What you need to know about STI's
Perimenopausal and postmenopausal women are at risk of contacting sexually transmitted diseases (STD's). If you have a new
sexual partner, have multiple partners, or are having sex with someone who has multiple partners, your risk of contracting an STD is increased. Do not ever hesitate to ask a new partner to be checked prior to beginning a sexual relationship. You should be checked, too. You must protect yourself, and unfortunately, a new potential partner may not always be honest about past relationships.
If you are in a new relationship after having had one partner for a very long time, you may not be aware of the transmission of varying types of STD's, and the importance of "safe sex". STD's are more often contracted from male to female, and symptoms may be absent or mimic a UTI or vaginitis. Women who are menopausal may have vaginal atrophy which can make their tissue more vulnerable to chafing and tearing. These breaks in the skin make transmission of bacteria and viruses easier.
Safe sex means more than just using a condom. It means taking care in knowing the history of your partner, including previous sexual history. A condom should be used for vaginal, anal, and oral sex. A condom is not always protective. Although a condom will prevent chlamydia, gonorrhea and HIV by containing secretions, it does not cover all areas of the male genitals, and the HPV virus and herpes virus are transmitted by skin contact. Latex and polyurethane condoms are protective, whereas condoms made of natural membranes are not as protective. Safe sex includes having your partner tested for STD's prior to beginning a physical relationship. It also includes having an honest discussion regarding past history of STD's. Many people know when they have a herpes outbreak, for example, and should avoid intercourse during an outbreak. Safe sex can include using preventive medications, and these drugs are available for prevention of herpes and HIV. Safe sex also means that if a sexually transmitted disease is diagnosed, it is important to have the partner treated as well, to prevent transmission to subsequent partners or re-infection.
Below is information about specific STD's:
HPV-human papilloma virus
Human papilloma virus, the virus that causes genital warts, is ubiquitous. It is thought that by the age of 50, 80% of women will have been infected with the HPV virus at some time in their lives. The virus is spread by contact, and resides in the skin of the vagina, cervix, vulva, anus, penis and oral cavity. It can lead to cancers of these tissues. There are many types of this virus. Some of them are low risk and cause warts. The high risk types are oncogenic. Viral infection is usually asymptomatic, although a wart on the vulvar skin may be visible or palpable. Infection of the cervix is not symptomatic unless there is cervical cancer, and disease has progressed . The purpose of doing regular PAP smears is to detect the virus and changes in the tissue before they progress to cervical cancer. At the time of a pelvic exam, a physician will inspect the tissues of the vulva to look for changes in the tissue that are indicative of viral infection. After initial infection with the virus, the virus may remain dormant in the tissues for many years. Most of the time when the virus is detected in women at midlife, it is a reactivation of a previously acquired virus. This is very important, because when the virus is detected in a women with a longstanding monogamous relationship, it may lead to concerns of infidelity, and women must be reassured that reactivation of a previous infection is the a likely possibility.
There is no way to rid the body of HPV. Young women under the age of 26 are offered a vaccine for several of the high-risk strains of the virus, but this is not recommended for women over the age of 26. More than 99% of cervical cancer are caused by the HPV virus. PAP smears take a sample of the cells on the cervix which are evaluated for pre-malignant changes. HPV DNA can also be detected on a PAP smear. The average age of cervical cancer is age 49, with 20% of cervical cancers are detected after the age of 65. Regular gynecologic visits allows for close inspection of the tissue of the vulva, vagina and cervix, as well as regular testing of the cervix for abnormal cells and the presence of HPV.
Chlamydia trachomatis is an STD spread through vaginal, anal and oral sex, through bodily secretions. It can be transmitted without ejaculation of the male partner. Although most chlamydia is detected in women under the age of 25, women who have new or multiple partners, or who are have sex with men with multiple partners, should be tested. Chlamydial infection is most often asymptomatic, but in some women symptoms include a yellow discharge, burning with urination, fever and pelvic pain. A swab of the cervix or a urine sample is used to detect this organism. A nucleic acid amplification test is ordered to detect the infection. Chlamydia is more serious in women of childbearing age, as it can cause pelvic inflammatory disease and infertility.
Chronic infections can cause scarring of the reproductive organs, leading to chronic pain. It is mandatory that the male partner be treated or re-infection may occur. Although it is not necessary to retest to be sure that the infection has cleared, this may be advisable if it is not certain that the partner has been adequately treated. The treatment is antibiotics, usually azithromycin or doxycycline.
Gonorrhea is transmitted mostly through sexual contact and can infect the reproductive tract, anus, mouth, throat, urethra, and eyes. The symptoms are often absent, but may be nonspecific, such as vaginal discharge and burning with urination. Infections of the anus can cause pain, discharge or itching High risk individuals, as previously mentioned, should be screened. If an infection remains untreated, it can lead to infections of the upper genital tract and compromise the ovaries and fallopian tubes, which can lead to chronic pain or infertility. In rare cases, an untreated infection can disseminate through the bloodstream and infect the joints. Gonorrhea is also detected with nucleic acid amplification testing, and is usually checked with a swab at the same time testing for chlamydia is done. Treatment is usually a cephalosporin plus azithromycin, or doxycycline.
Trichomonas is a very common STD caused by a protozoan parasite that is found in younger and older women. Although many cases are asymptomatic, symptoms develop within 5-28 days after exposure. The symptoms include discharge and odor, and vaginal discomfort. The discharge may be yellow-green or gray. When seen by the physician, the discharge may be frothy. The diagnosis can easily be made in the office by performing a wet mount, looking at the vaginal discharge under the microscope. The Trichomonas organism can be easily seen. It can also be detected with a nucleic acid test. Treatment is either metronidazole or tindazole. The sexual partner must also be treated or re-infection will occur
The herpes simples virus has two types, 1 and 2. Herpes simplex type 1 is most often an oral infection causing cold sores of the mouth and lips. Herpes type 1 can infect the genital tissues, often because of oral sex. Herpes type 2 is most often an infection of the genital tissues. About 16% of adults will test positive for the herpes type 2 virus by the age of 50. Most people who are infected with the virus and are not aware, and they do shed the virus periodically. This means that they may transmit the virus to a partner and be unaware that they were infectious. The symptoms of herpes infection are painful blisters on the genital skin. Often, the initial infection is more symptomatic and may last several weeks. There may be a viral type of syndrome with fever, malaise, and painful, swollen lymph nodes in the groin. If the infection involves the urethra, painful urination may be present, along with swelling and pain in the genital area. Subsequent infections are usually less symptomatic and may last about a week. Most women will notice a tingling in the area where the infection will break out, often the day before they see an ulcer. The reason for this is that the virus, after initial infection, will reside in the nerve root, and travel down the nerve to infect the skin. It is often thought that stress or illness will cause reactivation of the virus. The ulcer often lasts about a week, and is mildly bothersome. Medication is very effective in preventing outbreaks, and can be taken as soon as the prodrome, or tingling, is noted. If the medication is taken immediately when symptoms occur, development of the ulcer may be thwarted.
It is not infrequent that a patient will present in her 50's or 60's with a herpes lesion. She may have had this before, it was minimally bothersome, and not recognized as herpes. This may be her first recognized outbreak. In most of these cases, the actual first episode of herpes may have occurred many years ago and was not diagnosed. This always brings up the dilemma of "where did this come from?" Patients are cautioned that it is impossible to know how they were infected, and largely a waste of time to try to figure it out. These late recurrences happen, and why they become apparent many years later is largely unknown, but signifies a "mild" case that rarely becomes frequent and problematic. It can easily be managed by anti-viral medication.
The diagnoses of herpes can be made by culturing the ulcer. This must be done at the beginning of the outbreak, for as the lesion heals and dries, it is unlikely to retrieve active virus. Serologic tests for herpes antibodies can be checked, but the information only indicates that the person was exposed to the virus at some point.
There are three drugs that are used to treat and prevent herpes: acyclovir, famciclovir, and valcyclovir. These drugs are effective in treating initial outbreaks, may shorten the duration of subsequent outbreaks, and may prevent outbreaks if taken daily for a period of time. These drugs are very safe and have very few side effects. Suppressive daily therapy is suggested for those who have 6 or more recurrences per year, or if the partner with herpes is having intercourse with someone who has never had herpes. Taking the antivirals prophylactically will reduce the transmission by about 75%.
Hepatitis B is a virus transmitted through contact with mucous membranes or blood. The virus attacks the liver and causes inflammation. In most cases, the disease is self limited. In about 10% of patients, chronic infection can occur and leads to cirrhosis or liver cancer. Most cases of hepatitis B in the US are sexually transmitted. The virus can be found in vaginal secretions, semen, and blood, and is much more contagious than HIV.
A vaccine for hepatitis B was introduced in 1982. Children are now routinely vaccinated and have been for more than 30 years, but many people in midlife may not have had the vaccine. Adults who are at risk can still be vaccinated as adults. Blood tests are available to detect both acute and chronic hepatitis B infections.
Hepatitis C is also infects the liver, and is spread through contact with blood. It can be sexually transmitted because during sexual contact, tissue can be abraded which can allow the virus to enter the bloodstream The problem with hepatitis C is that it most often becomes chronic. It is recommended that men and women born from 1945-1965 be tested for this virus. Those who may have received transfusions prior to 1992 should be tested, as the blood supply was not tested before that time. This virus is most often transmitted by sharing IV needles during drug use, so having sex with those who use intravenous drugs increases the risk of transmission.
Women who are at risk for HIV include those who have been treated for other STD's, women with multiple partners or a partner who has sex with multiple partners, especially with other men, and IV drug users. Testing can be achieved by performing an ELISA test. Since there is a risk of false positives, especially in the first 12 weeks after infection, additional testing is done if there is a postive result. . The Western Blot test has a very low false positive rate. Once infected, the time that it takes to develop clinical AIDS is about ten years. When someone is diagnosed with an HIV infection, antiretroviral medication must be prescribed to reduce progression of disease and transmission to sexual partners. Treatment as soon as possible after infection results in improved outcomes.
Syphilis is caused by a bacteria, Treponema pallidum, which causes a chancre on the vulvar skin. These lesions are painless and last for 3-6 weeks. If treatment is initiated at this stage, the disease is not likely to progress. If untreated, the infection will progress to stage 2 disease. The hallmark of this stage is a rash on the skin and on mucous membranes. After that, the disease becomes latent. The disease may progress to involve the heart and brain, and may result in death.
Diagnosis of syphilis is made by blood tests. The RPR is done initially, but has false positives. Some medical conditions can cause false positives, such as HIV, Lyme disease, malaria, and lupus. The follow up test is a treponemal antibody test.
Syphilis can be treated easily with a single dose of penicillin if diagnosed early. After one year, multiple does of penicillin are needed to prevent progression of disease.