• • Monday, Tuesday, Thursday:  8.30am – 5pm
  • Wednesday:  8.30am – 2pm; 3pm – 5pm (closed between 14.00-15.00 for staff training)
  • Friday:  8.30am – 1pm
  • Saturday:  9am – 12pm

• The Faculty of Sexual and Reproductive Healthcare (FSRH) updated its intra-uterine contraception guideline in March 2023.
• There are two types of intra-uterine contraception:

1. copper intra-uterine device ( Cu-IUD) – previously referred to an IUD
2. levonorgestrel -releasing intra-uterine device ( LNG-IUD) – previously referred to as an IUS

There are several types of LNG-IUD:

1. 13.5mg LNG-IUD : Jaydess
2. 19.5mg LNG-IUD: Kyleena
3. 52mg LNG-IUD : Mirena, Levosert, Benilexa

• In line with this guidance Unity supports extended use of intra-uterine contraception as follows:

Any 52mg LNG-IUD may be used :

• until age 55 for contraception ( regardless of bleeding pattern) -when fitted at or after age 45
• for up to 5yrs for endometrial protection (HRT) – But note Unity is not commissioned to provide LNG-IUD for HRT purposes only
• Levosert and Benilexa are used for 6 years for contraception – when fitted before age 45
• Mirena now has an 8 year license for contraception

Any Cu-IUD may be used:

• until menopause when fitted at or over 40yrs
• as emergency contraception – see separate FAQ on emergency IUD guidance

For detailed instructions on testing for STIs, please see the British Association for Sexual Health and HIV (BASHH) STI testing guidance 2015.

Infections in alphabetical order:

Chlamydia and gonorrhoea testing

The test

• The test we use in BNSSG is a combined NAAT (Nucleic Acid Amplification test) which tests for chlamydial and gonorrhoeal RNA.
• The window period for testing is up to 2 weeks– do a test at first presentation then repeat 2 weeks later if required.

For people with a penis

• The preferred sample is a first catch urine. It is advised urine should be held for at least 1 hour prior to the test.

Vaginal, throat and rectal sampling

• Vaginal sampling: The preferred sample is a self-taken lower vulvovaginal swab. However, if a speculum examination is being performed for clinical reasons, it is acceptable to take an endocervical sample, then, using the same swab, sample the lower lateral vaginal walls.
• “3 site testing” is recommended for men-who-have-sex-with-men (MSM)- this involves a urine sample plus rectal and throat NAAT swabs using the orange bottle kits used for those with female genitalia. Make sure these are carefully labelled as to which site is being sampled, as treatment can differ depending on site of infection.
• Pharyngeal sampling: It is important to roll the swab over both tonsillar fossae and the posterior pharyngeal wall (warn the patient they are likely to gag) to get an adequate sample.
• The only situation in which we use a throat swab in heterosexual patient is if they have only had oral sex with a partner.

Contacts of infection

• Patients who are sexual contacts of someone with gonorrhoea should be referred to the sexual health clinic. If they decline to attend it is very important to take a culture swab, as well as the NAAT test, to test for antibiotic sensitivities from any exposed sites prior to treatment.

Other testing

• All patients having an STI screen should be recommended to have blood tests for HIV and syphilis.

Hepatitis B

The test

• Hepatitis B is diagnosed using serology.
• The incubation period for hepatitis B is up to 6 months.
• To screen for infection: Hepatitis B surface antigen and Hepatitis B core antibody
• To screen for adequate vaccination: Hepatitis B post-vaccination (surface antibody)

Who to test

Hepatitis B is a recommended part of sexual health screening for the following groups of patients:

• Men who have sex with men (MSM)
• Commercial sex workers
• People who inject drugs
• Those who have been sexually assaulted
• Those born in (or who have a sexual partner born in) a country with high HBV prevalence
• Those with a sexual partner who is infected with HBV or is at high risk of this
• Those born to a mother with HBV

Those who have a risk factor for Hepatitis B (see list above) can be offered vaccination against Hepatitis B. Please see High Risk Groups.

Management

• Anyone found to have a positive Hepatitis B surface antigen should be referred to Hepatology at the Bristol Royal Infirmary.

Herpes

The test

• A viral PCR (red topped) swab is used to test for Herpes simplex virus (HSV).

Who to test

• All genital ulcers should be tested for HSV.

Other tests

• It is also important to test for syphilis in patient with genital ulceration.

Management

• If genital herpes is suspected, treatment should commence immediately without waiting for the swab results.

HIV

The test

• The fourth generation HIV tests are much more sensitive than the older tests used. The window period has therefore reduced.
• It is recommended to test at the time of presentation, and repeat again at 45 days post-risk.

Other tests

• All patients having an STI screen should be recommended to have blood tests for HIV and syphilis (only one yellow top bottle required for both HIV and syphilis testing)

Management

• Any patients found to be HIV positive should be informed of their result; a confirmatory HIV test should be sent and the patient should be referred to the HIV service
• If a patient is high risk for HIV, patients can be directed to advice on accessing pre and post-exposure prophylaxis (PEPSE and PrEP) to prevent HIV acquisition.

Syphilis

The test

• Serology: One yellow top bottle required for both HIV and syphilis testing.
• The incubation period for serology testing is up to 3 months. National guidelines recommend repeat testing at 6 weeks and 12 weeks after a ‘high risk’ sexual exposure.
• PCR: If a primary syphilis chancre is suspected, a “viral HSV” swab can be used to sample the lesion and sent to the laboratory for “Syphilis PCR”. The result can take up to 3 weeks.

Clinical features

• The majority of patients with syphilis will not develop clinical features.
• The classic clinical features are genital ulcer (often painless) or macular rash involving palms and soles; any rash may occur.
• If a patient has an ulcer (chancre) with primary syphilis, the serology may still be negative at that time but should be positive by 2 weeks later. See above re: PCR testing.

Other tests

• All patients having an STI screen should be recommended to have a full screen including HIV test.

Management

• Any patients testing positive for syphilis, or with suspected primary syphilis, should be referred to Unity Central for assessment, treatment and partner notification.

Unity’s guidance is based on national guidelines.

National guidelines on the management of STIs are available through the British Association for Sexual Health and HIV (BASSH)

National guidance on contraception is available through the Faculty of Sexual and Reproductive Healthcare (FSRH)

National guidance on the management of HIV is available through the British HIV Association (BHIVA)

Clinical guidelines are available to download from the Document Management Service, which can be accessed from any NHS (nww) computer.  Click on ‘Clinical Guidelines’ then ‘University Hospitals Bristol NHS Foundation Trust’ then ‘Medicine’ and select ‘Sexual Health’If you have any queries you may call us on 0117 342 6913.

We have abridged versions of our guidance for primary care which may be found on the BNSSG Remedy Website – under Sexual Health

Other helpful websites include:

British Liver Trust

British Pregnancy Advisory Service (BPAS)

Family Planning Association (FPA)

Herpes Virus Association

National Osteoporosis Society

Society of Sexual Health Advisers

Introduction

When a patient is diagnosed with a sexually transmitted infection, it is important to ensure that any sexual contacts are informed.  This helps reduce the spread of infection, reduce risk of health problems for partners and ensure the asymptomatic are aware. The patient should understand the infection, be able to comply with treatment and ensure follow-up arrangements are adhered to. Any patients diagnosed with the following STI’s should have partner notification processes initiated:

• Gonorrhoea
• Chlamydia
• Syphilis
• Pelvic Inflammatory disease (PID)
• HIV
• Hepatitis B
• Non-Specific Urethritis (NSU)

Approaching Partner Notification

It is important to take a sexual history from patients diagnosed with a sexually transmitted infection. This serves to identify anybody at risk, relative risk factors in sexual behavior and acts as a cue for the health professional to remind the patient of who needs to be informed and why.

If the patient is concerned about informing partners, it may help to:

• Point out the risk of re-infection from untreated partners
• Make the patient aware that it is likely partners may not have symptoms, so wouldn’t know unless informed
• Mention that untreated partners may develop long term harm if not informed
• Reassure the patient that there are multiple ways to approach the topic to partners
• Inform the patient that their partners have a right to know of any risks to their health

Discuss with the patient how, where and when their contacts may be informed. Discussing the most appropriate time, place and how to broach the topic can help the patient minimise embarrassment. Usual methods of informing partners would be:

• Face to face
• Social media message
• Text message
• Phone call

Try to encourage patients to talk to contacts privately, rather than in public or on publicly-viewable media networks. It may help to emphasise not to blame anybody, and to tell partners that they have been to the clinic and have been diagnosed with an infection.

If the patient specifies the infection to their partners (for example, saying ‘chlamydia’ rather than ‘an infection’) then the partners can access treatment immediately as a contact, rather than getting a test and awaiting a result prior to treatment. This minimises the risk of further transmission or health complications.

Please see the table below for time frames :

Emergency IUD guidance

There is some useful information on the sexual health pages of the Remedy website.

Long acting reversible contraception (LARC) patient group directions (PGDs)

The CCG and Local Authorities have authorised LARC PGDs for use by registered nurses at BNSSG GP Practices. The following PGDs are available on the BNSSG Joint Formulary webpage.

1. Etonogestrel subdermal implant
2. Levonorgestrel intra-uterine device (LNG-IUD previously referred to as IUS)
3. Lidocaine to facilitate insertion and/or removal of  subdermal etonogestrel implant

Full training requirements are included within each PGD and include successful completion of the Faculty of Reproductive and Sexual Health Letter of Competence for subdermal implants and intrauterine techniques, level 2 or equivalent safeguarding children and vulnerable adults and basic life support and anaphylaxis.

There are national PGD templates developed by the Specialist Pharmacy Service

UK Medical Eligibility Criteria tables for contraception use (UKMEC)

Spotting the Signs proforma (for child sexual exploitation)

Brook Sexual Behaviour Traffic Light Tool

BMI calculator

Are you at risk of osteoporosis? National Osteoporosis Society

Alcohol Use Disorders Identification Test (AUDIT)

How to calculate the latest time in the cycle and that an emergency IUD may be fitted – please see document

National Chlamydia Screening Programme – NCSP

Changes are occuring to the Chlamydia Screening Programme commencing on 1st April 2022.

There has been a national programme of Chlamydia screening in England since 2003. BNSSG, Bristol North Somerset and South Gloucestershire and BANES, Bath and North East Somerset areas have had an active service since 2007 with the aim of preventing onward transmission and the harms of chlamydia though early detection and treatment.

To ensure the NCSP service is based on the best available evidence, Public Health England (PHE) convened a review of the evidence based research by national and international experts and consulted with stakeholders and public (including focus groups with young people) on the recommended way forward.

As a result, the aim of the NCSP is changing to focus on reducing the harms from untreated chlamydia infection. The harmful effects of chlamydia occur predominantly in women so the opportunistic screening (that is the proactive offer of a chlamydia test to young people without symptoms) should focus on women*, combined with re-testing after treatment:

· Reducing time to test results and treatment

· Strengthening partner notification

Everyone can still get tested if they need, but men will not be proactively offered a test unless an indication has been identified, such as being a partner of someone with chlamydia or having symptoms.

In light of these changes, the screening office will still provide test kits with vaginal swabs for use in the 15-24 yr old age range. A small number of urine test kits for male or transfemale clients will also continue to be available.

The Unity website for test requests can be found at www.unitysexualhealth.co.uk. This provides access to STI screening kits that link to a client’s own patient account in Unity Sexual Health.

Please contact the Chlamydia Screening team on 0117 342 9299 or csp.avon@UHBW.nhs.uk if you have any questions.

*References to women includes cisgender women, transgender men and non-binary (assigned female at birth) people who have not had hysterectomy or bilateral oophorectomy.

Consider the need for emergency contraception.
Advise other means of contraception.
Organise an ultrasound to confirm the position of the coil.

Refer to Unity- complex LARC clinic , please see Clinical services and How to Refer

Refer to Unity – Complex LARC clinic, please see Clinical services and How to refer

Please consider whether the attempted removal may have dislodged the intra-uterine contraceptive device and offer bridging contraception if necessary.

The patient should be referred to Gynaecology rather than Unity sexual health in this instance for removal with hysteroscopy.

Advise other means of contraception.

Note if the USS reports that one of the arms has embedded into the myometrium, we may consider removal at Unity.

Sayana Press is a subcutaneous version of depot medroxy progesterone acetate. It is licensed for self-administration and therefore advance supplies may be provided.

Whether it is an IUD or an IUS, the coil should not be removed if there has been any unprotected sex in the last 7 days due to risk of pregnancy from any remaining viable sperm. The removal should be deferred until 7 days after the last episode of condom-less vaginal sex, even if a refit is planned.

Do not attempt removal. Consider the need for emergency contraception. Advise interim contraception.

Refer to the Deep Implant clinic, please see Clinical services and How to refer

Refer to the Deep Implant clinic, please see Clinical services and How to refer

Yes you can. The FSRH guidance recommends giving oral emergency contraception for every episode of unprotected sex in a cycle.

For further guidance:

FSRH Emergency contraception guideline

Note however that ulipristal acetate must not be given in the 7 days after any other form progestogen – including levonorgestrel.

Levonorgestrel must not be given in the 5 days after ulipristal.

Enzyme inducers, like carbamazepine, can affect all progesterone containing contraception, with the exception of depot medroxyprogesterone acetate and the Intra-uterine system.

So carbamazepine does not have any significant interaction with the IUS

For further guidance:

FSRH UKMEC

From FSRH CEU statement

The medical help required by transgender and non-binary patients is highly individualised. People’s goals, from hormone therapy and surgery vary enormously, therefore so will the appropriateness and acceptability of different methods of contraception. Sensitive communication, with a clear attempt to avoid any stigmatising language, is therefore the key issue.

The Faculty of sexual and reproductive healthcare  have produced a statement on Contraceptive Choices and Sexual Health for Transgender and Non-Binary People (October 2017).

Aciclovir is safe to use at any point during pregnancy. Normal dosing regimen applies.

If she is more than 28 weeks, and if this is a primary episode, she will need to be referred for consultant led antenatal care and may require caesarean delivery.

For further guidance:

RCOG Management of Herpes in Pregnancy guideline (2014)

BASSH Herpes guideline

We advise that patients are seen by our service so they can have cultures taken to check for antimicrobial sensitivities, receive the correct IM treatment, discuss partner notification and have a test of cure.

If you are happy to do this is in surgery then they do not need to be seen by us.

Please refer to our local guidelines for recommended treatment regimens.

For further guidance:

BASHH Gonorrhoea guideline

Yes.

We recommend partner notification and treatment for recent sexual partners.

All partners should be treated empirically with Doxycycline 100mg BD for 7days. Advise no sex until both partners finished treatment.

Yes.

We recommend partner notification and treatment for recent sexual partners.

All partners should be treated empirically with Doxycycline 100mg BD for 7days. Advise no sex until both partners finished treatment.

No, treat the patient as per guidelines for TV but the coil does not need to be removed.

No, treat the patient for PID but the coil does not need to be removed routinely.

If there is no improvement after 72 hours you may wish to consider removal.

Please see Clinical services and How to refer

If you feel they need to be seen urgently, please ring us on  0117 342 6900

As of April 2018 the 4YP brand longer exists in Bristol.

Unity Sexual Health has taken over the sexual health related training that was previously provided by 4YP and has been renamed UYP ( Unity Young People Training).

The UYP training programme is available on the professional development pages of our website