididymal orchitis in men prostatitis and you know, it could even sort of spread, you know, systemically as well and lead to things like arthritis reaction. So that's actually another good point to know about. They could link it in that way as well with sort of reactive arthritis from gonorrhea. OK. Moving on to the next question. I'm really sorry for some of these questions. I couldn't think of 1/5 option to put down for you. So some of these are only four option questions. Very sorry. Um But yeah, have a go at this next question here. I will make the pole as you have a think you have a minute. OK. Yeah. So, right. Let me get the pull up. Actually, Rio's question back again. I don't know if um it may be a bit mean to miss or make you make that leap without maybe more information, but I'm hoping you have got the gist of this question. Um So yeah, the poll is up. Have a go at what you think the answer is. Okie Doke. So you got three responses so far. A bit of a split. OK. So first of all, I suppose let's go through what we actually think the condition is. So that will help us with um Knowing what to treat. So, yeah, so well done for those who picked D and I see why we have someone who may have picked B as well. Um So the key bits of this question are so she's pregnant. So that's important uh to know about and she's got vulval, itchiness, vaginal discharge could be a lot of different things, the discharge is not to be thick and white. Um So, and then the rest of this stem, I was just basically trying to get out that this is likely not um A S ti infection if that makes sense. Although actually it could, you know, who knows? You never know. Um Maybe stuff in the in the story might not be completely true. Um But I think maybe then in the exam they might give you something like a Ph as well to help you diagnose this or maybe another slide. But I figured I'd just wanted to see if you guys made that leap. Um And based on the options here, you can see that there's not much else it could be apart from um Candida. So the reason why it's not B is because oral fluconazole is not used in pregnancy. Um So you'd use the, the pessary if they're pregnant. If they weren't pregnant, you could use both. But yeah, because this lady's pregnant, that's why B is not the right answer. But I see where you were thinking now. Um and the rest of the answers. So A was the treatment for herpes and C is a treatment for trichomonas. So an S ti uh infection which of course, um sorry, which cause discharge. What are the implications of fluconazole in pregnancy? Um Yes, I see. Um your question there. I actually don't know off the top of my head, I'll be honest. But um just having done some, you know, research on these, in this area for this, for this, for these slides and obviously my own revision in the past, I've very clearly written to not use oral fluconazole. Um and it's also yeah, very clear in the BNF as well, not to use that, but I'm sure there is a natural specific reason why, but just remember that fact. Um Let me see if yeah, exactly. Even knowing it. Exactly. So now you'll know, don't give oral fluconazole in pregnant ladies. Um So yeah, just so you I think as well it's very useful when you're revising this topic. Um Just make a big, I think, make just a big table with all your key differential um findings and what's gonna help you differentiate between all of them. So this one only has BV, Candida and Tricho trichomoniasis. God, I'm so bad pronouncing these. Um but yeah, basically it's just gonna help you differentiate between all of them. Um Yeah, so you can see clearly between BV and the other two, something like itchiness. You not having an itch is gonna help you differentiate that the Ph um And then I think also the risk factors behind the history as well are gonna help you differentiate between them all. Um And I'm not gonna go into too much detail about Candida actually because I'll be honest, I was struggling a bit for time for me for all these slides, but I just wanted to focus on the main bits of this question here. So this is definitely where they could trip you up, you know, if they say that she's pregnant. Um And you don't notice that from the question. So the main thing is, yeah, treat with a pessary. Don't give oral antifungals. Um You can treat, yeah, with topical antifungals uh for vulval symptoms. Um And, but always bear in mind. Um If you know that there could be, could be an ST going on as well. Um Don't just simply take the history at fixed value. Um And yes. Okie Dokes moving on to the next question. So have a minute to think, hoping you're gonna get this one as well based on the picture. Okie Dokes, that's been about a minute there. So we'll start the pole. Have a go. OK. I'm glad it seems like my the picture is working fab. So yeah, well done to those who answered correctly. There. You are, right. It is trichomoniasis. I'm so sorry if I've been pronouncing it incorrectly. Um Anyway, so yeah, you can see here. So key bits of the history are so vaginal discharge could be a lot of different things, postcoital bleeding, itchiness as well. So I suppose you're starting to maybe rule out things like BV. Um And yes, and obviously the spectrum examination is gonna be what really um helps you diagnose this in this case. So that this is what we call like a strawberry cervix. If you think really hard it, you can see, I suppose it kind of looks like a strawberry there. But I think the main thing is just these little sort of red dots around there. Yeah, sorry for ruining that fruit for you guys. So, in a little bit more detail about this. So it's um so it's an sti caused by the trichomonas, vaginalis and it can be asymptomatic in sort of up to 50% of cases. Um Key things to remember are, yeah, so it can cause discharge um typically described as frothy, which I suppose differentiates it from other sts, but again, really tricky to know just from the description of the discharge. Um and something that yeah, will just help you diagnose unequivocally would be something like a strawberry cervix on the speculum examination. Um And yes, you're gonna get other findings here as well. So itchiness um discomfort and in males, uh sorry, dysuria as well and in males similar, yeah, discharge irritation, dysuria and balanitis as well. In terms of testing, it's not part of the, you know, the, the ST I screen that I was talking about at the beginning, you know, where you test for gonorrhea and chlamydia as a sort of standard, you sort of have to think, suspect it a bit more. Um So I suppose that's where you, you know, having things like the Wet Mount Masters copy when you're in the sexual health clinic, you can literally get a bit of the discharge, pop it on a slide, have a look and that maybe helps you think, ok, whether you need to actually add on a um test for tricho trichomoniasis. Um And yeah, for females using point of care testing using a posterior vaginal fornix swab is becoming increasingly popular. Um or you can do the vulvovaginal swab or use a first pass urine sample in men. You just need to specify um that you want to also test for trichomoniasis as well as the gonorrhea and chlamydia. Um Yeah, and you can also culture it as well. Um So yeah, in terms of treatment, we're gonna use metroNIDAZOLE 400 to 500 mg twice daily. Um or you can give it as um a single dose and yeah, you should avoid alcohol during the 1st 72 hours of treatment. Um should undergo full sexual health screen. So don't just go tunnel vision uh contact tracing partner notification. Um And a test of cure is not actually required routinely required in this case. Okey dokes moving on to the next question. So have a go start the minute timer. Ok. Um Poll is up. So have a go tell me what you think. Um The answer is any takers. Ok. We've got a few responses there. Any anyone think any different? Ah Thanks Ria. That's very helpful. Yeah, I remember seeing that in the B NF and not really having anything specific. But yeah, just a good fact to remember. Um OK. So sorry, back to this question here. So well done to those who answered um D you are correct. Um So yeah, this is another thing that I pretty sure came up in my exam, but the image was a lot blurrier in my exam. So this is a nice high definition picture for you guys. Um And again, why I put this question in the session? Because um yeah, like they like to use their images in these um in this area basically when they're asking MC Qs. Um So let's just go through the question here. Um So 26 year old female, I'm so sorry, I feel like I didn't delete the first bit there. Sorry, 26 year old female presents to you complaining of bleeding after sex. She's just started using the uh combined pill. Um She has no other bleeding at any points of her menstrual cycle. She had the same sexual partner for the past two years. So basically, just trying to steer you away from sort of the S ti route. She's also had a smear test, did not test positive for HPV. So she wouldn't um go further in the screening anyway. So very, very low risk of cervical cancer. Um And yeah, this is what you see on examination. So you can't see really any polyps there. Um And yeah, there's no discharge no really, nothing really to make you suspect an infection. Um I suppose endometriosis you never know, could always be up there on your differentials. But I think seeing this image here is gonna make you think um that this is more of an ectropion because that is exactly what it looks like on, on the speculum examination there. Um So go into a bit more detail about what a cervical ectropion is. So basically, it occurs when. So basically the um endocervix, um it was it basically inverts. So you were gonna see tissue that you wouldn't typically see in that area. Um So things like the columnar epithelium in the endocervical canal, you're gonna see that appear um where the endocervix, sorry ectocervix is. And in terms of who you're gonna see this most commonly in sort of adolescents in pregnancy. Um and women taking the um estrogen containing contraceptives. Um The reason why it might result in post coital bleeding um is because there are lots of fine blood vessels present within the epithelial endocervical canal type cells and that can be disrupted during intercourse. So that's why you see that relationship between this type of bleeding and the ectropion. Um So, here's it again, just to get that image in your head. Um So risk, risk factors, like I said, cop pregnancy adolescence um and generally happens in menstruating age. It's uncommon to find it in postmenopausal women. So, when you, this is kind of um in sort of guy in here as well, when you're thinking of differentials of vaginal bleeding in general, um the differentials you're gonna have for a premenopausal woman is very different to what you're gonna have for a postmenopausal woman. So just always bear that in mind, age is very important with these types of questions. Um in terms of clinical features, you may not get any um bleeding at all. Um But most commonly it appears as post quote bleeding. Um And then in terms of other differentials to consider, so obviously, you do need to consider things like cervical uh cancer and that can occur obviously in younger women, premenopausal women. Um but that's why I gave you that history of the um smear test being clear, you know, not there's there weren't any issues there, um also can occur in infections and pregnancy as well in terms of investigating it, it can be diagnosed clinically. So you don't often don't need to do any other tests. In fact, I've seen this diagnosed myself in, in clinic as well without really doing any other tests apart from just getting the history and having a look with the speculum. But obviously, if you are suspicious of other things, you can do pregnancy tests, a triple swab as well. And if there's any obvious lesion there, you can, you know, uh refer for a biopsy as well. Um in terms of treatment, no, normally doesn't really require treatment if it's associated with the pill, the combined oral contraceptive pill, you could stop it, find an alternative contraception that might solve issues. Um, or, and if symptoms still aren't resolved, you can consider a ablation as well of that area. All right. Moving on to the next question. So I'll give you another minute to have a think. Sorry. I just realized all on mute. I've just done a little board and back. Has it moved for you still or can you see the next question? Unfortunately not? Hm. Okie Dokes, you can't do. That's weird. Can you see me moving the slides now? No. So is it stuck on slide? Let's see if I can. Hm. This hasn't happened before we're stuck on the side. Oh, what a shame. All right. Um Let me see if I can. Ok. Present, present now. Yeah. Ok. How has, has that work? Brown? Perfect. Okey doke. Right. Let's start that minute again. So here we go. Have a think. Ok. That's been about a minute. Let me get the pole up for this two Ts, right? Give it a go. Ok. Hopefully made it um, not too difficult to figure out. Um But yeah, basically, I think this is a very useful topic to have a good handle on. You can definitely throw in a few more curveballs as well with this. Um I wouldn't spend too much time in an exam trying to sort of calculate the exact day of ovulation and get too caught up in it all. But hopefully they should give you a nice enough figure for you to be able to just work it out simply in your head. Um So yeah, so well done. I think most of you have put the right answer there. So well done. So yeah, the copper intrauterine device. So let's go through this question. Um She's got a 20 year old female, she presents to clinic after an episode of unprotected sexual intercourse. She wants to know about her emergency contraception options, you know that she has a 28 day cycle. Um She's currently on day 17. Um and the um unprotected er episode happened uh six days ago. So I suppose already knowing that is six days ago, that already rules out a lot of options here. So the la one and liver now that is already outside of their window regardless of what point of ovulation. Um We're at, at the moment. So actually, to be honest, it kind of leaves really the only one option there. The cop and Mirena in devices aren't really used as emergency contraception. So you basically have ac or D as your options. And yeah, to you've chosen correct there. So well done. Uh Let's go through a bit more information about emergency contraception. Um So this question requires you to just have um an understanding of when certain emergency contraceptions are effective. In this case. I suppose it doesn't really matter too much about, um, knowing the day of ovulation in a way because you already knew that Levonogestrel and Ulipristal aren't gonna be effective six days, um, after the unprotected sex anyway. Um, so, yeah, that's, but sometimes they might make it a bit trickier. Um, and maybe put it where it's, you know, 72 hours or less than 72 hours and you might have more options there and you may need to use when the ovulation day is to help, you know, which one's the most appropriate. Because as you can see here, levonogestrel and Ulipristal are most effective right before the LH hormone surge, which happens um during ovulation. And so, if you know, the ovulation has already taken place, even if it's within the 72 hours or, you know, less or less, um it, you know, both of those options aren't really, may not be effective anyway. Um And that's reflected in the guidelines which I'll show you in a sec. And um yeah, you can see that your intrauterine device is still effective past the ovulation point for a few days. Um So yeah, so it's basically very useful to know the timing of ovulation. So just try and have a think about that in these types of questions. Um So yeah, in terms of the mechanisms here, so the copper device, this helps you figure out why you would suggest certain things. So the copper device doesn't prevent ovulation, which is why I suppose it's useful for, even after ovulation has taken place, it prevents fertilization um and can prevent implantation. The levonogestrel and ulipristal er are only effective. Oh, sorry. The LEVO GSR only just before the LH surge and the Ulipristal can be affected up until the LH surge. But afterwards, it's gonna be less effective and both of them don't prevent fertilization. It's mainly the preventing the ovulation, which is why. Um Yeah, the guidance is the way it is. Um So I think if you want to know a bit more about this, um it's useful to have a look at um the guidelines. I have the name of this, the organization at the end, I just can't remember off the top of my head. It's one of these national organizations that forms these sorts of guidelines. Um So this one here is about um the algorithm for making decisions about emergency contraceptions. Um So you can see here just by knowing whether it's been um less than 100 and 22 hours. Um If you, um if you say yes to that, you have basically a few more options. Um So yeah, basically this is something useful to, to just have in your mind. I realize it's a bit overwhelming to go through everything at the moment. Um But just have a look at this sort of guidelines, maybe take a screenshot and I'll let you know where I actually got this from. Um But having a good idea of um yeah, how to make these decisions is helpful. Um And then in terms of knowing whether to use Ulipristal um or levonogestrel. Um If you're sort of before that ovulation window or just within that ovulation window. Um So knowing whether um the unprotected sex happened less than 96 hours ago. If that is, yes, then you need to figure out has it taken place before ovulation? Um And that's basically just gonna help you. Yeah, figure out which one's most useful there. And I suppose important considerations to have in mind are things like, um, you know, BMI, so they could throw you on that as well. They could maybe put a few different doses of L RE there. So if someone is BMI is over 26 or weighs over 70 consider a double dose, um which is three mgs there or if taking an enzyme inducer. So particularly I couldn't imagine them putting in that, you know, someone's got epilepsy and taking certain medications that can, isn't, there are enzyme inducers. Um And that's gonna afer impact um the effectiveness, especially for a eros acetate. So that's where you need to just bear in mind. Um Yeah, I realize it is quite a, it's quite a lot to this topic, but I think if you just break it down into when, as ovulation happened, um, how long ago did the unprotected sex happen? Um, and just a few more demographic characteristics like, wait, do they take an enzyme inducer? And that will just basically help you figure out which one is most effective? So, yeah, just have a little look at that in your time and here's just a bit more of a simplified version here. So the uh the copper UTR device can be used within five days, 100 and 20 hours or um within the five days after the earliest estimate date of ovulation. So that's why in that case, even it had been six days, it was still, er, just before. Oh no, sorry, just after er, within the five days after ovulation, um levere license for use within 72 hours. Um and Ulipristal license for use uh within 100 and 20 hours as well. There we go. All right. Um Hope I didn't frazzle your brains too much with all that information, but just have a, have a revise in your own time because it is quite a common topic that comes up. Um OK. Moving on to our last question. Let me know as well at any point. II kept meaning to ask if you have any questions basically. So just, just pop them in the chat if you do. If I, what I said hasn't made sense was confused. You even more, but hopefully that's been useful. So, yeah, moving on to our last question then. So question eight, I'll pop a poll on whilst you guys have a think. So I'll start the minute timer. OK. So that's been about a minute. I'll get the pole going. Do you have a think? OK. So we've got two answers for C oh, we've got a, got a contender for B um So the answer is C so, yeah, well done. Um For those who answered C and I can see why you may be thinking B as well. But let's just go through the question again. So we've got a 29 year old woman and she presents to her GP five days after the Cesarean sections. That's the important point here for why. That's something like an intrauterine device is not, uh you know, not advised in this case because, um, you can have an intra urine device inserted, um, as contraception after pregnancy if it's done within the 48 hours after birth, you know, vaginal birth or a Cesarean section. But as it's been more than 48 hours, uh you're going to have to wait a bit longer for that to be an option again. Um The progesterone only pill is absolutely fine to start at any point. Technically. Um, you know, if she had unprotected sex up until 21 days, um, you know, it, it'd be unlikely that a pregnancy would happen from that. So she doesn't necessarily need to start it now within five days, but it's best if she does actually because it means that you don't have to wait. Um, you don't have to wait. Uh after the, you know, if you, let's say sorry, start the progesterone pill, you have to wait a few days for it to be effective. Um Whereas if you start it before the 21 days, um it'll be effective right from 21 days onwards if that makes sense. Um Things like estrogen containing um contraception forms aren't recommended this early on as well to start. So if she wants to start it now, which is the indication I'm getting from this. Um Yeah, the progesterone only pill is pretty much the only option here and the D is just wrong. You can have different forms of contraception while breastfeeding. Um You can obviously do uh you know, lactational amenorrhea as well. And that's something, you know, if you don't want to use any form of contraception and want to just go more natural, that's absolutely fine. But you do have to meet sort of, you have to be meeting certain criteria, I think for that to work. Uh It's still definitely an option, but it's not that. Yeah, so it's not the option. D is yeah, wrong. You can't just say you don't. There's no options at all. So that's why it's c um I'll get to your question in a second here. So I'll just go through the bits here. Um So when should contraception be started? Like I said, it should be initiated by 21 days after childbirth. But again, this depends what the option they want if they want contraception at all. Um And if they'll need to use sort of barry methods if the contraception started 21 days or more after childbirth. Um So I made a little table here about the different options here. Um So the, the IUD can be inserted immediately after birth within 48 hours. After 48 hours, you need to delay that insertion um until 28 days after childbirth. Um progesterone, anything progesterone containing like conclusive implants or the pill, that's fine. Any time after childbirth, that can be including immediately after delivery, but don't need to necessarily start right then and there. Um But as long as it's just before the 21 days, so you don't have to wait after that. Uh the combined hormonal contraception. So it has to be at least six weeks after childbirth for women who are breastfeeding. And also consider um if they have um risk factors for VTE as well, if they don't have any additional vte risk factors and they're not breastfeeding, technically, they could um start it 21 days after childbirth. Um But yes, I'd say most women are gonna fall into the category of breastfeeding and may have risk factors for VTE. Um And then female sterilization, that's also an option. Um But I think a lot of sort of consent and discussion has to uh sorry, discussion surrounding sort of consent to the procedure has to be done. Prior to the C Cesarean section. Um and then lactational amenorrhea, like I said, the woman is less than six month postpartum breastfeeding. That could be an option as well. Um And yeah, so this is the guide guidelines where I took a lot of this information from and you're gonna see that they have guidelines basically for all sorts of contraception categories. And this one was specifically about contraception in the postpartum period. Um So I'm just gonna show you a few more tables which are relevant to this topic. So you can see here that they have different categories of risk. So category one is absolutely fine. Category two, there's, yeah, if you know, generally the benefits will outweigh any of the sort of theoretical proven risks. Category three is when you start thinking quite hard about um whether the risks outweigh er sorry, the benefits outweigh the risks or not. Um And then four is just, you wouldn't use it in the scenario, just cos it's the risks would definitely outweigh the benefits and the reason why this is relevant here. So you can see um in the postpartum period, um depending on the exact number of weeks and the type of um contraception here you're gonna see. Um yeah, the different UK me uh what do you call them? Sorry, categories. Yeah, so you can see here. Yeah, in 0 to 6 weeks that combined hormonal contraception is not going to be advised. Um Interestingly the depo injections. That's the, the D MPA, that's obvious that's, that contains progesterone, but it's still slightly riskier. Um, just because of slight risks of VT with that, but on balance, it's only a two. So it's not as risky. But I suppose, uh, the implant or the pill might be better options. Um, in that case. Um, but yeah, so hopefully it's a useful table, you know, feel free to go through it in your own time. Um And this is also to do with um contraception with women in history of pregnancy related conditions here. You can see, actually doesn't really make too much difference if a woman has had a complicated pregnancy, a lot of these are still options for, for them, you know, the different types of contraception. Um So yeah, so basically to summarize um indicated, oh, sorry, sorry, not summarized. This is a different topic here. So just a little side note. So emergency contraception in the postpartum period. So this is indicated for women who have had unprotected sex 21 days and after childbirth. Um So lenore er U Ulipristal are safe to uh 21 days after childbirth. Um and if not insert delivery, the copy of you into uterine device can use from 28 days after childbirth. Um But if you're using Ulipristal, just be aware that women who breastfeed should be er, they shouldn't breastfeed within the week uh after they've taken the Ulipristal and expressed their advice to express and discard that milk. So, just a few fun facts there. Um, yeah, and I think that comes, oh, now just a few more bits here. Um, ok. So I was basically reiterating the point. Um, so what you have to do if you insert, if the contraception is started 21 days or after. So with the levonogestrel, er, intrauterine system, seven days, progesterone only pill, two days, er, the progesterone only implant or injectable seven days or the combined hormonal contraception um would be seven days as well. So, or potential things they could test you on. I know it's a pain to remember all this stuff. So don't worry if you can't remember all of it. Um, but yeah, it's, it could, it could come up and maybe in an OSK as well, I suppose it could. Um, so some other areas that I didn't get a chance to cover in the session but I think could be examinable. I was just having a real think about what actually came up in my exam. So I think, um, knowing the criteria for HIV, prep and PEP. Um, so who should get treated with that? Who should get that? Um, and at what point you can give pep, for example, post exposure prophylaxis. Um for HIV, I suppose also another topic that came up was, um, how you monitor HIV treatment as well. So, what do you look at to make sure that that is effective I didn't really go over. Oh, gosh. Gen, gentle, gentle lumps, warts and ulcers, but very important as well to know differentials for those and how to treat those. Um, and syphilis as well could come up as topics. But I think I tried to cover all the main ones that, um, I definitely remember coming up, you know, just a particular emphasis on just knowing how things look under the slide. It's nice, straightforward marks. If you can just look at the slide and know for sure. Oh yes, that's gonorrhea, that's chlamydia, that's um trichomoniasis BV. All those er differentials that I was talking about um also have a look at cervix findings as well like we showed. So you the Trion strawberry Cervix, they could come up both in your MC QS or I suppose it could come up in a OSK as well. Um You know, if you have that as one of your stations, you know, vagina or uh penile examination uh could come up in those. So, yeah, just have, have a revise of those. Um And I'll get to rhea's question now. Sorry. So if this was an osk scenario and you needed to counsel the patient, would it be worth mentioning lactational maa or is it necessary if the patient closely mentions only breastfeeding and not having periods yet? Oh, I think it would be good in an osk scenario um to just get an idea of what the patient wants first I suppose, and that will help you narrow down what you want to talk about. I suppose you could always, um, you know, just say there are various options. Um, have you had a think? And if they say, oh, I definitely don't want any, um, I don't want to use any pills. I don't wanna use, um, any devices. Then I suppose that's one of your only methods really. But you do have to explain exactly that. Um there are certain conditions for it to be effective and only really affect up until six months as well. Um So yeah, I would say definitely worth mentioning, but I think always uh just get an idea of what they want first and hopefully they'll guide you to what you should be talking about. Um And yeah, you can get these marks that way. Yeah, very good point. OK. And just, oh yeah, so these are some of the sources where I got my information from. So the Fs Rh so that I think that's the Sexual Health Committee um in the UK, they have a lot of really good guidelines on there. Uh That's where I got the contraception guidelines, uh the UK Met guidelines. So have a look at those and then bash as well er is also very good for sexual health condition. Um you know, resources basically and guidelines have a look at that. Uh teacher has a sexual health section obviously specific for uh women con conditions that happen in women. Um Yeah, still very useful and GS as well has quite a good section on um sexual health articles and questions. So, yeah, have a look at those if you want to do some reading in your own time and follow up on what we talked about today. So, yeah, thank you so much for um bearing with me. I hope you found it useful. Um Yeah, feel free to find us on social media and we'll be posting the recordings on various pages that we have. So, um the website youtube and I haven't actually made a, a feedback form for this. So I'll try and what I'll do is I'll um send it out as an email. You'll, you'll hopefully get a notification about it and if you've got time, I really appreciate some feedback as well. But otherwise I hope you found that useful and let me know if you have any questions I can stick around for a bit, but if not, well done. And yeah, good luck for any upcoming exams. I think it, we're heading to that season now. And yeah. Oh, no problem, Ria. Uh I hope that was, I hope that was useful. Ok, I'm gonna guess there's no, no more questions. So, um yeah, that I'll end the session there. Yeah, thanks again.