Introduction to Family Planning

1. Introduction to Family Planning Iris Stendig-Raskin, MSN,CRNP,WHNP-BC Clinician/Consultant

2. http://www.mydr.com.au/default.asp?article=2946

3. http://www.mydr.com.au/default.asp?article=2946

4. Menstrual Cycle: An overview • Average cycle length is 28 days; • But normal cycles can range from 21-35 days • Menstrual cycle can be divided in 2 Parts: • Follicular and luteal phase • Proliferative/secretory phase

5. Follicular/Proliferative First half of cycle: From menstruation to ovulation Estrogen dominates Variable length Basal Body temperature Slightly lower Luteal/Secretory Second half of cycle: from ovulation to the first day of menstruation Progesterone dominates Consistent length (14-16 days) Rise in 0.4-0.8 temperature after ovulation Menstrual Cycle:Ovulation divides cycle in half.

8. Male Reproductive System

9. STD’s and Vaginitis

10. Discharges from the Vagina are Perfectly Normal….. • However…if it causes- • Itching • Burning • Irritation…. • It is not normal !!!!!

11. Vaginitis • Bacterial Vaginosis • Trichomoniasis Vaginalis • Vulvo-Vaginal Candidiasis

12. Bacterial Vaginosis • Lactobacillus replaced by bacteria • Diagnostic Criteria • Homogeneous white discharge that coats the vaginal walls • Presence of clue cells • pH of > 4.5 and • Fishy odor (amine release ) after addition of KOH Cadaverine, putrescine, and tyramine BUT • More than 50% women are asymptomatic

13. Normal Epithelial Cell and Clue Cell

14. Bacterial Vaginosis

15. Treatment for Bacterial Vaginosis CDC GUIDELINES 2006 Metronidazole 500 mg po, bid x 7days or Metronidazole gel 0.75% (5g) qd x 5 days or Clindamycin cream 2% (5g) qhs x 7 days CDC:STD treatment guidelines 2006: www.CDC.gov/std/treatment

16. Vulvo-Vaginal Candidiasis

17. Vulvo-vaginal Candidiasis • Some factors that may cause ‘yeast’ infections: • Stress • Antibiotic use • Use of hormonal contraception • Diabetes • Obesity

18. Vulvo-vaginal Candidiasis • Causative agent: • Candida albicans • Candida tropicalas • Torulopsisglabrata • Symptoms • Pruritis, • vaginal discharge (cottage-cheese like, clumpy) • soreness, • dysuria CDC STD GUIDELINES 2006. www.cdc.gov/std/treatment

19. CDC Classification of VVC • Uncomplicated VVC (80-90%) • Sporadic or infrequent VVC • Mild to moderate • Likely to be albicans • Non-immuno-compromised women • Complicated VVC • Recurrent • Severe • Non-albicans • Women with uncontrolled diabetes, pregnancy, immuno-suppression

20. Treatment for VVC • Topical intravaginal medications • Ie:Clotrimazole,Miconazole,Terconazole • 1 day, 3 day, 7 day….. • Oral Medication: • Fluconazole (Diflucan) 150 mg, one tablet, single dose.

21. Patient Counseling Tips • Do Not Douche • Avoid intercourse during treatment • Use condoms • Avoid vaginal insertion of fingers/penises/sex toys after anal insertion

22. Trichomoniasis Vaginalis • Caused by protozoan T. vaginalis • Sexually transmitted • Symptoms • Frothy, greenish-yellowish discharge • Punctated cervix • Diagnosis: • Motile trich viewed under microscope

23. TRICHOMONIASIS

24. Treatment for Trichomoniasis CDC GUIDELINES 2006 Recommended Regimen Metronidazole 2 Gram po, single dose or Tinidazole 2 Gram,po,single dose • Alternative Regimen • Metronidazole 500 mg bid x 7 days • Partner must be treated as well. www. cdc.gov/std/treatment

25. STD Statistics • Affects 1:5 people in the US • 2/3rd’s occur in people under 25 • 1:4 new infections occur in teenagers • < 50% of all adults ages 18-44 have ever been tested for an STD (excluding HIV) • Infertility in at least 15% of American women is directly linked to PID • tubal damage caused by an untreated STD • STD’s, other than HIV, cost about 8 billion/year to diagnose and treat

26. New CDC STD Guidelines 2006Clinical Counseling:Risk Reduction Strategies: 5 “P”’s • Partners: • Are you partners male, female or both? • Number of partners in the past 2 months • Number of partners in the past 12 months • Pregnancy Prevention: • Are you planning a pregnancy? • If not, what preventive measure are you taking?

27. New Guidelines 2006Clinical Counseling:Risk Reduction Strategies: 5 “P”’s • STD Protection • Practices (sexual behaviors): • Ascertain sexual risk • Type of sexual practices • Condom usage • Past history of STD’s

28. Partner Management • Partner notification • Providers should encourage patients to notify their partners and seek medical evaluation and treatment • When evaluation, counseling, and treatment cannot be done do to individual circumstances or resource limitations, consider expedited partner therapy. • www.cdc.gov/std/treatment

29. CHLAMYDIA • Most frequently reported infectious disease in the U.S. • 2007: 1, 108,374 cases of chlamydial infection reported to the CDC (50 states and DC) • From 1998-2007, the rate of chlamydial infection increased from 87.1 to 370.2 per 100,000 • 3 times more prevalent in women than men • Most prevalent in females aged 15-19 • Commonly asymptomatic http://www.cdc.gov/std/stats07/chlamydia.htm

30. Clinical Manifestations Chlamydial Cervicitis Source: STD/HIV Prevention Training Center at the University of Washington/Connie Celum and Walter Stamm

31. Clinical Manifestations Non-Gonococcal Urethritis: Mucoid Discharge Source: Seattle STD/HIV Prevention Training Center at the University of Washington/UW HSCER Slide Bank

32. Management Treatment of Uncomplicated Genital Chlamydial Infections CDC-recommended regimens • Azithromycin 1 g orally in a single dose, OR • Doxycycline 100 mg orally twice daily for 7 days Alternative regimens • Erythromycin base 500 mg orally 4 times a day for 7 days, OR • Erythromycin ethylsuccinate 800 mg orally 4 times a day for 7 days, OR • Ofloxacin 300 mg orally twice a day for 7 days, OR • Levofloxacin 500 mg orally once a day for 7 days www.cdc.gov/std/treatment

33. Chlamydia: Sequalae if left untreated: • Women: • PID, infertility, pelvic abcess • Men: • Sterility, epididymitis, • urethral strictures, prostatitis • Newborns: • Blindness, rhinitis, infections

34. Test of Cure

35. Screening and Testing Post Treatment • Test of Cure: NO!!!!! • Non-culture tests done <3 weeks post treatment could yield false positive results secondary to the continued excretion of dead organisms • High prevalence is found in women who were already treated • Re-screening is recommended 3-4 months after treatment • Prevalence of re-infection is found in young women • partner’s were not treated • Re-infection from new partner

36. Gonorrhea • Secondly most commonly reported infectious disease in the U.S. • Over 330,00 cases reported to the CDC in 2004 • Like chlamydia, under-diagnosed and under-reported • Approximately twice as many new infections are estimated to occur each year as reported. http://www.cdc.gov/std/stats/trends2004.htm

38. Epidemiology Risk Factors • Multiple or new sex partners or inconsistent condom use • Urban residence in areas with disease prevalence • Adolescents, females particularly • Lower socio-economic status • Use of drugs • Exchange of sex for drugs or money

39. Epidemiology Transmission • Efficiently transmitted by: • Male to female via semen • Female to male urethra • Rectal intercourse • Fellatio (pharyngeal infection) • Perinatal transmission (mother to infant) • Gonorrhea associated with increased transmission of and susceptibility to HIV infection

40. Clinical Manifestations Gonococcal Urethritis: Purulent Discharge Source: Seattle STD/HIV Prevention Training Center at the University of Washington: Connie Celum and Walter Stamm

41. Clinical Manifestations Gonococcal Cervicitis Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides

42. What is…….. QRNG ????

43. QRNG • Quinolone resistant N. Gonorrhea • Common in Europe, Middle East,Asia, the Pacific .. Some spots in the USA • California, Hawaii and….yes, • PENNSYLVANIA

44. Management Antimicrobial Susceptibility of N. gonorrhoeae On April 13th 2007, the CDC announced that the fluoroquinolones: • ciprofloxin, • ofloxacin, and • levofloxacin) Are no longer recommended for the treatment of gonorrhea. http://www.dsf.health.state.pa.us/health/cwp/view.asp

45. As a result…..Pennsylvania Department of Health :Statewide Recommendations-2007 • Quinolones are no longer recommended for the statewide treatment of gonorrhea… Following is current treatment protocol: • Ceftriaxone (Rocephin) 125 mg is the only recommended regimen • Safe to use during prenatal care • Appropriate for treating gonorhea in adolescents

46. PA Department of Health also recommends the following: • Providers are encouraged to ask patients about their sexual practices and to offer, when indicated, throat and rectal cultures • A test of cure by culture is strongly recommended for any patients with persistent symptoms after treatment with Ceftriaxone • All gonorrhea positive cultures should be tested for drug resistance, including Ceftriaxone resistance.

47. Gonorrhea: Sequalae if left untreated: • Women: • PID, infertility, pelvic abcess • Men: • Sterility, epididymitis, • urethral strictures, prostatitis • Newborns: • Blindness, rhinitis, infections

48. Syphillis • Rates decreased in the 1990’s, all time low in 2000 • However,between 2003 and 2004 national primary and secondary syphillis rate increased by 8 percent • 7980 Cases reported in 2004 • Increasing cases among MSM believed to be responsible for overall increase in national rate. http://www.cdc.gov/std/stats/trends2004.htm

49. Epidemiology Syphilis Definition • Sexually acquired infection • Etiologic agent: Treponema pallidum • Disease progresses in stages • May become chronic without treatment

50. Epidemiology Transmission • Sexual and vertical • Most contagious to sex partners during the primary and secondary stages