The effectiveness of any method of contraception is measured by the number of unwanted pregnancies that occur during 100 women years of exposure, i.e. during 1 year in 100 women who are normally fertile and are having regular coitus. This is known as the ‘Pearl index’ (Table 19.1).

Table 19.1

Failure rates per 100 women for different methods of contraception

	USA data used by WHO: % of women having an unintended pregnancy within the first year of use^a		Oxford/FPA Study (all women married and aged above 25)^b
	Typical use*	Perfect use^†	Overall (any duration)	Age 25–34 (≤2 years use)	Age 35+ (≤2 years use)
Sterilization
Male (after azoospermia)	0.15	0.1	0.02	0.08	0.08
Female (Filshie clip)	0.5	0.5	0.13	0.45	0.08
Subcutaneous implant	0.05	0.05	–	–	–
Nexplanon^®
Injectable (DMPA)	3	0.3	–	–	–
Combined pills
50 µg oestrogen	8	0.3	0.16	0.25	0.17
<50 µg oestrogen	8	0.3	0.27	0.38	0.23
Evra^® patch	8	0.3	–	–	–
NuvaRing^®	8	0.3	–	–	–
Cerazette^® progestogen-only pill		0.17^‡	–	–	–
Old-type POP	8	0.3	1.2	2.5	0.5
IUD
Levonorgestrel-releasing intrauterine system (LNG-IUS)	0.2	0.2	–	–	–
T-Safe^® Cu 380 A	0.8	0.6	–	–	–
Other >300 mm copper-wire IUDs (Nova-T 380^®, Multiload^® 375, Flexi-T^® 300)	≈1^‡	≈1^‡	–	–	–
Male condom	15	2	3.6	6.0	2.9
Female condom	21	5	–	–	–
Diaphragm (all caps believed similar, not all tested)	16	6	1.9	5.5	2.8
Withdrawal	27	4	6.7	–	–
Spermicides alone	29	18	11.9	–	–
Fertility awareness	25
Standard days method	–	5	15.5	–	–
Ovulation (mucus) method	–	3–4	–	–	–
Persona	6^‡		–	–	–
No method, young women	80–90		–	–	–
No method at age 40	40–50		–	–	–
No method at age 45	10–20		–	–	–
No method at age 50 (if still having menses)	0–5		–	–	–

Sources: ^aTrussell J (2007) Contraceptive efficacy. In: Hatcher RA, Trussell J, Nelson AL, et al. (eds). Contraceptive technology: nineteenth revised edition. Ardent Media, New York.

Other Notes (1) Note influence of age: all the rates in the fifth column being lower than those in the fourth column. Lower rates still may be expected above age 45. (2) Much better results also obtainable in other states of relative infertility, such as lactation. (3) Oxford/fpa users were established users at recruitment – greatly improving results for barrier methods (Qs 1.19, 4.9). (4) The Nexplanon, Cerazette and Persona results come from pre-marketing studies by the manufacturer, giving an estimate of the Pearl ‘method-failure’ rate.

^b Vessey M, Lawless M, Yeates D (1982) Efficacy of different contraceptive methods. Lancet 1(8276):841–842.

^*Typical use: Among typical couples who initiate use of the method (not necessarily for the first time), the percentage who experience an accidental pregnancy during the first year if they do not stop use for any other reason.

^†Perfect use: Among typical couples who initiate use of the method (not necessarily for the first time), and who then use it perfectly (both consistently and correctly), the percentage who experience an accidental pregnancy during the first year if they do not stop use for any other reason.

^‡Data not available from Trussell, so best alternative data given, e.g. from manufacturer’s studies.

(This Table was published in Guillebaud J, MacGregor A (2013) Contraception 6e. ©Elsevier. Reproduced from Trussell J, Wyn LL (2008) Reducing unintended pregnancy in the United States. Contraception 77(1): 1–5, with permission.)

Intrauterine contraceptive devices

Intrauterine contraception is used by 6–8% of women in the UK. A wide variety of intrauterine devices (IUDs) have been designed for insertion into the uterine cavity (Fig. 19.2). These devices have the advantage that, once inserted, they are retained without the need to take alternative contraceptive precautions. It seems likely that they act mainly by preventing fertilization. This is a result of a reduction in the viability of ova and the number of viable sperm reaching the tube.

The first device to be widely used was the Graefenberg ring, which was made of a silver–copper alloy. Introduced in the 1930s, it ran into considerable difficulties with haemorrhage, infection, miscarriages and uterine perforation. Later, inert plastic devices such as the Lippes loop were associated with a significant increase in menstrual blood flow in many users. The development of copper IUDs has been associated with improved contraceptive efficacy and a lessening of excess menstrual blood loss.

Types of devices

The devices are either inert or pharmacologically active.

Inert devices

Lippes loops, Saf-T-coils and Margulis spirals are plastic or plastic-coated devices. They have a thread attached that protrudes through the cervix and allows the woman to check that the device is still in place. Inert devices tend to be relatively large. They are not now available but may still be found in situ in some older users.

Pharmacologically active devices

The addition of copper to a contraceptive device produces a direct effect on the endometrium by interfering with endometrial oestrogen-binding sites and depressing uptake of thymidine into DNA. It also impairs glycogen storage in the endometrium. Examples of such devices are the Copper-T® or Copper-7® (first generation), the Multiload® Copper-250 (second generation) and the Copper-T® 380 (third generation).

Devices containing progestogen

The levonorgestrel-releasing intrauterine system or Mirena® contains 52 mg of levonorgestrel (Fig. 19.2) which suppresses the normal build up of the endometrium so that, unlike most IUDs, it causes a reduction in menstrual blood loss. However, there is a high incidence of irregular scanty bleeding in the first 3 months after insertion of the device. Unlike previous progestogen-containing devices it does not appear to be associated with a higher risk of ectopic pregnancy. The superior efficacy of third-generation copper IUDs and the levonorgestrel-releasing system means that these are now considered the devices of choice.

Life span of devices

The Copper-T 380 is licensed for 8 years in the UK and Australia (and 13 in the USA). Other copper devices and the Mirena are licensed for 5 years. However, IUDs do not need to be replaced in women over the age of 40 years. They should be left in place until 2 years after the menopause if this occurs under 50 and 1 year otherwise.

Insertion of devices

The optimal time for insertion of the device is in the first half of the menstrual cycle. With postpartum women, the optimal time is 4–6 weeks after delivery. Insertion at the time of therapeutic abortion is safe and can be performed when motivation is strong. It is unwise to insert IUDs following a miscarriage because of the risk of infection. Devices may be inserted within a few days of delivery but there is a high expulsion rate.

Ideally, the woman should be placed in the lithotomy position. A cervical smear should be taken, and a swab taken for culture if there is any sign of infection. The uterus is examined bimanually and its size, shape and position are ascertained. The cervix is swabbed with an antiseptic solution and a vulsellum can be applied to the anterior lip of the cervix, although this is not essential and may cause discomfort.

The passage of a uterine sound will indicate the depth and direction of the uterine cavity and the dimensions of the cavity may be assessed by devices known as cavimeters, which measure its length and breadth. Many IUDs are available in different sizes, and cavimeters help to choose the appropriate IUD.

Insertion devices vary in construction but generally consist of a stoppered plastic tube containing a plunger to extrude the device, which may be linear or folded. The device is inserted in the plane of the lumen of the uterus and care must be taken not to push it through the uterine fundus.

Attempts at insertion of a device where the cervical canal is tight may result in vagal syncope. Acute pain following insertion may indicate perforation of the uterus. The woman should be instructed to check the loop strings regularly and to notify her doctor immediately if the strings are not palpable.

Complications

The complications of IUDs are summarized in Figure 19.3.

Pregnancy rates

Pregnancy rates vary according to the type of device used, from 2–6/100 women years for non-medicated IUDs and 0.5–2/100 for early generation copper devices to less than 0.3/100 women years for third-generation copper and levonorgestrel IUDs. If pregnancy does occur with an IUD in situ and its strings are easily grasped, it is sensible to remove it to reduce the incidence of a septic miscarriage, there being a high incidence of miscarriage in such pregnancies. If the strings are not accessible, the IUD should be left and removed at the time of delivery, although the risk of a miscarriage or premature rupture of the membranes would be increased. The risk of failure of the IUD diminishes with each year after insertion.

Perforation of the uterus

About 0.1–1% of devices perforate the uterus. In many cases, partial perforation occurs at the time of insertion and later migration completes the perforation. If the woman notices that the tail of the device is missing, then it must be assumed that one of the following has occurred:

• The device has been expelled.

• The device has turned in the uterine cavity and drawn up the strings.

• The device has perforated the uterus and lies either partly or completely in the peritoneal cavity.

If there is no evidence of pregnancy, an ultrasound examination of the uterus should be performed. If the device is located within the uterine cavity (Fig. 19.4A), unless part of the loop or strings is visible, it will generally be necessary to remove the device with formal dilatation of the cervix under general or local anaesthesia. If the device is not found in the uterus, a radiograph of the abdomen will reveal the site in the peritoneal cavity (Fig. 19.4B). It is advisable to remove all extrauterine devices by either laparoscopy or laparotomy. Inert devices can probably be left with impunity, but copper devices promote considerable peritoneal irritation and should certainly be removed.

Fig. 19.4 (A) Ultrasound diagnosis of a plastic IUD. (B) Radiography of the abdomen showing an IUCD and a full-term pregnancy.

Pelvic inflammatory disease

Pre-existing PID is a contraindication to this method of contraception. There is a small increase in the risk of acute PID in IUD users, but this is largely confined to the first 3 weeks after insertion. If PID does occur, antibiotic therapy is commenced and, if the response is poor, the device should be removed. If the infection is severe, it is preferable to complete 24 hours of antibiotic therapy before removing the device. It is not uncommon to find evidence of Actinomyces organisms in the Pap smear routinely collected in an asymptomatic woman who has an IUD in place. This is generally not due to an actinomycotic pelvic infection, but due to the presence of these organisms on the surface of the IUD. There is no absolute consensus of what should be done if such organisms are found in the Pap smear. Some would remove the IUD, repeat the smear in 3 months and reinsert another IUD if the smear is clear, whereas others would leave the IUD in place but give a 2 week course of penicillin therapy.

Abnormal uterine bleeding

Increased menstrual loss occurs in most women with an inert or copper IUD, but this can be tolerated by the majority. However, in 15% of such women it is sufficiently severe to necessitate removal of the device. It can be controlled by drugs such as tranexamic acid or mefenamic acid. Intermenstrual bleeding may also occur, but if the loss is slight it does not constitute a reason for IUD removal. Amenorrhoea occurs in at least 20% of women using the Mirena and average menstrual blood loss is reduced by 90%.

Pelvic pain

Pain occurs either in a chronic low-grade form or as severe dysmenorrhoea. The incidence is widely variable, with up to 50% of women suffering some pain. However, the pain may be acceptable if it is not severe, and this is a decision that has to be made by the patient in relation to the convenience of the method.

Vaginal discharge

Vaginal discharge may be due to infection but most women with an IUD develop a slight watery or mucoid discharge.

Ectopic pregnancy

Compared with women having unprotected intercourse, the incidence of pregnancy is lower in women with an IUD in situ (1.2/100 women years). However, should pregnancy occur, there is a higher risk (10%) of the pregnancy being extrauterine. It is therefore essential to think of this diagnosis in any woman presenting with abdominal pain and irregular vaginal bleeding who has an IUD in situ.

Ectopic pregnancy should be excluded in any woman who conceives with an IUD in situ.

Hormonal contraception

Oral contraception is given as a combination of oestrogen and progestogen, as a combined pill, or as progestogen only.

Combined pill

Most of the current combined pills contain 20–30 µg of ethinyl oestradiol and 150–4000 µg of progestogen. The progestogens used are derived from 17-hydroxyprogesterone or 19-norsteroids (Box 19.1).

The pill is usually taken for 21 days, followed by a 7-day pill-free interval during which there is a withdrawal bleed. Everyday (ED) preparations include seven placebo pills that are taken instead of a pill-free week. The concentration of the hormones may be the same throughout the 21 days (monophasic preparations) or vary across the cycle (biphasic and triphasic preparations) in order to reduce breakthrough bleeding.

Progestogen-only pill

Progestogen-only pills contain either norethisterone or levonorgestrel and are taken continuously on the basis of one tablet daily. Because of the low dose, they should be taken at the same time every day.

Mode of action of the contraceptive pills

Combined and triphasic pills act by suppressing gonadotrophin-releasing hormone (GnRH) and gonadotrophin secretion and, in particular, suppressing the luteinizing hormone peak, and thus inhibiting ovulation. The endometrium also becomes less suitable for nidation and the cervical mucus becomes hostile. Progesterone-only pills act predominantly to reduce the amount and character of the cervical mucus, although they do alter the endometrial maturation as well. Ovulation is completely suppressed in only 40% of women.

Contraindications

There are various contraindications to the pill, some being more absolute than others.

The absolute contraindications include pregnancy, previous pulmonary embolism or deep vein thrombosis, sickle-cell disease, porphyria, current active liver disease or previous cholestasis (particularly where it is associated with a previous pregnancy), migraine associated with an aura or carcinoma of the breast. It is necessary to maintain a high level of vigilance in women with varicose veins, diabetes, hypertension, renal disease and chronic heart failure but none of these conditions constitutes an absolute contraindication and, in some cases, the adverse effects of a pregnancy may substantially outweigh any hazard from the pill. Women who smoke and are also over the age of 35 years have a significantly increased risk of coronary artery and thromboembolic disease.

The occurrence of migraine for the first time, severe headaches or visual disturbances, or transient neurological changes are indications for immediate cessation of the pill. There are a series of minor side effects that may sometimes be used to advantage or may be offset by using a pill with a different combination of steroids (Table 19.2).

Table 19.2

Minor side effects of combined oral contraception

Oestrogenic effects	Progestogenic effects
Fluid retention and oedema Premenstrual tension and irritability Increase in weight Nausea and vomiting Headache Mucorrhoea, cervical erosion Menorrhagia Excessive tiredness Vein complaints Breakthrough bleeding

Premenstrual depression

Dry vagina

Acne, greasy hair

Increased appetite with weight gain

Breast discomfort

Cramps of the legs and abdomen

Decreased libido

Other therapeutic uses

Therapeutic uses other than contraception include the treatment of menorrhagia, premenstrual syndrome, endometriosis and dysmenorrhoea.

Major side effects

The risk of venous thrombosis is increased from 5/100 000 to 15/100 000 women per year and is further increased in smokers and women with a previous history of venous thrombosis. This compares to a risk in pregnancy and the puerperium of 60/100 000 women. Several studies have suggested that so-called ‘third and fourth-generation’ combined pills containing desogestrel, gestodene or drospirenone, are associated with a twofold greater risk of venous thrombosis than those containing other progestogens, although the risk of venous thrombosis was lower in these studies than had previously been reported.

There is an increase in arterial disease, with a 1.6 to 5.4-fold increase in stroke and 3 to 5-fold increase in myocardial infarction (although there is no significant increase in women under 25 or in non-smokers). However, both these conditions are rare in women under the age of 35 years so the overall risk remains low, with deaths from venous thrombosis attributable to the combined pill of no more than 1–2/million women years.

Although some reports have suggested there is a small increase in the relative risk of breast (relative risk 1.24) and cervical cancer (relative risk 1.5–2) in pill users, especially if it is commenced before a first pregnancy, the breast cancer increased risk is not definitely proven, and the cervical cancer risk is probably due to the incidence of wart virus infection and not the taking of the oral contraceptive pill (OCP).

There is an increase in gallstone formation and cholecystitis and an increase in glucose intolerance.

The progestogen-only pill has a higher failure rate and is more likely to be associated with irregular bleeding. If it fails there is a higher risk of ectopic pregnancy.

Beneficial effects

In addition to the prevention of unwanted pregnancy, the use of the combined pill is associated with a 30% reduction in blood loss at menstruation, a lower incidence of ectopic pregnancy (0.4/1000) and some protection against PID and benign ovarian cysts. Pill users also have a reduced risk of both endometrial and ovarian cancer of up to 50%, depending on the length of use with this benefit lasting for up to 10 years after the OCP therapy has been ceased.

Practical patient care of a patient requesting to use the combined OCP

It is important to obtain a complete general history and examination before prescribing the pill, and also to perform annual check-ups and cervical cytology. There are a large number of compounds commercially available, and some pills are marketed by different companies but contain the same compounds at the same concentrations. The history taken must exclude the contra-indications detailed above. Examination should include breast examination, blood pressure assessment and, except in women who have never been sexually active, speculum examination, Pap smear testing, and PV assessment. An appropriate pill for that particular patient should then be chosen, and counselling then given along the following lines.

Which pill should you choose?

In general a 30 µg ethinyl oestradiol-containing pill is usually chosen first because of its effectiveness and low cost. The 20 µg containing preparations are much more expensive but preferred by many women, and the side effects are usually less, except that breakthrough bleeding during the first few months of treatment is more common. If the woman had evidence of androgen excess, hirsutism or clinical PCOS, the OCP Diane 35 should be given because its progestogen is cyproterone acetate, an anti-androgen. If the woman has fluid retention problems, an OCP containing drospirenone is usually advisable.

If the woman has used the OCP previously and had major problems with breakthrough bleeding, has conceived when taking the pill correctly, or is on treatment with an anti-epileptic medication, it is safer to advise them to take an OCP containing 50 µg of ethinyl oestradiol.

When should it be commenced?

It is best commenced on day 2–3 of the next period but can be commenced at any time. Many combined pills include 7 days of placebo (‘sugar’) tablets so that the user takes a pill every day of the month and so reduces the risk of forgetting when to restart the pill after the normal 7 ‘pill free’ days each cycle (sometimes labelled ‘ED’ or everyday preparations). Each tablet including the placebos are labelled with a day of the week in these calendar packs with the placebos being a different colour (Fig. 19.5) With these pills a woman should start taking the pill on the first day of her next period starting with the inactive tablet corresponding to the current day of the week. When changing from a higher to a lower dose pill preparation women should be advised to start taking the active tablets of the new pill immediately on completing the last tablet of her previous pill, omitting the normal 7 day gap.

Fig. 19.5 The ED combined oral contraceptive pill.

When will it achieve its contraceptive effect?

When 7 active hormone tablets have been taken on successive days.

What to do if a pill is missed or nausea, vomiting or diarrhoea occurs?

If the missed pill is not discovered until more than 12 hours after it was meant to be taken, that pill should not be taken, but the original course continued and alternative contraception used for the next 7 days. If discovered <12 hours after the time it was meant to have been taken, take that pill now, and continue the cycle taking the next one at the appropriate time. When the missed pill is close to the time the hormone tablets were due to be ceased and sugar tablets given, the original course can be stopped and a new pack commenced about 5–6 days later. There is no need for additional contraception under such circumstances.

What are the potential side effects, including the common ones of break through bleeding, and what to do if such bleeding occurs?

The main nuisance side effect is breakthrough bleeding where generally light bleeding occurs despite the hormone tablets still being taken. This usually settles spontaneously within 3 months of starting the OCP, but if it persists a higher dose pill should be given.

When is further review needed and why?

She should be reviewed in 2–3 months to check if any problems have occurred and to check that blood pressure has not become elevated. Further reviews, when blood pressure, breast examination and gynaecological assessment including Pap smear testing should be done, are generally done annually.

Interaction between drugs and contraceptive steroids

Many drugs affect the contraceptive efficacy of the pill, and therefore additional precautions should be taken (Table 19.3). Vomiting and diarrhoea also result in loss of the pill and hence the return of fertility – particularly with the low-dose pills now widely in use. Progestogen-only pills must be taken every day if they are to be effective.

Table 19.3

Interaction of various drugs with oral contraceptives

Interacting drug	Effects of interaction
Analgesics	Possible increased sensitivity to pethidine
Anticoagulants	Possible reduction of effect of anticoagulant – increased dosage of anticoagulant may be necessary
Anticonvulsants	Possible decrease in contraceptive reliability
Tricyclic antidepressants	Reduced antidepressant response; increase in antidepressant toxicity
Antihistamines	Possible decrease in contraceptive reliability
Antibiotics	Possible decrease in contraceptive reliability Possibility of breakthrough bleeding (this is most likely with rifampicin)
Hypoglycaemic agents	Control of diabetes may be reduced
Antiasthmatics	Asthmatic condition may be exacerbated by concomitant oral contraceptive
Systemic corticosteroids	Increased dosage of steroids may be necessary

Failure rates

The failure rate of combined pills is 0.27–5/100 women years. The failure rate for progestogen-only preparations is higher and varies between 0.3 and 8/100 women years.

The pill and surgery

The pill increases the risk of deep vein thrombosis and should therefore be stopped at least 6 weeks before major surgery. It should not be stopped before minor procedures – particularly before laparoscopic sterilization procedures. The risk of an unwanted pregnancy occurring before admission is substantially greater than the risk of thromboembolism.

The pill and lactation

Combined preparations tend to inhibit lactation and are therefore best avoided. The pill of choice at this time is the progestogen-only pill as it has minimal effect on lactation and may indeed promote it.

Injectable compounds

There are currently two main types – Depo-Provera® and Implanon®. Depo-Provera contains 150 mg of medroxyprogesterone acetate and is given as a 3-monthly intramuscular injection. Implanon is a single Silastic® rod containing etonogestrel that is inserted subdermally in the upper arm and is effective for up to 3 years. An earlier type of implant, the levonorgestrel-releasing Norplant® Silastic rod, has been discontinued but some women may still have this in place. Each of these injectable preparations works by making the cervical mucus hostile, the endometrium hypotrophic and by also suppressing ovulation.

Failure rates are low, at less than 0.1/100 women years in the first year rising to 3.9/100 over 5 years. Failures mostly relate to women already pregnant at the time of injection of the Depo-Provera or insertion of the Implanon device, so it is essential that these methods are commenced at the time of a pregnancy termination or within the first 5 days of menstruation.

Parenteral progestogen-only contraceptives are long-acting but easily reversible, effective, avoid first-pass effect liver metabolism, require minimal compliance and avoid the side effects associated with oestrogens. However, they may cause irregular bleeding or amenorrhoea, which can be a source of anxiety because of the possibility of pregnancy. Removal of the implants may be difficult and should only be carried out by a doctor trained in the procedure. Some women will experience systemic progestogenic effects such as mood changes and weight gain or develop symptoms of oestrogenic deficiency

Newer methods of hormonal contraception

In the last few years combined hormone transdermal patches and a vaginal contraceptive ring have been introduced. Each of these is as effective as the combined OCP and there is good evidence that the actual hormone levels achieved with either of these is less variable than that seen with oral therapy, and lower overall. The transdermal contraceptive patches are changed weekly for 3 weeks and the fourth week is then patch free. For the NuvaRing®, the device is left in the vagina for 3 weeks, then removed for 1 week, then a new vaginal ring inserted. With each of these methods, as with the OCP, the period occurs during the hormone free week.

Emergency contraception

After unprotected intercourse, missed combined pill or a burst condom, a single 750 mg levonorgestrel tablet is taken within 72 hours of intercourse, followed by a second dose exactly 12 hours later. The levonorgestrel-only method has fewer side effects than the previously used combined method and, in some countries, is available to women over the age of 16 years directly from pharmacists. Side effects include mild nausea, vomiting (an additional pill should be taken if vomiting occurs within 2–3 hours of the first dose) and bleeding. The woman should be advised that:

• Her next period might be early or late.

• She needs to use barrier contraception until then.

• She needs to return if she has any abdominal pain or if the next period is absent or abnormal.

If the next period is more than 5 days overdue, pregnancy should be excluded. Emergency contraception prevents 85% of expected pregnancies. Efficacy decreases with time from intercourse.

If the woman concerned does not attend until more than 72 hours after the sexual activity occurred, levonorgestrel therapy is ineffective, however an IUD can be inserted if it is still before the time implantation of any embryo produced would have occurred.

Non-medical methods of contraception

The most fertile phase of the menstrual cycle occurs at the time of ovulation. In a 28-day cycle, this occurs on day 13 or 14 of the cycle. The fertile phase is associated with changes in cervical mucus that a woman can learn to recognize by self-examination and hormone changes that can be measured by home urine testing kits. Avoidance of the fertile period can be an extremely effective method in well-motivated couples.

Natural methods of family planning include the following:

• The rhythm method: Avoiding intercourse mid-cycle and for 6 days before ovulation and 2 days after it. The efficacy of this method depends on being able to predict the time of ovulation. If a regular 28 day cycle occurs, ovulation is predicted for day 14, and abstinence should be from days 8 to 16. If the cycles are very variable, varying between 24 and 32 days, the earliest ovulation would be on day 10 and the latest on day 18, so abstinence would be required between days 4 and 20.

• The ovulation method: This method takes into account the ability of a woman to recognize the increase in vaginal wetness due to cervical mucus productionin the phase before ovulation, and abstaining from sex during that time and for 2 days after the peak wetness has been observed. This method is much better than the rhythm method, but many women only get 4 days advanced warning of the time of ovulation, so intercourse on the preceding 2 days can result in a pregnancy.

• Coitus interruptus (withdrawal): A traditional and still widely used method of contraception that relies on withdrawal of the penis before ejaculation. It is not a particularly reliable method of contraception, because the best sperm often reach the tip of the penis before the male experiences the imminent ejaculation, or he forgets in the ‘heat’ of the moment.

• Lactational amenorrhoea method: Breastfeeding has historically been the most important means of family ‘spacing’. Ovulation resumes on average 4–6 months later in women who continue to breastfeed. During the first 6 months after birth this is an effective method of contraception in mothers providing they are fully breastfeeding, not giving the baby any non-breast milk or other food, AND have remained amenorrhoeic, with failure rates as low as 1/100 women being seen.

Sterilization

Contraceptive techniques have the major advantage that they are easily reversible and provide a high level of protection against pregnancy. They have the disadvantage that they require a conscious act on behalf of the individual before intercourse. When family size is complete or there is a specific medical contraindication to continuing fertility, sterilization becomes the contraceptive method of choice. Around 30% of couples use sterilization for contraception and this increases to 50% in those aged over the age of 40 years.

Counselling

It is essential to counsel both partners about the nature of the procedures and their implications and to discuss whether it is better for the male or female partner to be sterilized. In many cases, only one partner will be seeking sterilization, in which case only one point of view needs to be considered. It is important, however, to ensure that there is a full discussion of the alternatives.

Counselling should include reference to the intended method, its risks and failure rates (1/200 for female sterilization, 1/2000 for male sterilization). Women should be warned of the increased risk of ectopic pregnancy in the event of failure.

Remember the reported failure rate for third-generation/levonorgestrel IUDs is comparable to that of sterilization but male sterilization has a significantly lower failure rate.

With the improvements brought about by microsurgery, it is no longer acceptable to say that sterilization is irreversible and the patient should be counselled according to the technique to be used. The partner to be sterilized will be a matter of choice and motivation. If one partner has a reduced life expectancy from chronic illness, then that partner should be sterilized.

Women should be advised to continue to use other contraception until the period occurs following the sterilization procedure. Men should be advised to use alternative contraception until they have had two consecutive semen analyses showing azoospermia 2–4 weeks apart, with these analyses not done until at least 10 ejaculations have occurred.

Timing of sterilization

The operation can be performed at any time in the menstrual cycle, but is best done in the follicular phase of the cycle. A pregnancy test should be performed preoperatively if a woman has a late or missed period or thinks she may be pregnant.

Techniques

Female sterilization

The majority of procedures involves interruption of the Fallopian tubes but may vary from the application of clips on the tubes to total hysterectomy. In general terms, the more radical the procedure the less likely there is to be a failure. However, very low failure rates can now be achieved using methods with high reversibility prospects and these should be the methods of choice.

Laparoscopic sterilization

The use of the laparoscope for sterilization procedures has substantially reduced the duration of hospital stay. This is the method of choice in most developed countries, but an open approach through a mini-laparotomy may be more appropriate in countries where endoscopic facilities or training are limited.

• Tubal clips. This is the most widely used method of sterilization in the UK and Australia. The clips are made of plastic and inert metals and are locked on to the tube (Fig. 19.6). They have the advantage of causing minimal damage to the tube, but their disadvantage is a higher failure rate. Failures may be due to application on the wrong structure, extrusion of the tube from the clip, recanalization or fracture of the clip so that it falls off the tube. The Filshie clip, which has a titanium frame lined by silicone rubber, has the lowest failure rate (0.5%) and is easier to apply. Yoon or Fallope rings are applied over a loop of tube and are similar to a Madlener procedure (see below). This technique is associated with considerably greater abdominal pain postoperatively, and the failure rates vary between 0.3% and 4%. The rings are not suitable for application to the tubes in the puerperium when the tube is swollen and oedematous.

Fig. 19.6 Sterilization by clip occlusion. (A) The right Fallopian tube is grasped with the clip. (B) The clip is closed and the tube is crushed. (C) The Filshie clip is closed and locked across the Fallopian tube.

• Tubal coagulation and division. Sterilization is effected by either unipolar or bipolar diathermy of the tubes in two sites 1–2 cm from the uterotubal junction. A considerable amount of tube can be destroyed with this technique. Division of the diathermied tube is said to reduce the risk of ectopic pregnancy. The failure rate depends on the length of tube destroyed. Because of the risk of thermal bowel injury with subsequent leakage and faecal peritonitis, diathermy should not be used as the primary method of sterilization unless mechanical methods of tubal occlusion are technically difficult or fail at the time of the procedure.

Tubal ligation (Fig. 19.7)

These procedures are usually performed through a small abdominal incision (mini-laparotomy) or at the time of caesarean section. They are less widely used with the increase in laparoscopic procedures. Even when laparoscopy is contraindicated for some reason it is still more common now to use clips to occlude the tubes.

Fig. 19.7 Sterilization by tubal ligation.

The most basic form of the procedure involving simple ligation of the tube is known as the Madlener procedure but the failure rate may be up to 3.7%. The Pomeroy technique is the same, but the loop of tube is excised and absorbable suture material is used for the ligation. There are several variations of this technique, including the separation of the cut ends of the tubes on contralateral sides of the broad ligament. The excised segments should be examined histologically to confirm that the tube has been excised.

The Essure® procedure

This procedure consists of insertion of a small device into each tube at the time of a hysteroscopic examination, with this device resulting in fibrosis and ultimate occlusion of the tube on each side. This insertion can often be done without anaesthesia and does not require a laparoscopy. The device has a stainless steel coil, which holds the device in position in the proximal portion of the tube, and inner polyethylene terephthalate fibres which induce the benign fibrotic reaction over the succeeding 3 months. Adequacy of tubal blockage is often checked by the performance of a hysterosalpingogram.

Complications

Apart from the complications of laparoscopy, if it was performed to enable sterilization, the longer-term complications of any tubal sterilization are tubal recanalization and pregnancy, ectopic pregnancy, menstrual irregularity and loss of libido.

Vasectomy

This procedure is generally performed under local anaesthesia. Two small incisions are made over the spermatic cord and 3–4 cm of the vas deferens is excised (Fig. 19.8). The advantage of the technique is its simplicity. The disadvantages are that sterility is not immediate and should not be assumed until all spermatozoa have disappeared from the ejaculate. On average, this takes at least 10 ejaculations.

The procedure is more difficult to reverse than most forms of female sterilization and, even when satisfactory re-anastomosis is achieved, only about 50% of patients will sire children, because of the adverse effect of the production of sperm-immobilizing and sperm-agglutinating antibodies. The failure rate is 1/2000.

Failures may follow spontaneous recanalization and excision of an inadequate length of vas deferens. The excised segments should always be examined histologically to confirm that the vas has been excised. Complications of the operation include haematoma formation, wound infection and epididymitis. Also a painful granuloma may form at the cut end of the vas as a result of a foreign body reaction induced by spermatozoa.

Psychological implications of sterilization

Sterilization in women has acquired the reputation of leading to psychiatric problems and a deterioration in sexual function. Modern studies do not confirm this reputation. Apart from the fact that modern studies tend to use prospective standardized methodologies, the population being sterilized in the 21st century is very different to that of 40 years ago. Sterilization used to be performed predominantly on older women in poor gynaecological health, with large numbers of children and living in conditions of social adversity. It was carried out on medical recommendation, frequently shortly after childbirth, abortion or some other gynaecological procedure. Nowadays, sterilization is a widely accepted form of contraception used by women of all ages and social classes. They are, therefore, more representative of the population as a whole. Sterilization usually takes place at the request of the woman as an interval procedure unrelated to either childbirth or abortion. Women being sterilized have fewer children and are in better general health than previously.

The rate of psychiatric disorder following sterilization is, in general, no higher than that in the general female population. However, for women who are sterilized immediately following childbirth, there is an increased risk of suffering from postnatal depression. A previous psychiatric history and ambivalence or uncertainty about sterilization are risk factors for psychiatric disorder. Postpartum status, previous psychiatric history, ambivalence and marital discord are also risk factors for deterioration of psychosexual functioning and regret. Some authors have also suggested that, in cultures where femininity is strongly associated with fertility and where there is guilt and shame about contraception, great care should be exercised to ensure that patients are properly prepared for sterilization. Regret, often measured by a request for reversal of sterilization, appears to be most strongly predicted by marital breakdown and subsequent remarriage.

Termination of pregnancy

In the UK this is carried out in approved centres under the provisions of the Abortion Act 1967. This requires that two doctors agree that either continuation of the pregnancy would involve greater risk to the physical or mental health of the mother or her other children than termination, or that the fetus is at risk of an abnormality likely to result in it being seriously handicapped (Box 19.2). The most recent amendment to the Act (1991) set a limit for termination under the first of these categories at 24 weeks, although in practice the majority of terminations are carried out prior to 20 weeks.

Box 19.2 Indications for termination

A Risk to the life of the mother would be greater if the pregnancy continues

B To prevent permanent harm to mental or physical health of the mother

C Risk to mother’s health greater * if the pregnancy continues

D Risk to other children in the family * if the pregnancy continues

E Risk of serious disability in the child

^*Only if less than 24 weeks.

All terminations carried out in the UK must be notified. Annual abortion numbers peaked in the UK in 1990 at 170 000 and declined after that until the scare over the risk of venous thrombosis with the ‘third-generation’ pills in 1996.

Methods

All women undergoing termination of pregnancy should be screened for STIs and/or offered antibiotic prophylaxis. Following termination, anti-D immunoglobulin should be given to all rhesus negative women. All women should be offered a follow-up appointment to check that there are no physical problems and that contraceptive measures are in place.

The rate of infection with Chlamydia spp. is 12% of women requesting termination of pregnancy. In these women there is a 30% risk of PID if appropriate antibiotic treatment is not given at the time of a surgical termination.

Surgical termination

This is the method most commonly used in the first trimester or pregnancy. The cervix is dilated by a number of millimetres equivalent to the gestation in weeks and the conceptus is removed using a suction curette. A variation involving piecemeal removal of the larger fetal parts with forceps (dilatation and evacuation) allows the method to be used for later second trimester pregnancies. Although most procedures are carried out under general anaesthesia in the UK, local anaesthesia is widely used in many countries for terminations before 10 weeks and reduces the time the patient needs to stay in the hospital or clinic.

Cervical dilation can be made easier by administration of prostaglandin pessaries before the operation.

Medical termination

This is the method most commonly used for pregnancies after 14 weeks and is increasingly being offered as an alternative to surgical termination in first trimester pregnancies up to 9 weeks gestation. The standard regimens for first-trimester termination use the progesterone antagonist mifepristone (RU 486) given orally, followed 36–48 hours later by prostaglandins administered as a vaginal pessary. There are several different regimens, but all have a success rate of greater than 95%. Second trimester terminations can also be performed using vaginal prostaglandins given 3-hourly or as an extra-amniotic infusion through a balloon catheter passed through the cervix. Pretreatment with mifepristone significantly reduces the time interval from induction to abortion. After delivery of the fetus, an examination under general anaesthetic may be necessary to remove the placenta.

Complications

Early complications include bleeding, uterine perforation (with possible damage to other pelvic viscera), cervical laceration, retained products and sepsis. All the procedures also have a small failure rate (overall rate 0.7/1000). Late complications include infertility, cervical incompetence, isoimmunization and psychiatric morbidity. Adequate counselling (supported by written information) and explanation of the procedures and their risks are essential.

Psychological sequelae of termination

The majority of women who find themselves with an unwanted pregnancy are very distressed. Despite this, evidence shows that the majority of women do not experience medium- to long-term psychological sequelae, nor is there any evidence of an increase in the rate of psychiatric morbidity. The available evidence is that the rate of psychiatric morbidity following termination of pregnancy is less than if the pregnancy was allowed to proceed.

Risk factors for adverse sequelae of first-trimester abortion

Being married and having children prior to a termination can lead to problems of guilt and regret. Women in such circumstances need careful counselling before proceeding with the termination. Ambivalence, coercion, previous termination of pregnancy, past psychiatric history and termination associated with sterilization are risk factors for psychiatric morbidity.

Later terminations of pregnancy

The number of women having terminations of pregnancy after 12 weeks for psychosocial reasons is falling. Second trimester terminations now account for fewer than 8% of all therapeutic terminations of pregnancy. A minority of these women are having a therapeutic abortion for psychosocial reasons; the majority for fetal abnormality.

Unlike first trimester abortions, later terminations of pregnancy are associated both with marked psychological distress and an increased rate of psychiatric disorder. Some 39% of women having an abortion for fetal abnormality are depressed at 3–9 months, although the rates fall to normal at 1 year. For women undergoing this procedure for psychosocial reasons, the cause for the increased rate of distress and morbidity is likely to be found in the delay in presenting for termination. The very young, the mentally handicapped and the chronically mentally ill may be found in this group, as well as those who have experienced marked ambivalence about their pregnancies.

The situation for women having a termination of pregnancy because of fetal abnormality is different. These are usually older women who have a much wanted pregnancy and whose problem has been diagnosed either because of a previous experience or as the result of screening. The decision to terminate the pregnancy is usually reached only after much thought and anguish. The consequence of termination is, therefore, very much like the spontaneous loss of a more advanced pregnancy, that is to say, a grief reaction. Their psychosocial recovery may be assisted by granting them the dignity of a naming and burial. Most late terminations of pregnancy involve the induction of labour and a prolonged process of giving birth. This can be a distressing and traumatic experience, and psychological recovery will be improved by sensitive and compassionate handling by the doctor and nursing staff.

Contraception following termination

Referral for termination should also be an opportunity to discuss future contraception and to ensure that adequate provision is made for this after the termination. The procedure can be combined with sterilization. This has the advantage of preventing further terminations for the woman who is certain that she has completed her family. There is little evidence that this is associated with an increase in the rate of complications or later contraceptive failure. However, because of the increase in the ‘regret rate’ for the sterilization, an interval procedure is generally recommended. IUD insertion can be carried out at the same time as termination and is not associated with an increased risk of perforation or failure. If the oral contraceptive is being used, this can be started on the same or following day.

Criminal abortion

Miscarriage induced by a variety of techniques makes up a substantial percentage of miscarriage in some countries. Where the indications for legal miscarriage are liberal, criminal abortion is infrequent but in many countries it contributes to a high percentage of apparently spontaneous miscarriages. The World Health Organization estimates that 250 000 women per year in the world die as a result of abortions, most of which are illegal. Mortality from abortion in the UK has fallen from a rate of 37/million maternities to 1.4/million since 1967. There have been no deaths from illegal abortion in the UK since 1982.

Genital tract infections

The female genital tract provides direct access to the peritoneal cavity. Infection may extend to any level of the tract and, once it reaches the Fallopian tubes, is usually bilateral.

The genital tract has a rich anastomosis of blood and lymphatic vessels that serve to resist infection, particularly during pregnancy.

There are other natural barriers to infection:

• The physical apposition of the pudendal cleft and the vaginal walls.

• Vaginal acidity – the low pH of the vagina in the sexually mature female provides a hostile environment for most bacteria; this resistance is weakened in the prepubertal and postmenopausal female.

• Cervical mucus that acts as a barrier in preventing the ascent of infection.

• The regular monthly shedding of the endometrium.

Taking a sexual history

Taking an accurate sexual history is essential to the management of genital tract infections, and aspects of sexual history are relevant to a range of other presentations including subfertility, pelvic pain and disorders of sexual function. A concise sexual history will help to:

• identify specific risk behaviours

• assess symptoms to guide examination and testing

• identify anatomical sites for testing based on risk

• assess other related sexual health issues such as pregnancy risk and contraceptive needs

• inform the counselling process, health education required and contact tracing.

Patients (and students!) are often anxious so it is important to create a relaxed and friendly environment and have a respectful and a non-judgemental attitude. Introducing self and role, maintaining eye contact and having appropriate body language are important aspects of good communication when obtaining a sexual history. The confidential nature of the consultation should be explained. It is important etc to use language that is understandable and does not use labels or make judgements. Ask general questions first, using open ended questions. Move on to the exploration of reasons for presentation and more closed ended questions (see below). Explain there are some ‘universal’ questions that are explicitly asked of everyone to assess risk and avoid making assumptions about sexual orientation based on appearance.

Specific questions

Reason for attendance: the problem/issue, including symptoms

Direct questions about symptoms may include:

– duration and severity of symptoms

– urethral and vaginal discharge: amount, colour, odour, character

– abnormal vaginal or rectal bleeding

– genital and extra genital rashes, lumps or sores

– itching and/or discomfort in the perineum, peri-anal and pubic region

– lower abdominal pain or dyspareunia

– difficulties/pain with micturition, defecation or during intercourse

Sexual behaviour risk assessment:

– last sexual intercourse (LSI)

– history of unprotected intercourse

– number and gender of sexual contacts in last 3 to 12 months (all men should be asked if they have ever had sex with another man in the past)

– type of sexual activity practised (oral, anal, vaginal, toys)

– STI prevention used and whether consistently used and remained intact (condoms)

– relationship with sexual contacts (regular, casual, known, unknown)

– have any recent sexual contacts had any symptoms or infections

STI and blood-borne virus (BBV) risk assessment: additional questions to assess timing of tests and other risks to inform testing and management planning:

– date and results of previous STI and BBV testing

– current or past history of injecting drug use, sharing of needles, syringes or of body piercing and/or tattoos including country, when done and whether sterile equipment used

– whether they have had sex overseas other than with the person they are travelling with

– sex industry worker or sexual contact with a sex worker

– vaccination history including Hepatitis A, B and HPV

Other relevant information: to identify issues that may be associated with or influence client management:

– current or recent medications

– history of allergies especially adverse reaction to penicillin

– contraceptive and reproductive health history, including contraceptive use and compliance and last menstrual period (LMP)

– cervical cytology history including date of last test and result, past abnormal cytology

– past medical and surgical history (including any overseas medical treatment and transfusions)

– alcohol, tobacco and other drug use

(Reproduced from NSW Sexually Transmissible Infections Programs Unit 2011. NSW Health Sexual Health Services Standard Operating Procedures Manual 2011.)

Lower genital tract infections

The commonest infections of the genital tract are those that affect the vulva and vagina. Infections that affect the vagina also produce acute and chronic cervicitis.

Symptoms

Swelling and reddening of the vulval skin is accompanied by soreness, pruritus and dyspareunia. When the infection is predominantly one of vaginitis, the symptoms include vaginal discharge, pruritus, dyspareunia and often dysuria. Cervicitis is associated with purulent vaginal discharge, sacral backache, lower abdominal pain, dyspareunia and dysuria. The proximity of the cervix to the bladder often results in coexistent trigonitis and urethritis, particularly in the case of gonococcal infections.

Chronic cervicitis is present in about 50–60% of all parous women. In many cases, the symptoms are minimal. There may be a slight mucopurulent discharge, which is not sufficient to trouble the woman and may simply present as an incidental finding that does not justify active treatment. In the more severe forms of the condition, there is profuse vaginal discharge, chronic sacral backache, dyspareunia and occasionally postcoital bleeding. Bacteriological culture of the discharge is usually sterile. The condition may cause subfertility because of hostility of the cervical mucus to sperm invasion.

Signs

These will depend on the cause. The appearance of the vulval skin is reddened, sometimes with ulceration and excoriation. In the sexually mature female, the vaginal walls may become ulcerated, with plaques of white monilial discharge adherent to the skin or, in protozoal infections, the discharge may be copious with a greenish-white, frothy appearance.

Bartholin’s glands are sited between the posterior part of the labia minora and the vaginal walls, and these two glands secrete mucus as a lubricant during coitus. Infection of the duct and gland results in closure of the duct and formation of a Bartholin’s cyst or abscess. The condition is often recurrent and causes pain and swelling of the vulva. Bartholinitis is readily recognized by the site and nature of the swelling.

In cervicitis the cervix appears reddened and may be ulcerated, as with herpetic infections, and there is a mucopurulent discharge as the endocervix is invariably involved. The diagnosis is established by examination and taking cervical swabs for culture.

Common organisms causing lower genital tract infections

Vaginal candidiasis

Candida albicans is a yeast pathogen that occurs naturally on the skin and in the bowel. Infection may be asymptomatic or associated with an increased or changed vaginal discharge associated with soreness and itching in the vulva area. There is no evidence of male to female sexual transmission. White curd-like collections attached to the vaginal epithelium may be seen on speculum examination, although these are not present in all cases.

Candidal infections are particularly common during pregnancy, in women taking the contraceptive pill and in underlying conditions involving immunosuppression, e.g. HIV infection, diabetes or long-term steroids. In each instance, vaginal acidity is increased above normal and bacterial growth in the vagina is inhibited in such a way as to allow free growth of yeast pathogens, which thrive well in a low-pH environment. Candida hyphae and spores can also be seen in a wet preparation and can be cultured.

Trichomoniasis

Trichomonas vaginalis is a flagellated single-celled protozoal organism that may infect the cervix, urethra and vagina. In the male the organism is carried in the urethra or prostate and infection is sexually transmitted. The organisms are often seen on the Pap smear even in the absence of symptoms. The commonest presentation is with abnormal vaginal bleeding, but other symptoms include vaginal soreness and pruritus. The vaginal pH is usually raised above 4.5. A fresh wet preparation in saline of vaginal discharge will show motile trichomonads (Fig. 19.9). The characteristic flagellate motion is easily recognized and the organism can be cultured.

Genital herpes

The condition is caused by herpes simplex virus (HSV) type 2 and, less commonly, type 1. It is a sexually transmitted disease. Primary HSV infection is usually a systemic infection with fever, myalgia and occasionally meningism. The local symptoms include vaginal discharge, vulval pain, dysuria and inguinal lymphadenopathy. The discomfort may be severe enough to cause urinary retention. Vulval lesions include skin vesicles and multiple shallow skin ulcers (Fig. 19.10). The infection is also associated with an increased risk of cervical dysplasia. Partners may be asymptomatic and the incubation period is 2–14 days.

Fig. 19.10 Herpetic vulvitis. Lesions can also occur in the cervix and in the perivulvar region.

The diagnosis is made by sending fluid from vesicles for viral culture or antigen detection. After the initial infection the virus remains latent in the sacral ganglia. Recurrences may be triggered by stress, menstruation or intercourse, but are normally of shorter duration and less severe than the primary episode. Serum antibodies are raised in well-established lesions.

Bacterial vaginosis

This is due to an overgrowth of a number of anaerobic organisms including Gardnerella spp. It is not sexually transmitted. It may be asymptomatic or cause a smelly vaginal discharge and vulval irritation. It is associated with an increased risk of PID, urinary tract infection and puerperal infection. Diagnosis is made by finding three of the following:

• An increase in vaginal pH of more than 4.5.

• A typical thin homogenous vaginal discharge.

• A fishy odour produced when 10% potassium hydroxide is added to the discharge.

• Clue cells on Gram-stained slide of vaginal fluid (Fig.19.11).

Fig. 19.11 Clue cells in bacterial vaginosis. These are epithelial squamous cells with multiple bacteria adherent to their surface.

Gonococcal and chlamydial vulvovaginitis

These organisms can result in extensive pelvic infection (see below) but may also be asymptomatic or indicated merely by vaginal discharge and dysuria. Chlamydia is the commonest sexually transmitted infection seen today.

Syphilis

The initial lesion appears 10–90 days after contact with the spirochaete Treponema pallidum. The primary lesion or chancre is an indurated, firm papule, which may become ulcerated and has a raised firm edge. This lesion most commonly occurs on the vulva but may also occur in the vagina or cervix. The primary lesion may be accompanied by inguinal lymphadenopathy. The chancre heals spontaneously within 2–6 weeks.

Some 6 weeks after the disappearance of the chancre, the manifestations of secondary syphilis appear. A rash develops which is maculopapular and is often associated with alopecia. Papules occur, particularly in the anogenital area and in the mouth, and give the typical appearance known as condylomata lata.

Swabs taken from either the primary or secondary lesions are examined microscopically under dark-ground illumination, and the spirochaetes can be seen. The serological tests have been described in Chapter 7.

The disease then progresses from the secondary phase to a tertiary phase. It may mimic almost any disease process and affect every system in the body, but the common long-term lesions are cardiovascular and neurological.

Genital warts (condylomata acuminata)

Vulval and cervical warts (Fig. 19.12) are caused by a human papilloma virus (HPV). The condition is commonly, although by no means invariably, transmitted by sexual contact. The incubation period is up to 6 months. The incidence has risen significantly over the last 15 years, particularly in women aged 16–25 years.

Fig. 19.12 Papilloma virus infection of the cervix: condylomata acuminata.

The warts have an appearance similar to those seen on the skin in other sites, and in the moist environment of the vulval skin are often prolific – particularly during pregnancy. There is frequently associated pruritus and vaginal discharge. The lesions may spread to the perianal region, and in some cases become confluent and subject to secondary infection. Diagnosis is usually made by clinical examination.

Vaginal discharge in a child may also be associated with the presence of a foreign body, and this possibility should always be excluded.

Treatment of lower genital tract infections

When the diagnosis has been established by examination and bacteriological tests, the appropriate treatment can be instituted. The treatment for Chlamydia and gonorrhoea is discussed below under infections of the upper genital tract. Whenever a diagnosis of sexually transmitted infection is made, it is essential to screen patients (and their partners) for other infections.

Vulval and vaginal monilial infections can be treated by topical or oral preparations. These include a single dose of clotrimazole given as a pessary or fluconazole taken orally. Recurrent infections can be treated by oral administration of ketoconazole and fluconazole. The patient’s partner should be treated at the same time, and any predisposing factors such as poor hygiene or diabetes should be corrected.

Trichomonas infections and bacterial vaginosis are treated with metronidazole 400 mg taken twice a day for 5 days, which must be taken by both sexual partners if recurrence of the infection is to be avoided. Metronidazole may be administered as a single dose of 2 g, but high-dose therapy should be avoided in pregnancy. Topical treatment with metronidazole gel or clindamycin cream is also effective for bacterial vaginosis.

If a patient is asymptomatic and there is no evidence of vaginitis on clinical examination, but trichomonal or monilial organisms are identified in a routine Pap smear, treatment of these patients is usually not required.

Non-specific vaginal infections are common and are treated with vaginal creams, including hydrargaphen, povidone–iodine, di-iodohydroxyquinoline or sulphonamide creams.

Syphilis is treated in the first instance with penicillin and, if this fails, for example in the case of coinfection, with penicillin-resistant strains of the gonococcus, doxycycline hydrochloride or other antibiotics can be used.

Infections of the vagina associated with menopausal atrophic changes are treated by the appropriate hormone replacement therapy using an oral or vaginal oestrogen preparation, or lactic acid pessaries when oestrogens are contraindicated. The same therapy may be used, with the local application of oestrogen creams, in juvenile vulvovaginitis.

Infections of Bartholin’s gland are treated with the antibiotic appropriate to the organism. If abscess formation has occurred, the abscess should be ‘marsupialized’ by excising an ellipse of skin and sewing the skin edges to result in continued open drainage of the abscess cavity (Fig. 19.13). This reduces the likelihood of recurrence of the abscess.

Fig. 19.13 Marsupialization of a Bartholin’s cyst or abscess. The incision is made over the medial aspect of the cyst (left) and the lining is sutured to the skin (right).

Vulval warts are treated with either physical or chemical diathermy using podophyllin applied directly to the surface of the warts. Any concurrent vaginal discharge should also receive the appropriate therapy.

Herpetic infections are notoriously resistant to treatment and highly prone to recurrence. The best available treatment is aciclovir administered in tablet form 200 mg five times daily for 5 days or locally as a 5% cream.

Acute cervicitis usually occurs in association with generalized infection of the genital tract and is diagnosed and treated according to the microbiology. Medical treatment is rarely effective in chronic cervicitis because it is difficult to identify an organism and antibiotics do not penetrate the chronic microabscesses of the cervical glands. If the cervical swab is negative, the next most effective management is diathermy of the endocervix under general anaesthesia. Following diathermy, an antibacterial cream should be placed in the vagina and the woman should be advised that the discharge may increase in amount for 2–3 weeks but will then diminish. She should also be advised to avoid intercourse for 3 weeks as coitus may cause a secondary haemorrhage.

Upper genital tract infections

Acute infection of the endometrium, myometrium, Fallopian tubes and ovaries are usually the result of ascending infections from the lower genital tract causing PID.

However, infection may be secondary to appendicitis or other bowel infections, which sometimes give rise to a pelvic abscess. Perforation of the appendix with pelvic sepsis remains a common cause of tubal obstruction and subfertility. Pelvic sepsis may also occur during the puerperium and after pregnancy termination or after operative procedures on the cervix. Retained placental tissue and blood provide an excellent culture medium for organisms from the bowel, including Escherichia coli, Clostridium welchii or C. perfringens, Staphylococcus aureus and Streptococcus faecalis.

PID affects approximately 1.7% of women between 15 and 35 years of age per year in the developed world. Up to 20% of women with PID will have a further episode within 2 years. The disease is most common between the ages of 15 and 24 years, and particular risk factors include multiple sexual partners and procedures involving transcervical instrumentation. PID is an important cause of infertility. After a first episode 8% of women will have evidence of tubal infertility; subsequent episodes approximately double this figure. Women with a past history of PID are 4 times more likely to have an ectopic pregnancy when they conceive.

40% of women who have had three or more episodes of PID have tubal damage.

Symptoms and signs

The symptoms of acute salpingitis include:

• Acute bilateral lower abdominal pain: Salpingitis is almost invariably bilateral; where the symptoms are unilateral, an alternative diagnosis should be considered

• Deep dyspareunia

• Abnormal menstrual bleeding

• Purulent vaginal discharge.

The signs include:

• Signs of systemic illness with pyrexia and tachycardia.

• Signs of peritonitis with guarding, rebound tenderness and often localized rigidity. (It should be noted that guarding and rigidity rarely are seen if blood is in the peritoneal cavity, such as due to an ectopic pregnancy, whereas tenderness and release tenderness are seen even in the absence of peritonitis.)

• On pelvic examination, acute pain on cervical excitation and thickening in the vaginal fornices, which may be associated with the presence of cystic tubal swellings due to pyosalpinges or pus-filled tubes; fullness in the pouch of Douglas suggests the presence of a pelvic abscess (Fig. 19.14).

Fig. 19.14 Acute salpingitis: the tubes are swollen and engorged.

• An acute perihepatitis occurs in 10–25% of women with chlamydial PID, which may cause right upper quadrant abdominal pain, deranged liver function tests and multiple filmy adhesions between the liver surface and the parietal peritoneum, and is known as the Fitz–Hugh–Curtis syndrome.

• A pyrexia of 38°C or more, sometimes associated with rigors.

Common organisms

Pelvic inflammatory disease is thought to be the result of polymicrobial infection with primary infection by Chlamydia trachomatis or Neisseria gonorrhoeae (or both) allowing opportunistic infection with other aerobic bacteria and anaerobes.

Chlamydia

C. trachomatis is an obligate intracellular Gram-negative bacterium. It is the commonest bacterial sexually transmitted infection in Europe, Australia and North America and is thought to be the causative agent in at least 60% of cases of PID in those areas. Prevalence rates vary from 11–30% in women attending genitourinary medicine clinics, with the peak incidence in the UK in women aged 20–24 years. The main sites of infection are the columnar epithelium of the endocervix, urethra and rectum, but many women remain asymptomatic. Ascent of infection to the upper genital tract occurs in about 20% of women with cervical infection.

Gonorrhoea

N. gonorrhoeae is a Gram-negative intracellular diplococcus (Fig. 19.15). Infection is commonly asymptomatic or associated with vaginal discharge. In cases of PID it spreads across the surface of the cervix and endometrium and causes tubal infection within 1–3 days of contact. It is the principal cause for 14% of cases of PID and occurs in combination with Chlamydia in a further 8%.

Differential diagnosis

It is often difficult to establish the diagnosis of acute pelvic infection with any degree of certainty. The predictive value of clinical signs and symptoms when compared to laparoscopic diagnosis is 65–90%. The differential diagnosis includes the following:

• Tubal ectopic pregnancy: Initially pain is unilateral in most cases. There may be syncopal episodes and signs of diaphragmatic irritation with shoulder tip pain. The white cell count is normal or slightly raised but the haemoglobin level is likely to be low depending on the amount of blood lost, whereas in acute salpingitis the white cell count is raised and the haemoglobin concentration is normal.

• Acute appendicitis: The most important difference in the history lies in the unilateral nature of this condition. Pelvic examination does not usually reveal as much pain and tenderness but it must be remembered that the two conditions sometimes coexist, particularly where the infected appendix lies adjacent to the right Fallopian tube.

• Acute urinary tract infections: These may produce similar symptoms but rarely produce signs of peritonism and are commonly associated with urinary symptoms.

• Torsion or rupture of an ovarian cyst.

Investigations

When the diagnosis of acute salpingitis is suspected, the woman should be admitted to hospital. After completion of the history and general examination, swabs should be taken from the vaginal fornices and cervical canal and sent to the laboratory for culture and antibiotic sensitivity. A midstream specimen of urine should also be sent for culture to exclude a possible urinary tract infection. An additional endocervical swab should be taken for detection of Chlamydia by enzyme-linked immunoassay (ELISA) or, preferably, polymerase chain reaction (PCR). Urethral swabs may identify chlamydial infection not detected by endocervical swabs. PCR assays of urine samples have a similar of better sensitivity (90%) compared to genital tract swabs and offer a potential means for screening for chlamydial infection in asymptomatic women.

Examination of the blood for differential white cell count, haemoglobin estimation and C-reactive protein may help to establish the diagnosis. Blood culture is indicated if there is a significant pyrexia. The diagnosis of mild to moderate degrees of PID on the basis of history and examination findings is unreliable and, where the diagnosis is in doubt, laparoscopy is indicated.

Negative swabs do not exclude the possibility of PID.

Management

When the patient is unwell and exhibits peritonitis, high-grade fever, vomiting or a pelvic inflammatory mass, she should be admitted to hospital and managed as follows:

• Fluid replacement by intravenous therapy – vomiting and pain often result in dehydration.

• When PID is clinically suspected, antibiotic therapy should be commenced. Antibiotic therapy initially prescribed for clinically diagnosed PID should be effective against C. trachomatis, N. gonorrhoeae and the anaerobes characterizing bacterial vaginosis. If the woman is acutely unwell, treatment should be started with an antibiotic such as cefuroxime and metronidazole given intravenously with oral doxycycline until the acute phase of the infection begins to resolve. Treatment with oral metronidazole and doxycycline should then be continued for 7 and 14 days, respectively.

• Pain relief with non-steroidal anti-inflammatory drugs.

• If the uterus contains an intrauterine device, it should be removed as soon as antibiotic therapy has been commenced.

• Bed rest – immobilization is essential until the pain subsides.

• Abstain from intercourse.

Women who consulted after 3 days of symptoms had an almost threefold increased risk of impaired infertility after PID compared with those who consulted promptly.

Patients who are systemically well can be treated as outpatients, with a single dose of azithromycin and a 7-day course of doxycycline, reviewed after 48 hours.

In all cases of confirmed sexually transmitted infection, it is important to treat the partner and arrange appropriate contact tracing.

Indications for surgical intervention

In most cases, conservative management results in complete remission. Laparotomy is indicated where the condition does not resolve with conservative management and where there is a pelvic mass.

In most cases, the mass will be due to a pyosalpinx or tubo-ovarian abscess. This can either be drained or a salpingectomy can be performed.

Chronic pelvic infection

Acute pelvic infections may progress to a chronic state with dilatation and obstruction of the tubes forming bilateral hydrosalpinges with multiple pelvic adhesions (Fig.19.16).

Fig. 19.16 Chronic pelvic inflammatory disease: a sheet of fine adhesions covering the tubes and ovary, which is buried beneath the tube.

Symptoms and signs

Symptoms are varied but include:

• chronic pelvic pain

• chronic purulent vaginal discharge

• epimenorrhagia and dysmenorrhoea

• deep-seated dyspareunia, or just

• infertility.

Chronic salpingitis is also associated with infection in the connective tissue of the pelvis known as parametritis.

On examination, there can be a purulent discharge from the cervix. The uterus is often fixed in retroversion, and there is thickening in the fornices and pain on bimanual examination.

Chronic pelvic pain occurs in 25–75% of women with a past history of PID.

Management

Conservative management of this condition is rarely effective and the problem is only eventually resolved by clearance of the pelvic organs. Women with a history of PID are 8 times more likely to have a hysterectomy than the general population. If the problem is mainly infertility due to tubal disease, the best treatment is IVF. Tubal removal prior to IVF is usually indicated if hydrosalpinges are present because this improves the pregnancy rate achieved.

Human immunodeficiency virus

Human immunodeficiency virus (HIV)-1 and HIV-2 are RNA retroviruses characterized by their tropism for the human CD4⁺ (helper) T lymphocyte. The proportion of cells infected is initially low and there is a prolonged latent phase between infection and clinical signs. Transmission occurs by sex, infected blood products, shared needles, breastfeeding and at the time of delivery. Risk groups include intravenous drug abusers and their partners, the partners of bisexual men, haemophiliacs, prostitutes and immigrants from high-risk areas. Although HIV infection is more common in men in the developed world, anonymous testing shows that 0.3% of pregnant women in London are infected and it is now the most common cause of death in African American females aged 24–35 years in the US. In parts of sub-Saharan Africa, 20–30% of all pregnant women are HIV positive. Vertical transmission rates can be reduced from 40% to less than 1% by antenatal treatment with the modern antiretroviral drugs, delivery by elective caesarean section and avoidance of breastfeeding. Although HIV infection was a life-ending sentence for most people in the past as most developed acquired immunodeficiency syndrome (AIDS) as an end result within a few years of becoming infected with the HIV, with modern continuous therapy most are able to be controlled and progression to AIDS is much less common.

The main clinical states can be identified as:

• a ‘flu-like’ illness 3–6 months after infection, associated with seroconversion

• asymptomatic impaired immunity

• persistent generalized lymphadenopathy

Common opportunistic infections include Candida, HSV, HPV, Mycobacterium spp., Cryptosporidium spp., Pneumocystis carinii and cytomegalovirus. Non-infective manifestations include weight loss, diarrhoea, fever, dementia, Kaposi’s sarcoma and an increased risk of cervical cancer.

The diagnosis is made by detecting antibodies to the virus, although these may take up to 3 months to appear.

Disorders of female sexual function

Disorders of sexual function are reported by up to a third of women. Sometimes they are accompanied by awareness of the underlying disturbance but often, as with other emotional difficulties, the link between cause and effect is obscure even to the sufferer. Sexual problems may therefore appear in the guise of mental or physical illness or disturbances of behaviour and relationships, and thus form a part of the working experience not only of doctors but of anyone in the ‘caring’ professions. Lack of knowledge about sex and the anatomy of the genital tract remain common and a source of anxiety.

The commonest complaints are:

• painful sex (dyspareunia)

• vaginismus

• loss of desire (libido)

• orgasmic dysfunction.

Pay attention to the non-verbal communication during the consultation and examination.

Dyspareunia

Dyspareunia is defined as painful intercourse. It is predominantly but not exclusively a female problem. The aetiology is divided on the basis of whether the problem is superficial (at the entrance to the vagina) or deep (only occurs with deep penile insertion) and it is therefore particularly important to obtain a concise history.

Superficial dyspareunia

Pain felt on penetration is generally associated with a local lesion of the vulva or vagina from one of the following causes:

• Infection: Local infections of the vulva and vagina commonly include monilial and trichomonal vulvovaginitis. Infections involving Bartholin’s glands also cause dyspareunia.

• Narrowing of the introitus may be congenital, with a narrow hymenal ring or vaginal stenosis. It may sometimes be associated with a vaginal septum. The commonest cause of narrowing of the introitus is the over-vigorous suturing of an episiotomy wound or vulval laceration or following vaginal repair of a prolapse.

• Menopausal changes: Atrophic vaginitis or the narrowing of the introitus and the vagina from the effects of oestrogen deprivation may cause dyspareunia. Atrophic vulval conditions such as lichen sclerosus can also cause pain.

• Vulvodynia: This is a condition of unknown aetiology characterized by persisting pain over the vulva.

• Functional changes: Lack of lubrication associated with inadequate sexual stimulation and emotional problems will result in dyspareunia.

Deep dyspareunia

Pain on deep penetration is often associated with pelvic pathology. Any woman who develops deep dyspareunia after enjoying a normal sexual life should be considered to have an organic cause for her pain until proved otherwise. The common causes of deep dyspareunia include:

• Acute or chronic pelvic inflammatory disease: including cervicitis, pyosalpinx and salpingo-oophoritis (Fig. 19.16). The uterus may become fixed. Ectopic pregnancy must also be considered in the differential diagnosis in this group.

• Retroverted uterus and prolapsed ovaries: If the ovaries prolapse into the pouch of Douglas and become fixed in that position, intercourse is painful on deep penetration.

• Endometriosis: Both the active lesions and the chronic scarring of endometriosis may cause pain.

• Neoplastic disease of the cervix and vagina: At least part of the pain in this situation is related to secondary infection.

• Postoperative scarring: This may result in narrowing of the vaginal vault and loss of mobility of the uterus. The stenosis commonly occurs following vaginal repair and, less often, following repair of a high vaginal tear. Vaginal scarring may also be caused by chemical agents such as rock salt, which, in some countries, is put into the vagina in order to produce contracture.

• Foreign bodies: Occasionally, a foreign body in the vagina or uterus may cause pain in either the male or female partner. For example, the remnants of a broken needle or partial extrusion of an intrauterine device may cause severe pain in the male partner.

Apareunia

Apareunia is defined as the ‘absence’ of intercourse or the inability to have intercourse at all. The common causes are:

• congenital absence of the vagina

• imperforate hymen.

Treatment

Accurate diagnosis is dependent on careful history taking and a thorough pelvic examination. The treatment will therefore be dependent on the cause. Congenital absence of the vagina can be successfully treated by surgical correction (vaginoplasty) and removal of the imperforate hymen is effective.

Medical treatment for deep dyspareunia includes the use of antibiotics and antifungal agents for pelvic infection, and the use of local or oral hormone therapy for post-menopausal atrophic vaginitis. Treatment for endometriosis is discussed in Chapter 17. Surgical treatment includes correction of any stenosis, excision of painful scars where appropriate, and reassurance and sexual counselling is necessary in functional disorders.

Vaginismus

Vaginismus is the symptom resulting from spasm of the pelvic floor muscles and adductor muscles of the thigh, which prevents or results in pain on attempted penile penetration. A physical barrier may be present but is not necessarily causative. The woman may be unable to allow anyone to touch the vulva. Primary vaginismus is usually due to fear of penetration. Secondary vaginismus is more likely to be the result of an experience of pain with intercourse after infection, sexual assault, a difficult delivery or surgery. Even after the condition has improved, fear of further pain may lead to involuntary contraction of the vaginal muscles, which is in itself painful, completing the vicious circle. Encouraging the patient to explore her own vagina and feel for herself that there is no abnormality or pain can help break this cycle. Resort to surgery is likely to confirm the patient’s fears of abnormality and often leaves the presenting problem unchanged

Loss of libido

Loss of desire is the commonest symptom in women complaining of sexual dysfunction. If it has always been present it may be a result of a repression of sexual thoughts as a result of upbringing or religious belief or a feeling that sex is dirty or unsuitable in some way. It may represent differences between the expectations of the couple. Loss of desire in a relationship that was previously satisfactory is more likely to be due to:

• major life events – marriage, pregnancy

• being ill, depressed or grieving

• endocrine or neurological disorders

• pain on intercourse

• medication (Box 19.3)

Box 19.3 Drugs that may impair libido

• Antiandrogens – cyproterone

• Anti-oestrogens – tamoxifen and some contraceptives

• Alcohol and illegal drug misuse

• menopause

• fear of pregnancy or infection

• stress or chronic anxiety.

Treatment

Helping the couple to look at the underlying reasons involved helps to identify what they might do to correct the situation. Relationship therapy may be an option for suitably motivated couples. Where loss of libido is a feature of menopausal symptoms this will occasionally respond to low dose testosterone therapy, along with conventional oestrogen hormone replacement therapy.

Orgasmic dysfunction

About 5–10% of women have not experienced orgasm by the age of 40 years. Orgasmic dysfunction is often linked to myths about it being the responsibility of the man to bring the woman to orgasm. The problem can be helped by breaking down inhibitions about self-stimulation and encouraging better communication during foreplay and intercourse.

Disorders of male sexual function

Normal male sexual function is largely mediated through the autonomic nervous system. Erection occurs as a result of parasympathetic (cholinergic) outflow causing vasocongestion. Orgasm and ejaculation are predominantly sympathetic (adrenergic). Emission occurs by the sequential expulsion of fluid from the prostate gland, vas deferens and seminal vesicles into the posterior urethra. Emission and closure of the vesical neck are mediated by alpha-adrenergic systems, while opening of the external sphincter (to allow antegrade ejaculation) is mediated through the somatic efferent of the pudendal nerve. Ejaculation is stimulated by the dorsal nerve of the penis and involves contractile activity of the bulbocavernous and ischiorectal muscles as well as the posterior urethra. These responses are easily inhibited by cortical influences or by impaired hormonal, neural or vascular mechanisms.

The principal features of sexual dysfunction in men are:

• failure to achieve erection

• problems with ejaculation

• loss of libido.

All or any of these may be present from adolescence or have their onset at any time of life after a period of healthy sexuality. The causes of loss of libido have been previously described above under female sexual dysfunction.