STIs & Contraception – Core Vocabulary

Guiding Course Principles

• Everyone has a unique gender identity, sexuality, strengths & challenges
• Practice compassion; highlight strengths; support challenges
• Diversity, equity & inclusion enrich the course & campus culture

Key Campus Resources

• CARE – advocacy & education
• CAPS – mental health
• International Student Resource Center
• LGBT Resource Center
• Undocumented Student Programs
• Student Disability Resource Center
• The Well
• Women’s Resource Center

Learning Outcomes – STIs & Infections

• Distinguish STIs from other infections; identify >25 agents & infection sites
• Master bacterial STIs: Chlamydia, Gonorrhea, Syphilis (symptoms, Dx, Tx, sequelae)
• Master viral STIs: Herpes, HPV, Hepatitis, HIV (history, biology, HAART, prevention)
• Recognize non-STI vaginal infections; fungal (jock itch), parasitic (pubic lice, scabies)
• Know what to expect in an STI exam; prevention strategies

Overview: Sexually Transmitted Infections (STIs)

• Definition: infections transmissible through sexual interaction (anal, oral, vaginal, skin-to-skin)
• Curability varies; untreated STIs → pain, infertility, death
• Stigma vs. other viruses (e.g., genital herpes vs. chicken pox) arises from moral/sexual connotations
• U.S. epidemic drivers: multiple partners, condom-less sex, weak public-health access, provider reluctance to ask sexual histories
• Transmission routes: mucous membranes (warm, moist passages), skin-to-skin, childbirth, fingers, shared linens, needles

Bacterial STIs

General

• Bacteria = single-celled; mutualistic & pathogenic
• Early antibiotic treatment prevents long-term damage

Chlamydia (Chlamydia trachomatis)

• Most frequently reported U.S. infectious disease
• Transmission: unprotected anal/vaginal sex, childbirth, autoinoculation (fingers→eyes)
• Symptoms
• Vulva: 75 % asymptomatic; discharge, bleeding, PID
• Penis: 50 % asymptomatic; watery discharge, dysuria, epididymitis
• Eyes: trachoma → blindness if untreated
• Complications: \text{PID} \rightarrow \text{endometritis} + \text{salpingitis} \rightarrow \text{infertility or ectopic pregnancy}; epididymitis in testes
• Treatment: single-dose or 7-day antibiotics; treat partners

Gonorrhea (Neisseria gonorrhoeae)

• Coffee-bean-shaped diplococcus; thrives in mucosa
• Higher infection rate in people with clitorises; symptoms show more in penises
• Sites: cervix, urethra, rectum, throat, eyes
• Symptoms:
• Vulva: often none; cervicitis, dysuria, subtle discharge
• Penis: cloudy malodorous discharge, groin lymphadenopathy
• Disseminated infection (DGI) → fever, arthralgia, petechial skin lesions
• Untreated → PID, infertility, epididymitis
• Drug resistance alarming; strain H041 (2011) resistant to all current antibiotics

Syphilis (Treponema pallidum – spirochete)

• Transmission: direct contact (oral/anal/vaginal), childbirth
• Stages:

1. Primary: painless chancre (2–4 wks)

2. Secondary: systemic rash, flu-like symptoms

3. Latent: asymptomatic, organ invasion

4. Tertiary: gummas, neuro/cardio involvement; ⅓ untreated reach this stage
   • Early stages ↑ HIV risk 2\text{–}5\times; fetal transmission possible
   • Diagnosis: dark-field microscopy, serology; Tx: IM penicillin (curative if early)

Bacterial Vaginosis (BV) – Non-STI

• Most common vaginal infection of reproductive-age vulvas
• Dysbiosis: ↓lactobacilli, ↑Gardnerella & Mycoplasma
• S/Sx: fishy-odor gray discharge, pain, itching; may raise PID, HIV risk
• Dx: vaginal swab; Tx: antibiotics (not yeast meds)

Fungal Infections

• Candidiasis (yeast): overgrowth of Candida; white “cheesy” discharge, pruritus
• Triggers: antibiotics, hormonal shifts, sex; OTC azole creams or oral fluconazole
• Jock itch: fungal groin rash; not STI but sex increases moisture/heat exposure

Parasitic Infections

General

• Parasites need host nutrients; classes: protozoa, helminths, ectoparasites
• Spread by prolonged skin contact, shared linens/towels, sex

Trichomoniasis (protozoan Trichomonas vaginalis)

• World’s most common curable STI; correlates with partner number
• S/Sx: redness, itching, frothy discharge, vaginitis
• Tx: single-dose oral metronidazole; treat all partners; untreated ↑ HIV risk

Pubic Lice (Phthirus pubis)

• Blood-feeding ectoparasite; visible “crabs”; intense pruritus
• Spread via sex, bedding; Tx: OTC permethrin creams; wash linens

Scabies (Sarcoptes scabiei)

• Mites burrow & lay eggs → itchy rash; can transmit via sex/bedding
• Tx: prescription scabicides (permethrin, ivermectin)

Viral STIs

General Virology

• Viruses ≠ living cells; require host; many incurable
• Antiviral drugs may block entry, replication, assembly

Human Papilloma Virus (HPV)

• >30 sexual types; low-risk warts vs. high-risk oncogenic strains
• Transmission: skin-to-skin, sex, childbirth
• Dx: warts, abnormal Pap, or serology
• Immunity: most clear in \approx 2 yrs
• Prevention: Gardasil (multi-type) & Cervarix vaccines; avoid contact

Herpes Simplex Virus (HSV)

• HSV-1 (oral) vs. HSV-2 (genital); both via skin contact
• Primary outbreak: flu-like + vesicles; recurrences w/ prodrome
• Dx: culture/PCR of lesion, serology
• Tx: antivirals (acyclovir, valacyclovir) lower outbreak freq & transmission
• Prevention: no contact with sores; condoms between outbreaks

Viral Hepatitis

• HBV: sex, needles, childbirth; 95\% clear acutely; 5\% chronic → cirrhosis/cancer
• HAV: fecal-oral (oral–anal sex)
• HCV: mainly blood/IV drugs; some sexual spread
• S/Sx: flu-like, abdominal pain, jaundice, dark urine
• Dx: serologic panels; Tx: interferon for HBV; DAAs for HCV
• Prevention: vaccines (HAV, HBV), barrier protection

Human Immunodeficiency Virus (HIV) & AIDS

Biology & Types

• Retrovirus (RNA → DNA via reverse transcriptase); integrates into host genome
• Forms: HIV-1 (global, virulent), HIV-2 (West Africa, less common)

Immune Impact

• Targets CD4 T-helper cells → immunodeficiency
• Normal CD4: 500\text{–}1{,}600\,\text{cells/mm}^3; AIDS if <200\,\text{cells/mm}^3

Stages

1. Acute (1–4 wks): flu-like, high viral load

2. Clinical latency (2 wks–20 yrs): asymptomatic, slow CD4 decline

3. Symptomatic: opportunistic infections begin

4. AIDS: severe OIs; untreated survival ≈3 yrs

History & Origin

• Cross-species SIV → HIV (1930s); first U.S. cases 1981; stigma exacerbated by political silence (e.g., Reagan)

Transmission

• Blood, semen, vaginal fluid, breast milk; anal sex highest risk; also needles, perinatal, transfusion

Diagnosis

• Antigen (p24), antibody (ELISA/rapid), nucleic acid (viral load) tests; home kits available

Treatment

• HAART = \ge 3 antiretrovirals:
• Reverse-transcriptase inhibitors
• Protease inhibitors
• Integrase & entry inhibitors
• Goals: viral load <\text{undetectable}, CD4 recovery; adherence challenged by side effects

Prevention

• Testing, condoms, barrier precautions
• PrEP (daily tenofovir+emtricitabine) ↓ infection by \approx 92\% if taken daily
• PEP: 28-day regimen within 72 h of exposure
• “U=U” principle: undetectable viral load ⇒ untransmittable (basis for NZ “Sperm Positive” donor bank)

STI Examinations

• Expect full sexual/medical history; honesty crucial
• Samples: urine, blood, cervical/vaginal/penile swabs, Pap, biopsy
• Positive Dx for reportable STIs (GC, CT, syphilis, HBV, HIV) → state notification & partner notification

Prevention Strategies

• Assess personal & partner risk; inspect genitals
• Limit partners; consistent condom/dental dam use
• Regular testing & sharing results (see test chart)
• Inform partners: educate, practice disclosure steps (educate → practice → timing → calm)

Contraception ‒ Historical Context

• Ancient methods: crocodile dung pessaries, lemon diaphragms, animal-membrane condoms (Casanova), toxic metals (Hg, Pb)
• 1873 Comstock Laws: banned mailing contraceptive info as “obscene”
• Margaret Sanger: illegal clinics, Planned Parenthood, lobbying; with K.D. McCormack financed pill research
• 1960: first oral contraceptive; legal access expanded via Supreme Court: \textit{Griswold v. Connecticut} (1965 married couples) & \textit{Eisenstadt v. Baird} (1972 singles)

Choosing a Method

• No perfect method—consider efficacy, side effects, cost, convenience, STI protection
• Five major groups:

1. Barrier & spermicides

2. Hormonal

3. Non-hormonal IUD

4. Fertility awareness

5. Sterilization

Hormonal Contraceptives

Mechanisms

• Synthetic estrogen &/or progestin → negative feedback on hypothalamus
\text{High }E,P \Rightarrow \downarrow \text{LH\,\&\,FSH} \Rightarrow \text{no ovulation}
• Progestin → thick cervical mucus + unreceptive endometrium

Effectiveness Table (perfect vs. typical) – selected examples

• Combo pill: 0.1\% / 9\% failures
• Implant: 0.05\% / 0.1\%
• Exterior condom: 2\% / 18\%
(See full table for others)

Oral Pills

• Categories:

1. Combination 24+4

2. Triphasic

3. Extended cycle \text{Seasonale}\,/\,\text{Seasonique}

4. Progestin-only (mini-pill) – strict timing, breastfeeding/smokers
   • Missed-pill rules differ (combo vs. POP)
   • Side-effects: breast tenderness, mood, nausea, \uparrow\text{SHBG} → ↓ libido, rare clots/strokes
   • Advantages: simplicity, cycle control, acne improvement, ↓ PID & some cancers
   • Drug interactions: barbiturates, rifampin, St John’s Wort, certain antibiotics

Vaginal Ring (NuvaRing)

• Insert days 1-5; in 3 wks, out 1 wk; can remove ≤3 h; less impact on libido; clot risk persists

Patch (Ortho Evra)

• Weekly change for 3 wks + 1 wk off; apply buttock, abdomen, arm, torso

Implant (Implanon/Nexplanon)

• Under-arm rod effective 3 yrs; progestin only

Injections

• Depo-Provera (progestin) q12 wks; fertility returns ≈10 mo
• Lunelle (combo) monthly; fertility returns immediately

Intrauterine Devices (IUDs)

• ParaGard copper: \le 10 yrs; sperm toxicity
• Mirena/Kyleena (progestin): thicken mucus, thin lining, may suppress ovulation; Mirena also treats menorrhagia; 5 yrs
• Insertion procedure; screen for GC/CT; threads for self-check; no STI protection

Barrier Methods

External Condoms

• Latex, polyurethane, polyisoprene, lambskin (STI pores)
• Variants: ribbed, warming, desensitizing, glow, vegan, sustainable latex
• Common user errors → slips/breaks; correct/consistent use critical

Internal Condom

• Polyurethane/latex pouch with rings; insert pre-sex; usable for anal by removing inner ring

Spermicides

• Nonoxynol-9 foams/jellies/films; new application each intercourse; may irritate & increase HIV risk if frequent

Cervical Barriers

• Diaphragm, FemCap, sponge; use with spermicide; insert ≤2 h pre-sex; leave ≥6 h ≤48 h; refit after pregnancy/weight change

Behavioral Methods

• Outercourse: non-penetrative sexual play; still risk for skin-to-skin STIs
• Fertility Awareness (cycle tracking):
• Standard Days (cycle length 26–32; avoid days 8–19)
• Cervical mucus, basal body temperature, calendar, LH kits
• Advantages: side-effect free, religious acceptance
• Disadvantages: record keeping, irregular cycles, lowest reliability
• Withdrawal: perfect-use failure 4\%; typical 18\%; little STI protection

Sterilization

• Vasectomy: seal vas deferens; semen w/o sperm
• Tubal ligation (laparoscopy): cut/clip fallopian tubes; hormones unchanged
• Most popular U.S. method (≈13 million users); considered permanent

Emergency Contraception (EC)

• Use ASAP post-coitus; not abortifacient if implantation occurred
• Hormonal pills (Plan B): high-dose progestin—delay ovulation
• Ella (ulipristal): progesterone-receptor modulator
• Copper IUD: \approx 99\% effective if placed ≤5 days; doubles as long-term contraception (10 yrs)
• Situations: no/failed contraception, sexual assault, missed pills, condom break, etc.

STI & Contraception Ethical / Practical Implications

• Stigma reduction critical (e.g., Sperm Positive bank, open disclosure)
• Public health requires partner notification & education
• Access disparities (Comstock legacy, modern insurance coverage) affect autonomy
• Informed choice balances efficacy, side effects, lifestyle, and reproductive goals

Quick-Reference Numerical Facts

• Chlamydia asymptomatic: 75\% vulva-bearers, 50\% penis-bearers
• Gonorrhea antibiotic resistance doubled since 2004
• HIV PrEP study: 92\% risk reduction with daily adherence
• Condom typical failure: 18\%; perfect: 2\%
• Mini-pill timing window: \le 3 h late requires backup
• Depo-Provera return to fertility: \approx 10 months
• Copper IUD longevity: 10 years; hormonal IUD: 5 years
• AIDS diagnosis threshold: <200\,\text{CD4 cells/mm}^3