SCORA - NPET Booklet

Standing Committee on Reproductive Health Including AIDS National Peer Education Syllabus Compiled by Nadia Abu Shamala SCORA – NPET Liaison Officer ’11-‘12

Preface

Peer education is a process through which well trained and motivated young people educate peers, meaning those similar to themselves in age group. Such education takes on a non formal style such that it creates an environment in which those learning feel comfortable to ask questions or discuss issues which they may not be comfortable discussing with their teacher or back at home. The aim therefore, is to develop young people’s knowledge, attitudes, beliefs and skills and to enable them to be responsible for their own health.

Peer education doesn’t involve directly telling teens what to do and what not to do; rather it elicits discussion and reflection through interactive techniques and non formal conversation.

Various studies have shown that instilling a sense of fear doesn’t work with teens. Peer education allows the youth to gain the required knowledge to make a proper and informed decision since it makes use of peer influence in a positive way.

In Malta, sexual and reproductive health are subjects that still have the power to raise many eyebrows, and some degree of taboo still surrounds the topic of sex for (too) many people, particularly in the extremely important context of adults educating children and youngsters.

This is why SCORA in Malta aims to provide both teens and the general public with all the skills and knowledge necessary to make proper sexual health decisions. Perhaps one of SCORA’s greatest challenges is removing the social stigma associated with sexual issues, not only amongst the general public but also amongst us as tomorrow’s doctors.

One of SCORA’s main projects (in liaison with NPET) is to reach youth through Peer education sessions. These sessions have a foundation of evidence, respect, equality, dignity and freedom of thought and expression. Our aim is not to impose on the students, but rather to equip them with the self-assertion needed to make responsible choices in life.

This Document is meant to act as a guide for Peer Educators when preparing for and delivering Peer Education Sessions. It can also be used as a good reference during sessions, should there be a degree of uncertainty pertaining to a particular topic. Moreover, the document can be used as a resource when approaching schools to advocate for delivery of these sessions in schools.

The following is a brief overview of what this document contains information about:

Sexual Health Syllabus (1hr 30mins)

1. Describe briefly the male and female anatomy. Talk about the changes during Puberty – physically and emotionally 2. Why is it important to have safe sex?  Definition of STDs/STIs  Talk about each STD using pictures of what they can cause 3. Different methods of contraceptives  ABC  Mention each one and say how it is used  Describe how to use a condom 4. Distinguish between SEXUAL Identity and Sexual Orientation. Also Gender Identity 5. IVF and Embryo Freezing 6. Breast / Testicular Examinations  Risk Factors and Reducing risks of breast cancer  Mammogram 7. Gynae consultation – Why? When? What happens?

8. Activities with the students –  Games  Ask questions  Hand out leaflets/bookmarks  Get students’ feedback

1. Physical and emotional changes during puberty Human development is a lifelong process of physical, behavioural, cognitive and emotional growth and change.

Throughout the transitions in life – from babyhood to childhood , from childhood to adolescence and from adolescence to adulthood – several changes take place and throughout the process each person develops attitudes and values that guide choices, relationships and understanding.

Puberty is the process of physical changes by which a child’s body matures into an adult body capable of reproduction. It is initiated by hormonal signals from the brain to the gonads i.e. ovaries in women and testes in men. Puberty occurs in the transition from childhood to adolescence.

Although there is a wide range of normal ages, girls typically begin the process of puberty at age 10 or 11; boys at age 12 or 133. Girls usually complete puberty by ages 15–17, while boys usually complete puberty by ages 16–18.

Physical changes in Males

1. Testicular enlargement – it is the first physical manifestation of puberty. Testes have 2 functions: to produce sperm and to produce the male steroid hormone – testosterone

2. Pubic hair – it appears on the male shortly after the genitalia begin to grow 3. Body and facial Hair - There is a large range in amount of body hair among adult men, and significant differences in timing and quantity of hair growth among different racial groups.

4. Voice change and Adam's apple- Under the influence of androgens, the voice box, or larynx, grows in both sexes. This growth is far more prominent in boys, causing the male voice to drop and deepen.

5. Male musculature and body shape – by the end of puberty, males have heavier bones and nearly twice as much skeletal muscle. Muscle growth can continue even after boys are biologically adult.

6. Body odour and acne - Rising levels of androgens (hormones) can change the fatty acid composition of perspiration, resulting in a more "adult" body odour. Regarding acne, it cannot be diminished or prevented but typically, it fully diminishes by the end of puberty. Some may desire using prescription topical creams or ointments to keep acne from getting worse or even oral medication, due to the fact that acne is emotionally difficult and can cause scarring.

Physical Changes in females

1. Breast development – is the first physical sign of puberty in girls.

2. Pubic hair – is the second noticeable sign of puberty. In the majority of girls, it starts to come out just after the first sign of breast development. It is first visible alomg the labia and after some time, it appears around the pubic mound. Then it spreads to the thighs and sometimes as abdominal hair upwards.

3. Vagina, uterus, ovaries- The mucosal surface of the vagina also changes in response to increasing levels of oestrogen, becoming thicker and duller pink in colour. Whitish secretions are a normal effect of oestrogen as well. The uterus, ovaries, and the follicles in the ovaries increase in size. The ovaries usually contain small follicular cysts visible by ultrasound 4. Body shape – in response to the rising levels of oestrogen, the hips widen to provide a larger birth canal. Fat tissue starts to increase in areas such as the breasts, hips, thighs, buttocks and upper arm.

5. Body odour and acne - rising levels of androgens cause the 6. Menstruation and fertility – the menstrual cycle is important for reproduction and it is what makes a woman fertile if there is ovulation. The first menstrual bleeding starts at an average age of 12 years but there are girls who get their period earlier than their 11th birthday and others after their 14th birthday.

What happens during the menstrual cycle (period) ?

The menstrual cycle lasts 28days in the human female but there is a lot of variation among individuals.

During the first half of each cycle, at least one primary oocyte matures into a secondary oocyte (the EGG) and is expelled from the ovary (female gonad). During the second half of the cycle, the cells in the ovary that were associated with the maturing oocyte develop endocrine functions (they start releasing hormones) and then regress if the egg is not fertilised.

The progression of these events is explained as follows:

1. The first day of the menstrual cycle is the first day of menstrual bleeding. It usually lasts 3-5 days (1 week maximum). At the same time, primary oocytes start maturing.

During menstruation, cramping in the abdomen, back and upper thighs is common.

2. Under the influence of hormones, all but one of the primary follicles will stop maturing. A follicle is made up of a primary oocyte and its surrounding cells. The latter start producing oestrogen.

3. Oestrogen causes the lining of the uterus, the endometrium. To proliferate, by addition of a new layer of cells.

4. The mature follicle is called the Graafian follicle, which has the secondary oocyte.

5. At midcycle, OVULATION takes place, where the follicle ruptures and the secondary oocyte is released. At this point, the woman is very fertile and unprotected sex is very likely to lead to pregnancy.

6. The remaining follicle cells in the ovary form the Corpus luteum which produces progesterone and oestrogen (hormones).

7. Progesterone plays a vital role in making the endometrium receptive to implantation of the blastocyst and supportive of the early pregnancy.

8. The uterus attains its maximum state of preparedness about 5 days after ovulation and remains in that state for another 9 days.

9. If a blastocyst has not arrived during that time (fertilization has not taken place), the corpus luteum degenerates, hormone levels decrease and the endometrium breaks down and the sloughed off tissue , including blood, flows from the body through the vagina – the process of menstruation.

2. Why is it important to have safe sex?

Safe sex is important for 2 reasons:  

To avoid unwanted pregnancy To protect oneself against STDs.

What are STDs and STIs? STDs stands for sexually transmitted diseases. They are passed from one person to another during sex. There are at least 25 different STDs with a range of dofferent symptoms. They spread through vaginal, oral or anal sex.

STI stands for sexually transmitted infections. STIs is another name for STDs but STIs is preferred as a term because NOT all STDs cause the disease but they do infect the person (ex. Chlamydia).

In fact, someone without symptoms might think that they do not have the disease but would still be infected and so, treatment would be required.

STD symptoms vary, but the most common are soreness, unusual lumps or sores, itching, pain when urinating, and/or an unusual discharge from the genitals

The most common STDs

CHLAMYDIA Chlamydia is one of the most commonly reported bacterial sexually transmitted diseases. It is caused by the chlamydia trachomatis bacterium. It infects the urethra, rectum and eyes in both sexes, and the cervix in women. If left untreated, long-term infection can lead to fertility problems in women. Chlamydia is transmitted through genital contact and/or sexual intercourse with someone already infected. Symptoms of chlamydia usually show between 1 and 3 weeks after exposure but may not emerge until much later.

In females it can lead to cervicitis and pelvic inflammatory disease.

GENITAL WARTS Genital warts are caused by some sub-types of human papilloma virus (HPV). They can appear on the skin anywhere in the genital area as small whitish or flesh-coloured bumps, or larger, fleshy, cauliflower-like lumps. They are unlikely to cause pain but may itch and can be difficult to spot. Often there are no other symptoms of genital warts, but if a woman has a wart on her cervix she may experience slight bleeding or unusual coloured vaginal discharge.

HPV – Human Papilloma Virus is a member of the papillomavirus family which is capable of infecting humans. HPVs establish productive infections only on skin cells and mucus membranes. Some types can cause warts while other can cause:  

In men – cancers of the anus and penis In women – cancer of the cervix , vulva, vagina and anus

30-40 types of HPV are transmitted sexually and infect the Anogenital area. HPV infection causes nearly all cases of cervical cancer in women.

Genital Warts around the Vagina and on the penis

GONORRHOEA Gonorrhoea is a sexually transmitted infection that can infect the urethra, cervix, rectum, anus and throat. Symptoms of gonorrhoea usually appear between 1 and 14 days after exposure, but it is possible to have no symptoms. Men are more likely to notice symptoms than women. Symptoms can include:

   

a burning sensation when urinating; a white/yellow discharge from the penis; a change in vaginal discharge; Irritation or discharge from the anus (if the rectum is infected).

Women may experience a change in vaginal discharge (left), a burning sensation or pain whilst passing urine, or irritation and/or discharge from the anus. Symptoms for men (right) may include a white or yellow discharge from the penis, a burning sensation or pain whilst passing urine, and irritation and/or discharge from the anus.

Genital Herpes Genital herpes is caused by infection with herpes simplex virus (HSV). There are two types of

HSV, HSV-1 and HSV-2, both of which belong to a wider group called Herpes viridae. Another well-known virus in this group is varicella zoster virus, which causes chicken-pox and shingles.

HSV-1 is acquired orally, causing cold sores.

HSV-2 is acquired during sexual contact and affects the genital area.

Genital herpes will often produce mild symptoms or no symptoms at all (asymptomatic infection). As a result, many cases of genital herpes go undiagnosed and frequently people unknowingly pass the virus on to their sexual partners.

Symptoms will usually appear 2 to 7 days after exposure and last 2 to 4 weeks. Both men and women may have one or more symptoms, including:      

Itching or tingling sensations in the genital or anal area; small fluid-filled blisters that burst leaving small painful sores (see STD pictures); pain when passing urine over the open sores (especially in women); headaches; backache; Flu-like symptoms, including swollen glands or fever.

Subsequent outbreaks are usually milder and last for a shorter period of time, usually 3 to 5 days. The sores are fewer, smaller, less painful and heal more quickly, and there are no flulike symptoms. Subsequent outbreaks or primary outbreaks in people, who have had the virus for some time but have previously been asymptomatic, usually occur during periods of stress or illness when the immune system is functioning less efficiently than normal.

Genital Herpes in males

Genital Herpes in females

SYPHILLIS It is an STD caused by a bacterium Treponema pallidum. Its symptoms are the same in both men and women. They may take up to 3 months to appear after infection. It is a slowly progressing disease with 3 stages. The first 2 stages are very infectious.

Primary Stage – Painless ulcers, which are highly infectious, appear at the place where the syphilis bacterium entered the body; 21 days after sexual contact with an infected person.

If the infection is not treated at this stage, it will progress to the secondary stage.

Secondary stage – this will occur 3 – 6 weeks after the appearance of the ulcers. Symptoms include :     

A flu-like illness, a feeling of tiredness and loss of appetite, accompanied by swollen glands (this can last for weeks or months).

A non-itchy rash covering the whole body or appearing in patches.

Flat, warty-looking growths on the vulva in women and around the anus in both sexes.

White patches on the tongue or roof of the mouth.

Patchy hair loss.

During this stage, syphilis is highly infectious and may be transmitted sexually.

If syphilis is treated at any point in the first 2 stages, the infection can be cured.

Tertiary stage - This usually develops after more than 10 years and is often very serious. It is at this stage that syphilis can affect the heart and possibly the nervous system. If treatment for syphilis is given during the latent stage the infection can be cured. However, any heart or nervous-system damage that occurred before the start of treatment may be irreversible.

Although using a condom reduces the chances of becoming infected with syphilis, it is not entirely effective. A condom may not cover all of the sores or rashes in the affected areas, and direct skin contact may result in transmission.

Syphillis symptoms on the penis

Syphillis around the vagina

THRUSH Thrush, also known as candidiasis, is a yeast infection caused by the Candida species of fungus. Thrush is not technically a sexually transmitted infection, as Candida is a common yeast that is found on the skin and genitals of most people, even those who have not had sex. Candida is usually suppressed by the immune system and the natural bacteria found in the body, but there are many things that can upset the balance and allow Candida to grow.

Thrush occurs a lot less frequently in men.

The symptoms of a thrush infection are:

In women - irritation, itching, thick white discharge, redness, soreness and swelling of the vagina and vulva.

In men – irritation, discharge from the penis, difficulty pulling back the foreskin usually caused by the swelling of the head of the penis (balanitis).

There are many causes of thrush, but the most common are:      

In women, wearing nylon or lycra clothes that are too tight (the lack of air circulation can cause Candida to proliferate).

Certain antibiotics or contraceptive pills that alter the pH balance of the vagina.

A change in the hormonal balance in pregnant women, causing a change in the level of normal bacteria.

Spermicides (found on some condoms) or perfumed toiletries that irritate the vagina or penis.

Douching (washing out the vagina) or using tampons.

Sexual contact (either genital or oral) with someone who carries the candida yeast.

HIV/AIDS HIV stands for Human Immunodeficiency Virus and it is a retrovirus that causes AIDS – Acquired

Immune Deficiency Syndrome; a condition in humans in which progressive failure of the Immune System causes life threatening infections and cancers to thrive.

Infection with HIV occurs by transfer of :     

Blood Semen Vaginal fluid Pre-ejaculate Breast milk

4 major routes of transmission:   

UNSAFE SEX Contaminated needles Breast milk



Transmission form infected mother to baby at birth

The stages of HIV infection are: 1. Acute Infection – lasts for several weeks and may include symptoms such as fever, lymphadenopathy (swollen lymph nodes), pharyngitis (sore throat), rash, myalgia (muscle pain) and mouth and oesophageal sores.

2. Latency – involves few or no symptoms and can last from 2 weeks to 20 years, depending on the individual.

3. AIDS is the last stage and is defined by low Tcell count (white cells involved in the Immune system), various infections, cancers and other conditions.

Certain groups of people have been linked to AIDS. These include homosexual men, sex workers and drug addicts. This creates a lot of stigmatisation and a lot of suffering, hence it is important to realise that anyone can contract the virus, no matter what the sexual orientation and lifestyle of the person is.

There is no cure for AIDS however PREVENTION is one way in which the transmission of the virus can be reduced:   

Educating people about HIV/AIDS Encouraging safer sexual behaviour, having one partner (who is trusted) and condom use Distribution of clean needles to drug abusers

There is still no cure for HIV but HIV treatment for people with HIV has improved enormously since the mid-1990s. Those who take a combination of three antiretroviral drugs can expect to recover their health and live for many years without developing AIDS, as long as they keep taking the drugs every day. (Still, not every person who is infected with the virus has availability to these drugs, for example, people living in third world countries).

3.DIFFERENT METHODS OF CONTRACEPTIVES

There are different contraceptives and one is free to choose the method which best suits him/her.

There are 3 approaches towards sex – ABC :   

Abstinence Be Faithful Condomize (always use a condom)

The contraceptives that one can use : The Contraceptive Pill (hormonal method): It contains hormones such as a mixture of oestrogen and progesterone or progesterone only. They act on the pituitary gland by inhibiting it form releasing hormones that cause ovulation, thus making the woman infertile.

The pill should be taken daily.

IntraUterine Device (IUD): It is an object inserted into the uterus to prevent pregnancy.

There are two types of IUDs – The copper-containing ones and the hormone-containing IUDs which release progesterone.

Copper IUDs work by negatively affecting the mobility of sperm and preventing them from joining with an egg. Additionally, the foreign body inside the uterus irritates the lining and wall making it hard for an embryo to implant

Barrier Methods: The Cervical Cap and the Diaphragm - The diaphragm is a dome-shaped poece of rubber with a firm rimthat fits over the woman’s cervix and thus blocks sperm from entering the uterus.

Smaller than the diaphragm is the cervical cap which fits just over the tip of the cervix.

Both the diaphragm and the cervical cap are treated forst with jelly or cream containing a spermicide – a chemical which incapacitates sperm- and inserted through the vagina before sexual intercourse.

The failure rate is less than 15%.

The Condom It is a sheath mad e of impermeable material such as latex that can be fitted over the erect penis. It traps semen so that sperm do not enter the vagina. Condoms also help in preventing the spread of sexually transmitted diseases.

It is highly effective but if leakage occurs, it is because of tearing or poor fit (ex. With the loss of the erection).

Putting on a condom: 1. Check expiry date 2. Make sure it was stored in a cool place 3. Push condom to the side in the wrapping and tear the wrapping open, very carefully!

4. It is wise to open it even before foreplay 5. Squeeze the end of the condom while rolling it over the fully erect penis. Make sure it is put on the right way.

6. Avoid using petroleum jelly, oils, whipped cream or anything else containing fats, as lubricants 7. After ejaculation, remove the condom carefully, tie a knot and dispose of it.

The female condom creates an impermeable lining of the vagina.

Sterilization methods

In female sterilization, the aim is to prevent the egg from travelling to the uterus and to block sperm from reaching the egg. The most common method is Tubal Ligation – cutting and tying the oviducts. Alternatively, the oviducts may be burned to seal them off.

In male sterilization, the procedure is a Vasectomy, where the procedure involves cutting and tying the vasa deferentia. After this minor surgery, the semen no longer contains sperm.

Sperm production continues but since the sperm cannot move out of the testes, they are destroyed bt macrophages.

In both males and females, these sterilization techniques do not alter reproductive hormones or sexual responses.

Behavioural Methods Coitus interruptus – This is also the withdrawal technique where the man withdrawsthe penis from the vagina before ejaculation. This depends on willpower and in fact the failure rate of this method may be as high as 40%.

The Rhythm Method This method is based on the woman’s menstrual cycle and it involves avoiding sexual intercourse just before, during and just after the woman ovulates. This is because during this period, the woman is very fertile since the egg (secondary oocyte) is released from the ovary and travels down one of the Fallopian tubes; hence there is high exposure to sperm.

Ovulation occurs 14 days before the first day of menstruation. Important facts to remember are that sperm in the female reproductive tract may remain viable for 6 days and the egg remains viable for 12 to 36 hours after ovulation.

The cycle can be tracked by use of a calendar, supplemented by the basal body temperature method, which is based on the on the observation that the woman’s body temperature drops on the day of ovulation and rises sharply on the day after.

This method is more effective when the woman menstruates every 28 – 32 days ; Days 1- 7 : the woman is considered infertile (and is menstruating) Days 8 – 20 : the woman is fertile and considered unsafe for unprotected sexual intercourse From Day 21 : infertility is considered to resume.

Since every woman’s menstrual cycle varies in days, she can still find out when she is most likely to be fertile and infertile.

To find the estimated length of the pre-ovulatory infertile phase, nineteen (19) is subtracted from the length of the woman's shortest cycle.

To find the estimated start of the post-ovulatory infertile phase, ten (10) is subtracted from the length of the woman's longest cycle Example : A woman whose menstrual cycles ranged in length from 30 to 36 days would be estimated to be infertile for the first 11 days of her cycle (30-19=11), to be fertile on days 12-25, and to resume infertility on day 26 (36-10=26). When used to avoid pregnancy, the rhythm method has a perfect-use failure rate of up to 9% per year The Calendar (Rhythm) Method is used to avoid pregnancy and not to prevent the spread of sexually transmitted diseases.

4. Sexual Orientation and Gender identity

An important factor one ought to keep in mind is that nature favours variety. We are all different in the way we look, the way we think and the way we look at other people. In the

past people who were left handed were seems as the devil’s children so they would be perceived as the ‘’bad people’’ and they would be forced to write with their right hand, apart from being left out. We have to avoid judging or putting aside people for not following what we all think is the ‘’norm’’ – Sexual orientation CAN be a factor which determines whether someone ought to be left out or not.

Sexual orientation refers to the sexual attraction between two individuals. Homosexuality is the sexual attraction between two individuals of the same sex. Heterosexuality is the sexual attraction between two individuals who are of a different sex. Bisexuality is when a n individual is sexually attracted to both sexes. In this case, the individual can actually decide what he/she prefers to be with - but in the case of homosexuality and heterosexuality, the individual does not choose but is born that way.

Sexual orientation is ot only about sexual orientation BUT also about affection. This means that any person will be able to fall in love with another person according to their sexual orientation. For example, a homosexual man will not be able to fall in love with a woman.

Puberty is a time of physical, emotional and sexual growth. It is extremely normal to feel confused and lost at some point. It is a time where individuals are discovering themselves and who they truly are. In actual fact, it is also known that many individuals experiment with their sexuality until they come to terms with their sexual orientation and have the courage to come out and allow people to see them for who they truly are.

At times, society does not allow us to be confused because everyone has to follow ‘’the norm’’ and for many people, heterosexuality is what is ‘’normal’’ BUT it is not the case – at all!

Individuals who are homosexual experience several feelings such as confusion , abnormal and ashamed of themselves. Unfortunately, they may start repressing their thoughts and feelings to avoid being teased at or even put aside by friends. This can lead to other problems such as depression and anxiety, which can lead to suicidal thoughts. In fact, there tends to be a high rate of suicide among these individuals.

Students in schools, who are not heterosexual feel unsafe at aschool as shown in the following bar chart :

One should keep in mind that homosexuality is NOT a disorder. A homosexual person is NOT sick and this is why we all need to learn about tolerance and accepting differences so it will help us accept the people around us and most importantly, accept ourselves the way we are.

Statistically, 10% of the people are gay, lesbian or bisexual but there can be many more because this percentage is based on the number of people KNOWN to have a sexual orientation other than heterosexuality.

Researchers believe that one’s basic sexual attraction is predisposed at birth. While one’s orientation may not be recognised or acknowledged for many years, once established, it tends not to change. ‘’Nothing’’ makes a person gay, lesbian or bisexual – not even homosexual parents.

Coming out as gay or lesbian or bisexual may be one of the hardest steps that an individual can take but it is much better than suppressing inner thoughts and feelings. One should be very careful with parents (especially guys boys with their fathers) so usually the first people to be trusted are very close friends (or one close friend) and there is a tendency for boys to tell a very close friend who is a girl. Initially, some parents, or one of the parents, may find it hard to accept, but in time and maybe with support from other members of the family or even from professional, everything falls into place.

In the end we are all different and everyone deserves to love and to be loved without feeling as though they are doing something bad or that the people around them (including

family and friends) are pointing fingers at them.

Gender Identity

First of all, biological sex is a physical condition identified at birth by one’s primary sex characteristics.

Gender identity is a combination of one’s personal recognition of the gender that is one’s own, the degree to which that internal recognition conforms to or fails to conform toone’s biological sex and how one desires to be recognised by others – as male or female.

Transgender, transsexual, and crossdressing (transvestites) people may have any sexual orientation.

Transgender refers to people whose gender identity differs from the social expectations for the biological sex identified as theirs at birth (using primary sex characteristics). Since these social expectations include gender roles (feminine women and masculine men), people who do not conform to prescribed gender roles may be considered part of the transgender community. A transgender person may or may not ever choose to become transsexual.

Transsexual refers to a person who experiences a mismatch of the body and the brain and sometimes undergoes medical treatment, including hormone therapy and sexual reassignment surgery, to change physical sex to match gender identity.

Crossdressers (formerly known as transvestites) are people who like to dress in the clothing of the gender identity opposite to that considered socially appropriate to their biological sex. Most crossdressers are content with their own biological sex and gender identity. Most crossdressers do not want to be the other biological sex or to be another gender.

5. Neoplasia Breast cancer is uncontrolled cell growth of breast cells. It occurs as a result of mutations or abnormal changes in the genes responsible for regulating the growth of cells and keeping them healthy.

In Malta, between 1999 and 2003, 1044 women and 15 men were diagnosed with Breast

cancer.

On average, per year, 209 women and 3 men are diagnosed with breast cancer.

Risk Factors:

1. Age and Gender The risk of getting breast cancer increases as one gets older. Most advanced breast cancer cases are found in women over the age of 50. Women are 100 times more likely to get Breast cancer than men.

2. Family History People whose close relatives suffered from breast, uterine ,ovarian or colon cancer are at a higher risk of having breast cancer. 20-30% of women with breast cancer have a family history of disease.

3. Genes Most common gene defects are found in BRCA1 and BRCA2 genes. These genes produce proteins which protect against cancer. If a parent passes a defective gene to her daughter, she has a n 80% chance of getting breast cancer.

4. Menstrual Cycle Women who get their periods at an early age (younger than 12 years) or went through menopause late (more than 55 years) have an increased risk of being diagnosed with breast cancer.

5. Alcohol Drinking more than 2 glasses of alcohol everyday 6. Childbirth Women who never had children or had them after the age of 30 have an increased risk of getting breast cancer.

7. Hormone Replacement Therapy (HRT) HRT with oestrogen increases the risk of breast cancer. Also, obese women tend to produce more oestrogen and can therefore fuel the development of breast cancer.

8. Radiation There is an increased risk if radiation is received at a young age especially during the development of breast tissue.

Reducing Risks     

Active lifestyle Losing extra weight More fruit and vegetables in the diet Quit smoking Breastfeeding

Catching it Early It is important that the breasts are self-examined monthly by Looking at them and Feeling them :

It is important to look out for: 1. Breast lump or lump in the armpit that is hard, has uneven edges and is not painful 2. Change in size, shape or feel of breast/nipple. For example, there may be redness, dimpling or puckering that looks like the skin of an orange.

3. Fluid coming out from the nipple which can be bloody , clear to yellow , green or looks like pus,

Not ALL lumps are Cancerous (in fact, 9 out of 10 are not cancerous) !

If the above signs/symptoms are present, one must immediately consult a doctor so that he/she can do a MAMMOGRAM.

Symptoms of Advanced Breast Cancer     

Bone pain Breast pain / discomfort Skin ulcers Weight loss Swelling of arm closer to the cancerous breast

Testicular Examination

Testicular cancer is cancer that starts in the testicles, the male reproductive glands located in the scrotum Testicular cancer is the most common form of cancer in men between the ages of 15 and 35 -Non-seminoma.

However, in some cases, it can occur in older men (25 – 55), and rarely, in younger boys Seminoma It is therefore important that young men test themselves and know what is normal and what changes might signal a problem.

Steps for self-examination: 1. Stand in front of a mirror and look for any swelling on the scrotal skin 2. Examine each testicle by placing the index and middle fingers of both hands under the testicle with the thumbs placed on top 3. Roll the testicle gently between the thumbs and fingers—no pain should be felt. It is normal to feel a cord-like structure on the top and at the back of each testicle. Lumps that may need to be checked by a healthcare professional may be small as a pea and feel hard.

Early symptoms include:     

Discomfort or pain in the testicle, or a feeling of heaviness in the scrotum Pain in the back or lower abdomen Enlargement of a testicle or a change in the way it feels Excess development of breast tissue (gynecomastia), however, this can occur normally in adolescent boys who do not have testicular cancer Lump or swelling in either testicle

Symptoms in other parts of the body, such as the lungs, abdomen, pelvis, back, or brain, may also occur if the cancer has spread.

Testicular cancer is one of the most treatable and curable cancers if caught at an early stage.

In fact, there is a survival rate of 95%. Obviously, this would depend on the size of the tumour and when the diagnosis began.

6. IVF and Embryo Freezing

IVF stands for In Vitro Fertilisation. The process involves hormonally controlling the ovulatory process in the woman. The eggs are removed from the ovaries and allowed to be fertilised by sperm OUTSIDE the body (in a fluid medium) – hence, in vitro. The fertilised egg, also referred to as a zygote, is transferred to the patient’s uterus with the intent of establishing a successful pregnancy.

IVF had been carried out in line with the best medical practices for 20 years in Malta.

Currently here is no legislation, but this does not mean that anything illegal is taking place.

(Show a clip explaining how IVF takes place)

This illustrates sperm being injected into the oocyte

Embryo Freezing (Cryopreservation of Human embryos) In the case of surplus embryos, the latter may be considered for cryostorage (freezing).

Via controlled-rate freezing the embryos are cooled in cryoprotectant fluid from body temperature down to -196°C. Following this, embryos are stored in nitrogen liquid containers. Special indelibly labelled plastic vials that contain the embryos are sealed prior to freezing.

The thawing of the embryos to room temperature takes about 1-2 minutes. Once this is done, the embryo is assessed for cryodamage to establish if it is appropriate for transferring.

All thawed embryos undergo routine assisted hatching prior to transfer. The cryopreservation causes the zona pellucida that surrounds the embryo to harden.

Fortunately this can be overcome by artificially making an opening in the outer embryo shell.

Advantages for Embryo Freezing (or Crypreservation) : • Extending the possibility for pregnancy when fresh cycles fail or when couples want additional children after a successful embryo transfer.

• Avoiding many ethical dilemmas by eliminating the need to dispose of embryos.

• Offering an alternative to couples that might transfer too many embryos and risk a

multiple gestation pregnancy.

• Avoiding embryo wastage by freezing embryos individually for efficient use.

• Increasing pregnancies per retrieval cycle with normal outcomes by 10-30% more. Many studies have evaluated the children born from frozen embryos. The result has uniformly been positive with no increase in birth defects or development abnormalities.

7. Gynaecological Consultation

To begin with, gynaecology is the medical practice dealing withthehealth of the female reproductive system i.e. uterus, vagina and ovaries.

(Andrology is the counterpart of gynaecology).

A woman is meant to have hher first gynaecological consultation at the age of 21 or when she becomes sexually active. One ever one might consider going to a gynaecologist just before she becomes sexually active to discuss issues such as the right contraceptive method for her.

It is ideal to go to the gynaecologist at mid-cycle, that is, when the woman is not menstruating.

Reasons why a woman should have a gynaecological consultation:    

Menstrual problems Sexual Health Fertility and Pregnancy Screening

What happens?

Gynaecological examination is intimate and requires unique instrumentation such as the speculum.

The latter is used to retract the tissues of the vagina and permit examination of the cervix, located within the upper portion of the vagina.

When this examination is carried out, the patient stays in a lithotomy position meaning that the individual’s feet are positioned above or at the same level as the hips, with tvhe perineum positioned at the end of the examination table.

If a PAP (Papanicolaou) smear is carried out, cells are collected form the outer opening of the cervix of the uterus. The cells are then examined under a microscope. The test is important at detecting potentially pre-cancerous changes, usually caused by sexually transmitted human papillomaviruses.

Hence, it is used as screening for cervical Cancer. It can alse detect infections and abnormalities in the endocervix and the endometrium.

A bimanual examination can be also carried out, where one hand of the gynaecologist is on the abdomen and the one or two fingers from the other hand are placed inside the vagina – to palpate the cervix, uterus, ovaries and pelvis.

A vaginal or abdominal ultrasound can be used to confirm any abnormalities appreciated by the bimanual examination or when indicated by the patient’s family history.

8. Questions to ask students

1. How can one protects against STIs? 2. Name the contraceptives that can be used against STIs. 3. Do condoms protect against all STIs? 4. How can one find out about STIs? Where can he/she go?

5. Do all STIs show symptoms?

6. Is there a cure for HIV? 7. Canmen get penile cancer as a result of HPV? 8. Can one get the HIV virus from kissing, shaking hands or toilet seats?

9. What about needles?

10. Differentiate between HIV and AIDS. 11. Can syphilis be treated? And cured?

12. Can children contract STIs from their mothers?

13. Does ABC protect against unwanted pregnancies?

(Use ppt presentation to show answers and questions)