Complex Issues in Reproductive and Sexual Health

1. Complex Issues in Reproductive and Sexual Health Charlotte Porter and Fiona Straw C&SH Nottingham

3. Complicated issues: • Termination of pregnancy • Sexual assault • Sexual Dysfunction • Teenagers • Issues of coercion and control • Consent

4. Termination of Pregnancy • International statistics: every woman of reproductive age has a TOP • A woman dies every 15 minutes from complications of illegal abortion • In the UK, ¼ women will have a TOP in their reproductive lifetime, and 1/17 every year • Annually 800000 deliveries, 200000 TOPs

5. TOP, Nottingham • 2000 terminations per year- UPAC took 2900 referrals in 2007 • 40-60 per week • 8000 deliveries annually

6. TOP notes audit- age at referral

7. TOP note audit- Parity • 45 women were in their first pregnancy • 45 were parous (range 1-7) • 20 had had a previous TOP (range 1-2) • 23 had had a live birth within the last 12 months • 12 had had a non completed pregnancy in the preceding 12 months • 4 had had a termination of pregnancy in the previous 12 months • Of the under 18s, 4 had children, 1 16 year old reported 3 miscarriages in the preceeding 12 months

8. Top note audit- occupation • 20 were students • 11 were still at school/college • 27 were primarily carers (mother) • 33 were employed (semi and non skilled) • 3 were unemployed • For 3 no occupation was recorded • 3 were asylum seekers/refugees

9. TOP notes audit 2007- Medical History • 3 had BMI >40 • 2 had IDDM • 1 had prior VTE • 2 others had significant PMH- pulmonary stenosis, Addison’s Disease.

10. TOP - Legal Issues • TOP = post implantation • 5 clauses on ‘blue form’ • Notification to Department of Health (is the responsibility of the operator) • BMA guidelines concerning conscientious objection

11. Other Issues Relevant to TOP • STI • Domestic violence (?25%) • Inability to access services • Gillick / Fraser guidelines, Child protection • RCOG guidelines • Reducing the rate of unplanned pregnancy • Regret

12. Scan audit- gestational age for women seen in Nottingham UPAC service

13. Options for TOP • Medical • Surgical • Late medical • Late surgical • Continue pregnancy (?adoption)

14. Medical Termination of Pregnancy • 1990, RU 486 used in France • Anti progestogen, initially used in the treatment of extradural tumours • Mild anti cortico steroid effects • Used alone will cause abortion in 1/3 of early pregnancies • Use in induction of labour

15. RU486 - Mifegyne • Initially 600ug dose • Increases myometrial tone • Priming for prostaglandin action • Addition of follow up dose of PgF2a (gemeprost, misoprostyl) increases abortion rate to >95% in women <63 days gestation

16. Current Medical Regimes • <9 weeks gestation • 480 procedures in Nottingham last year • 200mg RU486 • 800mcg misoprostyl 48 hours later • 95% complete miscarriage rate • 2% failure (locally <1%) • 5% ERPOC (locally 1%) • 1:2000 needs blood transfusion • 50% no analgesia requested • 2.5% readmission rate

17. Contraindications to Medical TOP • Ambivalence about TOP • Hypertension / cardiovascular disease • Smoker >35 years • Oral Steroid use • Bleeding disorder / anticoagulant use • Renal disease • *asthma (pg / steroid)

18. Early Surgical TOP • 8-13 weeks • Up to 5% re evac rate • Post procedure infection (1% readmission rate) • 1:500 major (>500mls) blood loss • ?1% reduction in fertility • Cervical / uterine instrumentation • General anaesthesia (or cervical block – and risk of LA toxicity)

19. TOP After 12 Weeks • STOP (dilation and evacuation) offered in some units up to 24 weeks • Late medical TOP – traditionally time consuming and invasive (intra / extra amniotic saline / prostaglandin) • Combination of RU486 and Pg reduce induction to delivery time and fewer problems than surgical option

21. Contraception pre and post TOP, 2004 compared with 2007

22. Sexual Assault • Difficulty assessing the true incidence • TOPAZ centre- Nottingham SARC, 180 clients in first year • Friday and Saturday nights • 5% incidence of pregnancy with rape • STI risk varies- (50% for GC, less than 1% for HIV)? Give antibiotics and consider PEPSI/ Hep B prophylaxis

23. Sexual Offences Act 2003 Comprehensive review of Sexual Offences • Modernise the catalogue of sexual offences • Render them appropriate for the 21st century • Protect individuals from sexual crime • > 70 offences • NOT intended to prosecute mutually agreed sexual activity between 2 young people of a similar age unless involves abuse or exploitation • Not intended to prosecute health professionals

24. Sexual Offences Act 2003 • Protecting <13 years • Intentional • penetration of vagina, anus and/or mouth (rape) • Max penalty life imprisonment • Intentional touching of sexual nature (sexual assault) • Max 14 years • Causing or inciting sexual activity • Charges with specific crime • Tougher sentences – max 14 years • Absolute offence- Children can NEVER give their consent

25. Sexual Offences Act 2003 • Sexual activity with a child • Commits an offence if • The girl under 16 • He intentionally touches (with or without clothes) • Or penetrates another person • The touching is sexual in nature Max sentence 14 years

26. Sexual Offences Act 2003 • Engaging in sexual activity in the presence of a child • Intentionally engage in an sexual act when you can be seen by a child • In order to get sexual gratification • Causing a child to watch a sexual act • Intentionally cause a child to watch someone else taking part in asexual act • Looking at images; videos, photos, webcams • In order to get sexual gratification

27. Sexual Offences Act 2003 • Meeting a child following sexual grooming • Communicated with a child at least twice (phone or internet) • Meet them, or travel to meet them • With the intention of committing one of the previously described offences • Arranging or facilitating a child sex offence • Knowingly arrange or carry out an action which leads to one of the above offences taking place

28. Sexual Offences Act 2003 • Protecting under 18’s • Even though age of consent is 16 there are a number of situations where it is important to protect 16-18 yr old girls from abuse • Indecent photographs • Abuse of children through prostitution or pornography • Abuse of positions of trust • Abuse by family member • Sexual activity • Inciting to engage in sexual activity • Sex between adult relatives

29. Child Sexual Abuse • Always need to be alert • Follow ‘Safeguarding Children Board’ guidelines • Not always informing the family • Joint examination

30. Child Sexual Abuse • Numerous definitions • Any use of a child for adult sexual gratification • In the UK, by law sexual relationships between children < 16 yrs and adults are always classed as abusive • Where abuse of trust, prostitution and sex workers occurs in YP < 18 years • Majority abused by carers • 1/3 cases involve juvenile perpetrators

31. References • Sexual Offences Act 2003 • Working together to safeguard Children 1999 • Children’s Act 1989 • www.homeoffice.gov.uk/crime/sexualoffences/legislation/act.html • Responsibilities of Doctors in Child Protection Cases with regard to confidentiality Feb 2004 RCPCH • Chapter 6 Children and Young People presenting to sexual health services

32. Female Desire Arousal Orgasm Pain Male Erectile Dysfunction Ejaculatory Dysfunction Decreased libido Sexual Dysfunction

33. Male sexual dysfunction • An inevitable complication of ageing? (the andropause)

34. Questions in the assessment of sexual dysfunction • How long? • How much distress is it causing? • Persistent or situational? • Only with intercourse? • Partner (+ relationship) problems?

35. Examination: Goniometer 2° sexual characteristics Prostate (BP) Sensation testosterone Investigation

36. Erectile Dysfunction • The inability to acquire or sustain an erection of sufficient rigidity for sexual intercourse • Commonest MSD- difficult to assess incidence? Still relying on the Kinsey report (1948!) • Commonly periodic or isolated • “impotence” is used to describe those with problems >75% of the time

37. Aetiology of erectile dysfunction • Hormonal abnormality • Medication • Psychological problems • Neurological disease • Vascular insufficiency

38. Treatment - ED • Restore libido, and improve capacity to achieve and maintain erection • PDE5- sildenafil, vadenafil, tadalafil- all CIxn in those taking nitrates • Self injectables (alprostadil) and vacuum devices • Penile implant • Weight loss and exercise

39. Ejaculatory Dysfunction • Prevalence 21-31% • Men are least likely to seek help • “persistent or recurrent ejaculation with minimal stimulation before, on, or immediately after penetration and before the person wishes it, over which the sufferer has no voluntary control and which causes suffereing or distress to the sufferer and his partner”

40. Anxiety, stress, guilt Early sexual experience Evolutionary (!) psychodynamic Genetic predisposition Hyperexcitable ER Penile hypersensitivity Endocrinopathy Central 5HT receptor dysfunction Infection Low Mg CNS problem Aetiology of premature ejaculation

41. Treatment (PE) • Psychotherapeutic- coping skills and confidence building, communication skills • Topical anaesthetic (IELT increase from 1.5 to 8.5 minutes in one study) • SSRI (paroxetine) • PDE5 (sildenafil)

42. FSD- Desire • 31% of women (NHSLS survey) report hypoactive sexual desire disorder • Age and postmenopausal status are risk factors • ?role of surgical menopause • Depression, anxiety, relationship factors and children living at home

43. FSD- treatment • Psychotherapeutic • Hormonal- oestrogen testosterone

44. Sexual arousal disorders • Inadequate genital lubrication and response • Psychological component • SSRIs inhibit female sexual responsiveness

45. SAD- treatment • Vaginal lubrication • Local oestrogen • Vacuum device (USA- only approved therapeutic aproach) • PDE5- no clinical evidence • Local prostaglandin application

46. Sexual Pain • Dyspareunia • Vaginismus • Vulvodynia (non localised) • Vestibulitis (localised) • Non coital sexual pain

47. Cycle of Vaginismus Fear of vaginal penetration Involuntary muscle spasm Relationship Breakdown Sexual Dysfunction in Partner Pain Avoidance of Sexual Intercourse & Gynaecological Examinations Anxiety & Humiliation

48. Treatment • Psychosexual Medicine – Examination & Exploration of Feelings and Emotions • Psychosexual Therapy – Cognitive Behavioural Approach • Fenton's Procedure • Medication • Botox !!

49. Useful Tips • Explanation • Rationale • Vaginal Trainers 1 by 1 • Lubricant • Breathing • Pelvic Floor Exercises • Feedback and Follow-up • Include Partner & Assess Sexual Functioning • BE CREATIVE

50. Teenagers