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Antiviral Medication for Genital Herpes

Genital herpes is an infection of the genitals (penis in men, vulva and vagina in women) and surrounding area of skin. It is caused by the herpes simplex virus. Antiviral medicines such as aciclovir, famciclovir, and valaciclovir are used to treat genital herpes infection. They do not clear the virus completely from the body, so the symptoms may come back (recur). They work by stopping the virus from multiplying, which reduces the duration and severity of symptoms.

What is genital herpes?
Genital herpes is an infection of the genitals (penis in men, vulva and vagina in women) and surrounding area of skin. The buttocks and anus may also be affected. It is caused by the herpes simplex virus.
Genital herpes is usually a sexually transmitted infection. Many people who are infected with this virus never have symptoms but can still pass on the infection to others. If symptoms occur, they can range from a mild soreness to painful blisters on the genitals and surrounding area.
This leaflet just discusses antiviral medication for genital herpes. See separate leaflet called Genital Herpes for more general details on genital herpes infection.

What is antiviral medication?
There are three antiviral medicines that are currently usually used to treat genital herpes:
Aciclovir
Famciclovir
Valaciclovir
They all come in different brand names. They work by stopping the herpes virus from multiplying. They do not clear the virus from the body. If an antiviral medicine is started early in an episode of symptoms, it tends to reduce the severity and duration of symptoms during an episode of genital herpes.
It is thought that these medicines all work as well as each other when used to treat genital herpes.
Antiviral medication for a first episode of genital herpes
An antiviral medicine is commonly prescribed for a first episode of genital herpes. (A first episode of genital herpes is also called a primary episode.) A five-day course of treatment is usual but this may be extended by a few days if blisters are still forming. With a first episode of genital herpes, the sores and blisters may last from about 10 days up to 28 days. This is usual

Antiviral medication for recurrent episodes of genital herpes
Further episodes of symptoms (recurrences) tend to be milder and usually last just a few days. You usually have 7-10 days of symptoms rather than 10-28 days that can occur with a first episode. Antiviral medication is often not needed for recurrences. Painkillers, salt baths, and local anaesthetic ointment (such as lidocaine) for a few days may be sufficient to ease symptoms. However, an antiviral medicine may be advised for recurrent episodes of genital herpes in the following situations:
⦁    If you have severe recurrences. If you take a course of an antiviral medicine as soon as symptoms start, it may reduce the duration and severity of symptoms. You may be prescribed a supply of medication to have ready at home to start as soon as symptoms begin. This kind of "as needed" treatment tends to be prescribed if you are getting severe attacks of genital herpes fewer than six times a year. There are a number of different options of courses of treatment to take, ranging from one to six days in length, and with different daily regimes.
⦁    If you have frequent recurrences. You may be advised to take an antiviral medicine every day. In most people who take medication every day, the recurrences are either stopped completely, or their frequency and severity are greatly reduced. A lower maintenance dose rather than the full treatment dose is usually prescribed. A typical plan is to take a 6- to 12-month course of treatment. You can then stop the medication to see if recurrences have become less frequent. This type of continuous treatment can be repeated if necessary. This type of daily treatment tends to be prescribed if you have severe attacks of genital herpes more than six times per year.
⦁    For special events. A course of medication may help to prevent a recurrence during special times. This may be an option even if you do not have frequent recurrences but want to have the least risk of a recurrence - for example, during a holiday or during exams.
Antiviral medication for genital herpes whilst you are pregnant
A specialist will normally advise about what to do if you develop genital herpes whilst you are pregnant, or if you have recurrent genital herpes and become pregnant. This is because there may be a chance of passing on the infection to your baby.

A first episode of genital herpes whilst you are pregnant
If you develop a first episode of genital herpes within the final six weeks of your pregnancy, or around the time of the birth, the risk of passing on the virus to your baby is highest. In this situation there is about a 4 in 10 chance of the baby developing a herpes infection. The baby may develop a very serious herpes infection if he or she is born by a vaginal delivery.
Therefore, in this situation your specialist is likely to recommend that you have a caesarean section delivery. This will greatly reduce the chance of the baby coming into contact with the virus (mainly in the blisters and sores around your genitals). Infection of the baby is then usually (but not always) prevented.
However, if you decide against a caesarean section and decide to opt for a vaginal birth, the specialist is likely to recommend that you be given antiviral medication (usually aciclovir). This is given into your veins (intravenously) during your labour and birth. They may also suggest that antiviral medication be given to your baby after he or she is born.
As long as there are two months between your catching the virus and giving birth to your baby, a normal vaginal delivery is likely to be safe for the baby. This is because there will be time for your body to produce protective proteins called antibodies. These will be passed on to the baby through your bloodstream to protect it when it is being born. The specialist may advise that you should be treated with antiviral medication at the time of infection. This helps the sores to clear quickly. In addition, your doctor may advise that you should take antiviral medication in the last four weeks of pregnancy to help prevent a recurrence of herpes at the time of childbirth. Antiviral medicines such as aciclovir have not been found to be harmful to the baby when taken during pregnancy.
If you have recurrent genital herpes and become pregnant
If you have recurring episodes of genital herpes, the risk to your baby is low. Even if you have an episode of blisters or sores during childbirth, the risk of your baby developing a serious herpes infection is low. This is because you pass on some antibodies and immunity to the baby during the final two months of pregnancy.
For most women with recurrent genital herpes, it is felt to be safe to have a normal vaginal delivery. This is even the case if you have a recurrence whilst giving birth. However, you and your specialist will weigh up the pros and cons of vaginal delivery vs caesarean section. If you do have a recurrent episode when you go into labour, you should discuss your options with your specialist and together decide the best way that your baby should be delivered.
Often antiviral medication will be advised in the last four weeks running up to childbirth. This may help to prevent a recurrence of blisters during childbirth. Again, your specialist will be able to advise on the pros and cons.
In summary
A first episode of herpes around the time of birth can be serious for the baby and a caesarean section is usually advised. In any other situation - an earlier primary infection or a history of recurrent episodes - the risk to the baby is low and your specialist will advise on possible options. This may include taking antiviral medication, as well as the type of delivery method.

Are there any side-effects from antiviral medicines?
Most people who take antiviral medication get no side-effects, or only minor ones. Feeling sick (nausea), being sick (vomiting), diarrhoea, and tummy (abdominal) pain, as well as skin rashes (including photosensitivity and itching) are the most common side-effects.
Read the leaflet inside the medication packet for a full list of possible side-effects.
How to use the Yellow Card Scheme
If you think you have had a side-effect to one of your medicines you can report this on the Yellow Card Scheme. You can do this online at the following web address: www.mhra.gov.uk/yellowcard.
The Yellow Card Scheme is used to make pharmacists, doctors and nurses aware of any new side-effects that medicines or any other healthcare products may have caused. If you wish to report a side-effect, you will need to provide basic information about:

It is helpful if you have your medication - and/or the leaflet that came with it - with you while you fill out the report.

Further reading & references
2014 UK National Guideline for the Management of Anogenital Herpes; British Association for Sexual Health and HIV (2014)
Management of Genital Herpes in Pregnancy; British Association of Sexual Health and HIV and Royal College of Obstetricians and Gynaecologists (Oct 2014)
Herpes simplex - genital; NICE CKS, September 2012 (UK access only)
British National Formulary; NICE Evidence Services (UK access only)
Caesarean section; NICE Clinical Guideline (November 2011)

Combined Oral Contraceptive Pill

The combined oral contraceptive pill (COCP) is often just called "the pill". It contains two hormones - an oestrogen and a progestogen. If taken correctly, it is a very effective form of contraception.

How does the pill work?
It works in three ways:
The pill changes the body's hormone balance so that your ovaries do not produce an egg (ovulate).
It also causes the mucus made by the neck of the womb (cervix) to thicken. This makes it difficult for sperm to get through to the womb (uterus) to fertilise an egg.
The pill also makes the lining of the womb thinner. This makes it less likely that a fertilised egg will be able to attach to the uterus.
There are different types and strengths of oestrogens and progestogens.

How effective is the pill?
About 3 women in 1,000 using the pill correctly will become pregnant each year. Correct use means not missing any pills, re-starting the pill on time after the pill-free week and taking extra contraceptive precautions when necessary - see below. Closer to 90 women per 1,000 will become pregnant with normal (not perfect) usage.
For comparison, when no contraception is used, more than 800 in 1,000 sexually active women become pregnant within one year.
What are the advantages of the pill?

It may also reduce the risk of pelvic infection (as the thicker mucus prevents germs (bacteria), as well as sperm, from getting into the uterus).
It may help to protect against some non-cancerous (benign) breast disease.

Are there any side-effects when taking the pill?
Most women who take the pill do not develop any side-effects. However, a small number of women feel sick, have headaches or find their breasts are sore when they take the pill. These usually go away within days or weeks of starting the pill. If they continue (persist) there are many different brands of pill you can try, which may suit you better.
Other side-effects are uncommon and include tiredness, change in sex drive, skin changes and mood changes. These are unusual and you should tell your doctor or practice nurse if you have any lasting side-effects. Many people believe that taking the pill makes you put on weight, but this has never been proven in studies.
The pill sometimes causes a rise in blood pressure, so people taking it should have their blood pressure checked every six months. The pill may need to be stopped if your blood pressure becomes too high.
It is common to have some light bleeding between periods when you start the pill. This is nothing to worry about. It usually settles by the end of the third packet. If it does not, you should tell your doctor.

Are there any risks in taking the pill?
The pill can have some serious side-effects, but these are very uncommon. For most women the benefits of the pill outweigh the possible risks. All risks and benefits of you taking the pill should be discussed with your doctor or nurse.
People taking the pill have a small increased risk of getting a blood clot (thrombosis). Blood clots can cause blockages in veins or arteries, and can cause heart attacks or strokes. This is more so in the first year of taking the pill. This is why people with a higher risk of blood clots cannot take the pill. The things that might mean you are at a higher risk are listed in the section "Who cannot take the pill?", below. The risk of a blood clot from taking the pill is considerably smaller than the risk of a blood clot if you were pregnant.
You must see a doctor straightaway if you have any of the following:

These symptoms could be due to a blood clot.
Taking the pill can increase the risk of some types of cancer but also protect against other types. Research into the risk of breast cancer in people taking the pill is complicated and the results are not straightforward. Some studies suggest a possible link between the pill and a slightly increased risk of cancer of the neck of the womb (cervix) if the pill is taken for more than eight years. Some research suggests a link between using the pill and developing a rare liver cancer.
However, there is a reduced risk of developing cancer of the ovary, womb (uterus) and colon in people taking the pill. When all cancers are grouped together, the overall risk of developing a cancer is reduced if you take the pill. Further research is ongoing.
Note: if you need to go into hospital for an operation, or you have an accident which affects the movement of your legs, you should tell the doctor that you are taking the pill. The doctor may decide that you need to stop taking the pill for a period of time to reduce your risk of unwanted blood clots whilst you recover.

Who cannot take the pill?
Most women can take the pill. If you are healthy, not overweight, do not smoke and have no medical reasons for you not to take the pill, you can take it until your menopause. Women using the pill will need to change to another method of contraception at the age of 50 years. Your doctor or family planning nurse will discuss any current and past diseases that you have had. Some diseases cause an increased risk or other problems with taking the pill. Therefore, the pill will not be prescribed to some women with certain diseases - for example, hepatitis or breast cancer, or if you are taking certain medicines.
These are some of the conditions which may mean you should not take the pill:

Not all these conditions mean you definitely shouldn't have the pill. Your doctor or nurse will be able to work out whether it is safe for you individually. There are very clear guidelines about who should or shouldn't take it, which they can refer to.

How do I take the pill?
There are different brands of pill which contain varying amounts and types of oestrogen and progestogen. There is usually a leaflet inside the packet of pills. Read the leaflet carefully. Make sure you understand how to take the pill and what to do in special situations, such as:

The following gives a general guide.
Brands with 21-day pills
Most brands of pill come in packs of 21. To start, it is best to take the first pill on the first day of your next period. You will be protected against pregnancy from then on. If you start the pill on any other day, you need an additional contraceptive method (such as condoms) for the first seven days. You should take your pill at about the same time each day for the 21 days.
You then have a break of seven days before starting your next pack. You will usually have some bleeding in the seven-day break, although it may happen later. This is called a withdrawal bleed and is like a period, although strictly speaking it is not a menstrual period. You will be protected from pregnancy during the seven-day break provided you have taken your pills correctly and you start the next pack on time. Start the next pack after the seven-day break whether you are still bleeding or not. If you take the pill correctly, you will start the first pill of each pack on the same day of the week. (It is only when you start the pill for the first time that you take the first pill on the first day of your period. After this, you should ignore your period and start each packet on the same day of the week as the month before. Write down the day of the week you start your first pack, and start all your packets after that on that day.)
Most 21-day pills have the same amount of oestrogen and progestogen in each pill. Some brands, called phasic pills, vary the dose in two or three steps throughout the 21 days. The pills in these packets have to be taken in the correct order as directed on the packet. One type of pill called Qlaira® has a changing dose throughout the cycle, and also needs to be taken in the correct order.
Brands with pills for every day
Most of these contain 21 active and seven dummy pills. There are 28 pills in a packet. Instead of a seven-day break, you carry on taking the dummy pills. As soon as you finish one packet, you go on to the next. The idea is that you don't have to remember to restart the pill after a seven-day break and you develop a routine of taking a pill every day. The pills have to be taken in the correct order. Read the instructions carefully, particularly on when to start, which pill to start with, and how long it takes for the contraceptive effect to begin. The newer pills Qlaira® and Zoely® are slightly different. In these pills there are 28 pills in the packet. Qlaira® has two dummy pills, as well as changing doses throughout the cycle. Zoely® has four dummy pills, and all the other pills in the packet are the same dose. These pills are also taken without a seven-day break.

What if I miss or forget to take one or more pills?
Read the leaflet that comes with your brand of pill for advice on what to do. Your ovaries could produce an egg (ovulate), and therefore you could become pregnant, if you miss pills. This is particularly a risk if the missed pills are at the end or beginning of the packet. The advice depends on how many pills you have missed, and when they were missed in the cycle. If you are 24 hours late, or more, taking your pill, it counts as a missed pill.
If one pill is missed, anywhere in the pack, take the missed pill now. This may mean taking two pills in one day. You should take the rest of the pack as usual. No extra contraception is needed. You should have the seven-day break as normal.
If two or more pills are missed anywhere in the pack, take the last missed pill now. This may mean taking two pills in one day. Any earlier missed pills should not be taken. You should take the rest of the pack as usual. You should also use extra precautions (ie use a condom or don't have sex) for the next seven days.
You may need emergency contraception (the morning after pill or similar) if you have had unprotected sex in the previous seven days and have missed two or more pills in the first week of a pack. This also applies if you start your pack two or more days late.
You should start the next pack of pills without a break, if there are fewer than seven pills left in the pack (after the missed pill).
If you are unsure what to do, or are unsure that you have taken the pill correctly, use other forms of contraception (such as condoms) and seek advice from a doctor or nurse.
Note: if you are on the pills called Qlaira® or Zoely® this advice may not apply. The information that comes with the packet should tell you what to do if you miss pills. If you are still not sure, ask your doctor or nurse.

Do other medicines interfere with the pill?
Yes, some do but most do not. Therefore, before you take any other medicines, including those available to buy without a prescription, herbal and complementary medicines, ask your doctor or pharmacist if they stop the pill from working properly. He or she will advise you on what to do.
For example, some medicines that are used to treat epilepsy and tuberculosis (TB) can stop the pill from working properly. St John's wort is an example of a commonly used herbal remedy that can affect the pill.
Antibiotic medicines
Antibiotics (other than one called rifampicin) do not interfere with the effectiveness of the pill. In the past it was recommended that, if you were taking antibiotics and were also taking the pill, you should use additional contraception. This is no longer the current recommendation after more recent evidence has been reviewed. You should continue taking your pill as normal if you also need to take any antibiotics.

What if I am sick (vomit) or have diarrhoea?
If you vomit within 2-3 hours of taking a pill, the pill will not have been absorbed. If you are well enough, take another pill as soon as possible. Provided that you do not vomit this second pill and it is taken on the same day, you will remain protected from pregnancy. If you continue to vomit, the advice is the same as missing pills (see above). Mild diarrhoea does not affect the absorption of the pill. Severe diarrhoea may affect it and if you have severe diarrhoea, consider this as the same as missing pills (see above).

What happens if I don't have a withdrawal bleed (period) between packs?
It is normal to have bleeding during the seven-day break between pill packs (or when taking the dummy pills in pills taken every day). However, it is quite common for there to be no bleeding between pill packs. You are not likely to be pregnant if you have taken the pill correctly and have not been sick (vomited) or taken any medicines that can interfere with the pill. Start the next pack after the usual seven-day break and continue to take your pill as usual. Do a pregnancy test or see your doctor or nurse if:

A pregnancy test may be advised.
Bleeding whilst on the pill (breakthrough bleeding)
During the first few months, while your body is adjusting to the pill, you may have some vaginal bleeding in addition to the usual bleeding between packs. This is not serious but more of a nuisance. It may vary from spotting to a heavier loss like a light period. Do not stop taking your pill. This usually settles after the first 2-3 months. If it continues (persists), see your doctor or nurse. Another brand of pill may be more suitable for you.

Can I delay or skip a withdrawal bleed (period)?
There are times when it is useful not to have a period - for example, during exams or holidays. Check with your doctor or nurse about the best way to do this with your particular brand of pill. For the commonly used pill types (that is, not bi-phasic or tri-phasic or the pills that are taken every day with 28 pills in the packet) you can go straight into your next pack without a break. Have the usual seven-day break at the end of the second packet.

Bacterial Vaginosis

Bacterial vaginosis (BV) is common and causes a vaginal discharge, often with a noticeable smell. BV is not a sexually transmitted infection. It is caused by an overgrowth of normal germs (bacteria) in the vagina. Symptoms are often mild, and BV may clear without treatment. Other cases can be treated with antibiotic medication.

What is bacterial vaginosis (BV) and what causes it?

BV is a common condition of the vagina caused by an overgrowth of various germs (bacteria). It is not just one simple infection caused by one type of germ (bacterium). The vagina normally has a mix of bacteria, but in BV the balance changes. It is not clear why this happens. As a result, certain bacteria multiply and thrive much more than usual. Some bacteria become much more prominent than they normally are.

BV is not caused by poor hygiene. In fact, excessive washing of the vagina may alter the normal balance of bacteria in the vagina, which may make BV more likely to develop.

Who gets bacterial vaginosis (BV) and how common is it?

It is not exactly known how common BV is, because it is often so mild that women may not go to the doctor. It may be that as many as about 1 in 3 women have BV at some time in their lives.

You are more likely to get BV if:

What are the symptoms of bacterial vaginosis (BV)?

The main symptom of BV is a vaginal discharge. BV is one of the most common causes of vaginal discharge in women of childbearing age. The discharge is often white-grey in colour, and often has a fishy smell. The smell may be more noticeable during sex. The discharge tends to be heaviest just after a period, or after sex. The discharge does not usually cause itch or soreness around the vagina and vulva.

Many women with BV do not have any symptoms (up to half of cases).

Note: BV is not the only cause of a vaginal discharge. Various conditions can cause discharge. For example, another common cause of vaginal discharge is an infection caused by a yeast called thrush (candida). Unlike BV, thrush typically causes a thicker white discharge which tends to cause itching and soreness around the vagina and vulva. (See separate leaflet called Vaginal Thrush for more information.) STIs, such as chlamydia, may also cause vaginal discharge. (See separate leaflet called Genital Chlamydia for more information.)

Is bacterial vaginosis (BV) a sexually transmitted disease?

No, BV can affect any woman, including those who do not have (or who have never had) sex. However, BV is more common amongst sexually active women than amongst non-sexually active women. No germ (bacterium) is passed on between sexual partners to cause this condition. Sexual partners of women with BV do not need any treatment. However, some cases of BV seem to be sexually related. It may develop after a change in sexual partner. In these cases, the infection is not caught from anyone. But a change in sexual partner may affect the balance of normal germs (bacteria) in the vagina. BV is also more likely in women in same sex relationships who have had a change of partner.

How is bacterial vaginosis (BV) diagnosed?

The typical discharge and its characteristic fishy smell make BV likely. If you are in a stable, long-term relationship, your doctor or nurse may be happy to diagnose BV just by it's typical symptoms. However, there are some tests available that can help to confirm the diagnosis. Also, if you are pregnant, it is important to make an accurate diagnosis if you have vaginal discharge so that any infection can be treated effectively. This will mean having one or more of the tests below.

Testing the acid level of your vagina

The discharge of BV has a typical pH level (acid/alkaline balance) compared to other causes of discharge. (The overgrowth of the germs (bacteria) of BV causes the pH to change in the vagina so that it becomes more alkaline, ie the pH rises.) If available, your doctor or nurse may suggest that they take a sample of your discharge and test it with some pH paper. In addition, if an alkali is added to a sample of the discharge, it often causes a characteristic fishy smell.

Taking a sample (a swab)

To confirm the diagnosis, your doctor or nurse may also suggest that a swab of your discharge be taken from your vagina and sent to the laboratory for testing. Large numbers of various bacteria that occur with BV are seen under the microscope. Your doctor or nurse may suggest that they take more than one swab from your vagina to rule out other causes of vaginal discharge.

What are the possible complications of bacterial vaginosis (BV)?

BV and pregnancy

If you have untreated BV during pregnancy, you have a slightly increased risk of developing some complications of pregnancy. These include:

If you have untreated BV, you may have an increased risk of developing HIV infection if you have sex with someone who is infected with HIV. You may also be more likely to pass on HIV if you have HIV and BV together. There is also some evidence that women with untreated BV may be at an increased risk of developing pelvic inflammatory disease (PID). (See separate leaflets called HIV and AIDS and Pelvic Inflammatory Disease.)

What is the treatment for bacterial vaginosis (BV)?

Not treating is an option for some women

BV often causes no symptoms, or the symptoms are mild. Also, there is a good chance that BV will gradually clear without treatment. Any disruption in the balance of vaginal germs (bacteria) may be corrected naturally, with time. So, if you have no symptoms or only mild symptoms, you may not need any treatment.

However, if you are pregnant and you are found to have BV but have no symptoms, you may still be advised to take antibiotic treatment. The benefit of treating pregnant women who have BV and no symptoms is a little uncertain. Your doctor may seek advice from a gynaecologist about whether or not you need treatment.

Note: all pregnant women who have symptoms due to BV should be offered treatment. If you are found to have BV and are undergoing a termination of pregnancy, treatment with antibiotics may also be advised even if you do not have any symptoms. This is because there is a risk of BV causing a more serious infection of the womb (uterus) or pelvis after the procedure if it is not treated. Some doctors also suggest antibiotics for women with BV (and no symptoms) who are about to undergo other gynaecological procedures such as an endometrial biopsy - a biopsy of the lining of the womb.

Metronidazole tablets

A course of metronidazole tablets is the common treatment. Metronidazole is an antibiotic. It clears BV in most cases. Read the leaflet that comes with the tablets for a full list of possible side-effects and cautions. However, main points to note about metronidazole include:

The usual dose is 400-500 mg twice a day for 5-7 days. A single dose of 2 grams is an alternative, although this may be less effective and may cause more side-effects. (Note: this single dose is not recommended if you are pregnant.) If you are taking the seven-day course, it is important to finish the course and not to miss any tablets.

Some people feel sick or may be sick (vomit) when they take metronidazole. This is less likely to occur if you take the tablets straight after food. A metallic taste is also a common side-effect.

Do not drink any alcohol while taking metronidazole, and for at least 48 hours after stopping treatment. The interaction with alcohol can cause vomiting and other problems such as flushing and an increased pulse rate.

Breast-feeding: metronidazole can get into breast milk but will not harm your baby. However, oral metronidazole is not recommended and instead you should use vaginal metronidazole or clindamycin.

Alternative antibiotic treatments

Metronidazole vaginal gel or clindamycin vaginal cream placed inside the vagina can be used if you prefer this type of treatment, or have unpleasant side-effects with metronidazole tablets. The ability of these treatments to clear BV is about the same as metronidazole taken by mouth.

Note: as with metronidazole tablets, you should avoid alcohol while using metronidazole gel and for at least 48 hours after stopping treatment. Also, vaginal creams and gels can cause weakening of latex condoms and diaphragms. Therefore, during treatment and for five days after treatment with clindamycin vaginal cream, do not rely on condoms or diaphragms to protect against pregnancy and STIs.

Other antibiotic tablets taken by mouth are also sometimes used to treat BV. These are clindamycin tablets or tinidazole tablets.

Other treatments

Overall, there is no strong evidence at the moment that live yoghurt or Lactobacillus acidophilus (found in certain commercial probiotic products) is helpful in treating or preventing BV. Antiseptics and disinfectants do not help treat BV.

Do I need a test of cure?

Women who are not pregnant

After treatment, you do not need any further tests to ensure that BV has cleared (a test of cure) provided that your symptoms have gone.

Women who are pregnant

If you are pregnant, it is suggested that you do have a test one month after treatment to ensure that BV is no longer present. A sample of the discharge in your vagina (a swab) is taken. This is tested to check you no longer have BV.

Treating recurrences

If you have a recurrence of symptoms and did not have a test using a sample of your vaginal discharge (a swab) taken initially, your doctor or nurse may suggest that they take swab tests now. This is to confirm that it is BV causing your symptoms.

BV may return (recur) if you did not complete your course of antibiotics. However, even if you have completed a full course of antibiotics, BV recurs within three months in many women. If it does recur, a repeat course of antibiotics will usually be successful. A small number of women have repeated episodes of BV, and need repeated courses of antibiotics.

If you have a copper coil for contraception - an IUCD - and have recurrent BV, your doctor or nurse may suggest that they remove your IUCD to see if this helps to improve your symptoms. You will need to discuss alternative contraception measures with them.

How can I prevent further episodes of bacterial vaginosis (BV)?

Most episodes of BV occur for no apparent reason, and cannot be prevented. However, the following are thought to help prevent some episodes of BV. The logic behind these tips is to try not to upset the normal balance of germs (bacteria) in the vagina:

Do not push water into your vagina to clean it (douching). The vagina needs no specific cleaning.

Do not add bath oils, antiseptics, scented soaps, perfumed bubble bath, shampoos, etc, to bath water.

Do not use strong detergents to wash your underwear.

Do not wash around your vagina and vulva too often. Once a day is usually enough.

Condom (Sheath)

The male condom is an effective method of contraception if used correctly. It also helps to protect against sexually transmitted infections.
What are condoms?
A condom covers the erect penis during sex and stops sperm from entering the woman's vagina. Most male condoms are made from thin latex (rubber). About 2 in 100 people are allergic to latex. The newer polyurethane (plastic) condom is an alternative. Polyurethane condoms are also odour-free, thinner and more sensitive than latex condoms. However, they are more expensive.
How effective is the male condom?
About 2 women in 100 will become pregnant each year if condoms are used perfectly for contraception. Nearer to 20 women in 100 will become pregnant with normal (not perfect) usage. When no contraception is used, more than 80 out of 100 sexually active women become pregnant within one year.
If condoms are used less carefully then they become less effective. Correct use means:
1.    Using a condom every time you have sex.
2.    Putting it on the penis before it touches the vaginal area.
3.    The penis should also not touch the woman's vaginal area after the condom is taken off.
What are the advantages of the condom?
They are easy to buy and use, and are free from medical risks. They can be very reliable if used carefully. They help to protect from sexually transmitted infections. They may help to prevent cancer of the cervix (neck of the womb).
What are the disadvantages of the male condom?
Some people feel sex has to be interrupted to put a condom on. Some men feel that their penis is less sensitive with a condom on. The condom may sometimes split. If it splits, there is a risk of pregnancy.
How do I use a condom?
Read the instructions on the packet carefully. The following is a general guide:
1.    Make sure the condom you use is of good quality (look for the British Standards Institute (BSI) kitemark and 'use by' date).
2.    Put the condom on the penis before any contact with the vagina.
3.    Use each condom only once.
4.    Pinch the teat end to get rid of air.
5.    Then roll the condom on to the erect penis.
6.    You should not use oil-based products - such as Vaseline®, body oils, or lotions - with latex condoms. They can damage latex and cause the condom to split. If you want to use a lubricant with a latex condom then use K-Y Jelly® or a spermicidal jelly. Any lubricant is fine with polyurethane condoms.
7.    After sex, withdraw the penis before it becomes too soft.
8.    Take care not to spill any semen when taking off the condom.
9.    If the condom splits or slips off, seek advice about emergency contraception within 72 hours.
Common errors when using a condom
These include the following:1.    The penis may leak sperm before the man ejaculates ('comes'). If there is any contact with the vaginal area before the condom is put on, the woman may become pregnant.
2.    The condom may also leak sperm when the penis is withdrawn.
3.    If you have had sex already there may be sperm still on the penis. If there is any contact with the vagina before a new condom is put on, the woman may become pregnant.
4.    Damage to the condom may cause the condom to split - for example, when handled by women with sharp fingernails.

Note: if any of the above happens then you should obtain emergency contraception within 72 hours. It is more effective the sooner it is taken after sexual intercourse.
See separate leaflet called Emergency Contraception for further details.
Further reading & references
Emergency Contraception; Faculty of Sexual and Reproductive Healthcare (2011)
Barrier Methods for Contraception and STI Prevention, Faculty of Sexual and Reproductive Healthcare (August 2012)
Contraception - barrier methods and spermicides; NICE CKS, June 2012
Trussell J; Contraceptive failure in the United States, Contraception, 2011

The Gut

This leaflet gives a brief overview of the gut and how the gut works.

What is the gut?

The gut (gastrointestinal tract) is the long tube that starts at the mouth and ends at the anus. Cross-section diagram of the abdomen showing the full gastrointestinal organs

Where is the gut found?

The mouth is the first part of the gastrointestinal tract. When we eat, food passes down the oesophagus (gullet), into the stomach, and then into the small intestine. The small intestine has three sections - the duodenum, jejunum and ileum. The duodenum is the first part of the small intestine and follows on from the stomach. The duodenum curls around the pancreas creating a c-shaped tube. The jejunum and ileum make up the rest of the small intestine and are found coiled in the centre of the abdomen. The small intestine is where food is digested and absorbed into the bloodstream. Following on from the ileum is the first part of the large intestine, called the caecum. Attached to the caecum is the appendix. The large intestine continues upwards from here and is known as the ascending colon. The next part of the gut is called the transverse colon because it crosses the body. It then becomes the descending colon as it heads downwards. The sigmoid colon is the s-shaped final part of the colon which leads on to the rectum. Faeces is stored in the rectum and pushed out through the anus when you go to the toilet. The anus is a muscular opening that is usually closed unless you are passing stool. The large intestine absorbs water, and contains food that has not been digested, such as fibre.

What does the gut do?

The gut processes food - from the time it is first eaten until it is either absorbed by the body or passed out as faeces. The process of digestion begins in the mouth. Here your teeth and enzymes (chemicals made by the body) begin to break down food. Muscular contractions help to move food into the oesophagus and on to the stomach. Chemicals produced by cells in the stomach begin the major work of digestion.

While some foods and liquids are absorbed through the lining of the stomach, the majority are absorbed in the small intestine. Muscles in the wall of the gut mix your food with the enzymes produced by the body. They also move food along towards the end of the gut. Food that can't be digested, waste substances, bacteria and undigested food all get passed out as faeces.

How does it work?

The mouth contains salivary glands which release saliva. When food enters your mouth the amount of saliva increases. Saliva helps to lubricate food and contains enzymes that start chemically digesting your meal. Teeth break down large chunks into smaller bites. This gives a greater surface area for the body's chemicals to work on. Saliva also contains special chemicals that help to stop bacteria from causing infections.

The amount of saliva released is controlled by your nervous system. A certain amount of saliva is normally continuously released. The sight, smell or thought of food can also stimulate your salivary glands.

To pass food from your mouth to the oesophagus you must be able to swallow. Your tongue helps to push food to the back of the mouth. Then the passages to your lungs close and you stop breathing for a short time. The food passes into your oesophagus. The oesophagus releases mucus to lubricate food. Muscles push your meal downwards towards the stomach.

The stomach is a j-shaped organ found between the oesophagus and duodenum. When empty, it is about the same size as a large sausage. Its main function is to help digest the food you eat. The other main function of the stomach is to store food until the gut is ready to receive it. You can eat a meal faster than your intestines can digest it.

Digestion involves breaking food down into its most basic parts. It can then be absorbed through the wall of the gut into the bloodstream and transported around the body. Just chewing food doesn't release the essential nutrients, so enzymes are needed.

The wall of the stomach has several different layers. The inner layers contain special glands. These glands release enzymes, hormones, acid and other substances. These secretions form gastric juice, the liquid found in the stomach.

Muscle and other tissue form the outer layers. A few minutes after food enters the stomach the muscles within the stomach wall start to contract (tighten). This creates gentle waves in the stomach contents. This helps to mix the food with gastric juice.

Using its muscles, the stomach then pushes small amounts of food (now known as chyme) into the duodenum. The stomach has two sphincters, one at the bottom and one at the top. Sphincters are bands of muscles that form a ring. When they contract the opening, the control closes. This stops chyme going into the duodenum before it is ready.

Digestion of food is controlled by your brain, nervous system and various hormones released in the gut. Even before you begin eating, signals from your brain travel via nerves to your stomach. This causes gastric juice to be released in preparation for food arriving. Once food reaches the stomach, receptors (special cells which detect changes in the body) send their own signals. These signals cause the release of more gastric juice and more muscular contractions.

When food starts to enter the duodenum this sets off different receptors. These receptors send signals that slow down the muscular movements and reduce the amount of gastric juice made by the stomach. This helps to stop the duodenum being overloaded with chyme.

Diagram showing detail around the pancreas

The duodenum, jejunum and ileum make up the small intestine. The first part of the duodenum receives food from the stomach. It also receives bile from the gallbladder via the bile duct, and pancreatic enzymes made by cells in the pancreas via the pancreatic duct. Pancreatic enzymes are needed to break down and digest food. Bile, although not essential, helps in the digestion of fatty foods. Cells and glands in the lining of the the small intestines also produce intestinal juice that helps digestion. Contractions in the wall of the small intestine help to mix food and to move it along.

The small intestine also has special features which help to increase the amount of nutrients absorbed by the body. The inner layer of the small intestine has millions of what are known as villi. These are tiny finger-like structures with small blood vessels inside. They are covered by a thin layer of cells. Because this layer is thin, it allows the nutrients released by digestion to enter the blood. Most of the important nutrients needed by the body are absorbed at different points of the small intestine.

Following on from the ileum is the large intestine. The inside of the large intestine is wider than the small intestine. It does not contain villi, and mainly absorbs water. Bacteria in the large intestine also help with the final stages of digestion. Once chyme has been in the large intestine for 3-10 hours it becomes semi-solid. This is because most of the water has been removed. These remnants are now known as faeces.

Movements of the muscles found in the large intestine help to digest the chyme and move faeces towards the rectum. When faeces are present in the rectum, the walls of the rectum stretch. This stretch activates special receptors. These receptors send signals via nerves to the spinal cord. The spinal cord signals back to the muscles in the rectum, increasing pressure on the first sphincter of the anus. The second, or external sphincter of the anus is under voluntary control. This means you can decide whether you will open your bowels or not. Young children have to learn to control this during toilet training.

Some disorders of the gut

•Acid reflux and oesophagitis

•Anal fissure

•Appendicitis

•Barrett's oesophagus

•Cancer of the bowel

•Cancer of the liver

•Cancer of the oesophagus

•Cancer of the pancreas

•Cancer of the stomach

•Cholecystitis

•Coeliac disease

•Constipation

•Crohn's disease

•Cystic fibrosis

•Diarrhoea

•Diverticula

•Duodenal ulcer

•Dyspepsia

•Gallstones

•Gastroenteritis

•Haemorrhoids (piles)

•Helicobacter pylori and stomach pain

•Hernia

•Hiatus hernia

•Irritable bowel syndrome

• ect..