Week 8: STIs & Women's Health

How to Take A Sexual Health History → Step 1

• Listen & React in a Nonjudgmental Manner

• Use Teachable Moments to Educate

How to Take A Sexual Health History → Step 2

• Avoid making assumptions

• Be respectful

How to Take A Sexual Health History → Step 4

• Proceed from easier to more difficult topics

• Be aware of patient body language

• Use open body language

U.S. Preventive Services Task Force (USPSTF)

provides evidence-based recommendations for screenings, behavioral counseling and preventative meds; decides how often to do screenings

• recommendation grades from A-I w/ A (strong benefit) and I (insufficient evidence)

Health Promotion

motivation to increase well-being and actualize health potential

Illness Prevention

desire to avoid illness, detect it early, or maintain optimal functioning when illness is present

Why Do We Screen?

• early detection and prevention → improves health outcomes, reduces mortality

• evidence-based approach → helps make informed decisions

• tailored to different life stages → recognizes risk for certain disease changes as we age

USPSTF Screening Topics → ETOH & Smoking

1. Smoking Cessation Screening (A Recommendation) → for everyone

2. Alcohol & Drug Use (B Recommendation) 

3. CAGE, AUDIT-C, SAAQ for alcohol use

USPSTF Screening Topics → Mental Health & Emotional Wellbeing

• Depression Screening (B Recommendation)

• Intimate Partner Violence, Elder Abuse (B Recommendation) 

Pregnancy is a time of increase risk of

abuse from partner

When Would We Perform Screenings Earlier?

Family history of illness, patient presenting with symptoms, increased risk

Why Don’t We Perform Some Screenings?

Increased healthcare costs, unnecessary anxiety & testing, can cause physical harm 

Breast Cancer Is…

• 2nd leading cause of death from cancer in American women

• Most common cancer is women besides skin cancer

• Increased risk as you age

Breast Cancer → Screening

mammography is standard

• ultrasound or MRI considered when woman has dense breast tissue 

Why would you not perform a mammogram on 20-30 yr old?

Opt for ultrasound due to cyclical changes to the breast as a result of menstruation

Breast Cancer → Risk Factors

anything leading to increased estrogen exposure

• nonmodifiable: female sex, early menarche, late menopause, BRCA1/2 gene mutation, family hx

• modifiable: alcohol use, obesity, inactivity, nulliparity, not breastfeeding, exogenous hormones (birth control)

Concerning Breast Findings

• breast sores that don’t heal

• hard/soft lump in breast, armpit or chest

• redness, puckered, scaly or thickened skin

• inverted/sunken nipple

• bloody, cloudy, smelly fluid leaking from nipple

• breast shape/size changes (shrinks, swells, etc)

Cervical Cancer → Guidelines for Screening

Pap test (cytology) & HPV Screening

• some providers will only do one

• stop screening at 65yr or if have hysterectomy

Cervical Cancer → Guidelines for Screening (21-29yr)

pap smear every 3 yr 

Cervical Cancer → Guidelines for Screening (30-65yr)

pap smear every 3 yr, HPV every 5 yr

Cervical Cancer→ Prevention

HPV vaccination

• HPV infection can lead to cervical cancer which takes decades to appear

Symptoms of Early-Stage Cervical Cancer (+ late signs)

bleeding after sex, intermenstrual bleeding, post-menopausal bleeding, abnormal discharge, pelvic pain/pain during sex

• pain that has moved to other areas of the pelvis, bowel, bladder, abdomen, legs

Menstrual Disorders → Amenorrhea

absence of menstruation defined as missing one or more periods

Menstrual Disorders → Primary Amenorrhea

No menarche by age 15; commonly due to hormonal or anatomical issues

Menstrual Disorders → Dysmenorrhea

Painful menstruation

Menstrual Disorders → Primary Dysmenorrhea

recurrent menstrual cramps not due to other diseases usually beginning 1-2 days before your period

Menstrual Disorders → Dysfunctional Uterine Bleeding

Heavy uterine bleeding with no identifiable cause (diagnosis of exclusion)

Menstrual Disorders → Premenstrual Syndrome (PMS)

wide variety of symptoms including mood changes, bloating, breast tenderness, food cravings, depression and more occurring before menstruation

Menstrual Disorders → Premenstrual Syndrome (PMS)

Severe form of PMS appearing a week before menstruation and ending a few days after it starts that impairs daily functioning

• treated with SSRIs, OCPs, lifestyle changes

Menstrual Disorders → Endometriosis

Presence of endometrial tissue outside the uterus causing pain, heavy bleeding, infertility and pain during sex

Menopause

absence of menstruation for 1 year (ovaries no longer participate in ovulation) usually occurring between 45-52 yr 

• very little to no estrogen

Perimenopause

Transitional period lasting 2–10 years before menopause

• symptoms: hot flashes, mood changes, and trouble sleeping

Perimenopause

characterized by a drop in estrogen

Postmenopause

menopause is complete but symptoms like hot flashes can continue; estrogen no longer present

General Physiologic Changes of Menopause

headaches, alterations in mood, hot flashes, weight changes, osteoperosis risk, vaginal dryness, low sex drive, changes in digestion, alterations in energy and sleep, thinning hair, dry skin, etc

Physiologic Changes of Menopause → Cardio

increased risk of cardiac disease, stroke, hypertension

Physiologic Changes of Menopause → Cognitive

dementia, Alzheimer’s

Physiologic Changes of Menopause → Reproductive

anovulation, atrophy, decreased lubrication

Physiologic Changes of Menopause → Vasomotor

“power surges”, night sweats

Physiologic Changes of Menopause → Skin & Musculoskeletal

osteoporosis, wrinkling, dry skin

Hormone Replacement Therapy (HRT)

treatment combining estrogen + progesterone (prevents cell overgrowth) that helps reduces menopause related symptoms

• used in women w/ uterus

• helps reduce risk of uterine cancer

Estrogen Replacement Therapy (HRT)

estrogen only treatment that helps reduces menopause related symptoms in women with hysterectomy (no uterus)

Hormone Replacement Therapy (HRT) → Side Effects

• common: breast tenderness, spotting, nausea, headaches, bloating/cramps, hair loss, yeast infection

• serious: heart attack/stroke, blood clots, breast cancer, gallbladder disease, high BP, dementia (if 65+)

Hormone Replacement Therapy (HRT) → Contraindications

hx breast/uterine cancer, clotting disorders, bleeding disorder, heart attack/stroke, liver disease (metabolized in liver), abnormal bleeding, pregnant

Hormone Replacement Therapy (HRT) → Outweighing Risks

Best outcomes when initiated before age 60 or within 10 years of menopause

Types of STIs

genital herpes, genital warts, HPV, chlyadmyia, gonorheaa, syphilis, trichomoniasis, hepatitis, HIV, trichomoniasis, chancroid 

STI Risk Reduction Strategies

Immunization, honest communication, limiting partners, protection use, routine testing

STI Screening

• tested before sex & 2 weeks after

• annual screening until 25yr and after based on risk (+ PAP)

• pregnant individuals 25+ at risk and again in 3rd trimester

Test of Cure

Repeat testing to ensure eradication of STI (ex: gonorrhea, chlamydia)

Chlamydia → Symptoms + Diagnosis

curable STI caused by chlamydia trachomatis bacteria

• incubation: 1-2 wk

• symptoms: asymptomatic; may include smelly white/yellow/grey discharge, dysuria, pelvic/testicular pain, bleeding between periods

• diagnosis: NAAT testing at urine, vaginal, rectal, or pharyngeal sites

Chlamydia → Treatment

doxycycline 100 mg BID × 7 days

• if pregnant → Azithromycin 1mg PO 1x or Amoxicillin 500 mg 3x daily for 7 days

• alternative → levofloxacin 500mg PO daily for 7 days

Gonorrhea → Symptoms + Diagnosis

STI caused by neisseria gonorrhoeae (bacteria)

• symptoms: asymptomatic; may include smelly white/yellow/grey discharge, dysuria, pelvic/testicular pain, bleeding between periods

• diagnosis: NAAT testing at urine, vaginal, rectal, or pharyngeal sites

Gonorrhea → Treatment

Ceftriaxone 500 mg IM 1x

• if pregnant → same

• alternative → gentamicin 240 mg IM 1x AND azithromycin 2mg PO 1x

• test of cute recommended 2wk after for pharyngeal infection

Herpes Simplex Virus (HSV) → Symptoms + Diagnosis

STI caused by HSV-1 or HSV-2 virus

• incubation: 1-2 days

• symptoms: painful genital sores, prodromal flu-like symptoms, asymptomatic (maybe)

• diagnosis: NAAT testing

Herpes Simplex Virus (HSV) → Treatment

no cure

• symptomatic relief → OTC NSAIDs, Sitz bath, cold compress

• antivirals (acyclovir, valacyclovir, famciclovir) reduce outbreaks

Genital Warts → Symptoms + Diagnosis

STI caused by HPV low-risk strains

• incubation: weeks, months, years after exposure

• symptoms: painless cauliflower-like lesions on genital areas

Genital Warts → Treatment

not curable; if lesion present can be passed to partner; based on extend of infection

• ex: podofilox solution/gel, aldara cream, cryotherapy, burn, TCA acid, surgical removal

Syphilis → Symptoms + Diagnosis

STI caused by Treponema pallidum (bacteria) characterized by stages (primary, secondary, latent, tertiary, neurosyphilis)

• can be passed from mom to fetus causing congenital syphilis

Syphilis → Treatment

• Primary/Secondary/Early Latent: Benzathine penicillin G 2.4 million units IM 1x

• Late Latent / HIV+ / Pregnancy: Benzathine penicillin G weekly × 3 doses in 1 wk intervals

• Neurosyphilis: cystalline pencillin G 18-24 million units IV daily for 10-14 days

• if allergic → doxycycline 100mg BID for 28 days

Primary Syphilis (Stage 1)

Firm, round, painless chancre lasting 3–6 weeks appearing where syphilis entered the body

• heals on own

Secondary Syphilis (Stage 2)

Rash (rough, red, reddish-brown spots) on palms/soles, flu-like symptoms, patchy hair loss

Latent Syphilis

No symptoms; early <12 months, late >12 month

Tertiary Syphilis (Stage 3)

rare appearing 10-30yr post-infection; can be fatal affecting multiple organ systems

Neurosyphilis

can invade at any stage causing headache, muscle weakness, numbness, mental changes

Congenital Syphilis

Passed from mother to fetus; can cause severe neonatal complications (seizures, death, developmental delays)

• may be asymptomatic

• testing performed at 1st prenatal visit, 28 wk, delivery

Human Papilloma Virus (HPV)

uncurable self-limiting STI with 150+ strains associated w/ most cervical cancer

Human Papilloma Virus (HPV) → Prevention

• cervical cancer screening → pap smear at 21yr ending at 65

• vaccination → from 9-26 yr (recommended at 12yr)

Trichomoniasis → Symptoms + Diagnosis

common STI caused by Parasite Trichomonas vaginalis

• symptoms: Green/white frothy genital discharge, dysuria, itching

• diagnosis: pap or NAAT testing

Trichomoniasis → Treatment

curable

• women: Metronidazole 500 mg BID × 7 days OR Tinidazole 2mg PO 1x

• men: Metronidazole 2mg PO 1x OR Tinidazole 2mg PO 1x

Hepatitis B

STI caused by virus transmitted w/ contact of infected blood or body fluids

• incubation: 6 wk to 6 months

• symptoms: maybe asymptomatic, tiredness, abdominal pain, jaundice

• diagnosis: serology (blood) testing

• tx: vaccination for prevention, no cure

Hepatitis C

STI caused by virus transmitted w/ contact of infected blood

• incubation: max 6 months

• symptoms: maybe asymptomatic, tiredness, abdominal pain, jaundice

• diagnosis: serology (blood) testing

• tx: treated but no cure

Human Immunodeficiency Virus (HIV) → Symptoms + Diagnosis

STI caused by virus transmitted w/ contact of infected blood

• incubation: 2-12 wk

• symptoms: flu-like, rash, joint pain

Human Immunodeficiency Virus (HIV) → Prevention

routine STI screening, screening during pregnancy, condom use, preventative meds like PREP

Human Immunodeficiency Virus (HIV) → Prevention

no cure, lifelong meds w/ antiretroviral tx (maintain viral load <200 copies/ml)

PREP

medication taken via daily pill or injection that decreases chance of HIV

• routine testing every 3 months

PEP

Post-exposure prevention of HIV within 72 hours; 28-day regimen

Molluscum → Symptoms

not just an STI caused by Molluscum contagiosum virus

• incubation: 1wk to 6 months

• symptoms: painless bumps on lower belly, thighs, genital area, umbilicated papules

Molluscum → Treatment

can resolve on own, otherwise: cryotherapy, podofilox, curettage, OTC remedies

Chancroid → Symptoms + Diagnosis

STI caused by Haemophilus ducreyi (bacteria)

• symptoms: lymphedema, pain/tender/nonindurated genital ulcer

• diagnosis: NAAT testing

Chancroid → Treatment

Azithromycin 1 g PO 1x OR Ceftriaxone 250 mg IM 1x OR Ciproflaxcin 500 mg PO BID 3 days OR Erythromycin 500mg PO TID 7 days