Human S

4.2 "Prevention of Sexually Transmitted Disease" Gay

- STIs are common and preventable causes of morbidity and serious complications - Consequences of untreated G & C PID which can cause infertility, ectopic preg, and chronic pelvic pain - STIs can also cause preg problems spont abortion, still birth, premature birth, and cong infxn - STIs can also facilitate HIV transmission • Review the epidemiology and risk groups for STDs. - key strategy in prevention of STIs screening, dx, and tx of pts as well as their partners to interrupt transmission - all pts who have hx of or risk factor for STI should be offered HIV testing and anyone who is HIV + should be tested for STI - Risk factors for STI: o Unmarried status (wtf? Just cause I aint married don't mean im a hoe just saying...) o Residence in urban area o Mult sexual partners (concurrent) o Hx of prior STI o Illicit rx use o Contact with sex worker (you nasty) - risk groups that should be offered testing all sexually active teens, adults w/ current/past hx of STI or hx of mult sex partners, ppl who live in areas w/ high prevalence of STI, pts in a nonmonogamous relationships - 2004-2006 adolescent study showed: 47.4% high school kids had had sex, 39.8% reported not using a condom, and ½ of the estimated 19 million STI infxns occur in ppl ages 15-24 - AAP rec: asking teens about sexual hx at annual visits and offering STI testing to all sexually active kids - MSM are at high risk for HIV infxn and STIs due to unsafe sexual practices - Study on MSM HIV and HSV-2: inc risk of HIV acquisition was reported in assoc w/ HSV-2 infxn compared to nml pts o Risk factors for HSV-2 infxn being black, unprotected receptive anal intercourse, having an HIV+ partner, 6 or more partners in a 6mo period - Common practices assoc w/ clusters of acute Hep C infxn serosorting (HIV+ men having sex w/ one another), group sex, use of cocaine or other non-IV drugs during sex • Recognize the vaccines available for STDs and those NOT available for others. - Immunizations are available for prevention of Hep A, B, and HPV - Vaccines should be administered to HIV+ pts when CD4 counts >200-300; vaccines given when counts are <200 should be repeated after count is >200 - Hep A: rec for MSM, IV drug users, and pts w/ chronic liver dz o Postvaccination serologic testing in immunocompromised pts is rec 1 mo after initial vaccine to assess need for supplementation o Virus replicates in the liver and is shed in the feces from 2wks before to 1 wk after onset of sxs o Sexual transmission is fecal-oral (that's ****ing nasty) so condoms are not effective - Hep B: primary risk factors unprotected sex w/ infected partner or more than one partner and hx of other STIs, MSM, and IV drug users o Universal hep B vaccine for all unvaccinated adults w/ STI including those who did not complete their initial series, and HIV+ pts o Pts w/ hx of HBV vaccine should show proof of immunizations or titers o All preggers w/ STI should be tested regardless of vaccination status o Efficacy of vaccine can be affected by HIV RNA so Hep B surface antigen should be checked 1 mo after completing series and pts w/ titers <10 should be revaccinated o Study showed that many high risk pts were actually not immunized; 23% showed previous infxn and only 9% showed vaccination - HPV: 2 vaccines avail bivalent (Cervarix) protects against 16 & 18 and quadrivalent (Gardasil) protects against 6, 11, 16, 18 (only Gardasil approved in the states o Rec for females and males 9-26yo - no vaccines avail for HIV of Hep C • Discuss the effects of condoms on STD transmission - condom use is one of the most important means of preventing STIs despite limited data avail due to ethical limitations - study in 2000 from the NIH: condom use prevented HIV transmission in men and women and prevented gonorrhea in men (all data related to male condom use) • Discuss male circumcision in different populations, and with different STDs, and how it effects STD transmission - Studies suggest a dec risk of STI acquisition in males who have been circumcised particularly for HIV infxn - Multiple studies in Africa show that the reduction of female to male HIV transmission was by 50-60% in circumcised men - Reduction might be related to the high density of HIV target cells in the foreskin - Although circumcision has shown reduction in acquisition in men it has not demonstrated a reduction in acquisition in women and no trials have been performed in MSM - Circumcision is assoc w/ reduced risk of viral STIs such as HSV-2 and HPV but not G&C nor syphilis - Uganda studies: all showed dec acquisition of HSV-2 in circumcised men and dec rates of GUD, trichomonas, and BV in women • Recognize the strategies of post-exposure prophylaxis and pre-exposure prophylaxis against HIV. - limited data has shown that post-exposure prophylaxis w/ antiretrovirals does red risk of HIV infxn - for non infected pt who are at hi risk for acquiring HIV and are committed to medication adherence and close follow-up pre-exposure prophylaxis might be effective • Recognize that topical microbicides have shown to reduce the risk of HIV acquisitions. - topical microbicides have been proposed as STI preventive agents - they provide chemical, biological, and physical barriers at the mucosal surface - classes of microbicides: surfactants, membrane disruptors, vaginal milieu protectors, viral entry inhibitors, and reverse transcriptase inhibitors - delivery sys include gel formulations and vaginal rings • Describe the recommendations for STD prevention. - 2010 CDC STI tx guidelines : o clinicians need to assess sexual risk for all pts during routine clinical visits, esp teens and MSM o all pts being evaluated should be offered HIV counseling and testing o Hep B shots for susceptible MSM, pts w/ hx of multiple sex partners, HIV+ pts, and pts w/ risk factor for STI o Hep A shots in seronegative MSM and HIV+ pts w/ chronic liver dz or risk factors for Hep A including IV drug users o HPV shots for men and females ages 9-26 o STI prevention efforts should include barrier methods like condoms as they have shown dec risk of HIV, G &C, HSV, and HPV o Male circumcision can reduce HIV transmission and dec risk of HSV and HPV o Post-exposure and pre-exposure prophylaxis w/ antiretrovirals are a possible option for prevention of HIV infxn in high risk individuals o Valcyclovir 500mg qday in pt w/ genital HSVwho are in a monogamous discordant relationship

3.17 "The "choking game" and other stranguation activities in children and adolescents" Ullrich Describe the "choking game" and autoerotic asphyxia.

-"choking game" refers to strangulation with the hands or a ligature to produce a euphoric state caused by cerebral hypoxia -more accurately described as a "strangulation activity" than as a game -intent is to release the pressure just before loss of consciousness; failure to do so can result in death, particularly when the activity is performed alone using ligatures -Other names for strangulation activities include the American dream, air planing, black hole, black-out game, breath play, California choke, choke out, cloud nine, dream game, fainting game, five minutes of heaven, flat lining, funky chicken, gasp game, ghost, knock-out game, natural high, pass-out game, purple dragon, purple hazing, rising sun, rush, the scarf game, something dreaming game, space cowboy, space monkey, speed dreaming, suffocation roulette, and the tingling game (wasn't sure if this was important ) -Autoerotic asphyxia involves choking oneself during sexual stimulation in order to heighten the sexual pleasure -may involve elaborate bindings, sophisticated escape mechanisms, sexual images, or cross-dressing -Death may occur if loss of consciousness leads to loss of control and inability to reverse or stop the means of strangulation -almost exclusively older adolescent and adult males

3.15 "Female Circumcision and Genital Cutting" Nour. Describe female genital cutting and the four different types.

-def: manipulation or removal of external genital organs in girls and women (from WHO) -type 1: excision of prepusce, with or without excision of part or all of the clitoris -type 2: clitoridectomy, partial or total excision of the labia minora -type 3: (infibulation): removing part or all of external genitalia and reapproximation of remnant labia majora leaving a small neointroitus -type 4: other forms of injuries to the genital region including piercing, stretching, burning, scraping, or any other manipulation of external genitalia Discuss the origins, rationale, procedure, complications, and outcomes of female circumcision. -origins: -unknown but could date back to Egypt, pre-Islamic Arabia, ancient Rome, and Tsarist Russia -now comes to represent an important rite of passage for girls into woman hood -NOT a religious custom (not condoned by any religions) but moreso reinforced by customary beliefs that maintain girls chastity, preserves fertility, ensures marriageability, improves hygiene, and enhance sexual pleasure for men -up until the 1930s: US and Europe performed female circumcisions for clitoral enlargement, redundancy, hysteria, lesbianism, and erotomania -rationale -is done to provide benefit, not harm, to girls: allows them to enter womanhood in societies. Without circumcision, she is condemned to a life of isolation -those who undergo female circumcision do not consider themselves to be mutilated since the majority of other women have the same thing -those women who immigrate to the US may be surprised American woman do not get circumcised SO those circumcised may be offended that this is considered "genital mutilation" use circumcision, genital cutting, or the word their culture uses for it -procedure: -performed between ages 5-12, in some places during a celebration in which girl receives gifts; food and music, or... -girls are abducted in the middle of the night to be circumcised -performed by nonmedically trained operatos without anesthesia and antiobiotics -instruments may be old, rusty knives, razors, scissors, heated stone which are rarely washed between procedures -hemostasis using catgut sutures, thorns, homemade adhesive concoctions (sugar, egg, animal excrement) -girls legs bound around ankles and thighs for approx. one week after, kept in bed -SOMETIMES, the circumcision is done with sterile equipment and anesthesia -complications: -not all women suffer complications -periprocedural complications: surgical precision can be compromised by lack of anesthesia, struggles of child, and experience of operator success usually dependent on chance, not accuracy -early post op complications: hemorrhage, infection, oliguria, sepsis -outcome: -long term gyno issues: type 2 or type 3 cutting can lead to long term complications than type 1 or 4 -dysmenorrhea, dyspareunia, chronic vaginal infxs -meatal and urinary obstructions, preventing proper urination -infibulated scar can also result in urine becoming stagnant infx in urethra (infibulated woman have a higher risk for urinary issues) -fibrosis, keloids, sebaceous (epidermal) cysts, vulvar abscesses, partial or total fusion of labia majora or minora (majora leads to backing up menstrual blood into uterus (hemometra) and/or vagina (hematocolpos) -small neointroitus may cause vaginismus, chronic infx, and neuromas -infertility rate in circumcised woman higher (25-30% versus 8-14%) -correlates to anatomical extent of cutting -d/t physical barrier made by vaginal and introital stenosis -couples may need to "practice" until full penetration possible -can lead to persistent dyspareunia apareunia; ascending infection can damage fallopian tubes -effect on sexual satisfaction: difficult to ascertain -one survey claimed women were able to achieve orgasm -1836, Nigerian women: type 1 and 2 did not attenuate sex (drive) but associated with higher prevalence of discharge and pelvic pain -another study: those who had type 3 infibulation were heavily affected compared to type 1 -obstetrical issues -monitoring labor: labor progress is typically monitored using successive cervical exams -difficult on infibulated woman (narrow neointroitus + bimanual exam = not good) -treat: -defibulate woman early in labor: very early epidural and irritation of incision with every cervical assessment -monitor labor via rectal exam: rectal examination of the cervix is uncomfortable and most OBs have no experience with this -inaccurate cervical assessment is also problematic because latent phase of labor may be falsely diagnoses as active labor lead to an unnecessary C-section -difficulty placing fetal scalp electrode, intrauterine pressure or foley cath, and performing fetal scalp pH -infibulated scar can prolong only the second stage of labor may obstruct crowning and delivery defibulation procedure during second trimester strongly recommended -pregnancy outcome: WHO study compared OB outcomes of women with and without genital cutting -type 2 and 3 had higher risk of C-secton, postpartum hemorrhage, and extended hospital stay, infants at higher risk of requiring resuscitation and dying than those without genital cutting -risks higher in type 3 than 2 -nulliparous and parous women with type 1, 2, and 3 had higher rates of episiotomy and tears than those without cutting

Define defibulation and reinfibulation.

-defibulation: surgical opening of the labia, reconstructive surgery of the scar tissue caused when the labia are joined together by infibulation -reinfibulation: Some women who have just given birth will request immediate reinfibulation. The procedure may create the long-term complications previously mentioned and should be strongly discouraged. The woman may only feel comfortable being infibulated

Review causative medication for inadequate vaginal lubrication.

-tamoxifen: premenoupausal women anti estrogenic effect; estrogenic effect in postmenopausal women, leading to candidiasis -aromatase inhibitors -antidepressants - loss of libido, issues with arousal or orgasm, anticholinergic meds may result in dryness -antihistamines -anticholinergics -depot medroxyprogesterone acetate

3.14 "Differential dx of sexual pain women" stewart..Describe common etiologies of sexual pain disorders in women

-vulvar pain syndromes: -localized vulvo/vestibulodynia is provoked by touching vestibule (involves primary and secondary, see above^) -dx: +Q tip test, exclusion of other pathology, most common cause of pain in woman <50 YO -generalized vulvodynia - unprovoked stinging etc. anywhere on vulva; may not be invoked by sex, may be not physical findings -dx: clinical based on findings of hx, exclusion of other causes of vulvar pain -urogenital atrophy: most common cause of dyspareunia in perimenopausal and menopausal women -vulvar, vaginal, urinary tract epithelium have many estrogen receptors —> susceptible to hypoestrogenism —> vaginal changes, lack of adequate vaginal lubrication with arousal —> dyspareunia -dryness, burning, pruritus, discharge, bleeding, UT problems, mucosa is thin with diffuse erythema, possible petechia/ecchymoses, few/no folds, pH > 5 -hypoestrogenism can be d/t postpartum period and/or breastfeeding, meds (dose contraception, gonadotropin releasing hormone agonist, tamoxifen,) hypothalamic-pituitary disorders -inadequate lubrication unrelated to hypoestrogenic states -young: inadequate foreplay, relationship/interpersonal issues, meds for HTN and depression, also antihistamines and anticholinergics -sjogrens syndrome: disorder involving lack of saliva, lacrimation, associated with vaginal dryness -diabetes -vaginismus: involuntary contraction of muscles of pelvic floor surrounding vaginal orifice, preventing penetration (primary—>psychological; secondary—> conditioned response to pain from physical cause or relationship problems -dx: can use single diagnostic entity "genitor-pelvic pain/penetration disorder" -% of success of vaginal penetration, pain with penetration, fear of penetration, or of genitor-pelvic pain during penetration -hard to dx using EMG via spasms, not reliable -UT disease: painful bladder syndrome/interstitial cystitis -pain associated with bladder function + urgency, frequency, nocturia, dyspareunia (w/ superficial or deep thrusting), sometimes chronic pelvic pain, IBS, dysmenorrhea, endometriosis, vulvodynia, fibromyalgia -cystitis: dysuria usually + frequency, urgency, suprapubic pain, and/or hematuria -urethral diverticulum: dyspareunia, dysuria, may have a midline mass palpable through anterior vaginal wall -vulvovaginitis: due to candida albicans or trichomonas vaginalis superficial vaginal pain during sex d/t inflammation and edema -wet mount (THE LAB TECHNIQUE, YOU SICKO) may be negative, must culture when there is increased suspicion -group b strep or e. coli do not cause dyspareunia -hypertonicity of local musculature: myofascial pelvic pain syndrome, coccydynia, pelvic floor tension myalgia, piriformis syndrome, levator ani spasm, proctalgia fugax all share hypertonicity of some of the pelvic musculature as underlying problem -involuntary spasm of pelvic muscles, hypersensitive trigger points -caused by inflammation, childbirth, pelvic surgery, endometriosis, trauma -spasms can continue after primary injury is repaired -sex: pelvic floor trigger points refer pain to vagina, vulva, perineum, rectum, bladder but can also be referred to thighs, buttocks, lower abdomen -initial sxs: urinary urgency, vulvovaginal burning, rectal fullness -postpartum: perineal pain after episiotomy and OB lacerations persist -7-10% women still experience dyspareunia 12 months postpartum -d/t distortion anatomy, persistent inflamed granulation tissue, development of a trigger point -previously mild myofascial pelvic pain may be exaggerated by delivery -endometriosis: deep dyspareunia is a common symptom of endometriosis especially when it involves uterosacral ligaments or rectovaginal septum -uterine retroversion: normal positional variant but some women have pain upon deep vaginal thrusting -configuration of bony pelvis in these women may not provide enough room to accommodate the posterior shift of the uterus during sex -can be complicated by endometriosis -pelvic organ prolapse: not usually painful but can produce dyspareunia when there is marked descent -postoperative dyspareunia (gyno surg) -hysterectomy: touching of vaginal apex may be painful even after healing -d/t persistent/recurrent pelvic disease, prolapse of fallopian tube or ovary, levator/obturator/piriformis muscle spasm, neuopathic pain -surg repair of pelvic relaxation causes dyspareunia in 1/3 pts -dysparunia most common in mesh repairs -dyspareunia may improve after non-mesh repair for urinary incontinence -leiomyomata: women with leiomyomata do not have higher prevalence for dyspareunia but the leiomyoma can be the source of dyspareunia (large post myoma impacted during sex) -adnexal pathology: ovarian cyst, etc deep dyspareunia -pelvic adhesions: from surgery, infx, endometriosis can cause dyspareunia -seminal plasma allergy: allergy or hypersensitivity characterized by post sex itching, burning, edema, erythema with/without systemic signs/sxs -systemic: dyspnea, dysphagia, rhinoconjunctival complaints, generalized urticaria, angioedema, GI sxs, exacerbation of existing atopic eczema, or anaphylactic shock -typically younger than 40 years old -psychogenic dyspareunia: -psychoanalytic theory: hysterical or conversion symptom symbolizing an unconscious intrapsychic conflict involving phobic reaction, anxiety conflicts, hostility, aversion to sexuality -learning theory: dyspareunia as a result of absent or faulty learning, which may cause a woman to enter a sexual relationship with a set of negative expectations -others (?): suggested that an initial painful sexual experience or sexual abuse leads to repetitive conditioned negative responses with subsequent experiences -likely those patients with dyspareunia have both physical and psychological factors -lichen planus: erosive lichen planus most common type of vulvar lichen planus -desquamative, erosive, chronic dermatitis often involves the vagina -lesions: glassy, brightly erythematous erosions with white striae and or white border -also located on labia minora and vestibule as isolated lesions -recurrent exacerbations, slow healing, scarring are common -leading to significant anatomic disruption stenosis of vaginal opening and urethral obstruction -initial sxs of intense itching or vulvar pain, soreness, or burning -lichen sclerosus: classic white, atrophic papules that may coalesce into plaques -located on labia minora and/or majora, may extend over perineum and around anus in keyhole fashion (the irony) -dyspareunia is a late symptom -pain caused by introital stenosis, fissures, posterior deflection of fused labial tissues at times of intromission -fusion over clitoris can lead to anorgasmia -dyspareunia can occur around menopause (estrogen deficiency)

Sexual dysfunction in Women

1) Desire (libido): wanting to have sex, sexual thoughts, images, wishes 2) Arousal- (excitement) subjective sense of sexual pleasure by physiological changes (genital vasocongestion, inc HR, BP, RR) 3) Orgasm- peaking of sexual pleasure and release of sexual tension w/rhythmic contractions of perineal muscles, repoo rgans 4) Resolution- muscular relaxation; general sense of well-being *for many women, the phases vary in sequence* • Although desire may be initiating factor, women are often motivated by other reasons (wish for emotional closeness; strengthening of relationship)

Taking a Sexual history

1) Partners a. Determine number and gender to assess risk of contracting an STD b. If only one partner over the last year, inquire about length of relationship and partner's risk factors c. If more than one partner noted over last year, explore risk factors like condom use 2) Practices a. Questions will guide the assessment of patient risk, risk-reduction strategies, determination of necessary testing, and identification of anatomical sites from which to collect specimens for STD testing b. "What kind of sexual contact do you have or have you had before?" 3) Protection a. Open ended questions b. Of Pt has been in a monogamous relationship for the last year than risk-reduction counseling may not be needed 4) Past History a. "Have you ever been diagnosed with an STD?" b. "Have you had any recurring symptoms or diagnoses?" c. "Have you ever been tested for syphilis?" 5) Prevention of Pregnancy a. Based on partner information from prior section; risk of pregnancy b. Questions should be gender appropriate c. "Are you concerned about getting pregnant or getting your partner pregnant?"

Discuss screening of special populations for STDs

1) Preg women: Infections of concern include herpes, hepatitis B, chlamydia and gonorrhea, syphilis, HIV and hepatitis C 2) Men who have sex w/ men (MSM): the following tests are rec to be offered at least on an annual bases: a. HIV ab b. Urethral or urine test for G&C c. Pharyngeal cx for gonorrhea in men w/ hx of oral-genital exposure but testing for pharyngeal chlamydia infxn is not rec d. Rectal G&C for men who have had receptitve anal intercourse w/ in the past year e. Syphillis serology (VDRL) - Screening q3-6 mo is rec by the CDC for MSM who have multiple or anonymous partners - One study showed that 1/3 of the total number of gonorrhea cases would've been missed if only urethral/urine samples were tested test for oral and anal G&C; similar studies have showed the same results for HIV - It's rec to screen for past Hep B and Hep A infxns as they are more prone if seronegative both vaccines should be offered to pt - Evidence of inc Hep C transmission amongst MSM pops rec offering pts Hep C ab screening - For MSM pts that are HIV + ongoing screening for Hep C is warranted to detect acute infxns - Anal CA is also inc among HIV+ MSM - Anal cytologic abn or anal HPV infxn is not rec until more data is available 3) Women-w/- women (WSW): diagnostic testing for STIs should be performed in women w/ sxs and annual screening for G&C is rec for WSW who are sexually active - Routine cervical CA screening and HPV vaccine according to stnd guidelines 4) HIV infected pt: high rates of STIs - One study showed 1.8% pt had syphilis, 10% G&C; 88% were cx from nonurethral sites - Another study in Kenya showed HIV infxn was assoc w/ significantly higher incidence of genital ulcer dz that inc w/ progression of immunosuppression - The rate of primary and secondary syphilis in pts w/ HIV is higher than the general pop (25% of 6862 cases in 2002 were coinfected) - Routine STI screening of HIV infected pt is rec it reduces the spread of STIs and STIs can inc HIV transmission. Specifically test for: o Gonorrhea, Chlamydia, and Syphilis initial eval and annually o Hep A, B, and C initial eval and vaccinate if susceptible (A & B); for C annual screening for drug users (including intranasal cocaine use), unprotected sex, and those undergoing hemodialysis o Areas of high STI prevalence biannual STI testing maybe prudent o HIV + women should have cervical screenings twice the first yr after dx and if nml then annually o HIV + women w/ abn pap should be managed w/ colposcopy and OBGYN consultation - It was noted that 42% of healthcare providers (HCP) providing HIV care never or almost never performed initial STI screening on HIV infected pts nor do they ask about ongoing risky behavior; also 1/3 never to almost never performed annual G&C testing - Hep C among HIV-infected pts has inc internationally o Periodic screening w/ LFTs, Hep C ab, and RNA testing if ab test is abn is rec to identify acute infxns which has a higher response rate than in the chronic setting o Cost effective analysis showed: screening yearly w/ HCV ab and LFTs and reflex RNA q6mo when incidence of hep C is below 1.25%; screening LFTs q3mo when incidence is >1.25 - Health dep notification of STIs is just as imp as tx; notifiable dz include: o Chancroid o G&C o Acute Hep B and C o HIV o Syphilis

1.3 Female Condoms - Theresa Hatzell Hoke, PhD, MPH; et al; June 5, 2015

1. Describe the female condom and its intended use. All have an anchor (Ex: ring, frame) outside the vagina to prevent the condom from being pushed inside during use and for removal. Made of natural rubber latex, synthetic latex (nitrile), and polyurethane. They prevent preejaculatory fluid and semen from entering the vagina. No spermicide is required, but a lubricant is often needed. o FC1 - the first, now off the market. Polyurethane. Loose. 2 rings--one inside and one outside the vagina. Pre-lubed on inside only o FC2 - the next generation. Most widely availble now No seem, nitrile, quieter, cheaper WHO, FDA, and CE Marking stamps of approval o PATH WC (Program for Appropriate Technology and Health, Women's Condom) - Dissolvable insertion capsule. Clings (via hydrophilic interactions) to vaginal wall. Not pre-lubed but sold w/a water-based lubricant. o The VA w.o.w® (worn of women) Natural rubber latex w/a medical grade sponge at one end for insertion; the other end has a triangular frame to anchor it outside the vagina. Prelubricated. o Others (limited availability): polyurethane Phoenurse in China; the natural rubber latex Cupid FC in India; and the Natural Sensation Panty Condom in parts of Europe and South America. 2. Discuss the advantages and the disadvantages of the female condom. o Pros Safe Effective Reversible No delayed fertility afterwards OTC No fitting needed - Unlike diaphragm - Unaffected by weight changes or recent birth - Better protection than diaphragm as result Hypoallergenic Minimal side-effects STI protection Great option for women with non-compliant partners Broader coverage externally than male condom Clitoral stimulation by external ring Placed prior to start of intercourse - No need for erect penis (wellll); no interruption Typically synthetic, without latex - Storage not dependent on temp or moisture - Can use oil-based lube - Hypoallergenic o Cons Difficult insertion Visible outer ring Higher failure rate than male condom or nonbarrier methods Noisy Embarrassment possible with purchase or discussion w/partner Not widely available worldwide More expansive than male condom Not for anal sex One-time use 3. Explain the instructions for use of the FC2 female condom, the one available in the United States, and its description. - Not to be used concurrently w/male condom as friction will cause breakage - Assume position of comfort for insertion - Up to 8hrs prior to sex - With thumb & middle finger, squeeze inner, closed ended ring - Insert into vagina - Index finger inside condom, push as far as it will go - Don't twist condom - Outer ring extends ~inch beyond labia - Ensure outer ring does not get pushed inside or that penis does not slip between vagina and outer surface of condom - Remove at any time after intercourse but prior to standing to prevent leakage - Twist outer ring to seal - Pull out and wrap (tissue or original packaging) - Dispose in trash, not toilet Reuse not advised.

HIV 4.4 HIV Treatement as prevention

1. Describe the meaning of "treatment of prevention" in HIV patients. a. "Treatment as prevention" describes the personal and public health benefits of using ART to suppress detectable viremia, which decreases the risk of HIV transmission to others. The term "HIV serodiscordant couples" refers to an HIV-seropositive person who is sexually active with an HIV-uninfected partner. This topic will specifically address the use of ART in the HIV-infected partner to decrease the sexual transmission of HIV to the uninfected partner. 2. Recognize the risk factors for HIV sexual transmission a. High levels of viremia (Transmitting partners appear to have higher levels of HIV RNA than nontransmitting partners) b. Acute HIV infection- Transmission events appear to be more frequent from patients with acute HIV infection and late-stage disease (ie, AIDS) compared with chronic infection; probably linked to high levels of viremia. c. During acute HIV infection, there is ramp-up of viremia followed by onset of a cellular immune response, which leads to a new lower viral "set point" (eg, equilibrium) seen in chronic infection [7,8]. Acute infection is also associated with increased viral shedding in genital secretions for several weeks after infection compared with the stable lower levels seen in chronic infection. d. One modelling study estimated that 38 percent of all HIV transmissions in Malawi were attributable to sexual contact with acutely infected individuals e. Chronic HIV infection — In patients with chronic infection, a dose-response relationship also exists between the magnitude of the viral load in the blood and genital compartments and the risk of HIV transmission f. HIV can still be intermittently detectable in seminal fluid of some HIV infected men, despite suppression of HIV viremia with antiretroviral therapy However, it is unclear whether this poses a significant transmission risk in serodiscordant couples. Results of the HIV Prevention Trials Network 052 trial similarly suggest a low risk of HIV transmission in the setting of effective antiretroviral therapy g. Lack of circumcision- circumcision reduces the likelihood of female-to-male HIV transmission by 50 to 60 percent. The biologic basis for this observation may be related to a high density of HIV target cells in male foreskin, including Langerhans cells and macrophages. However, male circumcision does not decrease the risk of HIV transmission to the female partner. h. Unprotected intercourse (WHAT?!)- 0.9 seroconversions per 100 person years i. Sexually transmitted disease- increased risk of acquiring and transmitting if you have a genital ulcerative disease (herpes, syphilis). Other STDs of the genital tract also appear to increase HIV infection risk. (urethritis). 3. Review HIV prevention strategies and public health. a. HIV PREVENTION STRATEGIES AND PUBLIC HEALTH i. As of December 2010, 33 million people were estimated to be living with HIV/AIDS, and more than 35 million have died since the beginning of the epidemic. Potent ART medications greatly reduce the chance of infection. Can test a large population, give them all ART. Could greatly help the population. This is the "test-and-treat' strategy. 4. Discuss clinical management of HIV serodiscordant couples with current recommendations. a. Condom use —to decrease transmission among HIV serodiscordant couples includes consistent use of condoms and should be offered regardless of ART use. b. ART greatly decreases the risk of HIV transmission to the HIV-seronegative sexual partner. c. Each organization has their recommendations on when and with who to use ART but the general trend is if you have the resources (western world) you give ART to anybody HIV positive, if resources are limited then only give them to people with a lowered CD4 count. d. WHO and PEPFAR- recommends ART initiation for personal health in all patients with a CD4 cell count <350 cells/mm3. In addition, the WHO released new guidelines in 2012 that recommend ART for the HIV-infected patient in a relationship with an uninfected individual, regardless of CD4 cell count, to reduce transmission e. Pre-exposure prophylaxis for the HIV-uninfected partner in a serodiscordant couple can also reduce the risk of HIV transmission f. There is also the added benefit of decreased morbidity with ART because of overall viral repression and they specifically site TB infected patients with decreased morbidity while on ART g. Counsel the patient that early ART treatment is good for them and their partner but chronic treatment may have toxicities

5.2 Male Condom - Katherine M. Stone, MD; et al; June 5, 2015

1. Describe the types of male condoms. a. Types: Natural Membrane - Ex: lamb cecum aka "lambskin" condoms. - Pros: use w/any lube - Cons: porous, so may allow transmission of STIs. Not recommended Latex - 97% of male condoms. - Pros: less expensive, effective against STIs & babies - Cons: incompatible with oil-based lube, latex allergy reaction Synthetic - polyurethane - Pros: long shelf-life, compatible with oil (not all synthetics) & water based lubes - Cons: non-allergenic, FDA recommended only in cases of allergies because limited data on effectiveness (but thought to be the same as latex condoms) Spermicidal condoms - prelubricated w/spermicide nonoxynol-9 (N-9) - Pros: - Cons: more expensive, shorter shelf-life, doesn't improve effectiveness, increases risk of adverse side-effects like UTIs in women. Not recommended. 2. Discuss the effectiveness of the male condom. Condom effectiveness depends on the motivation, skill level, and experience of the user. a. Contraception 2% pregnancy rate per year w/perfect use - Condom placed on the penis before any genital contact and used throughout intercourse 18% with typical use b. STI transmission Primary purpose Highly effective barrier to transmission to/from penile urethra - Ex: Gonorrhea, chlamydia, trichmononiasis, Hep B, HIV Somewhat effective against skin or mucosal transmission - Ex: Herpes, Syphilis, Chancroid, HPV - Decreased protection if condom doesn't cover effected area o HIV Condoms highly effective High quality studies showed only 11 of 587 "discordant couples" (one person being HIV positive) had seroconversion w/consistent latex condom use o Other STIs Data limited d/t low-quality studies, but appears effective for men and women Associated w/female fertility protection secondary to STI prevention 3. Review the advantages and the disadvantages of this form of contraception. a. Pros Latex allergy is only contraindication Reversible No delayed fertility afterwards OTC Super Cheap/Cost-effective Portable Minimal side-effects Reduced pre-mature ejaculation b. Cons Decreased sensation Interrupted foreplay Possible difficulty maintaining an erection with condom on Embarrassment for some assoc. w/buying OTC or suggesting them to a partner (Briana soapbox moment: if you can't talk to your partner about condoms, you shouldn't be having sex.) Requires partner cooperation Poor condom fit 4. Review recommended counseling information including strategies for promoting effective condom use and instructions for use All pts should understand why condoms are recommended, when & how to use them effectively, how to discuss condom use with partners, and how to integrate condom use into intercourse, adjusting for skill and risk levels and attitudes. Explain options and risks vs benefits a. Counseling o Pregnant women at high risk for STI should be counseled to use condoms to protect fetus, mother, partner o Latex sensitivity 1-6% Americans have allergy, prevalence dependent on amt of exposure All clients questioned for allergy & referred for skin testing if suspected Allergy may be specific to a condom brand if other latex products don't cause rxn b. Strategies for promoting condom use Want to decrease inconsistent use, incorrect use, and nonuse Incorrect use can lead to non-use if pt has a bad experience o Intervene w/inconsistent use by emphasizing condom use... ...during every act of anal, vaginal, and oral intercourse ...for each new sex act. o Intervene w/incorrect use by emphasizing... Importance of practice. Consider supervising practice (giggidy). o Intervene w/nonuse by emphasizing condom use... ...for contraception in addition to disease prevention ...from beginning of genital contact to after ejaculation. o Provide free condoms o Counsel on what to do if condom slips or breaks Avg 2% occurrence with vaginal intercourse; slightly higher with anal Advise keeping spares Reduce risk of pregnancy - immediate insertion of spermicide; - OTC non-Rx emergency contraceptive - Do not douche Reduce risk of STDs by immediately washing affected and adjacent areas with soap and water

5.4 Optimizing Natural Fertility in Couples Planning Pregnancy - Mark D. Hornstein, MD; William E. Gibbons; October 15, 2015

1. Review the definitions related to natural fertility. o Fertility = aka fecundity, capacity to conceive and produce offspring o Infertility = (sometimes called subfertility.) Despite frequent coitus, inability to conceive for a period of 12 months for women under 35yo or 6 months if older. Diminished, but not necessarily absent, fertility. o Sterility = inability to produce offspring o Fecundability = probability of achieving pregnancy in a single menstrual cycle o Subfecundity = decrease in fecundability o Time to pregnancy = length of time to conceive 2. Discuss normal fertility with fertile period and the frequency of coitus with fertility. o Normal fertility - usually conception occurs within the first 6 cycles of intercourse. 85% couples become pregnant within a yr w/o protection. Half of the remaining become pregnant in the following 1.5 years. o Fertile period - extends from 5 days prior to ovulation to the day of ovulation. Highest likelihood of conception 2 days prior through to the day of ovulation. o Frequency of coitus - peak semen quality with 2-3 days sans ejaculation. Increased likelihood of conception with sex every 1-2 days. Regular intercourse 2-3x/week after woman's period = more likely to have sex within fertile period + optimum semen quality. o Things that don't affect fertility: use of lube, female orgasm, woman's position post-sex o Optimize fertility: sex when woman's cervical mucus changes to "slippery, clear." Track ovulation with kit measuring luteinizing hormone. 3. Recognize the effect of age on fertility. Dependent more on maternal vs paternal age. Probability of pregnancy w/sex on most fertile day was 50%, 40%, and 30% for age groups 19-26, 27-34, 35-39, respectively, w/male partner being the same age. It was 45%, 40%, and 15% is the male partner was 5yrs older. Counsel pts the delayed childbearing can decrease fertility 4. Describe the effects on fertility concerning tobacco use, body mass index, exercise, alcohol, diet, caffeine, and stress. a. Tobacco 13% of infertility is d/t smoking o Women Subfertility with >10 cigs/day - Increasing # of cigs/day = more days to conceive - Possible tubal changes, cervical changes, damage to gametes, and increase in spontaneous abortion and ectopic pregnancies. - Early menopause - Premature depletion of oocytes, premature aging of ovaries by 1-4 years, may cause oxidative stress and DNA damage in the ovarian follicle. - Ovarian aging is thought to be a major contributor to unexplained infertility. Affects reproductive tech too. Increases avg # of in vitro cycles necessary to conceive May damage pregnant woman's fetus. Study showed reduced fertility in women whose mother smoked during pregnancy, possibly d/t ovary damage in-utero. Men of smoking mothers had reduced sperm counts. o Men Inconclusive if has an effect on male fertility Modest reduction in semen quality & altered hormone levels. In infertile males, smokers had a 23% decrease in sperm concentration & 13% decrease in sperm motility vs infertile nonsmokers. - Effects are dose dependent - o Cessation Subfertility largely reversed w/in a yr of quitting Counsel pts to give each other social support when attempting to quit. Odds of quitting better if both partners quit. Also still exposed to secondhand smoke an its effects if one partner smokes b. BMI - too high or too low affects women. Unclear in males. o Females Increased anovulatory (menstrual cycle in which ovaries don't release an oocyte) infertility with BMIs >27 and < 17. Mechanism if too high: - Insulin resistance → insulin excess (Hyperinsulinemia) → androgen excess by reducing sex hormone-binding globulin synthesis + stimulating ovarian androgen production rates. Excess androgen, in turn, is a major factor leading to altered ovarian physiology and anovulation. - Hyperleptinemia may directly impair ovarian function. Too low: - Anovulation, especially in women who exercise excessively and/or have low caloric intake. - Hypothalamic amenorrhea d/t suppression of pulsatile GnRH secretion from the hypothalamus → decreased secretion of follicle-stimulating hormone (FSH) + luteinizing hormone (LH) → loss of ovarian cyclicity and estrogen deficiency - Changes in leptin may also be involved. o Males Possible link to decreased pregnancy rates with increased BMI, but not enough studies. Maybe hormone levels affected. - ... o Ideal weight BMI between 18.5-25 Women: Weight reduction in obese, infertile women associated w/increase in the frequency of ovulation & likelihood of pregnancy. Weight loss best with diet + exercise (but no more than 60min per day for women d/t increased primary ovulatory infertility if more than that). c. Exercise o Women Intensity & duration of exercise can affect female fertility Type of exercise not a factor Slightly positive effect of all levels of exercise among overweight and obese women Recommend < 5hrs/wk exercise in women trying to conceive In vitro affected w/4hrs or more of exercise per wk. o Men Unclear effect - Semen quality seems unaffected, but decreased sperm concentrations & motile sperm seen in men who bicycled ≥5 hours/week d. Alcohol o Women Moderate and heavy drinking may lead to taking longer to achieve a pregnancy & higher risk of undergoing an infertility evaluation o Men Heavy, but not moderate alcohol use= abnormalities in gonadal function, including reduced testosterone production, impotence, and decreased spermatogenesis o Optimum Intake Men: moderate drinking is ok Women: US Surgeon General and the Secretary of Health and Human Services recommend abstinence at conception and during pregnancy because a safe level of prenatal alcohol consumption has not been determined. e. Diet Effect unclear Celiac dz may cause subfertility in men and women. Resolved by adopting a gluten-free diet. o Women One study looked at a "fertility diet" with higher monounsaturated to trans fat ratio, high percentage of protein from vegetable rather than animal sources, low glycemic index carbohydrates, high fat dairy foods, and use of iron and multivitamin supplements. - Healthy women had a significantly reduced risk of ovulatory disorder infertility. - Possibly because helped glucose homeostasis and insulin sensitivity, - Study subject to recall bias however "Mediterranean diet" may also be beneficial o Men One study: Normospermic men seen to consume more skim milk, shellfish, tomatoes, and lettuce, as well as much less dairy and meat processed products vs oligoasthenoteratospermic men o Healthy diet One study: Men with defects in sperm made lifestyle/dietary changes (eg, reduced caffeine, alcohol, & tobacco, and increased fruits and vegetables), return to normal sperm 76% of the men f. Caffeine Conflicting studies, but some suggest that increased caffeine consumption (eg, >300-500mg) is associated with a modest decrease in fecundability o Women Linked to infertility from tubal factors and endometriosis - ... o Men No strong evidence that caffeine consumption by the male partner influences fertility o Suggested intake Females: intake less than 200 mg per day, or one or two 6-8 ounce cups of coffee per day g. Stress Many studies suggest stress can cause infertility, but no evidence that reduced stress prior to infertility Tx improved pregnancy rates Assisted reproductive technology (ART) outcomes were negatively impacted slightly with stress and anxiety. However, the association with anxiety disappeared when livebirth rates were examined

5.7 Overview of Male Sexual Dysfunction - Glenn R. Cunningham, MD; Raymond C. Rosen, PhD; August 19, 2015

1. Review the physiology of male sexual function. Normal male sexual function requires interactions among neurologic, vascular, hormonal, and psychological systems. Neural influences Psychogenic erections are triggered by neural impulses originating in discrete loci of the central and peripheral nervous systems. - The centrally perceived sensual input is relayed by neural signals to a spinal cord neural center located at T-11 to L-2 (the thoracolumbar erection center). - more common during man's early sexually active years Reflex erections are created by tactile stimulus to the penis or genital area - activates a reflex arc with sacral roots originating at S-2 to S-4 (the sacral erection center) - dominates during his mature years Nonsexual, nocturnal erections, occurring three to four times nightly, start in early adolescence and persist throughout life - Occur only during REM sleep Role of blood flow and nitric oxide (NO) Normal erections require blood to flow from the hypogastric arterial system into specialized erectile chambers (corpora cavernosae and corpus spongiosum). Increased blood flow = increased pressure within the intracavernosal spaces, and prevents penile venous outflow from emissary veins. This combination of increased intracavernosal blood flow and reduced venous outflow allows a man to acquire and maintain a firm erection. High levels of intrapenile nitric oxide act as a local neurotransmitter, promoting the generation of cyclic GMP, to facilitate the relaxation of intracavernosal trabeculae, thereby maximizing blood flow and penile engorgement. Nitric oxide — formed from amino acid Arginine with nitric oxide synthase + NADPH & oxygen The absolute prerequisites for erection are an adequate arterial inflow (for constant intracavernosal oxygen supply) and sufficient nitric oxide synthase Detumescence (loss of erection) - occurs when nitric oxide-induced vasodilation disappears because of metabolism of cyclic GMP Erectile Dysfunction (ED) - associated with low levels of NO - Low NO levels commonly seen with smokers, diabetics, and those with testosterone deficiency - Interference with oxygen delivery or nitric oxide synthesis can prevent intracavernosal blood pressure from rising to a level sufficient to impede venous outflow, leading to an inability to acquire or sustain a rigid erection. - PDE-5 inhibitors enhance intracavernosal cyclic GMP levels to improve the erectile response to sexual stimulation with ED. Hormonal influences Testosterone plays an integral role in normal male sexual function. - Deficiency results in impotence, and sexual potency returns when testosterone levels are normalized. o Normal sexual activity with age Sexual activity is affected by age, health status, and gender. Men were more likely than women to be sexually active and report a good quality sex life. Gender differences increased with age (most prevalent in group 75-85yo) Men and women in good health were more likely to be sexually active compared to those in fair or poor health. Men lost more years of sexually active life as a result of poor health than women. Age-associated changes: delay in erection, diminished intensity and duration of orgasm, and decreased force of seminal emission. 2. Review decreased libido in men. ~5-15% men affected Often accompanies other sexual disorders ED usually not accompanied by reduced libido or sexual desire. Causes (often treatable): - Medications (SSRIs, anti-androgens, 5-alpha reductase inhibitors, opioid analgesics) - Alcoholism - Depression - Fatigue - Hypoactive sexual disorder - Recreational drugs - Relationship problems - Other sexual dysfunction (fear of humiliation) - Sexual aversion disorder - Systemic illness - Testosterone deficiency 3. Discuss the risk factors for erectile dysfunction (ED). ED = consistent or recurrent inability to acquire or sustain an erection of sufficient rigidity and duration for sexual intercourse. Prevalence The frequency of sexual activity decreases with age in both men and women, and sexual problems become more common. Most common sexual problem in men Overall prevalence of ED was 16%; 8% in men 20-30yo, 37% in men 70-75yo o Risk factors Lower risk: exercise, lowest if no chronic medical problems + healthy behaviors Higher risk: obesity, smoking, watching TV, and the presence of comorbid conditions, risk factors for coronary heart disease (smoking, obesity, dyslipidemia) in midlife, - Systemic sclerosis (scleroderma), Peyronie's disease, and prostate cancer treatment (eg, brachytherapy, prostatectomy). - best predictors: diabetes mellitus, hypertension, obesity, dyslipidemia, cardiovascular disease, smoking, and medication use. Improvement of ED in 1/3 of obese men following weight loss and increased physical activity Frequency of sexual activity appears to predict the development of ED. 4. Identify the importance of the association between cardiovascular disease and ED. ED may be an early warning sign of future cardiovascular events. - Risk of cardiovascular events in men with ED comparable to risk factors of smoking or family hx of MI men with ED without an obvious cause (eg, pelvic trauma) and who have no symptoms of coronary or other vascular disease should be screened for cardiovascular disease 5. Discuss the association of ED with drugs. Eight of the 12 most commonly prescribed medications list ED as a side effect 25% of cases of ED are due to medications. Examples: - Antidepressants - especially selective serotonin reuptake inhibitors (SSRIs) - Spironolactone - Sympathetic blockers such as clonidine, guanethidine, or methyldopa - Thiazide diuretics - Ketoconazole - Cimetidine, but apparently not ranitidine or famotidine Beta blockers thought to be an important cause of ED, but a systematic review of randomized, controlled trials found only a small increased risk of sexual dysfunction (5 per 1000 patients treated). OTC products like nicotine & alcohol disrupt sexual function Recreational drugs eventually affect erections 6. Discuss the association of ED with psychosocial factors, neurological factors, bicycling, and endocrine disorders. Psychosocial factors Depression, stress, or the drugs used to treat depression Neurological stroke, spinal cord or back injury, multiple sclerosis, or dementia, pelvic trauma, prostate surgery, or priapism Bicycling Anything that places prolonged pressure on the pudendal and cavernosal nerves or compromises blood flow to the cavernosal artery can result in penile numbness and impotence. The penile numbness d/t pressure on the perineal nerves, and ED d/t decrease in oxygen pressure in the pudendal arteries Endocrine disorders Testosterone deficiency affects peripheral mechanisms that are responsible for penile erections. - With deficiency, still have some nocturnal erections in tumescence studies, but penile swelling in this setting usually is not of sufficient rigidity to permit vaginal penetration. - corrected after normalization of testosterone levels, probably due to restoration of intrapenile nitric oxide synthase levels. - Tx more effective with testosterone + PDE-5 inhibitor Cutoff level for ED uncertain, but one study: testosterone levels <225 ng/dL hyperprolactinemia, hyperthyroidism, and hypothyroidism are commonly associated with ED. Tx with improving hormone levels A third of type 2 diabetic men have subnormal testosterone concentrations suggests that this hormone deficiency, and not just diabetic vasculopathy/neuropathy, may play a role in the ED 7. Describe the different types of ejaculatory disorders. Ejaculatory disorders = heterogeneous group of disorders that include premature, delayed, and retrograde ejaculation, anorgasmia, and possibly painful orgasm Premature ejaculation (PE) = rapid or early ejaculation, defined by the presence of all three of the following criteria: (1) brief ejaculatory latency (of about a minute or less) (2) loss of control (3) psychological distress in the patient and/or partner. Ejaculatory latency is the consistent inability to delay or control ejaculation, and marked distress about the condition. Subtypes are symptom-based, including lifelong versus acquired, global versus situational PE, and the co-occurrence of other sexual problems, particularly ED. About 30 percent of men with PE have concurrent ED (early ejaculation without full erection). Pts typically present for infertility concerns Uncertain etiology usually - Possibly negative conditioning, penile hypersensitivity, or genetic basis (lacking adequate scientific support). - Frequently associated with sexual problems in the partner, particularly anorgasmia or a sexual pain disorder (eg, vaginismus). Tx: possibly w/couples or sex therapy, combined with pharmacotherapy or behavioral therapy Ejaculatory dysfunction (EjD) = a spectrum of disorders in men ranging from delayed ejaculation to a complete inability to ejaculate, anejaculation, and retrograde ejaculation. Multiple etiological factors, including organic and psychogenic factors; Any medical disease, drug, or surgical procedure that interferes with either central (including spinal or supraspinal) control of ejaculation or the autonomic innervation to the seminal tract, including the sympathetic innervation to the seminal vesicles, the prostatic urethra, and bladder neck, or sensory innervation to the anatomical structures involved in the ejaculation process, can result in delayed ejaculation, anejaculation, and anorgasmia. Retrograde ejaculation -- occurs following surgery for benign prostatic hyperplasia Anejaculation - always associated with radical prostatectomy or cystoprostatectomy. Lower urinary tract symptoms in aging men are often associated with ejaculatory disorders. Drugs: alpha blockers (eg, tamsulosin), antidepressants (especially serotonin-uptake inhibitors) associated with loss of orgasm or ejaculation. EjD may be almost as prevalent as erectile dysfunction (ED) in aging men. Loss of ejaculation is often age-related and may be associated with other sexual dysfunction.

5.1 "overview of contraception"

1. Review the statistics and generalized statements regarding contraception in the introduction. a. Unintended pregnancy is a common problem in the United States b. 49 percent of the 6.7 million pregnancies in the United States in 2006 were unintended c. About 5 percent of women of reproductive age had an unintended pregnancy that year, comprising 3.2 million pregnancies d. Forty-three percent of the unintended pregnancies were terminated e. These alarmingly high statistics occurred even though most women reported using some form of contraception. The high rate of unintended pregnancy despite contraception highlights the importance of understanding contraceptive efficacy in terms of typical, rather than perfect, use. f. Explanations for the apparent failure of contraception when used by the typical patient include inconsistent adherence to method requirements, incorrect use, gaps in use, discontinuation of the method, as well as failure of the method itself. g. Cost and drug coverage issues also impact upon use of and adherence to contraception. As an example, many insurance plans require women to fill prescriptions for contraception on a monthly basis, which increases the chance of a delay in obtaining a needed contraceptive refill. This is a common reason for contraceptive failure. h. The best way to address the problem of high failure with typical use is by encouraging women to choose long acting, highly effective reversible methods (long-acting reversible contraceptives, LARCs) such as intrauterine devices (IUDs) and implants, which are underutilized in the United States. The contraceptive failure rate among participants using pills, patch, or ring was significantly higher than among participants using LARC, who had a very low failure rate (4.55 versus 0.27 per 100 participant-years) i. Some women choose to not use birth control- women gave the following reasons for unprotected intercourse: 33 percent felt they could not get pregnant at the time of conception, 30 percent did not really mind if they got pregnant, 22 percent stated their partner did not want to use contraception, 16 percent cited side effects, 10 percent felt they or their partner were sterile, 10 percent cited access problems, and 18 percent selected "other." j. one-third of these women did not perceive themselves to be at risk of becoming pregnant speaks to the need for more education. 2. Review the factors to consider when choosing a method of birth control. a. Factors to consider — An understanding of the available contraceptive methods allows clinicians to counsel women about methods that are most consistent with their lifestyle and beliefs i. Efficacy ii. Convenience iii. Duration of action iv. Reversibility and time to return to fertility v. Effect on uterine bleeding vi. Frequency of side effects and adverse events vii. Affordability viii. Protection against STDs ix. Medical contraindications b. No method of contraception is perfect. Each woman must balance the advantages of each method against the disadvantages and decide which method she prefers. Women should be counseled to choose the most effective method that they are likely to be able to use successfully. This means they will be able to comply with the requirements of using the method and they will likely adhere to the method despite these requirements and the method's potential side effects. 3. Discuss the effectiveness of contraceptives and compare effectiveness of contraceptive methods. a. The effectiveness of a contraceptive method is expressed as both the theoretical (perfect use) efficacy and the actual (typical use) effectiveness. The former refers to the pregnancy rate among those who use the method correctly on every occasion; actual effectiveness is usually lower due to inconsistent or incorrect use. i. Actual effectiveness is also influenced by frequency of intercourse, age, and regularity of menstrual cycles, as pregnancy is less likely in women who are older, have infrequent sexual intercourse, and have irregular menstrual cycles. b. Effectiveness is often quantitated by the Pearl Index, which is defined as the number of unintended pregnancies per hundred women per year. i. it does not account for the fact that contraceptive failure rates generally decline with continued use; therefore, a Pearl Index determined by a study of new and short-term users of a method will likely be higher than that in a study including long-term users c. contraceptive methods can be divided into three categories based upon their theoretical and actual effectiveness i. Most effective: Long-acting reversible contraception (intrauterine contraception, contraceptive implants) and sterilization are associated with a low pregnancy rate regardless of the population studied, as the rate is minimally influenced by adherence. Women should be encouraged to first consider a method from this tier of options. ii. Effective: Injectable contraceptives are the most effective in this tier of choices. OCs, the transdermal contraceptive system, and the vaginal ring are also associated with a very low pregnancy rate if they are taken consistently and correctly, but actual pregnancy rates are substantially higher because of inconsistent/incorrect use. iii. Least effective: Other methods of contraception, including diaphragm/cervical caps, condoms, spermicides, withdrawal, and periodic abstinence are associated with actual pregnancy rates that are much higher than perfect use rates. The overall pregnancy rates associated with these methods have varied considerably among studies. 4. Compare adherence by contraceptive methods a. Discontinuation of contraception for method-related reasons is common, and accounts for a significant proportion of unintended pregnancies since many women switch to less effective methods or use no method at all. b. the 2002 National Survey of Family Growth, 46 percent of women reported discontinuing at least one method because they were dissatisfied with it. c. Continuation rates at 12 months by method are: i. Implantation-84% ii. Intrauterine contraceptive device 78-80 % iii. Vaginal Ring, contraceptive patch, progestin-only pill (68%) iv. Diaphragm 57% v. Depo-provera (56 %) vi. Male condom (53%)/ Female Condom 49%) d. Two-thirds of women discontinued hormonal methods because of side effects, while almost 40 percent of those who discontinued the condom did so because of partner dissatisfaction. 5. Discuss contraception in men including future directions. a. Condoms — The condom is the only reversible method of contraception available to men. It prevents pregnancy in the female partner and provides protection from acquisition and transmission of sexually transmitted infections. b. Vasectomy — Vasectomy (ligation of the vas deferens) can be performed in a physician's office under local anesthesia. It is a safe, highly effective sterilization procedure. Although men should be counseled before vasectomy that the procedure is permanent, the procedure can often be reversed with a return of fertility. c. Future directions i. Hormonal methods — No male hormonal contraceptives are available for clinical use, although scientists have been attempting to develop them for many years. A practical limitation of the use of male hormonal contraception is that it takes a few months to significantly reduce sperm counts, thus there is a considerable delay before the contraceptive becomes effective. There is more info in the doc but basically they just can't get the hormones (LH,FSH and Testosterone) at the right levels. ii. Vas injection — Vas occlusion methods, such as injectable silicone plugs, block the vas deferens without disrupting it, making reversal easier. Reversible Inhibition of Sperm Under Guidance (RISUG) is another approach in which the vas is injected with a polymer gel that kills sperm. If reversal is desired, the polymer can be flushed out with an injection of dimethyl sulfoxide. 6. Review recommendations for contraception. a. SUMMARY AND RECOMMENDATIONS Choosing a contraceptive depends upon a number of factors, including efficacy, reversibility, convenience, cost, availability (prescription versus nonprescription), and side effects. Thus, each patient's choice of contraceptive method should reflect her opinion of the utility of each of these variables and where she is willing to make tradeoffs between desirable and undesirable features of each method. Women should be counseled about the difference in typical use effectiveness between the methods, and should be counseled to consider a highly effective method such as one of the long-acting reversible contraceptives (LARCs) methods. b. Some generalizations can be made: I LEFT THESE PRETTY MUCH IN FULL BECAUSE THEY ARE PROBABLY HIGH YIELD! i. In addition to any method of contraception, we recommend use of condoms for individuals at risk of sexually transmitted infections. ii. For couples who desire permanent contraception (sterilization), we suggest vasectomy. Vasectomy is as effective, but less morbid and costly than tubal occlusion. iii. For women desiring tubal occlusion, hysteroscopic tubal occlusion does not require an incision and is usually performed using a local anesthetic, as opposed to laparoscopic tubal occlusion. However, at this time the laparoscopic approach is more widely available and most surgeons are experienced and facile with this technique. Women who request sterilization should be counseled about availability of IUC as a long-term method that rivals sterilization in terms of efficacy, but is non-surgical and reversible. iv. For women who desire reversible contraception, we suggest intrauterine contraception, or implants, given they are associated with pregnancy rates comparable to permanent methods and they are more convenient than combined estrogen-progestin methods. Combined estrogen-progesterone hormonal methods (pills, patch, vaginal ring) are rapidly reversible, but less effective than the methods described above (although still highly effective when used properly). Hormonerelated side effects are common. Convenience depends upon the specific method and varies from daily administration (oral contraceptive pills, standard or extended cycle), to weekly (patch), to monthly (vaginal ring). Patients should not use these methods if they have a contraindication to taking estrogen preparations. In particular, patch users may be at higher risk of thrombosis than pill users. v. The diaphragm and male condom are less effective and less convenient than hormonal methods. However, they are the most readily reversible methods and not associated with systemic side effects (except for individuals who are sensitive to latex products). Diaphragms are most effective when used with a spermicide.They are not recommended as the primary method for women with serious medical conditions in whom pregnancy is life-threatening. These women require use of the most effective methods of contraception. vi. Women using a barrier contraceptive (eg, condom, diaphragm, cervical cap) or who are at risk for pregnancy should be informed about use of emergency contraception in case of failure of the barrier contraceptive method (broken condom, failure to use, etc). Women prescribed hormonal contraceptives should also be informed about use of emergency contraception since they may miss doses of their contraceptives and be at risk for unintended pregnancies. vii. Progestin-only pills are an option for women who want a contraceptive pill, but need to avoid estrogen. They are associated with more unscheduled bleeding and require a stricter schedule for perfect adherence (to be taken at the same time each day).

4. Distinguish between the three stages of adolescent development Stages of adolescence are based loosely on chronologic age and level of functioning; healthy adolescent development is the acquisition of a mature and responsible sexual identity.

1.) Early (ages 10 to 14) coincides w/ onset of puberty o typically involves concrete thinking, preoccupations and insecurities surrounding the physical changes of the body, and an egocentric approach to sexuality o sexual curiosity/exploration may lead to initiating sexual experimentation w/ masturbation, or early sexual activity with same- or opposite-gender sexual partners. 2.) Middle (ages 15 to 18) completes the physical changes of puberty o begins to have more romantic relationships typically characterized by serial monogamy or having several partners at once and over brief periods of time o middle teens can begin to imagine the consequences of their actions but still may not fully understand them and, because of this, engage in risk-taking behaviors such as substance use and unprotected sexual activity. 3.) Late adolescence (ages 18 and up) o more mature social skills, empathy, and an understanding of risks and consequences that help them develop more intimate and serious relationships o mature understanding and enjoyment of their physical self, gender role, sexual orientation, and sexual behaviors o can participate in a variety of intimate and social relationships (romantic partners, friends, family, professional colleagues) w/ a broader sense of connection and purpose in the community.

Teen dating violence

14. Teen dating violence & risky behaviors of youth a. TDV includes psychological, physical, and sexual aggression, and is common in adolescent relationships with highest rates in young women ages 16-20. In 2011, 9% of all high school adolescents reported some form of physical violence in their romantic relationships. i. TDV more common in teens engaging in other risk activities like AOD use, suicidal ideation and unprotected sex. ii. Adolescent males and females report equal perpetration and victimization from violence; females perpetrate less severe and less physical violence and suffer more psychological sequelae. b. Gender non-conforming and sexual minority youth have increased risk behaviors, victimization and adverse health outcomes: child abuse, bullying, sexual harassment, TDV, mental health problems (depression, anxiety, suicide, disordered eating and body image, substance use, unprotected sex with increased risk of STI and pregnancy. Teens who identify as having partners of both sexes at highest risk. c. Chronic victimization of MSM repeatedly victimized less likely to request partners use condom d. Overall, important to promote adolescent sexuality as normative, healthy, respectful and meaningful in the contexts of development.

5.1 Overview of Contraception - Mimi Zieman, MD; July 22, 2015

5. Discuss contraception in men including future directions. a. Current methods: o Condoms - only reversible contraception for men. Prevents pregnancy and STIs. o Vasectomy - ligation of the Vas Deferens. Pts advised that procedure is permanent, but reversal is possible. Safe, effective, done in-office under local anesthesia. b. Future directions: o Hormonal methods - none available currently. Theory: inhibit spermatogenesis via exogenously administered sex steroids to suppress pituitary secretion of luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Endogenous testosterone production is also suppressed, so these regimens involve administration of exogenous testosterone. - Combination regimen probably necessary to fully suppress spermatogenesis. Ex: testosterone + progestin or testosterone + GnRH analog (synergistic). - Pros: lower doses of testosterone (though still above physiologic levels). - Cons: oral & transdermal aren't effective or long-active; undesirable side effects, increased risk prostate dz w/long-term administration of supraphysiological quantities of testosterone. Months before reduction in sperm counts. Delivery: injections or implants, transdermal gel, a potent synthetic androgen, and an oral formulation are all being investigated. o Vas injections Vas occlusion methods - Ex: injectable silicone plugs to block the vas deferens. Reversible. Reversible Inhibition of Sperm Under Guidance (RISUG) - vas is injected w/a polymer gel that kills sperm. Reversal with injection of dimethyl sulfoxide to flush out polymer.

Erectile Dysfunction in Diabetes Mellilitus

A study showed ED in diabetes increases with age from 6% in 20-24 year olds to 52% in 55-59 year olds. Neuropathy, retinopathy, duration of diabetes, and poor glycemic control were also major factors in increasing frequency of ED with diabetes. Within 5 years, many of those patients had started having ED and only 9% regained erectile function who had previously lost it. These men were usually younger, had shorter duration of diabetes, and had psychogenic ED. Diabetes patients with persistent ED were more likely to get retinopathy or neuropathy than men with normal ED. Another study agreed with these findings. ED can also predict cardiovascular events in men with diabetes and without. Depression is a contributor to ED. Most patients with ED and diabetes were not asked by their physicians about sex health. • Discuss the etiology and evaluation of ED in DM. Etiology-Erection requires parasympathetic activity and reducing sympathetic activity. This changes blood flow to corpora cavernosa of penis and relaxes trabecular smooth muscle. Pathways are activated by touch, visual, hearing, and imaginative stimuli and are modified by psych factors. Local nerve damage, impaired blood flow, or psych factors are seen in most cases. Loss of trabecular smooth muscle in cavernosa is seen in men with diabetes. Evaluation- all men with diabetes should be asked about ED because patients are bitches and don't tell us shit. Doctors should look for all possible causes besides diabetes. The man should be looked at for retinopathy, neuropathy, hypertension, vascular disease, hypogonadism, and gynecomastia. Men are not routinely screened for coronary heart disease if they have diabetes and Ed. Depression was seen in 24-34% of patients with Ed. Severe Ed due to severe diabetes. Tests should include glycemic control, hemoglobin A1C, serum creatinine, cholesterol, testosterone, prolactin, thyrotropin, and urinary protein excrete ions. Low testosterone was found in men with ED (300ng/mL or 10.4 nmol/L) 4% under 50 and 9% over 50. Tests for nerve function are not usually necessary. • Identify the treatment for patients having ED and DM. Identify the treatment for patients having ED and DM. There is no ED treatment specific for men with diabetes. Glycemic control reduces risk of ED, but no data suggests it can reverse it. Psychosexual counseling may help along with exploring the relationship of the man and his partner, though it is not often effective. PDE5 inhibitors help. Adverse effects are possible including headache, flushing, flu-like symptoms, dyspepsia, abnormal vision, and back pain. Taking them with nitrates can cause syncope and should be cautioned. They do not appear to have adverse effects in men with coronary disease. Intraurethral administration (cause that doesn't sound awful) of alprostadil (prostaglandin E1) can help ED. Intracavernosal injections also work. These drugs include papaverine, phentolamine, and alprostadil. They are not used as much because Viagra exists. Rarely used therapies include a constricting band at the base of the penis to maintain an erection, penile revascularization, and prostheses. Apparently this surgery on diabetics can cause penile gangrene, which may be the worst thing I've heard all day. • Describe the recommendations for this population of patients. Diabetic men with ED are the same as men without diabetes. PDE5 inhibitors are recommended (first line therapies). Second line therapies include self-injectable drugs, and vacuum devices. Surgical treatment should be reserved for men who can't get relief from these options.

6. Review the summary and recommendations for contraception.

Choice of BC contraception should be based on efficacy, reversibility, convenience, cost, availability (Rx versus non Rx), and side effects. Women should be counseled about the difference in typical use effectiveness. o General Recommendations: Highly effective methods of BC, such as long-active reversible contraceptives (LARCs), for women Condoms for anyone at risk of contracting STIs (in addition to any other BC method) Vasectomies (or perhaps IUDs) for couples wanting permanent sterilization o For women: Hysteroscopic tubal occlusion - no incision, but fewer Drs skilled in this Laparoscopic tubal occlusion - cautery, banding or clips. Done w/general or neuraxial anesthesia, but more widely available IUC (aka IUD) - long-acting, comparable efficacy to sterilization, reversible, non-surg., more convenient than combined estrogen-progestin methods. Combined estrogen-progesterone - pills, patch, vaginal ring. Rapidly reversible, but variable effectiveness d/t compliance, contraindications for estrogen in some, hormonal side-effects possible, variable convenience - Patch carries increased clotting risk vs pills Barrier methods - condom, diaphragm, cervical cap. Reversible, no systemic effects (unless latex allergy), but less effective Emergency contraceptives Progesterin-only pill - ↑ unscheduled bleeding, requires a stricter schedule for perfect adherence

Testicular Function during different phases in life

Fetal-testosterone-production by testes commences during week 7 of gestation, remains through 2nd trimester (serum testosterone of males and females is similar at birth)and then fall, so that at the time of birth testosterone is similar in males and females • Neonatal surge results from rise in plasma LH levels, remain elevatd for 3-6mo; falls to a low level by 1 yr of age; remains low until puberty. - Pubertal- serum testosterone conc rises until reaches adult levels at age 17 - Adult- by age 17, serum test reached adult levels (1k ng/dL). Serum conc of bioavailable test remains constant until 5th decade of life, when it begins to decline at a rate of 1.2% per year. • Serum concentrations of testosterone remain constant until 5th decade and then begins to decline at about 1.2% per year

Recognize the high female predomanince in precious puberty

GDPP is idiopathic in more than 80% of cases, an almost all idiopathic cases occur in girls. Female to male ratio- 23:1

Review normal sexual development

Gonads • 1-4 weeks: sexually indifferent phase • 5 weeks: initial phase of gonad formation w/ development of paired gonadal ridges • 6 weeks: process becomes sexually dimorphic after germ cell seeding • 7 weeks: bipotential gonad formation o gonads with a Y-chromosome begin expressing SRY (sex-determining region on the Y chromosome), the transcription factor thought to initiate the downstream molecular events of testis formation Genes: after SRY production begins, transcription factors are involved in bipotential gonad formation; disruption often causes nongonadal malformations and diseases • SOX9 gene (required for Sertoli-cell differentiation and type II collagen production) • Steroidogenic factor 1 (SF-1) plays a role in steroidogenesis, fertility, and male sexual differentiation. • Dose-sensitive sex-reversal locus on the X chromosome (DAX-1) is upregulated in the ovary. • Wilms tumor (WT-1) gene is involved in both gonadal and renal development • Wnt-4, and Wnt-7a are signaling molecules found in Müllerian ducts and show XX-specific gonadal expression. Internal genitalia: Wolffian (mesonephric) and Müllerian (paramesonephric) ducts develop • ~ week 7 in MALES: testicular Sertoli cells begin secreting Müllerian-inhibiting substance; Leydig cells begin producing testosterone, stabilizing Wolffian duct and promoting development of the epididymis, vas deferens, and seminal vesicle. • FEMALES: the lack of these hormones leads to Wolffian duct regression and permits Müllerian duct maturation into oviduct, uterus, cervix, and upper vagina External genitalia: become sexually distinct around week 9, after Leydig cells produce sufficient testosterone to permit peripheral synthesis of DHT (dihydrotestosterone) • DHT induces posterior fusion of the genital folds and growth of the genital tubercle into a phallic structure. • 12-16 weeks in MALES: external genital morphogenesis is complete; initial embryonal stimulation is via placental hCG; subsequent fetal phallic growth is from fetal pituitary LH stimulation of testicular Leydig cells • 12 weeks in FEMALES: the nonhormone-dependent separation of vagina and urethra is complete. 3. Recognize the clinical features of disorder of sexual development in both genders. • Penile length — measured from the pubic ramus to the tip of the penis. o In a term infant, normal penile length is ≥2.5 cm, and normal penile diameter is ≥0.9 cm. • Gonads o a 46,XY child, bilateral nonpalpable testes may arise from anorchia or persistent Müllerian duct syndrome o asymmetry of the gonads or other genitalia may indicate gonadal dysgenesis or development of both gonadal structures called"ovotesticular DSD"(previously termed "true hermaphroditism".) • Urethral opening — an opening at the base of the phallus may be either an incompletely fused penile urethra (hypospadias) or a virilized urogenital sinus • Clitoral size o Normal clitoral width in a neonate ranges from 2 to 6 mm. Lengths of more than 9 mm are unusual. o Clitoromegaly secondary to androgen exposure in a 46,XX infant can be caused by CAH (congenital adrenal hyperplasia), ovotesticular or testicular DSD, maternal androgen exposure, or, rarely by a tumor • Virilization — the degree of masculinazation of the urogenital sinus and the external genitalia. • Anogenital ratio — the distance between the anus and posterior fourchette divided by the distance between the anus and the base of the clitoris. o A ratio of >0.5 suggests virilization with some posterior labial fusion.

Hemodynamic stress during lab study.

Hemodynamic stress during a study in a laboratory o Peak heart rates were 140 to 180 beats per minute o The mean increase in blood pressure was 80/50 mmHg o Respiratory rates and tidal volumes increased significantly, approaching values seen with moderately severe physical exertion o Pts w/ stable angina often noted chest discomfort during or immediately after intercourse. Hemodynamic stress during a study of couples monitored remotely in their own bedrooms o Mean heart rate at the time of orgasm was 117 beats per minute o The mean estimated blood pressure was 162/89 mmHg.

Effect of age on sexual response

Males-Erection takes 2-3x longer to occur in 50s than 40s and men reach orgasm slower in mid to late life. Age 60+ have more difficulty regaining a lost erection. Older men require more direct genital stimulation for election-difficult if partner assumed completely passive role. Regular sexual activity protects against ED. Females-Decreased vaginal secretions after menopause. May take several minutes to happen after 60. Narrow, shorter vagina with atrophic walls during aging=painful sex. Continuing to have sex after menopause has less changes. Estrogen replacement also helps. May need changes in foreplay or use of water soluble lubricants for sex.

Management of Patients with a Colostomy or Ileostomy" Doughty • Discuss sexual activity for the patient having ostomies performed. (p. 6)

Ostomy does not affect sexual function. During pelvic dissection, autonomic nerves controlling sexual function may be injured. Men may have short or long term ED or retrograde ejaculation. Women may have dyspareunia or vaginal dryness following rectal dissection. Counseling is important to these patients. Patients should empty pouch and make sure it is sealed before sex. Patients may conceal pouch with orcummerbunds during sex.

• Discuss the benefits and concerns with phosphodiesterase-5 (PDE-5) inhibitors (ex.: Viagra) and other therapies.

PDE5 inhibitors (Viagra) treat ED and work for patients with stable ischemic heart disease. Study showed Viagra improved erection in 70% of people vs 20% with placebo. Viagra is also effective in men with hypertension, diabetes, and nonvascular organic or psych causes for ED. Viagra lowers blood pressure and interacts with nitrates. Sildenafil is a vasodilator reducing systemic vascular resistance. It lowers systolic pressure 8 mmHg and is more pronounced with antihypertensive drugs. Viagra dilates epicardial coronary arteries, improves endothelial dysfunction, and inhibits platelet activation. tadalafil and vardenafil are more selective and potent than sildenafil. They are as effective. Tadalafil is longer acting. There is limited data on heart disease and these drugs. Don't use with nitrates. Use with alpha blockers can lead to symptomatic hypotension. Don't use these together either. Don't use vardneafil in men with congenital long QT syndrome. Antihypertensive drugs can usually be used with PDE 5 inhibitors. Androgen replacement therapies, penile prostheses, or vacuum-assisted erection devices can be used in men with stable cardiac disease. There is no cardiovascular contraindication to using alprostadil penile injection Yohimbine (alpha 2 receptor blocker) should be used with caution with cardiovascular disease.

4.1 "Screening for Sexually Transmitted Diseases" Swygard

Review taking a sexual history. -ask about: -Any new sexual partner(s) -History of multiple sexual partners -History of genital ulceration (which can increase the risk of HIV acquisition) -History of sexual intercourse with trauma (which can increase the risk of acquisition of hepatitis B or C) -Frequency of condom use -Straightforward and non-judgmental with appropriate counseling regarding risk-taking behaviors, as necessary Review risk factor and general principles in STD screening. -Young age (15 to 24 years old) -African-American race -Unmarried status -Geographical residence -New sex partner in past 60 days -Multiple sexual partners -History of a prior STI -Illicit drug use -Admission to correctional facility or juvenile detention center -Meeting partners on the internet -Contact with sex workers Review the pathogens considered to be STDs. -HIV: -All patients being evaluated for sexually transmitted infections (STIs) should be offered counseling and referral for HIV testing -dx important because pt may need to initiate anti retrovirals -opt out and annual screening for high risk pts -pregnant women: recommended screening in 1st trimester, again in 3rd if living in area with increased rates of HIV -Ig screening through rapid test or enzyme immunoassay (EIA) -reactive Ig tests need to be confirmed by addtl testing -important to recognize that some patients with STIs may also have very recently acquired HIV infection -often have complaints of a fever, "mono-like illness", or diarrhea not common among STI patients. -Dx of acute HIV infection during this "window period" is made by measuring HIV RNA -Gonorrhea: -urethritis, cervicitis, pharyngitis, and anorectal infection. -serious complications in women, including pelvic inflammatory disease and infertility testing for Neisseria gonorrhoeae performed annually in asymptomatic women with one or more of the following risk factors -Sexually active women younger than 25 years -Inconsistent condom use -A history of multiple partners or a partner with multiple contacts -Sexual contact with a partner with culture-proven STI -A history of repeated episodes of STI Sex work or drug use -Pregnancy -men: commonly overt sxs -less common: asymptomatic disease leads to sustained transmission to women -Regardless of symptoms, sexual partners should be evaluated, tested, and treated if they had sexual contact with the index patient during the 60 days preceding onset of symptoms or diagnosis of chlamydia -urethral Gram stain, culture on Thayer-Martin media, DNA probes, and DNA amplification techniques -Chlamydia (trachomatis): most commonly reported STI in the United States -urethritis, cervicitis, epididymitis, and proctitis -women can lead to tubal pregnancy, infertility, and chronic pelvic pain -majority of women are asymptomatic annual screening with these at risk groups: -All sexually active women age 25 years or younger (including pregnant women) -Sexually active women older than 25 years with risk factors (eg, a new sex partner in prior 60 days, more than one sex partner, inconsistent condom use, unmarried, or history of STI) -men: can result in infertility, chronic prostatitis, reactive arthritis, and urethral strictures. -screening of sexually active men in settings associated with a high prevalence of chlamydia infections (eg, correctional facilities and STI clinics) -Testing with nucleic acid amplification techniques (NAAT) on cervical or urine specimens -Trichomoniasis: protozoan T. vaginalis. -Sxs: urethritis in males and diffuse malodorous vaginal discharge with vulvar irritation in females. -can also be asymptomatic in men and women -males that are partners of + women are typically asymptomatic -screening for T. vaginalis in women: -a) with new or multiple partners; b) with a history of STIs; c) who trade sex for drugs or money; d) who use injection drugs -dx in a female patient can be made by microscopy, rapid antigen testing, nucleic acid amplification testing, and culture. -Among men, microscopy has poor sensitivity; culture or NAATs is preferred -Some studies have suggested that vaginal trichomoniasis is also a risk factor for HIV acquisition (study in reading, happened in Kenya, Uganda, and Zimbabwe) -Syphilis: -20% increase 2007-2008 -MSM: increased 15% -women: 36% increase -high rate of HIV coinfection -at risk groups to be screened: -All pregnant women at the first prenatal visit (and during the third trimester and at delivery for women in high-risk groups) -Commercial sex workers -Persons in correctional facilities -Persons diagnosed with another STI -MSM who engage in high-risk behaviors -inexpensive nontreponemal test with confirmation using a more specific treponemal test -controversy about which one first now -recommended to not screen asymptomatic people due to false positives -ulcerative lesions risk of HIV transmission -other coinfections: bacterial vaginosis, gonorrhea, trichomoniasis, and syphilis -confirmed by viral culture, polymerase chain reaction (PCR), direct fluorescence antibody, Tzanck preparation, and type-specific serologic tests. -Hepatitis A -usually a cause of food-borne outbreaks, it can be transmitted through some forms of intimate and sexual contact -screening should be offered to MSM and injection drug users -If susceptible, vaccination should be offered in these patient groups. -Hepatitis B -efficiently transmitted by percutaneous or mucous membrane exposure to infected blood or body fluids that contain blood. -screening: offered to patients with multiple sex partners, MSM, and injection drug users. -If the patient is susceptible, vaccination should be offered -Hepatitis C -Sexual transmission much less efficient than through injection drug use. -Risk factors for sexual transmission include exposure to an infected partner or exposure to multiple sex partners. -Case reports of acute hepatitis C among HIV-positive MSM have suggested that the risk of HCV transmission may be increased in the setting of genital ulcerative disease (eg, syphilis). -Ig testing in asymptomatic persons based on their risk for infection or recognized exposure (eg, IDU, hemodialysis) -also screen a sex partner of a patient who has been diagnosed with hepatitis C, particularly if there is a history of traumatic anal receptive sexual intercourse. -no vaccine available those that are + should be evaluated further to determine activity of disease -HPV -specific high-risk genotypes cause virtually all cancers of the cervix ( screening) -if a woman (aged >21) has not had a Pap test within the recommended screening interval cervical screening -women ages of 9-26 are recommended to receive HPV vaccine to prevent cervical dysplasia and cervical cancer -Routine vaccination is recommended for females between the ages of 11-12 years, series can be started as early as nine years, and females age 13-26 years can benefit from the vaccine as well -Pap smears and HPV DNA or antibody testing is not required before starting the series. -*clinicians need to be aware that HPV immunization is NOT effective in clearing infx -Quadrivalent HPV vaccine can also be used in males and females aged 9-26 years to prevent genital warts and anogenital cancers.

body piercing

Review the epidemiology and risks associated with body piercing. -epidemiology: -studies show increasing amounts of body art, now mainstream in ages 16-25 -study on adolescents: tattooing and body piercing were associated with disordered eating behaviors, gateway drug use, hard drug use, sexual activity, and suicide -study on college students: those with piercings reported substantively and significantly greater frequency of premarital sexual activity than non pierced -inconsistent frequency of risky behavior -those with MANY tattoos and/or piercings and/or genital/nipple piercings more likely to report high risk behaviors than students without -students with and without body art share similar demographics -risks: -purchase risks: expense and pain impulsive purchasing may lead to overpaying for body art, endure pain, and get infection -possession risks: negative response from others significant to adolescent, parents, teachers, and others that express displeasure -potentiates low self esteem -health risks: piercing is associated with health risks but medical literature lacks data on incidence of these dangers compared to overall incidence of body art -typically infectious complications of localized skin reactions and potential for blood borne diseases -embedded earrings -local infections (most common): ears and navel staph aeruginosa -risk of infx because of diminished skin integrity, warm weather months -high rim piercing: lack of vascularity; auricular chondritis (with outbreak of P. aeruginosa in spring loaded piercing guns) -risk of infx reduced when individual understands procedure, obtains in a studio using sterile procedures, and follows appropriate after care -soap and water, NOT benzalkonium chloride sold at shopping malls (no abx against P. aeruginosa) -jewelry not be removed with a localized infection - outlet for drainage -prompt use of abx in infx -systemic infx: less frequent than local infx -frequent in people who have had amateur body piercings or have not followed the after-care instructions. -tetanus, acute poststreptococcal glomerulonephritis, streptococcal septicemia, staphylococcal toxic shock syndrome, and pseudomonal abscesses -mixed-oral-flora cerebellar abscess was reported after tongue piercing in a patient who developed an early local infection in the tongue and removed the jewelry within six days of the piercing -infective endocarditis: small risk -tongue piercing infx those with congenital heart disease and also healthy individuals MRSA, MSSA (susceptible, not resistant), Staph epidermidis strep viridans, H. parainfluenzae, H. aphrophilus, Neisseria mucosa -healthcare providers should consider endocarditis in pts presenting with unusual symptoms 1-2 weeks after a piercing -clinicians (but not the American Heart Association) recommend prophylactic abx for CHD patients before getting body art -hepatitis: B & C via reused or improperly sterilized equipment; actual numeric risk unknown -risk for Hep C higher when tattoos done in prisons or friends -Hep B is highly contagious with minimal blood exposure and states do not require body piercers to get immunization -HIV: many healthcare providers claim piercings to be a risk factor for HIV infx but no real evidence -skin rxns: generalized (hypersensitivities) -hypersensitivies: avoided by using jewelry made of 14k gold, surgical stainless steel, niobium, or titanium -keloids: benign fibrous growths present in scar tissue that form because of altered wound healing -suggest that postmenarcheal patients with a family history of keloids avoid earlobe piercing d/t cosmetic concerns and lowered self-esteem -surgical correction possible -oral complications: -gingival recession secondary to gingival trauma has been reported with lip piercing -difficulty maintaining adequate oral hygiene, which, combined with mechanical trauma, may lead to localized periodontitis -increased salivary flow; chipping, cracking, and fractures of the teeth; interference with mastication and swallowing; and speech impediments -study: effect of duration of tongue piercing and length of the barbell stem on gingival recession and tooth chipping -Dental effects were directly related to duration of piercing -the rate of recession is increased with long barbells, and the rate of chipping is increased with short barbells. -ER med and anesthesia removal of oral piercings during anesthesia? -aspiration, tongue swelling leading to blocked airway -prolonged tongue bleeding -limit radiographic evaluation (scatter, obscuring visualization) -penile piercings: prolonged priapism and recurrent condyloma acuminate -nipple piercings (bilateral*): hyperprolactinemia (whatttt?) -friction from clothes and shearing forces during physical activity can cause abrasions -forensic science: body piercing tracts or grooves in jewelry holding DNA

Discuss the cardiovascular effects of sexual activity

Sexual activity is in part dependent upon changes in the autonomic nervous system. o Sexual arousal and penile erection in men results from stimulation of parasympathetic nerves in the penis, reduced activity of sympathetic pathways, and the release of NO from the endothelium . (The importance of NO constitutes the rationale for the use of sildenafil (Viagra).) o Early sexual arousal in women = sympathetic nervous system activation. o Outflow to the cardiovascular system during sexual intercourse is sympathetic and is mediated by outputs from the brain carried by efferent pathways originating from the thoracic spinal cord. o Studies have found that sexual activity contributes to only a small percent of infarctions. o Exercise training attenuates heart rate response and reduces the small risk of MI following sex o It has been assumed that the man would perform less physical work during sexual intercourse if he were supine. However, studies show that this does not appear to be important.

Sexual coercion

Sexual assault attempted sexual touching of another person without their consent and includes intercourse, sodomy, and fondling Sexual play occurs in absence of coercion and involves children of the same age (separated by no more than 4yrs); considered normal behavior/development Epidemiology of Sexual Abuse: • >60,000 children are sexually abused annually (gross underestimate of true prevalence) • Abuse of children primarily during the preadolescent years (13-14); girls are more likely than boys to be abused but boys are less likely to report the abuse • Perpetrators are usually male and often trusted adult acquaintances • Father and other male relatives responsible for 21 and 19 % of sexual abuse victims • Some features related to family structure/parenting have been associated w/increased risk of childhood sexual abuse (poor parent-child relationships, poor relationships b/t parents, absence of a protective parent and presence of nonbiologically related male in the home) Presentation of a rape victim w/possible indications of sexual abuse • Present with a variety of medical complaints, usually nonspecific • More specific indicators are rectal/genital bleeding and STIs • Behaviors that indicate a child has been abused include perpetration of sexual abuse and/or sexually explicit acting out, developmentally inappropriate knowledge of sexual activities or inappropriate play. • (see table 1 page 28-29 for clinical findings associated w/ abuse)

Chronic complications of spinal cord injury- Abrams

Spinal cord injury may cause decreased libido, impotence, and infertility. Impotence is seen in 75% of men with spinal cord injury. This is most seen in patients with complete injury. Meds, assisted devices, and prostheses may treat ED. Sildenafil, vardenafil, and tadalafil have been used. Reproduction often requires artificial insemination. Women may have impaired sexual responses, but ovulation/fertility are unaffected usually. Personal choice typically lowers pregnancy with injury.

Adolescent Sexuality

a. Adolescent sexuality is an important public health issue- pregnancy planning prevention of unintended pregnancy, promotion of healthy sexual behaviors, increased access to quality services to prevent STDs b. Young women reach sexual maturity earlier than ever before; ½ of high school youth report having had sexual intercourse and 1/3 report being currently sexually active. c. Prevalence of sexual activity increases w/ age, rising from 33% in 9th graders to 63% in 12th graders. d. YRBSS comparison from 1991 to 2011 shows: rates of sexual activity decreased from 51 to 47%; rates of sex with more than 4 people decreased to 15%, rates of condom use at last intercourse increased from 1991-2003 to 63% use, but steady from 2003-2011. e. ¼ of STI's each year occur in young people 15-24yo (overrepresented) and account for ½ of NEW infections. HPV, Chlamydia, and Trichomoniasis are most common STIs in this age group. One in four women ages 14-19 infected w/ at least one of four STIs. f. 5% of teens ID as LGBT officially (definitely underrepresented). Over 10% of females and 2-6% of males report having participated in same-gender sexual activity. Adolescent uncertainty about sexual orientation decreases w/ age from 26% of 12yo's to 5% of 17yo's. Adolescents w/ both male and female sexual partners have higher rates of unprotected sex, teen dating violence, and forced sex. g. Challenge to HC providers: give adolescents guidance to maintain optimal sexual health and to help adolescents avoid behaviors and expression that put at risk for negative consequences- sexuality is a normal part of adolescent development.

Review of normal development

a. Both XX and XY fetuses have similar reproductive structures in early fetal development- called sexually indifferent phase. Ambisexual state continues until formation of bipotential gonad @ 7 weeks where males w/ Y chromosome develops testes. b. Gonads: 5 weeks the gonadal ridges form and 6 weeks becomes sexually dimorphic and bi-potential gonads @ 7 weeks. Y chromosome males express SRY, a transcription factor for testis formation. c. Genes: After SRY expression, SOX9 gene expressed which allows for Sertoli cell differentiation. Haploinsufficiency in SOX9 genes results in dysplasia associated w/ sex reversal in 75% of XY. Steroidogenic factor 1 (SF1) gonadal transcription factor w/ role in steroidogenesis, fertility and male sexual differentiation. SF1 mutations cause agonadism, adrenal insufficiency, hypogonadism, cryptorchidism, micropenis, and XY sex reversal. d. Dose-sensitive sex-reversal locus on X-chromosome (DAX1) is a gonad specific transcription factor upregulated in ovary- mutations responsible for adrenal hypoplasia associated w/ hypogonadism in 46XY males. Functions as an anti-testis factor in the ovary but not required for testicular function. e. Wilms Tumor WT-1 gene is a TF involved in gonadal and renal development- all mutation associated w/ renal malformation or dysfunction. 3 phenotypes seen: i. WAGR syndrome: wilms tumor, aniridia, genitourinary anomalies, mental deficits ii. Denys-Drash syndrome 46XY: progressive renal disease, 46XY karyotype w/ undervirilization, Wilms tumor. Affected individuals usually have ambiguous genitalia or normal female external genitalia iii. Frasier syndrome 46XY: altered ratio of WT1 protein where affected individuals have normal female external genitalia but fail to develop secondary sexual characteristics. At risk for gonadoblastoma, a glomerulonephropathy and renal failure. f. Wnt4 and Wnt7 show XX gonadal expression. Then lots of bullshit about various TFs with letters & numbers g. Internal genitalia: Wolffian/mesonephric and Mullerian/paramesonephric ducts develop in both sexes. In males, at 7th week of gestation, testicular Sertoli cells secrete Mullerian-inhibiting substance, which induces mullerian duct regression. Then Leydig cells begin producing testosterone. Testosterone stabilizes Wolffian duct and promotes development of the epididymis, vas deferens, and seminal vesicle. In females, lack of hormones leads to Wolffian duct regression and permits Mullerian duct maturation into oviduct, uterus, cervix, and upper vagina. h. External genitalia becomes sexually distinct at 9th week of gestation after Leydig cells produced sufficient testosterone to permit peripheral synthesis of dihydrotestosterone. Synthesis of this dihydrotestosterone induces posterior fusion of the genital folds and growth of genital tubercle into a phallic structure. Differentiation & growth of external genitalia dependent on DHT and 46XY who lack 5-alpha-reductase (metabolizes DHT) born with normally functioning testicles but undervirilized external genitalia. i. Male external genitalia morphogenesis complete by 12-16 weeks. In females by the 12th week, non-hormone dependent separation of vagina and urethra complete- excess androgen exposure before can cause labial fusion and development of a phallic urethra.

Delayed puberty

a. Delayed puberty: absence of incomplete development of secondary sexual characteristics bounded by an age at which 95% of children of that sex and culture have initiated sexual maturation. Upper 95% in US for boys is 14, and for girls is 12. i. Usually occurs due to inadequate gonadal steroid secretion which is caused by defective gonadotropin secretion from anterior pituitary due to defective gonadotropin-releasing hormone GnRH.

5.5 Causes of Male Infertility - Ronald S. Swerdloff, MD; Christina Wang, MD; November 18, 2015 1. Review these specific causes of male infertility associated with primary hypogonadism: cryptorchidism, testicular cancer, varicocele, infection, drugs, radiation, smoking, and hyperthermia.

a. Drugs — Opioid-like or other CNS-activating drugs, including many psychotropic drugs, can inhibit GnRH or gonadotropin secretion b. Cryptorchidism — failure of descent of the testes into the scrotum during fetal development. Unilateral and bilateral cryptorchidism → impaired spermatogenesis and an increased risk of testicular tumors. Common in patients w/congenital disorders of testosterone secretion or action Formerly cryptorchid men with low serum inhibin B and high FSH concentrations may be at particularly high risk for infertility. Boys whose testes are permanently located in the scrotum by the end of the first year of life are not infertile c. Testicular cancer — Increased incidence of testicular cancer in men presenting with infertility d. Varicoceles — dilatations of the pampiniform plexus of the spermatic veins in the scrotum. Left-sided varicoceles are 10 times more common Found in ~10-15% of normal men and an even higher percentage of infertile men; Unclear if a varicocele alone can cause infertility. e. Infection — Viral orchitis, especially mumps, cause of infertility. Infertility due either to germinal cell damage, ischemia, or the immune response to the infection. Germ cell failure is much more common than androgen deficiency. Other infectious causes of orchitis and infertility: tuberculosis, leprosy, STDs such as gonorrhea and chlamydia, HIV (may have low sperm motility and infertility) f. Radiation — Ionizing radiation impairs spermatogenesis. Doses above 6 Gy (600 rad) usually cause irreversible azoospermia and infertility. g. Hyperthermia — may impair spermatogenesis. Small increases in testicular temperature accelerate germ cell loss through apoptosis. High testicular temps seen with spinal cord injuries, varicocele, sauna and Jacuzzi exposure, febrile illness, prolonged sitting, welding, baking, tight fitting underwear, and laptop.

3 stages of adolescent development

a. Early adolescence: 10-14yo coincides w/ onset of puberty and involves concrete thinking, preoccupations and insecurities surrounding physical changes of the body and egocentric approach to sexuality. Curiosity and exploration may lead to experimentation w/ masturbation and sexual activity w/ same/opposite gender b. Middle adolescence: 15-18yo complete the physical changes of puberty and begin to have romantic relationships typically characterized by serial monogamy or having several partners at once and over short periods of time. Imagine consequences but not fully understand them risk taking c. Late adolescence: 18+yo have mature social skills, empathy and understanding of risks & consequences that help develop serious and intimate relationships. Understand and enjoy physical self, gender role, sexual orientation and sexual behaviors. i. Mature young adults healthy in their sexuality can identify and live according to one's own values, take responsibility for one's behavior, practice effective decision-making and critical thinking skills, affirm own gender identity and sexual orientation and respect gender identities of others, appreciate one's body and express sexuality congruent w/ values, express love/intimacy in appropriate manner, develop meaningful relationships avoiding exploitation or manipulation, exhibit skills that enhance personal relationships with family, peers and partners.

5.6 The Sexual Dysfunction in Women: Epidemiology, Risk Factors, and Evaluation - Jan L. Shifren, MD; May 20, 2014 1. Review the basic endocrinology as related to sexual dysfunction in women.

a. Estrogens Sexual dysfunction seen in peri- and postmenopausal women with declining estrogen levels Sxs: reduction in vulvovaginal lubrication & vasocongestion during sexual arousal, vaginal atrophy, more likely to have sexual pain Estradiol decrease associated with decreased libido and sexual responsivity b. Androgens The major androgens in women, as in men, are dehydroepiandrosterone sulfate (DHEA-S), dehydroepiandrosterone (DHEA), androstenedione, testosterone, and dihydrotestosterone. 98% circulating testosterone is protein-bound (mainly to sex-hormone binding globulin [SHBG] or albumin) and biologically inactive - Thus increasing SHBG (EX: pregnancy, oral contraceptives or estrogen therapy) decreases free testosterone Magnitude of role that androgens play in female sexual function is unclear - Studies: correlation between androgen levels and sexual function in women is either weak or nonexistent. - Women with high androgen levels due to polycystic ovarian syndrome (PCOS) do not exhibit beneficial sexual effects. - Study: surgically and naturally menopausal women with hypoactive sexual desire disorder (HSDD) (low sexual desire associated with distress) had satisfying sexual activity, desire, arousal & response increased significantly when receiving testosterone compared with those receiving placebo. 2. Discuss the epidemiology of women with sexual complaints. Sexual complaints are reported by approximately 40 percent of women worldwide. Limitations: Most studies have not assessed whether sexual issues are associated with personal distress. Some studies exclude women not in sexual relationships, so that women for whom sexual dysfunction is a barrier to forming sexual relationships are not assessed. Prevalence of Female Sexual Problems Associated with Distress and Determinants of Treatment Seeking (PRESIDE): largest US study of female sexual dysfunction, - 30k women, taking into account personal distress and women not in a sexual relationship - questionnaire regarding low desire, low arousal, and orgasm difficulties. Prevalence was 43%; 22% reported sexually related personal distress, 12% attributed distress to a specific type of sexual problem (eg, desire). Low desire was the most common sexual problem in women, followed by low arousal, then orgasm difficulties 3. Discuss the risk factors with sexual dysfunction in women. Multifactorial etiology - Including psychological problems, relationship conflicts, fatigue, stress, lack of privacy, prior physical or sexual abuse, medications, physical problems that make sexual activity uncomfortable (such as endometriosis or atrophic vaginitis), presence of any serious medical condition (d/t both associated physical and psychological impact). - Study: in women 57-85yo, physical health was more strongly associated with sexual problems than age alone. Age & Menopause In PRESIDE study, sexual problems associated with distress were highest in women aged 45-64 years (15 percent), lowest in women 65 years or older (9 percent), and intermediate in women aged 18 to 44 years (11 percent). However, the National Health and Social Life Survey study show that sexual problems tended to decrease with increasing age expect for lubrication issues - Limitations: only looked at women 18-59 who'd had a sexual partner in the last year Study: sexual activity declines with age Vaginal dryness and dyspareunia are consistently increased after menopause Low desire or arousal in postmenopausal women is likely Decreased libido may be secondary to other menopausal sxs, like depression, sleep disturbances, and night sweats o Surgeries Surgical menopause results in decreased androgen levels, unlike natural menopause - Decreased arousal and noted orgasm problems Conflicting studies on oophorectomy - One study: hysterectomy + bilat. oophorectomy = decreased sexual satisfaction, despite estrogen Tx. - Other studies: no effect o Psychiatric and neurologic disease Depression and anxiety were significant correlates of distressing sexual problems in the PRESIDE study. Antipsychotic medications are associated with sexual dysfunction in both men and women. These meds inhibit dopamine and maybe increase prolactin Sexual dysfunction seen in Multiple sclerosis & Parkinson's Dz, depending on the degree of sensory dysfunction in the genital region Sexual dysfunction in women w/epilepsy, typically associated w/antiepileptic drugs 4. Indicate the diagnostic criteria for sexual disorders from the American Psychiatric Association. Female sexual dysfunction is Dx'd by identifying diagnostic criteria through the medical and sexual history The APA guidelines for sexual disorders require that a sexual problem be recurrent or persistent and cause personal distress or interpersonal difficulty to establish the diagnosis. defined in relation to a specific phase of the sexual response cycle: - Hypoactive sexual desire disorder — deficient (or absent) sexual fantasies and desire for sexual activity - Female sexual arousal disorder — inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication-swelling response of sexual excitement - Female orgasmic disorder — delay in, or absence of, orgasm following a normal sexual excitement phase - Dyspareunia — genital pain that is associated with sexual intercourse - Vaginismus — involuntary contraction of the perineal muscles surrounding the outer third of the vagina when vaginal penetration with penis, finger, tampon, or speculum is attempted Female sexuality differs from males' in that spontaneous desire is unusual in women except in new relationships, and this its absence is not necessarily a disorder. Desire in women typically is responsive Self-reports by women often do not distinguish between desire and arousal. 5. Review the medical history, sexual history, and physical exam in a patient with this concern. o Medical Hx A complete medical and medication history is elicited to identify organic, psychological, medication, and substance-related issues that may affect sexuality. An assessment of sexual problems should be a part of every comprehensive woman's health visit. A gynecologic history and review of systems should include symptoms and conditions that may affect sexual activity or signal the need for further evaluation, including: - Menopausal status (natural, surgical, or post-chemotherapy) - Pregnancy and childbirth history - History of pelvic injury, cancer, or surgery - Vulvovaginal or pelvic pain - Vulvovaginal pruritus, dryness, or discharge - Abnormal genital tract bleeding - Urinary or anal incontinence The following questions help to assess whether the patient needs assistance to engage in safe sexual practices: - Are you currently sexually active? - Do you need contraception or preconceptional counseling? - Are you practicing safe sex? - Would you like to be screened for sexually transmitted infections? - Are you currently experiencing or have you experienced previous sexual abuse? o Sexual Hx All women should be asked an open-ended question, such as: Do you have any sexual concerns? Menopausal women should be asked specifically about vaginal dryness and dyspareunia. - If yes, typically inadequate time in the current encounter to complete a thorough sexual history and discuss Tx options. A follow-up visit is then scheduled for a comprehensive sexual history is taken. Sexual dysfunction may be a lifelong problem or acquired later, may be generalized or situational, persistent or recurrent, and may or may not cause personal distress and/or interpersonal difficulty. Women with partners should be asked about the quality of their relationships, whether her partner has sexual issues - In older women, a common reason for sexual inactivity was not having a partner or a male partner's sexual problem. o Physical examination A pelvic examination is required only for the sexual pain disorders, but it's still recommended for various other reasons

Evaluatoin of infant w/ ambiguous genitalia

a. Infants w/ congenital discrepancy b/w external genitalia, gonadal and chromosomal sex are classified as having a disorder of sex development (DSD)- DON'T use pseudohermaphrodism and intersex anymore. b. Some DSD present w/ ambiguous genitalia/external genitalia abnormalities. Can include bilateral cryptorchidism, perineal hypospadias w/ bifid scrotum, clitoromegaly, posterior labial fusion, phenotypic female appearance w/ palpable gonad, hypospadias and unilateral nonpalable gonad. Include infant w/ discordant genitalia and sex chromosome. i. 46 X,Y infants w/ palpable gonads & hypospadias or microphallus don't truly have ambiguous genitalia

Normal pubertal development

a. Mini puberty of infancy: 6-8wks- the hypothalamic-pituitary-gonadal axis is biologically active- no clinical effects seen. Long pre-puberty stage marked by active suppression of hypothalamic-pituitary-gonadal axis. Puberty-Children enter puberty when suppression is released. b. Tanner: first sing of puberty in girls is breast development, pubic hair then menarche. In boys, have testicular enlargement followed by penile growth and pubic hair growth. Fat children enter puberty at younger ages, and occurs earlier in African-American children compared to white (Hisp/non-Hispanic)

Recognize clnical features of sexual development in both genders

a. Penile length: measured from pubic ramus to the tip of the penis excluding excess foreskin after stretching to point of increased resistance b. In a term infant, normal penile length is greater than 2.5cm and normal diameter greater than .9cm. Micropenis may be caused by decreases testosterone exposure in second or third trimester and deficiencies of GH or gonadotropin. c. Gonads- scrotum, labia majora, and inguinal area should be carefully palpated to ID presence and position of gonads. In 46XY child, a bilateral nonpalpable testes may arise from anorchia or persistent Mullerian duct syndrome; in a 46XX child, virilizing congenital adrenal hyperplasia should be ruled out. Gonads palpable below inguinal ligament are usually testes. d. Urethral opening is a single opening at base of phallus. e. Clitoral width is measured by gently but firmly pressing the shaft of the clitoris between the thumb and forefinger to exclude excess skin- in neonates 2-6mm. Mean clitoral length in newborn infant vary but more than 9mm are abnormal. Clitoral size fully developed by 27 weeks gestation and because there is less fat in labia majora. f. Virilization: female virilization standards of CAH have been established based on degree of virilization of urogenital sinus and external genitalia. More BS that we don't need to ever know/use. g. Anogenital ratio: the distance between the anus and posterior fourchette divided by the distance between the anus and base of clitoris. A ratio of >.5 suggests virilization.

Testosterone

a. Produced in Leydig cells under control of LH b. Concentration in Leydig cells is 100X that in peripheral circulation

Pages 136-150 1. Discuss the screening and diagnostic testing on sexually active adolescents.

a. Sexually active adolescent patients should be screened at least annually for gonorrhea and chlamydia. In addition, patients who have particular risk factors should be screened annually for human immunodeficiency virus (HIV) and syphilis. b. Screening for HPV is not recommended because the results do not alter clinical management. HPV infections are not curable, and there is no evidence that screening influences risk of transmission c. In 2006 the Centers for Disease Control and Prevention recommended "opt-out" HIV Testing be offered to 13-64 year old patients, informing the patient, orally or in writing, that HIV testing will be performed unless he or she declines d. The Society for Adolescent Health and Medicine also supports offering HIV testing as part of routine care for sexually active adolescents e. The American Academy of Pediatrics recommends HIV testing at least once by 16 or 18 years of age in areas where HIV prevalence is >0.1% f. If HIV prevalence is lower than >0.1%, the AAP encourages routine HIV testing for sexually active adolescents and those with other risk factors for HIV. g. the AAP encourages routine HIV testing for sexually active adolescents and those with other risk factors for HIV. i. IV drug users ii. Exchange sex for money iii. Have sex with multiple partners iv. Men who have sex with men h. Adolescents tested for other STD should be tested for HIV at the same visit. i. Tests available for the detection of STD include light microscopy, culture, serology, Western blot, and several DNA probe or nucleic acid amplification methods. Each of these tests has an ongoing role in screening or in clinical diagnosis. i. Microscopy — Microscopy includes examination of vaginal fluid mixed with saline and with potassium hydroxide, and Gram stain. Self-obtained vaginal swabs perform comparably to clinician-obtained swabs and are well accepted by adolescent patients. There are multiple conditions where microscopy is useful: 1. Trichomoniasis- saline wet mount for diagnosis of trichomoniasis is considered to be 50 to70 percent sensitive. 2. Bacterial vaginosis. 3. Vaginal candidiasis. 4. Gonococcal and non-gonococcal urethritis (in males). a. finding of gram-negative intracellular diplococci is both sensitive and for the diagnosis of gonococcal urethritis in symptomatic males b. Non-gonococcal urethritis is diagnosed by finding five or more PMN per oil-immersion microscopic (1000x) field in the absence of gram-negative intracellular diplococci 5. Performing Gram stain of cervical secretions in females is not recommended unless other diagnostic modes are unavailable ii. Culture — Culture is used widely for the diagnosis of gonorrhea, chlamydia, and genital herpes. 1. A relatively inexpensive self-contained culture system for Trichomonas is available. The culture system may be preferable to microscopy because it has greater sensitivity iii. Serology 1. Serologic tests for herpes simplex virus (HSV) type 2 that identify circulating antibodies to specific herpes glycoproteins are available. The tests are highly sensitive and detect seroconversion within two to three weeks after initial infection. 2. Syphilis serology remains substantially dependent upon non-treponemal (eg, RPR or VDRL) screening tests followed by treponemal (eg, FTA) screening tests. Reasonably common causes of false-positive screening tests in adolescents include pregnancy, injection drug use, acute hepatitis B, and systemic lupus erythematosus. 3. Serologic testing for HIV is discussed separately. 4. Nucleic acid amplification tests — Nucleic acid amplification tests (NAAT) are highly sensitive tests for N. gonorrhoeae and C. trachomatis that can be performed on genital specimens (urethral or cervical), as well as urine. a. Urine screening for gonorrhea, chlamydia, or both using NAAT has been used successfully in difficult-toreach adolescents ("street kids"), as well as in pediatric emergency departments and school-based settings. Screening in school-based settings was associated with significant reduction in chlamydia rates during a one-year period.

Threshold for evaluation in precocious puberty

a. Some Pediatric Endocrine society suggested setting precocious puberty ages, but basically this didn't work because saying young girls were just undergoing early puberty actually would miss real endocrine issues b. IN females, occurs much more frequently c. Age 8, 48% African-American females and 15% of white females showed breast & pubic hair development, at 7yo 27% AA and 7% white girls showed. Current definition of 2.5-3SD below mean pubertal age is problematic and should instead should just depend on clinical features and rate of pubertal progression.

FSH

aids in conversion of testosterone to estradiol, resp for regulating spermatogenesis a. Receptors present in Sertoli cells/spermatogonia b. Acts on Sertoli cells to increase production of androgen binding protein, transferrin, inhibin, CYP19, and plasminogen activators c. Enhances glucose transport and conversion of glucose to lactate d. Converts testosterone to estradiol

Recognize the risk factors for HIV sexual transmission

c. During acute HIV infection, there is ramp-up of viremia followed by onset of a cellular immune response, which leads to a new lower viral "set point" (eg, equilibrium) seen in chronic infection [7,8]. Acute infection is also associated with increased viral shedding in genital secretions for several weeks after infection compared with the stable lower levels seen in chronic infection.

Transexualism

condition in which a person w/ apparently normal somatic sexual differentiation of one gender is convinced that he or she is actually a member of the opposite gender; associated with an irresistible urge to be that gender hormonally, anatomically, and psychosocially.

Most common cause of delayed puberty

defective production of GnRH from the hypothalamus; this causes defective gonadotropin secretion from the ant. pituitary, which then causes inadequate gonadal steroid secretion.

Recognize the clinical features of a patient engaging in the "choking game".

do not come to medical attention unless they have suffered a serious complication of asphyxia, (eg, coma, seizures, stroke, brain damage) and death -less severe hypoxia: -Recurrent confusional episodes and seizure-like events -syncope or recurrent syncope -episodes of altered awareness -vision changes/loss, resulting from Valsalva retinopathy (hemorrhagic retinopathy related to a sudden increase in intrathoracic pressure), characterized by intraretinal and subretinal hemorrhage over the macula -warning signs (I guess different): -Mention of the "choking game" -Curiosity about asphyxiation (eg, how it feels) -Unexplained bruising or red marks on the neck -Wearing high-necked shirts, even in warm weather -Bloodshot eyes or pinpoint bruising around the eyes -Petechiae on the face, especially the eyelids or conjunctiva -Frequent, severe headaches -Disorientation after spending time alone -Unusual need for privacy -Increased and uncharacteristic irritability or hostility -The unexplained presence of dog leashes, choke collars, bungee cords, etc -Ropes, scarves, and belts tied to bedroom furniture or doorknobs, or found knotted on the floor or in unusual places -Wear marks on bedposts and closet rods -Internet history of Web sites or chat rooms mentioning asphyxiation or the "choking game"

LH

enhances testosterone synthesis

Primary hypogonadism

high serum concentrations of LH and FSH and/or defects in their receptors on the membrane of the gonadal cells

Distinguish terms used in human sexuality

i. Gender identity formed early childhood- continuum, use terminology gender variance, gender queer, gender fluid, transgender. ii. Transgender generally refers to individuals who gender role or gender identity is not congruent w/ their biologic or anatomically assigned sex. d. Sexual orientation refers to an individual's pattern of physical and emotional arousal (including fantasies, activities and behaviors) and the gender of people who they're physically and sexually attracted to. Formation of sexual identity is often fluid in youth- heterosexual youth may experiment with same-gender partners, homosexual youth may have opposite-gender partners.

sexual terms

i. Genitals are external sex organs that are sensitive to and stimulated by being touched during sexual activity. Penis and scrotum, vagina, vulva and clitoris. ii. Petting is feeling parts of another person's body iii. Orgasm is a pleasurable release of tension felt in genital area and elsewhere in body resulting usually from genital stimulation. Men & boys release semen via ejaculation and has sperm. Cum/come=slang iv. Sexual intercourse: sex involving man's penis being put inside woman's vagina, when ejaculates the semen goes into the vagina and woman gets pregnant if the sperm fertilizes the egg. v. Oral sex involves using the mouth and tongue to stimulate the genitals vi. Anal sex involved penetration of the anus by penis or object vii. Masturbation involves using hands or a device called a vibrator/sex toys to stimulate yours or someone else's genitals.

b. Some generalizations can be made: I LEFT THESE PRETTY MUCH IN FULL BECAUSE THEY ARE PROBABLY HIGH YIELD!

i. In addition to any method of contraception, we recommend use of condoms for individuals at risk of sexually transmitted infections. ii. For couples who desire permanent contraception (sterilization), we suggest vasectomy. Vasectomy is as effective, but less morbid and costly than tubal occlusion. iii. For women desiring tubal occlusion, hysteroscopic tubal occlusion does not require an incision and is usually performed using a local anesthetic, as opposed to laparoscopic tubal occlusion. However, at this time the laparoscopic approach is more widely available and most surgeons are experienced and facile with this technique. Women who request sterilization should be counseled about availability of IUC as a long-term method that rivals sterilization in terms of efficacy, but is non-surgical and reversible. iv. For women who desire reversible contraception, we suggest intrauterine contraception, or implants, given they are associated with pregnancy rates comparable to permanent methods and they are more convenient than combined estrogen-progestin methods. Combined estrogen-progesterone hormonal methods (pills, patch, vaginal ring) are rapidly reversible, but less effective than the methods described above (although still highly effective when used properly). Hormonerelated side effects are common. Convenience depends upon the specific method and varies from daily administration (oral contraceptive pills, standard or extended cycle), to weekly (patch), to monthly (vaginal ring). Patients should not use these methods if they have a contraindication to taking estrogen preparations. In particular, patch users may be at higher risk of thrombosis than pill users. v. The diaphragm and male condom are less effective and less convenient than hormonal methods. However, they are the most readily reversible methods and not associated with systemic side effects (except for individuals who are sensitive to latex products). Diaphragms are most effective when used with a spermicide.They are not recommended as the primary method for women with serious medical conditions in whom pregnancy is life-threatening. These women require use of the most effective methods of contraception. vi. Women using a barrier contraceptive (eg, condom, diaphragm, cervical cap) or who are at risk for pregnancy should be informed about use of emergency contraception in case of failure of the barrier contraceptive method (broken condom, failure to use, etc). Women prescribed hormonal contraceptives should also be informed about use of emergency contraception since they may miss doses of their contraceptives and be at risk for unintended pregnancies. vii. Progestin-only pills are an option for women who want a contraceptive pill, but need to avoid estrogen. They are associated with more unscheduled bleeding and require a stricter schedule for perfect adherence (to be taken at the same time each day).

c. contraceptive methods can be divided into three categories based upon their theoretical and actual effectiveness

i. Most effective: Long-acting reversible contraception (intrauterine contraception, contraceptive implants) and sterilization are associated with a low pregnancy rate regardless of the population studied, as the rate is minimally influenced by adherence. Women should be encouraged to first consider a method from this tier of options. ii. Effective: Injectable contraceptives are the most effective in this tier of choices. OCs, the transdermal contraceptive system, and the vaginal ring are also associated with a very low pregnancy rate if they are taken consistently and correctly, but actual pregnancy rates are substantially higher because of inconsistent/incorrect use. iii. Least effective: Other methods of contraception, including diaphragm/cervical caps, condoms, spermicides, withdrawal, and periodic abstinence are associated with actual pregnancy rates that are much higher than perfect use rates. The overall pregnancy rates associated with these methods have varied considerably among studies.

STI

iii. HIV is a serious STI- it's the virus that causes AIDS, a serious incurable disease of the immune system. New treatments now help people live longer, but there isn't a vaccine or cure. Incidence of 40-80k/year, and ½ in people under 25yo. Early detection is key! iv. HPV most common STI in adolescents, and can cause genital warts or be undetected. Can cause cervical cancer in women, penile cancer in men and anal cancer. Pap smears screen for cervical cancer. Vaccine available for men and women. v. Chlamydia and gonorrhea are bacteria infections of genital tract that can lead to PID in women. Both cured w/ antibiotics. If had unprotected sex should be screened for it. vi. HSV: viral infection that causes painful or itchy sores in the genital region- sores heal but can come back at any time. Medications can reduce outbreaks but there isn't a cure. vii. HepB: viral infection that affects the liver, that usually resolves. viii. Syphilis: on the rise, caused by spirochete which can cause an ulcer on the genital or anus. Doesn't cause pain sometimes in vagina or anus. ix. Trichomonas/trich is a parasitic infection that causes itching and discharge from the genitals. Females notice symptoms more than males but both affected and require treatment. Treated w/ antimicrobial

Male dyspareunia

iscuss the definition of male dyspareunia, its epidemiology, and etiology. Dyspareunia is pain with sex, usually referring to females. Some males also have this. The physician should know this is embarrassing and uncomfortable. In women it is chronic pelvic pain. Epidemiology-unreported symptoms is common. It is unknown if this is because it is so infrequent or if men don't like complaining about their dicks. It is estimated that 5% of men suffer from painful sex. Etiology-often the cause can't be determined. It is possibly proinflammatory cytokines in the genital tract similar to prostatitis/chronic pelvic pain symdrome. Research in this area is limited. • Describe the given classifications of male dyspareunia. There is no uniformly accepted classification system. It is felt to be a sexual pain disorder involving recurrent sexual pain for 3+months. Ejaculation dysfunction is common and can be classified as anejaculation, delayed, retrograde, premature, and painful. Painful is the only one with pain. It is 1-6.7% of men 50 years or older. Common presentations include penis pain, perineal ache, or suprapubic discomfort during or after ejaculation. Pain may also be seen in the testicles or glans and may result due to perineal muscle spasm. Atypical pain can be in the abdomen, urethral meatus, or rectum. Pain can be from ejaculatory duct obstruction. 90% of men with this problem consider it a serious problem. Chronic prostatitis/chronic pelvic pain-can be associated with noninflammatory or inflammatory conditions of the prostate. Medical causes include peyronie's disease (plaque or scar form in the tunica albuginea causing penis curving), phimosis leading to inability to retract the foreskin, and frenulum breve (short frenulum). Hernia repair can cause pain related sexual dysfunction (about 3% of males age 18-40). Pudendal nerve entrapment-compression of pudendal nerve in Alcock's canal or ligaments can cause pain. Topiramate (oral) and perineural injections of anesthetics into pudendal nerve can treat some causes. Surgical decompression may also help. Infections can cause burning or itching following ejaculation. STDs can cause penile pain and genital ulceration. Interstitial cystitis-compression of the bladder during sex can cause pain. Some meds (especially antidepressants and antipsychotics) cause male dyspareunia. Uncircumcised men are more likely to have dyspareunia. Psychological trauma can cause this including child abuse, relationship difficulties, and body image issues. Guild can also lead to pain, often in patients from strict religious backgrounds. Anodyspareunia-pain receiving anal sex. • Describe the diagnosis process using the H&P and ancillary studies for male dyspareunia. History-A thorough history and physical can diagnose most conditions of male dyspareunia. Get a detailed history including correlative factors such as neuropathy, anatomical abnormalities, trauma, genital infections, surgery, and meds. Dysuria, discharge, and testicular swelling and pain indicate infection. Ask if pain occurs with noncoital sex, including masturbation. If there is no pain with masturbation, it may be psychologic. If pain occurs outside of sexual activity, chronic prostatitis should be considered. Pay attention to urinary flow, ejaculation history, nocturnal erections, and pschosexual issues. Physical-focus on genital and rectal areas, especially the prostate, bulbocavernosus reflex, and anal sphincter tone. Look for Peyronies plaque, lesions, short frenulum, and phimosis. Check for testicular mass. Prostate tenderness supports diagnosis of acute or chronic prostatitis. Bulbocavernosus reflex should be checked for pudendal nerve function (S2-4). Test involves squeezing the glans penis and seeing if the anal sphincter contracts. No reflex could show sacral spinal cord trauma or nerve entrapment. Ancillary studies-urinalysis and culture to look for infection. If negative, refer to urologist. Microscopic eval of prostatic secretions after prostatic massage can show infection or inflammation. Cystoscopy, transrectal ultrasonography, and other tests can be used to rule out neurologic origin, abdominal masses, or congenital anomalies. Most of these tests are normal in male dyspareunia.

Male dyspareunia can be divided into 4 categories:

isolated painful ejaculation, chronic prostatitis/chronic pelvic pain, medical causes, and other causes. Some medications may help treat chronic pain including gabapentin and imipramine.

Secondary hypogonadism

low or normal serum LH and FSH concentrations associated with diminished GnRH-induced gonadotropin secretion; this can be because of hypothalamic dysfunction (anatomic or functional), hypopituitarism, hypothyroidism, or hyperprolactinemia.

o Gender, gender identity, gender role, and gender expression are personal, psychological, and cultural constructs referring to various aspects of maleness and femaleness.

o Gender identity: an individual's innate sense of being male, female, or somewhere in between, generally established during early childhood. o Transgender: individuals whose gender role or gender identity is not congruent with their biologic or anatomically assigned sex. o Gender role: society's expectations of attitudes, behaviors, and personality traits typically based on biologic sex. Masculinity and femininity are main concepts. o Gender expression: how gender is presented to the outside world; does not necessarily correlate with gender identity. o Sexual orientation: an individual's pattern of physical and emotional arousal (including fantasies, activities, and behaviors) and the gender(s) of persons to whom an individual is physically or sexually attracted. o Sexual identity: an individual person's assessment of her or his sexual orientation. Formation of sexual identity among youth often is fluid, and experimentation with same-gender sexual contacts can be part of healthy adolescent development. **Sexual behavior alone is neither a sensitive nor specific predictor of gender identification, sexual orientation, or sexual identity.**

• Screening WSW are more likely to smoke and drink alcohol and have high BMI and have fewer preventative health screenings than heterosexual women.

o Less likely to use oral contraceptive or to have breastfed o Cervical cancer screening: WSW have lower rates of screening than heterosexual women; may be linked to perception that they are at lower risk of acquiring HPV however bisexual and lesbian women actually had higher rates of cervical cancer Risk is highest in those who have a history of incest of early age, sex w/more than one male sexual partner, infected w/high oncologic risk HPV types, smoke cigarettes, treated for abnormal cervical cytology in the past High risk HPV can be transmitted by skin-skin or skin-to-mucosa contact Screening guidelines based on age and risk factors o Breast cancer Risk of 1/3 WSW compared to 1/8 heterosexual women overall Possibly due to receiving less screenings and because they may become pregnant at an older age than heterosexual women o Ovarian cancer WSW have higher theoretical risks because of factors like lower likelihood of being pregnant or using hormonal contraceptive for a prolonged period of time Screening recommendations are based on risk factors and not sexual orientation o STD screenings performed in women w/symptoms or those with risk factors Transmitted via behaviors resulting in the exchange of vaginal secretions on hands or objects; also can be exchanged by sex toys and fingers Study found association between bacterial vaginosis (BV) and a history of female sexual partners and increases with increasing number of female partners...this is not considered an STD in heterosexual women For unclear reasons, oral-genital, oral-anal, and sex toys may be more important risk factors for infection than penile intromission All women being evaluated for STDs should be offered counseling and referral for HIV testing Prevention of STDs: suggestions for safer sex Pharmacoprophylaxis includes offering vacyclovir to the affected partner in HSV and HPV vaccination

1. Describe the clinical features of headaches associated with sexual activity, both types. Headache associated with sexual activity (also called: benign vascular sexual headache, and coital cephalalgia). They're unpredictable and are not necessarily precipitated with every sexual encounter.

o Preorgasmic headache o dull, usually bioccipital pressure-like or aching pain that appears during sexual activity and increases with mounting sexual excitement o often an awareness of increased contraction in neck and jaw muscles. o headaches persist about 30 minutes on average with a range from 1 to 180 minutes o frequency of the headaches was related to that of orgasm o Orgasmic headache o sudden explosive onset followed by severe throbbing head pain that occurs just prior to or at the moment of orgasm o may rapidly generalize to involve the entire head. o orgasmic headache is more common and the only one associated with stroke o worrisome because of its similarity to the headache of subarachnoid hemorrhage (SAH), and because 4-12% of patients presenting w/ SAH due to aneurysmal rupture cite sexual intercourse as the precipitating event. o it is mandatory to exclude intracranial bleed and arterial dissection at the first presentation

Recognize sexual dysfunctin post-MI

o Sexual dysfunction is common in patients with cardiovascular disease because of... o concern about risk of triggering an MI or sudden death o side effects of medications (diuretics, beta blockers, lipid-lowering drugs) o coexistence of shared risk factors, such as lipid abnormalities, diabetes, smoking, and hypertension o the presence of psychologic factors o Sexual dysfunction after an MI (most often ED in men) is estimated to occur 1/2 to 3/4 of patients o Both men and women have less sexual activity and less satisfaction with sexual activity after an MI

Describe the risk of myocardial infarction (MI) after sex

o The relative risk of MI w/in 2 hrs after sexual activity was 2.5; there was no increased risk of MI beyond this time period. The risk was reduced in patients who underwent regular exercise. o Relative risk of MI after sexual activity was similar in patients w/ a history of prior angina or MI or no prior cardiac disease. o The absolute increase in risk was small, as sexual activity appeared to contribute to the onset of MI in only 0.9% of patients. o Many other triggers of an MI, such as psychologic stress, anger, or physical activity may cause a greater increase in absolute risk because they occur more frequently. o What is important to the individual is the absolute increase in risk (ie, the risk from sex minus the risk at all other times, referred to as the "attributable risk") o Patients can be categorized in to "low risk", "intermediate risk" and "high risk" depending on cardiovascular health factors. o Obviously, patients w/ intermediate risk should receive evaluation before participating in sexual activity and patients with high risk should not participate at all.

7. Discuss the benefits and concerns with phosphodiesterase-5 (PDE-5) inhibitors (ex.: Viagra) and other therapies.

o phosphodiesterase-5 (PDE-5) inhibitors sildenafil, vardenafil, and tadalafil are widely used in the treatment of ED in men and can have important effects in patients with heart disease. o Sildenafil — can improve ED in patients with stable ischemic heart disease; is also effective in men with hypertension, diabetes, and nonvascular organic or psychogenic causes for ED; it can lower blood pressure and it can interact with nitrates; it's a vasodilator and reduces systemic vascular resistance; it dilates epicardial coronary arteries and, in patients w/ coronary heart disease, improves endothelial dysfunction and inhibits platelet activation. o Adverse interaction with nitrates — An important limitation is the contraindication to the use of PDE-5 inhibitors in patients taking nitrates of any form, regularly or intermittently. Men treated with PDE-5 inhibitors and nitrates are at risk for severe hypotension and syncope. o Antihypertensive drugs — PDE-5 inhibitors are typically well tolerated with only minor reductions in blood pressure in patients taking conventional antihypertensive drugs (eg, angiotensin converting enzyme inhibitors, angiotensin II receptor blockers, calcium channel blockers, beta blockers, and diuretics), even when used in combination o Other therapies — Treatment options for sexual dysfunction other than a PDE-5 inhibitor can be pursued in patients with stable cardiac disease. There are no specific cardiovascular effects of androgen replacement therapy, penile prostheses, or vacuum-assisted erection devices.

Precocious puberty

onset of pubertal development at an earlier age that in expected: before age 8 in girls (normal mean is 10.5) and 9 in boys (normal mean is 11.5), 2.5-3 standard deviations below mean age of puberty b. Can be gonadotropin-dependent or independent i. Gonadotropin-dependent precocious puberty: caused by early maturation of hypothalamic-pituitary-gonadal axis. Sequential maturation of breasts and pubic hair in girls, and of testicular enlargement and pubic hair development in boys. Sexual characteristics appropriate for gender ii. Gonadotropin-independent precocious puberty: caused by excess secretion of sex hormones derived from gonads or adrenal glands, exogenous sources of sex steroids or ectopic production of gonadotropin from germ tumor. Puberty may be appropriate for child's gender, or inappropriate w/ virilization of girls and feminization of boys. c. Incomplete precocious puberty: usually a variant of normal puberty. isolated breast development in girls (premature thelarche) or isolated male hormone-mediated sexual characteristics in boys or girls that result from increased adrenal androgen production. Clincal manifestations are pubic and/or axillary, acne, apocrine odor

Discuss the predisposing factors and pathophysiology of the "choking game".

predisposition: -peer pressure, risk- or thrill-seeking behavior, and the possibility of a drug-free "high" -In some cases, engaging in strangulation activities begins as a social activity but progresses to being performed alone -first group: athletic and average to above-average students who would ordinarily avoid alcohol and drugs -appear to be unaware of the dangers of strangulation activities -second group: adolescents with limited access to drugs or alcohol who may use the activity as a means to "self-medicate" problems, such as anxiety or depression -some studies have found that students who participate in other risky behaviors (substance abuse, sex) are more likely to participate in strangulation -pathophysiology (not been well studied) - cerebral vascular engorgement, decreased cardiac output (related to increased thoracic pressure), and hypercarbia -cerebral hypoxia and hypoperfusion: breath holding, external limitation of chest wall expansion, and compression of the carotid arteries -Compression of the carotid sinuses further reduces cerebral oxygenation through reflex bradycardia and vasodilation -acute severe hypoxia: LOC for around 10-20 secs, perm brain damage in 3 minutes, death in 5 minutes -less severe: impaired judgement, drowsiness, dulled pain sensation, excitement, disorientation, and headache -other sxs: anorexia, nausea, vomiting, tachycardia, and tachypnea -severe hypoxia: HTN -when the pressure is released, there may be a secondary "high" related to the rush of blood and oxygen to the brain -EEG correlates: Cerebral hypoperfusion and hypoxia are associated with initial slowing of the background on electroencephalogram (EEG), followed by high-amplitude delta activity -Loss of consciousness, with flattening of the EEG background, occurs if hypoperfusion and hypoxia persist

Is homosexuality a mental disorder?

research has found there is no association between any sexual orientation and psychopathology • All major national mental health organizations have officially expressed concerns about therapies promoted to modify sexual orientation • Seems promotion of change, reinforces stereotypes • Helpful responses of a therapist include helping the person actively cope with social prejudices, successfully resolve issues associated with and resulting from internal conflicts, and actively lead a happy and satisfying life • Mental health professional organizations call on members to respect a person's right to self-determination; be sensitive to the clients race, culture, ethnicity, age, gender identity, sexual orientation....

emergency contraception

vi. If you have birth control but have an accident where forget pill or condom breaks or sex without BC occurs, you can get emergency contraception to reduce risk of pregnancy- NOT an abortion since won't harm current pregnancy if exists. Morning after offered w/in 5 days of unprotected sex but loses efficacy rapidly after the 1st day and is low efficacy at day 3.

Review epidemiology of child sex abuse

• >60,000 children are sexually abused annually; ~1% of children experience sexual abuse each yr • Worldwide, ~25% of girls and 9% of boys are exposed to any form of sexual abuse during childhood • Note: the # of reported sexual abuse grossly underestimates the true prevalence • Only ~10% of instances are reported b/c of fear of medical eval, social stigma, and desire for privacy • Sexual abuse of children occurs primarily in the preadolescent years. • Girls are more likely than boys to be sexually abused, but boys are less likely to report sexual abuse. • Perpetrators are usually male, and often trusted adult acquaintances • Father and other relatives were responsible for 21 and 19 % of sexual abuse victims, respectively • Mother acting alone or with another person accounted for 4 and 8%, respectively • Perpetrators gain access to children thru caretaking, target them using bribes, gifts, and games, and systematically desensitize them through touch, talk about sex, and persuasion. • Increased risk is assoc. in children w/ poor parent-child relationships, poor relationships btwn parents, the absence of a protective parent, and presence of a nonbiologically related male in the home.

Factors that may indicate and increase in risk for specific diseases in lesbians

• Breast cancer nulliparity, older age at first childbirth, no breast-feeding, smoking ,increase alcohol use, higher BMI, fewer screening exams • Ovarian cancer no oral contraceptive use, nulliparity, smoking • Endometrial cancer no oral contraceptive use, nulliparity, oligoparity • Colon cancer smoking, increased BMI, fewer screening exams

Medical issues targeted towards the gay population

• Cancer, HIV/AIDS, immunizations and infectious diseases, STDs, substance and tobacco abuse, behavioral health, mental disorders, domestic violence • Cancer increased rates of anal carcinoma via infection with HPV o HPV associated with oropharyngeal cancer o HPV vaccine suggested for boys and young men to prevent • STDs prevention! Via risk reduction and safe sex practices • HIV stable numbers overall in the US but has increased in populations of MSM o Increases particularly in African American MSM o Often new cases were among MSM who also use IV drugs o Counsel about use of condoms and discuss risk of transmission via oral sex o CDC recommends HIV screening routinely but pts are allowed to refuse testing • Hep A and B vaccines are recommended for MSM • Tobacco abuse more common in gay men than heterosexual men in the US • Alcohol abuse more common in gay men that in the general population and is thought to contribute to some of the risky behavior associated o Clinicians can be the ones to detect this problem and association with risky behaviors and take a n approach to stopping alcohol use is necessary! • Drug abuse trends of drugs that predominate in the gay community (clubs and party drugs o Several years ago was MDMA and ketamine o More recently methamphetamine hydrochloride use (often injected, contributing to transmission of HIV, Hep C and other STDs) • Behavioral Health in 1973 homosexuality was classified as a mental disorder and was removed in 1986 o Small studies have identified higher rates of major depressive disorders and bipolar disorders in gay men; also increased prevalence of anxiety; some studies show increased suicide attempts

Review differential diagnosis possibilities n sexual abuse case

• DDx of child sexual abuse includes other types of genital injury, infection, dermatologic conditions (ie. nonspecific vulvovaginitis, dermatitis, psoriasis), congenital conditions affecting the perineum, and other conditions affecting the urethra (urethral prolapse, caruncle, sarcoma botryoides, and uterocele) or anus (hemorrhoids, Crohn's disease, rectal prolapse, hemolytic uremic syndrome, rectal tumors) • Unintentional injuries of the perineum include straddle injuries, zipper entrapment, hair tourniquet, and seat belt or motor vehicle accident injury to the genitalia. The history in these unintentional injuries is usually readily available. • Straddle injuries typically involve the anterior structures, such as the clitoris, clitoral hood, mons pubis, and labial structures, and even posterior fourchette. Penetrating sexual abuse usually results in injury to the hymen and other more posteriorly located structures such as the posterior fourchette and fossa navicularis

3.13 "Approach to the Woman with Sexual Pain" Stewart

• Describe "general sexual problems" in women. About 40% of women have sexual concerns in the US and 12% have distressing sex problems. These can include lack of desire, impaired arousal, inability to reach orgasm, or pain. Pain can start at first sex encounter or develop later, and can be with every encounter or only with some. Problems can be caused by anatomic problems and psych issues. • Recognize the neuroanatomic pathophysiology with women with sexual pain. The vulvar vestibule, urethra, and bladder have common embryonic origin. This may explain concurrence of pain at multiple sites. All lower genital tract structures have estrogen receptors, with most being in the vagina. The pudendal nerve innervates the vulva and vestibule. Inferior hypogastric plexus and caudal sympathetic chain nerve fibers are involved in genital sensation. They are involved in inflammatory pain. Afferents from reproductive, urinary, and GI tracts impinge the spinal segments served by nerves from skin and muscles. This explains some patterns of pain due to visceral stimuli. Sex pain can be nociceptive (related to disease or injury) or neuropathic. Myelin A-delta fibers are nociceptive and in the vestibule. Unmyelinated C fibers are in vestibule, vagina, and cervix. Worsening pain is due to interplay from local sensory input and biochem systems. Generalized vulvodynia represents neuropathic and centralized pain. The vestibule is sensitive to touch and temperature-can cause pain. Distal vagina has greater number of pain fibers than proximal vagina. • Describe the sexual pain disorder classifications. Classified with 3 categories: dyspareunia (genial pain with sex), vaginismus (involuntary spasms of muscles of outer 1/3 of vagina interfering with sex), and non-coital sexual pain disorder (genital pain caused by nonsexual sexual stimulation). Vaginismus may be caused by high pelvic floor muscle tension or fearing penetration. Vulvovaginal pain disorders are divided into 2 groups; 1 causing vulvar pain, from infections, inflammatory, neoplastic and neurologic conditions, and 2 pain without etiology. Discuss the risk factors for dyspareunia in women with chronic pelvic pain -hx of PID* -depression -anxiety -hx of sexual abuse -african american -peri/post-menopausal age <50 yrs -difficulty and pain with first tampon use Explain the clinical manifestation and history evaluation of these^ patients -presentation: pain may be localized to the vulva/vagina or sensation of pain within the pelvis -dx: based on report of pain related to sexual activity -hx: hesitant to open up to doc -"do you have any concerns about your sex life?" -need thorough hx of sxs and conditions, eval for possible physical and psychosocial origins of pain (many cases are multifactorial) -pain: pain with first intercourse? ask about partner and the intercourse itself -inadequate development of intimacy or poor technique, trauma —> remembered pain, tightening of pelvic floor with subsequent episodes -trauma is not always sexual, can be d/t procedures -primary pain disorder can be caused by anatomical anomaly or undiagnosed disorders (lichen sclerosus) leading to tissue changes -was there ever pain free, enjoyable sex? surgeries? (mesh) -specific event triggering pain? -chemo/radiation therapies —> premature ovarian failure —> atrophy; scarring, fibrosis from radiation -female circumcision? :( -buncha other hx q's (CODIERS SMASHFM) -menstrual, pregnancy, other vaginal sxs, contraception use -other general history: urinary/GI conds —> cystitis, IBS, crohns, MSK conds, OA, spine and/or hip issues and/or new exercise can irritate pudendal nerve, HTN (that or its meds), other meds (producing hypoestrogenism)

4.3 "Sexually Transmitted Diseases: Overview of Issues Specific to Adolescents" Fortenberry

• Describe adolescence in age requirements. - adolescence is a heterogenous developmental period in terms of sexual behavior and acquiring STDs - Early adolescence first yrs of 2nd decade and is marked by rapid physical growth and attainment of secondary sex characteristics - Middle adolescence begins at 14yo end at 17-18yo marked by maturation of reproductive sys and achievement of adult physical stature; inc sexual interest and noncoital sexual behaviors are characteristic - Late adolescence ends w/ transition into young adulthood and is assoc w/ high levels of sexual activity and acquisition of STD - Average age of first coitus is 16yo but can be lower in inner city youth • Discuss epidemiology, risk factors, and unique issues found with adolescents. - 2003-2004 NHANES study: 24% females aged 14-19yrs were infected w/ at least one of the following (in order) HPV, Chlamydia, Trichomonas, HSV-2, and gonorrhea - in 2010-2011: gonorrhea rates remained steady while chlamydia rates inc in 15-19yo - repeated acquisition of STD is common; as many as 40% of G&C annually reported cases occur in teens that were previously infected - HIV is primarily an STD among adolescents - Behavior risk factors: o Time elapsed since 1st intercourse 25% were dx w STD w/in 1 yr of 1st intercourse and repeated infxns were common o Sexual activity w/i early and middle adolescence 29% tested positive for chlamydia w/ 14yo having the highest prevalence o Multiple partners o New partners o Partners w/ mult other partners o Inconsistent use of condoms o Alcohol and other drug consumption - 1991-2001 study: 16-24% decline in sexual experience and mult sexual partners and an inc in condom use - Biologic risk factor: 2 theories neither one has really been proved o Cervical ectopy or cervical immaturity refers to the are that is covered by columnar epithelium after puberty this epithelium is more susceptible to G& C and HPV making teens more susceptible to these STISs o Secretory IgA which is a local protective antibody teens have less of this antibody in the cervical mucosa making them more susceptible - Unique issues in teens: o Self-consent for dx and tx of STD is recognized in all 50 states but remember that state laws vary in terms of what infxns are considered STIs o Privacy and confidentiality are imp barriers in teens seeking medical help o Most states have "age of consent" laws that req notification of CPS if sexual activity is identified esp if there are lg age discrepancies in partners' ages lg discrepancies >5yrs btw partners are seen in 1/3 of teens w/ first sexual encounter in very early adolescence, 1/10 are seen in middle or late adolescence o Only 20% of teen girls report physical and sexual violence from partners o 25% of teens report self-tx with topical medications, abx, or douching on average teen girls wait 10days to seek medical help vs guys who take 6days o SYPHILIS, G&C, HIV are reportable dz in EVERY STATE o IOWA IS THE ONLY STATE THAT req parental notification for HIV infxns o About 30% of pharmacists compromise confidentiality accidently about prescriptions for abx for STI tx (*******es) o 20% of teens fail to fill prescriptions so single dose tx is preferable when appropriate o many teens don't tell their partners they're infected reinforcement is key • Describe the evaluation of an adolescent patient regarding sexual activity and risk for STDs. - sexual hx should be straightforward and nonjudgemental w/ assurance of confidentiality - if you take a good hx, ROS, and obtain non-invasive screening test you can skip doing a pelvic exam genital examination should be reserved for eval of specific sxs or to r/o a differential dx o external genital exam is indicated for eval of genital lesions o menstrual irregularities not due to pregnancy and abd/pelvic pain warrant speculum and bimanual exam o vaginal d/c also warrants spec exam to look for foreign objects o PAP smear for cervical CA screening is not indicated for any girl <21yr unless they are immune compromised - studies show that teens prefer urine or other pt-obtained specimens including self-administered vaginal swabs • Recognize the different STD clinical patterns. - Discharge synd: urethral/vaginal d/c and dysuria are the hallmarks of G&C, trichomoniasis, BV, and candidiasis o Characteristic of the d/c such as color are unreliable - Genital ulcer synd (GUS): genital herpes most common cause of GUS in teens o Keep in mind Primary syphilis as well o Less com forms chancroid, LVG, and granuloma inguinale o Nonsexually transmitted vulvular ulcers may also occur in pts w/ viral illnesses, Crohn's, vasculitis, and Behcets dz - PID: com sequel of G&C - Dermatologic synd: most com derm STD is genital warts (condyloma acuminate) HPV types 6, 11 o Although less com secondary syphilis also gives you skin rash conylomata lata= large, raised, gray to white, lesions, warm, moist areas in mucous mem in the mouth and perineum o Skin rash is also a com manifestation of disseminated gonococcal infxn o Pediculosis pubis (crab louse) and scabies can also cause lesions

Primary headache associated with sexual activity

• Describe the clinical features of headaches associated with sexual activity, both types. Sexual headaches can be preorgasmic and orgasmic. They are unpredictable and not seen with every sexual encounter. Preorgasmic headache-dull, bioccibital pressure/aching pain. It appears during sex and increases with more arousal. Increased contraction in neck and jaw muscles is seen. Less than 1/3 of benign sex headaches. One study showed headaches lasted 30 minutes on average, ranging from 1-180 minutes. Orgasmic headache-sudden explosive onset followed by severe throbbing just before or at orgasm. May include entire head. Orgasmic headache is more common than preorgasmic and is only of the two associated with stroke. It is similar to headache of subarachnoid hemorrhage and 4-12% of patients with subarachnoid hemorrhage have sex as precipitating event. Lifetime prevalence of sex headache was found to be 1%. Ean age of onset was 35 years with a male to female ratio of 2.9:1. Migraines, benign exertional, and tension headaches are also seen in patients with sexual headache. • Discuss the differential diagnosis with patients having sexual headaches. Sexual headaches may be benign or primary disorder. They can also be symptoms of subarachnoid hemorrhage, meningitis, encephalitis, hemorrhage into cerebral tumor, pheochromocytoma, stroke, segmental arterial narrowing, and reversible cerebral vasoconstriction syndromes. Spontaneous low cerebrospinal fluid pressure headache may also arise during sex. Myocardial ischemia can also cause sex headache. Drugs like amiodarone, cannabis, oral contraceptives, and pseudoephedrine cause sex headache. Sinusitis, glaucoma, hypoglycemia, myxedema, anemia, COPD, Cushing's disease and abdominal aorta occlusion can cause sex headache. Numbness can occur with headache. • Recognize the pathophysiology, evaluation work-up, and the generalized treatment of sexual headaches. Pathophsyiology mechanisms are speculative. It was proposed that excessive contraction of neck/jaw cause headache and may be relieved by relaxing muscles during sex. Also attributed to rapid increase in blood pressure and heart rate during orgasm. • Describe the prognosis and recommendations for sexual headaches. Good prognosis. One study showed 75% had single attacks of sex headaches. 69% of patients had remission of headaches.

"Sexual Activity in Patients with Heart Disease" Sauer

• Discuss the cardiovascular effects of sexual activity. Sex is partially depending on autonomic changes. Sexual arousal and erection result from parasympathetic nerve stimulation in the penis, reduced activity of sympathetics, and nitric oxide release from endothelium. Sildenafil for ED is used to increase nitric oxide. Arousal in females comes from sympathetic nervous system activation. Main cardio outflow is sympathetic and is mediated by efferent pathways through the thoracic spinal cord. Hemodynamic stress (early studies) on sex in volunteers in a lab found: o Peak heart rate was 140-180 bpm o Bp increased 80/50 mmHg o Respiratory rates and tidal volumes reached levels similar to moderately severe exercise. Patients with stable angina often had chest discomfort during/after sex. Real life situation studies (married couples in their own bedroom) found: o Mean heart rate was 117bpm (lower than during normal activities. o Blood pressure was estimated to be 162/89 mmHg (not measured, based on blood pressure achieved during exercise to that heart rate. Does not account for sympathetic response to arousal). Other studies supported this estimate. Metabolic equivalent of oxygen consumption (MET) is the clinical measure of exertion. 1MET is 3.5 mL O2 uptake/kg per min=resting oxygen uptake when seated. Sex is usually 2-3 METs before orgasm and 3-4 METs during. This is like walking 2-4 miles. Exercise testing is used to assess tolerance for sex. Sex is associated with increased myocardial oxygen demand for brief time. Sex only accounts for a small percent of myocardial infarctions. Exercise regimens decreased heart rate (from 127 to 120) during sex and increased max oxygen consumption 11.5% in a study of 16 patients with MI. One study of 8 normal men in their bedroom saw no difference in heart rate (114 to 117) or blood pressure (163/81) with man on top or bottom. Another study found slightly lower oxygen consumption for men in supine position for brief period. Increased heart rate and blood pressure is the same as in exercise, so angina may become symptomatic during sex. In a study of 35 patients, 65% had angina during sex and had to stop. Beta blockers and prophylactic sublingual nitrates can prevent this. Patients with chronic coronary disease who underwent bypass surgery had no increased symptoms. • Describe the risk of myocardial infarction (MI) after sex. Case crossover with each patient as their own control was performed. Used in Determinants of Myocardial Infarction Onset Study of 1774 patients. 858 of them were sexually active within 1 week. The following findings were seen: o Relative risk of MI within 2 hours of sex was 2.5. There was no increased risk after this time. o Risk was reduced in patients who exercised regularly. o Relative risk of MI after sex was similar in patients who had an MI or angina and people with no previous cardiac disease. o 9% patients had sex in the 24 hours before MI o 3% had sex within 2 hours of MI o Increased risk of MI with sex was small. Only contributed to 0.9%. o Other triggers (stress, anger, physical activity) cause greater risk. A second study of 699 patients found only 1.3% had sex within 2 hours of MI. The risk of MI in the hour after sex was estimated at 2.1% and 4.4% in patients with sedentary lifestyle. According to the study, a 50 year old man without cardiac disease with a baseline risk of MI of 1% would increase his annual risk to 1.01% with weekly sexual activity. Even a high risk patient (risk of 10%) would only increase his risk to 10.1% with sexual activity. Exercise and medical therapy modulate risk of MI after sex. Exercise reduced risks in both studies. Exercise at levels of 6+ METs modified association between sex and MI. More regularly a person exercises, the lower the risk of MI from sex. Findings were consistent with observations that regular exercise reduces risk of MI form heavy physical exertion and that exercise increases aerobic capacity and decreases heart rate. Another analysis from Determinants of Myocardial Infarction Onset Study showed 4.4% reported heavy physical exertion within 1 hour of MI with symptoms starting during activity. Relative risk of MI was inversely related to amount of regular exercise before MI ranging from 2.4 to 107 in patients who exercised 5+times per week and those that do 1 or less per week. People who are physically and sexually inactive require more careful medical advice and monitoring prior to sex. Medications that reduce heart rate, blood pressure, or inhibit platelet aggregation my reduce risk of MI. Beta blockers reduce myocardial oxygen demand and minimize angina during sex. The Onset Study found beta blockers reduced risk of MI following anger, but not sex. Aspirin lowers risk of MI following anger and in waking hours. Aspirin therapy showed a nonsignificant reduction in risk of MI after sex. • Recognize sexual dysfunction post-MI. Sexual dysfunction is common in patients with cardiovascular disease because of concern over risk, meds, diabetes, smoking, and hypertension. Sexual dysfunction is seen in ½ to ¾ of patients after MI and sometime in bypass surgery. Men and women have less sex and it's disappointing after an MI. This is often psychological due to perception of illness. In a report of 130 women with MI, 71% had decreased/no sex mainly due to fear. Many physicians don't discuss sex with MI patients/ spouses. Going to a cardiac rehab, treatment for psych condition, and reassurance of low risk may improve their sad sex life. • Describe the general principles of the treatment of sexual dysfunction in patients with cardiovascular disease. Sexual dysfunction is higher in people with cardiovascular disease. Enabling exercise is the greatest risk in MI patients. Low risk patients can be safely encouraged to resume sex intermediate risk patients need further evaluation achieved by stress testing. Consult with a cardiologist. High risk patients should have appropriate therapy before having sex. Important treatment includes correcting reversible cause. Tell them when it is safe to have sex. Thiazide diuretics, beta blockers, and lipid lowering drug side effects should be discussed. Also phosphodiesterase 5 inhibitors should not be used with nitrates.

Male Reproductive Physiology

• Each spermatogonium gives rise to 16 primary spermatocytes after puberty which each give rise to 4 spermatids and 4 spermatozoa • 300 mill. Spermatogonium begin the process each day and about 100 are actually produced • Spermatogonia-specific transcription factor, Plzf is required for stem cell self-renewal

Donor insemination

• Expensive, time-tested method of achieving pregnancy with reasonable success rate in fertile recipients • Timed to take place just prior to ovulation and use kits for measuring LH levels • Basal body temp is not helpful in determining timing in insemination because ovulation has typically already occurred once an increase in temp is apparent • Can be performed by the women, her partner, or a health care provider • Study showed IUI (intrauterine) was slightly more effective than ICI (intracervical) • Most health insurers d/n cover cost of semen until there has been 12 cycles of insemination w/out contraception • Some WSW request from males they know who are MSM which sperm banks typically d/n accept as donors • Issues concerning legal relationship with sperm donor and nonbiologic same sex parent should be addressed before insemination • Co-Maternity some couples chose this; the egg of one partner is aspirated, fertilized as in vitro and then transferred to uterus of other partner who is the gestational carrier; more costly and risky than simple insemination • Prenatal care, childbirth and hospitalization needs o In US, hospitals that accept Medicaid and Medicare funding must grant same sex partners visitation rights

Factors that may indicate an increase in risk for specific diseases in gay men

• GI infections oral-anal sexual contact • STDs (HBV, HCV) anal-receptive, oral genital • Colon cancer smoking, decreased frequency of screening • Anal cancer increased HPV from anal-receptive • Hepatocellular Cancer HBV and HCV from anal-receptive • Eating disorders, bulimia nervosa, anorexia nervosa subculture attitudes and pressures toward thinness and beauty and/or biological basis with structural brain studies

MSM vs Gay

• Gay typically describes a sexual orientation • MSM describes a behavior • Some MSM do not regard sex with other men as sexual activity (reserved for sex relations with women); especially true in people from non-western cultures

Suspicious findings of child sex abuse

• Genital or anorectal injury that requires surgical care; 25 % of such injuries were caused by sexual abuse. • Deep notches or clefts (>50 % of the width of hymenal rim) in the posterior/inferior rim of hymen may be caused by previous blunt force or penetrating trauma; deep notches may be artifact of exam technique • Thin posterior hymenal rim may also be indicative, but accurate measurement is difficult. • Lesions that appear to be genital warts may be skin tags, nongenital warts, or genital warts acquired by perinatal or nonsexual transmission. • Vesicular lesions or ulcers in the anogenital area may be caused by STIs (such as syphilis or HSV) as well as other viruses (including Epstein-Barr virus), Behcet's disease, Crohn's disease, and others. • Marked, immediate anal dilation to a diameter of 2 cm or more, in absence of other predisposing factors (chronic constipation, sedation, anesthesia, or neuromuscular conditions) may be indicative of sexual abuse

LH and FSH play roles in spermatogenesis

• Hypogonadotropic hypogonadism • Normal men, FSH is selectively suppressed by administration of testosterone and hCG • LH by itself is sufficient for reinitiation and maintenance of spermatogenesis

Spermatagonia => mature sperm

• Reconstructing of blood-testis barrier; development of flagellum • Nucleus relocates to eccentric position at head and is covered by acrosomal cap • Cilial core of tail (9 inner and 2 outer fibers) with mitochondria and cell membrane • Motility by sliding of fibers in axial portion of tail o Use dynein ATPase: hydrolysis of ATP provides energy • Sperm formation about 70 days after spermatocyte stage • Transport from epididymis to ejaculatory duct takes 14 days (where maturation occurs except for final step in the female reproductive tract) • Spermatogenesis needs low temperature of scrotum (compared to abdomen)

Androgen action in males

• Regulation of gonadotropin secretion by hypothalamic-pituitary system • Initiation and maintenance of spermatogenesis • Formation of male phenotype during embyogenesis. • Promotion of sexual maturation at puberty and maintenance after • Testosterone increases lean body mass and decreases fat mass

Factors that may indicate a decrease in risk for specific diseases in lesbians

• STDs sexual practices may be less likely to transmit but a history of male partnered sex may exist • Cervical cancer less HPV; but is present 80% since of lesbians have engaged in heterosexual sex o other mechanisms of transfer of HPV sex toys, digital intromission, oral genital, rubber exam gloves, biopsy forceps, cryoprobe tips, vaginal speculae, sexual abuse, vertical transmission, parturition transfer

Non-classical pathway

• Take place within seconds and may involve cell surface binding • Mediated by several mechanisms: o Classical intracellular AR via activation or co-regulator (Src) kinase o Direct binding to specific binding sites of target molecules without AR o Distinct cell surface transmembrane androgen receptors or G-protein receptors o Changes in membrane permeability • Responsible for stimulation of Ca++ influx and activation of mitogen-activated PK pathway in Sertoli cells

Classical pathway

• Testosterone and dihydrotestosterone bind to same high affinity androgen receptor (AR) • Binding causes receptor to dissociate from hsp90forms homodimer w/2nd hormone-AR receptor • Active transcriptional regulatory complex binds to androgen response elements (AREs) in DNA

Transsexualism: Biologic Considerations, Definitions, Diagnosis

• The condition in which a person w/apparently normal somatic sexual differentiation of one gender is convinced that he/she is actually a member of the opposite gender o Associated with irresistible urge to be that gender hormonally, anatomically, psychosocially

Gonadal steroids

• Transported in plasma bound to ALBUMIN and SEX HORMONE-BINDING GLUBULIN(SHBG) • Normal men, 2% free/unbound, 44% bound to SHBG and 54% is bound to albumin ( albumin binds more readily because of higher concentration but SHBG has a much higher affinity) • Prepubertal boys and hypogonadal men have higher SHBG levels than normal men; serum concentration is decreased by androgen and increased by estrogen administration • Note: SHBG levels are higher in prepubertal boys and hypogonadal men than normal men. • Androgen administration and hypothyroidism decreases serum concentration of SHBG, while estrogen administration and hyperthyroidism increase concentrations of SHBG.

3.) Distinguish difference btwn Transsexualism, transgenderism, homosexuality, & juvenile gender dysphoria

• Transsexualism- transsexuals experience the physical functioning of their sex organs as estranged from their selves and seek a reassignment to the desired sex. • Transgenderism- individuals who want to rid themselves of the natal sex without seeking reassignment to the opposite sex or want only partial adaptation to the opposite sex seek to have an in-between sex status. There may be a social transition to the opposite sex, which may be part-time. • Homosexuality- homosexuals are erotically attracted to persons with the same genital morphology. • Juvenile gender dysphoria- children w/ gender identity problems; some studies indicate homosexuality will be the outcome in these prepubertal children; depot forms of antagonists/agonists of gonadotropin-releasing hormone can be used if clear signs of sexual maturation are present to delay pubertal development until an age when balanced and responsible decision can be made.

Men sexual excitement is most evident by tumescence or penile erection

• Vasocongestion causes testes size to increase • Muscles in spermatic cord and scrotum draw testes close to body • As body prepares for orgasm, respiration increases, HR and BP increase; small amount of clear mucoid fluid secreted from Cowper's gland (precum) and emits from meatus • Contractions of vas deferens, seminal vesicles, and prostate followed by contraction of urethra and perineal and penile base muscles • Refractory phase after ejaculation (duration depends on man)

Women vasocongestion

• Vasocongestion of tissues causes transudation of clear fluid: occurs w/in 10-30 seconds after sexual arousal is initiated • Fluid serves as lubricating function for penile movement, neutralize normal vagina acidity, and aids in sperm survival • Breasts are areola enlarge because of vcasocongestion • Clitoris enlarges and becomes more sensitive to touch and pressure • Labia majora in nulliparious women are made flatter/thinner by muscle contraction while multiparous women have an extensive vascular network which swells in size during vasocongestion • Uterus becomes engorged and lifts upward • Just prior to orgasm, clitoris turns up 180 degrees and retracts behind pubic symphysis, flattened

Maintenance of proper conditions for germ cell development in the tubules

• ^because of the sertoli cell barrier of tight junctions b/t spermatogonia and primary spermatocyte • Glucose and testosterone can penetrate readily • Peptide hormones are retained in the tubular lumen • Paracrine/autocrine regulatory substances are produced by testes • Factors that influence spermatogenesis: neuropeptides, vasoactive peptides, growth factors, immune-derived cytokines

Goal of physician in working with WSW

• is to optimize fertility and minimize pregnancy complications: higher risk for pregnancy complications b/c they tend to be of older age at conception and experience more stress, higher BMI, and higher prevalence of smoking and drug abuse.

Explain spermatogenesis and its regulation

• spermatogonia =>Sertoli cells; Sertoli cytoplasm encompasses the differentiating spermatocytes and spermatids as they move =>lumen of the seminiferous tubules; tubules ducts (rete testes) =>epididymis. • Each spermatogonium that undergoes differentiation after puberty gives rise to 16 primary spermatocytes, each of which then enters meiosis and gives rise to four spermatids and finally four spermatozoa. Thus, the 3 million spermatogonia that begin the process each day give rise to approximately 200 million spermatozoa. • Regulation: pulsatile secretion of GnRH into the hypophyseal portal system elicits pulsatile secretion of LH and FSH by cells of the ant. pituitary o LH enhances testosterone synthesis o FSH aids in conversion of testosterone to estradiol and is responsible for regulating spermatogenesis.