Female	Male
Vasodilatation and vasocongestion of all erectile tissue. Breasts enlarge, the vaginal ostium opens and secretion from the vestibular glands and vaginal exudations cause ‘moistening’	Penile erection occurs and may be transient and recur if this stage is prolonged. Scrotal skin and dartos muscle contract and draw testes towards the perineum

Plateau phase

In both, the male and the female, the pulse rate, blood pressure and respiratory rate increase. Both partners make involuntary thrusting movements of the pelvis towards each other.

Female	Male
Vasocongestion increases, and contraction of the uterine ligaments (which contain muscle) lift the uterus and move it more into alignment with the axis of the pelvis. The cervix dilates. There is engorgement of the lower third of the vagina and ballooning of the upper two thirds	The intensity of penile erection increases and the testes are enlarged by congestion. Seminal fluid arrives at the urethra as a result of sympathetic nervous stimulation of the vas deferens, seminal vesicles and the prostate. There is some pre-ejaculatory penile discharge which may contain sperm

Orgasm

Pulse and respiration rate are at double their resting rate, and blood pressure may reach 180/110. Pelvic and genital sensations are completely dominating, and there is a noticeable reduction in the sensory awareness in other parts of the body. The pelvic floor contracts involuntarily, with rhythmic contraction of the vagina, urethra and the anal sphincter.

Female	Male
Climactic sensations appear to be caused by spasmodic contractions of vaginal muscles and uterus. The female is potentially capable of repeated orgasm	Strong contractions pass along the penis causing ejaculation of seminal fluid. The greater the volume of ejaculate (after several days’ abstinence) the more intense the sensations of orgasm

Postcoital phase or resolution phase

Pulse, respiratory rate and blood pressure rapidly return to normal and there is marked sweating. Vasocongestion recedes over about 5 min and there is complete relaxation of all muscles and a detumescence of erectile tissue. In the male, but less so in the female, there occurs a refractory period, which varies with individuals, from a few minutes to several hours during which there is no response to further stimuli.

Sexual problems

Normal sexual activity and behaviour change with a number of factors including age, social circumstances, background and values, but it can also be affected by illness or medication and adverse psychological experiences.

Loss of libido

As previously discussed, interest in sex is a more complex process for women and it can be adversely affected by a number of common social factors, for example having a baby, stress at work, bereavement, etc. There is some evidence that it is influenced by hormonal factors; in particular, it has been shown that women who have had their ovaries removed have lower levels of androgens and these women may benefit from testosterone supplementation. For some postmenopausal women standard hormone replacement therapy may be of benefit.

Failure to achieve orgasm

The failure to achieve an orgasm is a common problem in women, although relatively few women seek medical advice. As with the loss of libido, there may be a number of causative factors. However, many women do not experience orgasm during penetrative intercourse and require stimulation of the clitoris or other erogenous zones. Psychosexual counselling should be offered.

Dyspareunia

Dyspareunia (painful coitus)

Sexual problems affecting the male

The gynaecologist is not normally called upon to deal directly with the male, but it can be useful to be aware of their sexual problems and know something of their management.

Premature ejaculation

The male ejaculates with minimal sexual stimulation or before he wishes it to occur.

There are a number of behavioural techniques that can prolong the sexual episode, such as stopping repeatedly or the squeeze technique where intermittent pressure is applied to the penis by the partner.

There are also some medications that may be beneficial, including some antidepressants, but referral should be made to a specialist with an interest in male sexual disorders.

Treatment options for erectile dysfunction

Organic causes

These may be reversible, as in endocrine lesions and drugs, and, where possible, treatment of the underlying condition may be of benefit.

Psychosexual counselling

This is most useful when social and psychological factors predominate and is often used in conjunction with drug treatment.

Sildenafil (Viagra)

An oral therapy for erectile difficulties, this does not produce an erection without sexual stimulation. Side effects have been reported in men with cardiovascular problems who are on cardiovascular medication.

Sex hormones

Simple prescription of a male sex hormone is seldom successful and its part in the physiology of erection and ejaculation is not yet known. It has been shown that testosterone levels do decline with age, but there does not appear to be a male equivalent of the female menopause, and the role of testosterone replacement therapy remains unclear.

Papaverine

This is a smooth muscle relaxant. Intracavernosal injection is an effective treatment for impotence.

Ejaculatory failure

It is the inability to ejaculate although there is no loss of erotic drive, erection and intromission are normal.

The ejaculatory reflex requires intact pathways in both the autonomic and somatic systems. Somatic nerves receive the sensory stimuli of coitus and pass these impulses to the sympathetic nerves which then stimulate the delivery of seminal fluid to the urethra by the vasa deferentia, seminal vesicles and prostate, and prevent retrograde ejaculation into the bladder by causing contractions of the internal urinary sphincters.

Sympathectomy from T12 to L3 will abolish ejaculation without affecting erectile ability or the sensations of an orgasm, producing a phenomenon known as ‘dry sex’.

Medico-legal problems

Rape

The doctor may on occasion be asked to examine a victim of alleged rape. This crime has heavy penalties and the examination must be thorough and careful. Ideally, the examination should be performed by a clinician with requisite specialist training and experience. The victim is likely to have experienced significant trauma and an appropriate supportive environment and staff trained in counselling techniques, should be available. Major police forces have specially trained rape investigation teams whose expertise is invaluable.

The following preliminary notes should be made:

1. Authority for examination.

2. Consent for examination.

3. General appearance of person and clothing.

4. History of the circumstances of crime.

Rape is defined as unlawful sexual intercourse with a woman by force and against her will.

Sexual intercourse is described as the slightest degree of penetration of the vulva by the penis and entry of the hymen is therefore not necessary. (Use of vaginal tampons by virgins may confuse the issue.)

The vulva should be inspected for signs of bruising, scratching or tearing. The hymen may be torn and bleeding.

When the orifice is small or the hymen is vestigial, bruising may be present because of the force needed for penetration against the resistance of the victim. The presence of seminal fluid in the vagina and cervix may, sometimes, be the only sign. This fluid is removed and examined microscopically.

General examination of the patient may show injuries and bruising, confirming a story of resistance that has been overcome by violence.

Skin should be swabbed for blood, semen or saliva, if there is evidence of these fluids, using a swab moistened with sterile water, for DNA analysis. Finger nail clippings should be taken if there is blood or debris under them.

Comb the head and pubic hair for hairs from the assailant and cut 10 hairs from each site of the victim for comparison. Blood and urine samples should be taken. These may require to be tested for drugs.

Careful record keeping is essential. Collection, storage and transport of specimens must comply with legal requirements so that their source cannot be challenged.

Methods of contraception

Natural methods	Rhythm or Billings Breastfeeding (while baby is totally breast fed)
Barrier methods	Diaphragm Cervical cap Condoms male and female
Spermicides (usually used in conjunction with barrier methods)	Creams, films, foams, jellies, pessaries, sponges	(These are mainly Nonoxynol based)
Hormonal methods	Oral contraceptive Depot progestogens Vaginal	Combined oestrogen/progestogen Progestogen only Injections Subcutaneous silicone implants Silicone rings releasing oestrogen and progestogen
Intrauterine devices	Inert Copper bearing Progestogen releasing (Mirena).
Surgical methods	Laparoscopic sterilisation
	Hysteroscopic tubal occlusion (Essure)
	Intrauterine quinacrine producing tubal fibrosis, in developing countries
	Vasectomy

The ideal contraceptive would have a 100% success rate, have no side effects, and be completely reversible and totally convenient. Clearly, none of the above fulfil all of these conditions. Many people are often ill-informed about contraception, and fears about possible side effects, together with problems experienced by friends and relatives, may play a greater role in influencing choice than medical advice and statistics. Some medical professionals have limited knowledge of the details of contraceptive choices and are therefore unable to give appropriate advice. An informed choice should provide information and counselling, and written details should, ideally, be supplied along verbal details. Within the UK, specialist family planning services offer free contraception and advice.

Failure rates in contraception

There are four factors that affect the failure rate of any method of contraception:

1. Inherent weakness of the method

For example, the rhythm method, which depends on the accurate determination of the time of ovulation, can never be as reliable as an oral contraceptive (OC).

2. Age

With all methods, the failure rate declines as age increases and fertility and frequency of intercourse also decrease.

3. Motivation

Every method depends on the determination of the woman to use it correctly. Thus pills may be forgotten, diaphragm users ‘take a chance’, even with intrauterine devices (IUDs), a suspicion that the device is out of place may be ignored.

4. Duration of use

The failure rate, especially with occlusive methods, declines as duration of use and therefore habit, increase.

Patient suitability for contraception

Many factors need to be taken into consideration when choosing an appropriate contraceptive method. These include age, parity, recent pregnancy, smoking, body mass index, medical history and concomitant medication. The Faculty of Sexual and Reproductive Healthcare provides evidence-based guidance on its website www.fsrh.org.uk

Potential contraindications are categorised as below

UKMEC categories	Definition
UKMEC 1	A condition for which there is no restriction for the use of the contraceptive method
UKMEC 2	A condition for which the advantages of using the method generally outweigh the theoretical or proven risk
UKMEC 3	A condition where the theoretical or proven risks usually outweigh the advantages of using the method. The provision of a method required expert clinical judgement and/or referral to a specialist contraceptive provider since the use of this method is not generally recommended, unless other more appropriate methods are not available or are unacceptable
UKMEC 4	A condition which represents an unacceptable health risk if the contraceptive method is used

Hormonal contraception

Combined oral contraception

The pill is a mixture of oestrogen and progestogen, the combined oral contraceptive pill (COCP)

Mode of Action

The high oestrogen and progestogen levels reduce the negative feedback effect so that follicle stimulating hormone (FSH) secretion is depressed and the luteinising hormone (LH) peak is abolished. The combined pill, therefore, reliably prevents ovulation.

The absence of a corpus luteum inhibits the preparation of an endometrium that is suitable for implantation, and a ‘pseudo-atrophy’ develops.

Changes in cervical mucus make sperm penetration less likely.

All these effects are the result of a synergistic action between oestrogen and progestogen.

Constituents

Oestrogens (O)	Progestogens (P)
Ethinyloestradiol	Levonorgestrel
	Norethisterone
Mestranol (ethinyloestradiol-3-methyl-ether)	Ethynodiol diacetate
Mestranol (ethinyloestradiol-3-methyl-ether)	Desogestrel
	Gestodene
	Norgestimate
	Drospirenone

Choice of Pill

There are over 30 brands available, using different drugs in different proportions.

Low dose preparations contain 20 µg of ethinyloestradiol and are particularly suitable for women with risk factors for circulatory disease.

Standard strength preparations contain 30–35 µg of ethinyloestradiol; however, the risk of venous thromboembolism varies with the progestogen used.

There are a range of different progestogens, and may have a variety of effects, depending on their derivation. Side effects such as acne are more likely to be associated with progestogens that have an androgenic derivation. Drospirenone, a new progestogen, is derived from spironolactone and has antiandrogenic and anti-mineralocorticoid activity. It is been found to be useful in women who have fluid retention and is useful in women with the premenstrual syndrome.

Women should however be offered levonorgestrel- and norethisterone-containing pills as a first line and alternatives considered only if side effects are problematic.

Risk of venous thromboembolic disease
Non-pregnant, not on the pill	5–10 women per 100,000 per year
Levonorgestrel-and norethisterone-containing pills	15 women per 100,000 per year
Desogestrel and gestodene	25 women per 100,000 per year
Pregnancy	60 women per 100,000 per year

Minor side-effects of OCs

Oestrogen	Oestrogen and progestogen	Progestogen
Breakthrough bleeding	Weight gain	Acne
Nausea	Post-pill amenorrhoea	Depression
Painful breasts		Dry vagina
Headache		Loss of libido

Higher doses of 50–60 µg (taking two pills) can be used by women who are on enzyme inducing drugs that affect hepatic metabolism. However, this not an ideal long-term option and it may be best for the woman to consider an alternative approach of contraception that is not affected by hepatic metabolism.

In the combined pill, the oestrogen and progestogen component is usually given as a uniform dose for 21 days. This is followed by a 7-day pill-free interval. This break is usually associated with a withdrawal bleed. Some women opt to exclude the pill-free interval to avoid a withdrawal bleed. This works well but may be associated with breakthrough bleeding if used for long periods and it may be best to ‘tricycle’ the COCP, meaning that they run three packets together at a time followed by a 7-day break to allow a withdrawal bleed.

Failure of the pill

The failure rate of the combined pill is very small, between 0% and 1%, and there is often an avoidable factor.

1. The patient may forget to take the pill. Packing by the pharmaceutical firms is ingenious but not foolproof. If one pill is missed, two are taken the next day and additional precautions should be undertaken.

2. Gastroenteritis may impair absorption.

3. Certain groups of drugs such as anticonvulsants, usually phenytoin and phenobarbitone, and the antibiotic rifampicin are known to increase the metabolic activity of hepatic enzymes and increase the rate of excretion of contraceptive steroids.

4. Several antibiotics, including ampicillin, are associated with an increase in breakthrough bleeding, and pregnancy has been reported. Oral contraceptives are conjugated in the liver, excreted in the bile, and partly reabsorbed. If gut bacteria are inhibited by antibiotics, reabsorption may not occur, leading to increased bowel excretion but lower circulating levels of steroids.

Oral contraception: risks

Conditions where COCP is contraindicated or special precaution is required:

History of cardiovascular disease	Collagen diseases
Hypertension	Otosclerosis
Smoking	Diabetes mellitus
Obesity	Sickle cell anaemia
Chronic hepatitis	Severe varicose veins
Depression	Migraine
Acute porphyria	Arterial or venous thrombosis

A great deal of clinical and laboratory research and epidemiological analysis are available to support an association between COCPs and thromboembolism and stroke, and there is a increase in the risk of ischaemic heart disease in women with underlying risk factors. Women on the COCP, who are over 35 and smoke, have a significant increase in the risk of stroke. Women with migraine on the COCP are more at risk of stroke.

Vascular disease

The risk of vascular disease, either venous or arterial, depends on the dose of oestrogen and also on the type of progestogen (see above). The risk remains low, but traditional risk factors increase the risk during pill use. These include thrombophilic tendencies, hypertension and obesity.

Hypertension

OCs gradually raise the blood pressure, sometimes to the hypertensive range. The blood volume is increased by fluid retention, and the secretion of angiotensin is increased.

Oral contraceptives and neoplasia

No causal link has yet been established between OCs and any kind of neoplasia, but there is evidence of a small increase in risk of cervical and breast cancer. There has been much epidemiological debate about the possible mechanisms. It may be that pill users are less likely to use barrier contraception and, as such, have a higher risk of human papilloma virus infection.

Endometrium and ovary

Prolonged OC use depresses mitotic activity in the endometrium and follicular maturation in the ovary, and these effects significantly reduce the risk of both cancers.

There is also a lower risk of benign conditions such as fibroids. Dysmenorrhoea, premenstrual syndrome and menstrual loss are also reduced.

Progestogen-only pill (POP)

Some 50% of women, on progestogen-only oral contraceptives, ovulate and menstruate, and the main contraceptive effect is a change in the cervical mucus. Some women bleed irregularly and around 15% of women are amenorrhoeic with no follicular development. The POP should be taken at the same time every day for maximum efficacy. Cerazette, a new POP containing desogestrel, has a 12-h missed pill window similar to COCP, and its contraceptive efficacy is over 99%.

Other routes

Vaginal rings

Silastic ring pessaries have been developed which release either a progestogen alone or both oestrogen and a progestogen, which are absorbed vaginally, thereby avoiding the first pass through the liver that results in a subsequent reduction in dosage.

Injectable progestogens

The most widely used injectable progestogen is medroxyprogesterone acetate (Depo-Provera), an intramuscular injection.

Three-monthly injections offer an effective method for contraception for women. The higher dose of progesterone inhibits ovulation and many women will be rendered amenorrhoeic. Irregular bleeding is common in the first months of use and some weight gain may also occur.

Long-term use is associated with some loss of bone mineral density and careful consideration should be given to the risks and benefits. Particular caution should apply in adolescents as skeletal development is ongoing.

Progestogen-only implants

Implanon is available in the UK. It consists of a single rod for subdermal insertion in the inner aspect of the upper arm and releases etonogestrel. The mode of action involves inhibition of ovulation but irregular bleeding is common and it may sometimes be persistent. Insertion and removal should always be performed by someone trained in the procedure.

Intrauterine devices (IUDs)

Intrauterine devices (IUDs) have been made from a number of different materials. Inert coils simply contain plastic but the common devices also contain a copper or progestogen implant (Mirena). Most devices have threads that hang through the cervix to enable easy removal of the device.

Mode of action

Intrauterine devices prevent fertilisation and implantation. Copper is toxic to both the ova and the sperm and an inflammatory reaction is induced in the endometrium. Progestogen releasing intrauterine systems deliver the progestogen directly to the endometrium, rendering it unreceptive to implantation, and cervical mucus is thickened.

There is an increased risk of pelvic infection. It is thought that lower genital tract organisms enter the uterus either during insertion of the device or via the threads. The risk of pelvic infection is much lower with Mirena as it thickens the cervical mucus which in turn helps prevent lower genital tract organisms from entering the uterus.

These devices can also be colonised by actinomyces. This does not merit a removal of the coil, but occasionally, pelvic actinomycosis can occur. This is a chronic, granulomatous infection which should be treated aggressively with antibiotics and, possibly, surgery.

The length of time that an IUD can last for depends on the type of device.

The Mirena

This levonorgestrel releasing (20 µg/24 h) intra-uterine system is licensed for 5 years. It is said to be as effective as female sterilisation, but the effects are immediately reversible upon removal.

IUDs commonly cause heavy painful periods but the Mirena reduces menstrual loss and dysmenorrhoea due to the local effect of the progestin on the endometrium and its muscle relaxant effect on the myometrium.

Intrauterine devices (IUDs)

Principle of insertion of IUDs

Insertion Technique

Insertion of an IUD is always easier when a woman has had a previous vaginal delivery. Coil insertion can also be achieved in nulliparous women. The woman should be examined vaginally to assess of the size and direction of the uterus, to reduce the risk of uterine perforation.

1. The IUD is first of all folded and pulled into a plastic tube called the introducer.

2. The introducer is then inserted into the uterus until it reaches the fundus.

3. The surrounding introducer is drawn back holding the rod in place so that the device has now opened out in the uterine cavity.

4. The rod and introducer is now removed carefully and the threads are trimmed to about 4 cm.

A local anaesthetic and a tenaculum forceps can be useful. The Mirena has a specific introducer that makes insertion simpler, although it is very slightly thicker than most copper coils, at 4 mm.

Occasionally some sedation or even a general anaesthetic may be required to insert a coil.

Complications of intrauterine devices

1. Increased menstrual loss

The cause may be due to the increased fibrinolytic activity that occurs around the IUD. It can be minimised by the use of antifibrinolytic agents such as tranexamic acid. Antiprostaglandin agents, such as mefenamic acid or diclofenac, are also effective. Progestogen releasing devices decrease loss.

2. Infection

There is an increase in the risk of pelvic inflammatory disease, especially during the first months after insertion. Inert IUDs can be associated with actinomycosis infection if retained for long periods. Women with active pelvic infection should not have a coil fitted. Women with an existing coil in place may be given antibiotic treatment with the coil left in place, but with severe or persistent infection, consideration should be given to coil removal.

Progestogen releasing systems reduce the incidence of infection as the cervical mucus is thickened due to the effect of progestin.

3. Pregnancy

The chances of pregnancy are about 1–1.5 per 100 woman years and it is most likely to occur in the first 2 years. It is lower with copper-bearing coils and may be as low as 0.1 per 100 with the Mirena.^† The risk of ectopic pregnancy is lower in IUD users as the risk of pregnancy is very low, but in those women who become pregnant with a coil in situ, the risk of ectopic pregnancy is higher.

4. Expulsion

There is a 5–10% incidence, usually in the first 6 months. It is recommended that a speculum examination be performed at 6 weeks after coil insertion to check that the threads are visible. If the threads are not visible, an ultrasound scan should be performed to check for the presence of an intrauterine coil.

5. Translocation

The IUD passes through the uterine wall into the peritoneal cavity or the broad ligament. It is thought that this begins at the time of a faulty insertion.

An intrauterine coil is usually identified on scan but an extrauterine coil can be very difficult to visualise using the ultrasound. If an intrauterine location has not been confirmed, an abdominal/pelvic X-ray should be performed. If the coil is outside the uterus, a laparoscopy, and possible laparotomy, may be needed to locate it.

Diaphragms and caps

The diaphragm is inserted into the vagina prior to intercourse. It is used in conjunction with a spermicidal cream and it acts by preventing sperm cells from reaching the cervical canal. It has a higher failure rate compared to oral contraceptives or IUDs but it has few side effects.

1. The diaphragm is smeared with spermicidal cream round the edges and on both sides, and guided into the posterior fornix.

2. The front end is tucked up behind the symphysis pubis.

The diaphragm must not be removed until 6 h after intercourse, and if intercourse is repeated in that period more cream must first be injected using an applicator.

Caps act in a similar way but are designed to fit over the cervix.

Condoms

A thin rubber sheath fits over the penis. Condoms can interfere with sensation; however, they reduce the risk of sexually transmitted infections and may be used in addition to other contraceptive methods. Condoms can split and they are liable to come off as the penis is withdrawn after the act. The failure rate is higher than for oral contraceptives. Lubricants, such as ‘baby oil’, can weaken condoms.

The sponge

A disposable plastic sponge, impregnated with spermicide, is inserted into the vagina and can be left in situ for at least 24 h. Sponges need no fitting and are comfortable; however, they have a higher pregnancy risk than the diaphragm.

Contraception based on time of ovulation

The Rhythm Method (‘Safe Period’)

The woman must take her temperature every morning and watch out for the sustained rise which indicates ovulation. Women with regular periods can often usually identify the peri-ovulatory time with a fair degree of accuracy. However, an episode of hormonal irregularity may occur without warning and this can put the woman at risk of pregnancy.

However, assuming the cycle is regular and lasts for 28 days, ovulation usually occurs between the 12th and 14th days of the cycle. 24 h are allowed for ovum survival and 3 days should be allowed as survival time of the sperms in the genital tract, although sperm have been shown to survive for up to a week.

This means that intercourse must be avoided from the 9th to the 15th day and a 24 h safety margin at either end increases the avoidance period from the 8th to the 17th day, both inclusive.

The Ovulation Method (The Billings’ Method)

The woman is taught to identify the peri-ovulatory phase by noting the changes in cervical mucus.

This method provides the same opportunities for coitus as the rhythm method. In practice, many women will use these methods concurrently. The failure rate depends very much on the motivation of the couple and on an understanding of the method. It may be more useful to help women understand and know if they are fertile when they wish to conceive.

Say 5 days	Menstruation
2–3 days	‘Early safe days’	Sensation of vaginal dryness
4–5 days	Moist days – not safe	Increasing amounts of sticky mucus
2 days	Ovulation peak – not safe	Copious, clear ‘slippery’ mucus
3 days	Post-ovulation Peak – not safe	Gradual decrease in secretion
11 days	‘Late safe days’	Minimal secretion