Opportunistic Screening (NICE NG221 recommends):

• All sexually active under-25s annually (chlamydia)
• New sexual partners or change in partner
• Men who have sex with men (MSM) - 3-monthly if high risk
• Pre-conception or antenatal booking
• HIV testing in high prevalence areas (>2/1000) offered to all new registrants

Symptom-Triggered Testing:

• Vaginal/penile discharge: Swab for chlamydia, gonorrhoea; microscopy for trichomonas, candida, BV
• Genital ulcers: Swab for HSV PCR and syphilis serology
• Systemic symptoms: Consider disseminated gonorrhoea, secondary syphilis, HIV seroconversion illness

A simple primary care decision pathway:

1. History: Characterise discharge, associated symptoms, sexual risk
2. Examination: Visual inspection, speculum if indicated
3. pH test: >4.5 suggests BV or trichomoniasis
4. Microscopy: If available (clue cells, trichomonads, hyphae)
5. NAAT swabs: For chlamydia/gonorrhoea if risk factors present
6. Empirical treatment: Based on likely cause if testing not available

When to refer to GUM:

• Treatment failure
• Recurrent symptoms
• Confirmed or suspected STI needing partner notification
• Complex cases (pregnancy, immunosuppression)

Key Checks Before Prescribing (UKMEC categories):

• Category 1: No restriction for use
• Category 2: Advantages generally outweigh risks
• Category 3: Risks usually outweigh advantages (use if other methods not acceptable)
• Category 4: Unacceptable health risk (do not use)

Drug Interactions:

• Enzyme inducers: Rifampicin, rifabutin, some anticonvulsants, St John's Wort reduce efficacy of combined hormonal contraception and progestogen-only pill
• Alternative: Use non-enzyme affected method (IUD, IUS, implant, injection) or higher dose COC

HIV Medications (check BNF/specialist advice):

• Some protease inhibitors and NNRTIs interact with hormonal contraception
• Dolutegravir may reduce efficacy of oral contraceptives
• Always consult HIV specialist or check updated BNF interactions

Same-Day Action Needed:

• Testicular torsion: Unilateral painful testis with sudden onset
• Ectopic pregnancy: Pain + bleeding + positive pregnancy test
• Severe PID: Systemically unwell, vomiting, severe pain
• Acute sexual assault: Within 72 hours for forensic examination

Referral Routes:

• GUM: STI diagnosis/treatment, partner notification, complex cases
• Gynaecology: Pelvic pain, menstrual disorders, suspected cancer
• Early pregnancy unit: Pain/bleeding in pregnancy
• Safeguarding teams: Child protection, domestic violence, FGM
• Specialist contraception: Complex medical conditions, previous complications

Bacterial Vaginosis (NICE CKS):

• Diagnosis: Amsel criteria (3 of: thin grey discharge, pH>4.5, fishy odor with KOH, clue cells on microscopy)
• Treatment: First-line: metronidazole 400mg BD for 5-7 days OR 2g stat. Alternative: clindamycin 2% cream
• Follow-up: Not routinely needed if symptoms resolve. High recurrence rate common
• Complications: Increased risk of PID, post-procedure infection, preterm labour in pregnancy

Candida (Thrush):

• Diagnosis: Typical symptoms + microscopy or clinical diagnosis. Consider swab if atypical/diagnostic uncertainty
• Treatment: Topical imidazole (clotrimazole, econazole) or oral fluconazole 150mg stat
• Recurrent (≥4 episodes/year): Exclude diabetes, consider maintenance therapy (fluconazole 150mg weekly for 6 months)
• Red flags: Immunosuppression, pregnancy (avoid oral azoles in 1st trimester)

Chlamydia (primary care role):

• Testing: NAAT on self-taken vulvovaginal swab (female) or first-pass urine (male)
• Treatment: Doxycycline 100mg BD for 7 days OR azithromycin 1g stat (if pregnant/breastfeeding)
• Partner notification: Essential! Current and recent partners need testing/treatment
• Refer to GUM if: Treatment failure, pregnancy, complicated infection, partner notification issues

Long-Acting Reversible Contraception (LARC):

• First-line recommendation: For most patients due to highest efficacy and convenience
• Copper IUD: Effective for 5-10 years, can be used for emergency contraception
• Hormonal IUS (Mirena etc): Effective 3-5 years, reduces menstrual bleeding
• Contraceptive implant: Effective 3 years, rapid return to fertility
• Common complications: Irregular bleeding (usually settles in 3-6 months), expulsion, infection risk at insertion

Emergency Contraception:

• Levonorgestrel: Up to 72 hours (effectiveness declines with time)
• Ulipristal acetate: Up to 120 hours, prescription only, more effective than LNG
• Copper IUD: Up to 120 hours, most effective option, provides ongoing contraception
• Important: Check pregnancy not already established, offer STI testing, discuss ongoing contraception

Contraception Complications:

• Combined hormonal: VTE risk (highest in first year), hypertension, migraine with aura
• Progestogen-only: Irregular bleeding, functional ovarian cysts
• IUD/IUS: Expulsion, perforation (rare), infection (first 20 days after insertion)
• Escalation triggers: Suspected VTE, severe abdominal pain (perforation), severe headache with neuro symptoms

Low Libido:

• Biopsychosocial assessment: Medical causes (hypothyroidism, depression, medications), relationship context, stress, lifestyle factors
• Safeguarding: Always consider coercion, abuse, FGM as contributing factors
• Management: Address underlying causes, relationship counselling referral, consider psychosexual therapy
• Medications: Testosterone may be considered in postmenopausal women with diagnosed hypoactive sexual desire disorder

Erectile Dysfunction:

• Assessment: Onset, situational vs global, morning erections, relationship factors
• Differential: Vascular (most common, associated with CVD risk factors), neurological, endocrine (testosterone, diabetes), medication-related, psychological
• Red flags: Sudden onset (consider psychological), associated with trauma, symptoms of cardiovascular disease
• Management: Lifestyle advice, PDE5 inhibitors (sildenafil, tadalafil), treat underlying causes

Vaginismus/Vulvodynia:

• Assessment: Pain characteristics, triggers, examination findings (if possible), psychological impact
• Vaginismus: Involuntary muscle spasm preventing penetration, often anxiety-related
• Vulvodynia: Chronic vulval pain without identifiable cause
• GP management: Reassurance, topical lidocaine, pelvic floor physio referral, psychosexual therapy referral

Gender Dysphoria (first presentation):

• Exploration: Open questions about feelings, duration, impact on life
• Mental health/safeguarding: Screen for depression, anxiety, self-harm, bullying, family acceptance
• Referral pathways: Gender Identity Clinic (GIC) for adults, GIDS for under-18s
• GP role: Supportive, use correct name/pronouns, address immediate health needs

Unwanted Pregnancy Support:

• Non-directive counselling: Present all options (continue pregnancy, adoption, termination)
• Safety assessment: Coercion, abuse, safeguarding concerns
• Referral routes: NHS abortion services, BPAS/Marie Stopes if preferred, early pregnancy unit if complications
• Follow-up: Contraception counselling, emotional support, check for complications

Female Genital Mutilation (FGM):

• Recognition: History from high-prevalence countries, physical signs (scarring, absence of structures), psychological sequelae (PTSD, flashbacks)
• Legal duty: Mandatory reporting for girls under 18 to police within 1 month of discovery
• Consultation: Culturally sensitive approach, understand it's a form of child abuse not cultural practice
• Management: Document carefully, refer to safeguarding lead, offer specialist FGM clinic referral

Sexual Abuse/Assault:

• Recognition: Disclosure, unexplained injuries, STIs in children, behavioural changes, pregnancy
• Immediate actions: Safety first (are they safe now?), forensic considerations if acute (<72 hours), refer to Sexual Assault Referral Centre (SARC)
• Documentation: Detailed, factual, verbatim quotes, may be used in court. Avoid opinions or interpretations
• Support: Psychological support, STI prophylaxis, emergency contraception, follow-up arrangements

Confidentiality Limits in Under-18s:

• Fraser/Gillick competence: Assess understanding, risks, benefits, ability to retain information
• Break confidentiality if: Serious risk of harm to self or others, safeguarding concerns, not competent to consent
• Best practice: Encourage involving parents, document competence assessment, explain why confidentiality might need to be broken

Unilateral Painful Testis:

• Rule out torsion first: Acute onset (<24 hours), severe pain, nausea/vomiting, elevated testis, absent cremasteric reflex
• Same-day urology referral: If torsion suspected, immediate surgical exploration needed (within 6 hours for best salvage)
• Differential: Epididymo-orchitis (more gradual onset, dysuria, fever, urethral discharge), torsion of testicular appendage, trauma
• If uncertain: Refer! It's safer to over-refer testicular pain than miss torsion

Pelvic Inflammatory Disease (PID):

• Don't miss: Can cause tubal damage leading to infertility, ectopic pregnancy, chronic pelvic pain
• Diagnosis: Lower abdominal pain + cervical motion tenderness/adnexal tenderness + at least one of: fever, abnormal discharge, raised inflammatory markers, positive STI test
• Urgent referral: If systemically unwell, surgical emergency suspected, pregnant, IUD in situ, tubo-ovarian abscess suspected, not improving after 72 hours of treatment
• Treatment: Broad-spectrum antibiotics covering chlamydia, gonorrhoea, and anaerobes

Complications of Early Pregnancy:

• Ectopic pregnancy: Pain + bleeding + positive pregnancy test. Risk factors: previous ectopic, PID, endometriosis, assisted reproduction
• Miscarriage with infection: Fever, offensive discharge, tender uterus, sepsis signs
• Molar pregnancy: Excessive nausea, uterus large for dates, very high hCG
• Action: Urgent referral to early pregnancy unit or gynaecology. If unstable: A&E

Post-Coital & Intermenstrual Bleeding:

• Cervical cancer risk: PCB is classic symptom. Persistent IMB also concerning
• Assessment: Always examine cervix if PCB. Cervical screening up to date? Consider STI screen (chlamydia can cause cervicitis)
• Urgent referral (2WW): Persistent unexplained PCB or IMB, suspicious cervix on examination
• Other causes: Cervical ectropion (common, benign), polyps, infection, trauma

Genital Ulcer with Systemic Illness:

• Secondary syphilis: Rash (palms/soles), condylomata lata, lymphadenopathy, malaise
• Disseminated gonorrhoea: Arthritis-dermatitis syndrome, tenosynovitis, pustular lesions
• HSV with dissemination: In immunosuppressed, can cause hepatitis, pneumonitis, encephalitis
• HIV seroconversion: Flu-like illness, maculopapular rash, mucocutaneous ulcers
• Action: Urgent STI screen, consider admission if systemically unwell