PAG over Pastries
A pediatric and adolescent gynecology review podcast. Started by a fellow for residents, fellows, and others to learn more about PAG topics.
PAG over Pastries
8 - Sexually Transmitted Infections
This episode, we are joined by Dr. Aliah Fonteh, a PGY2 resident, and Dr. Alla Vash-Margita a PAG attending at Yale to break down what every provider should know about sexually transmitted infections.
Outline
- Introducing STIs in Adolescent Care
- Confidential Interviews with Teen Patients
- Common STIs: Chlamydia, Gonorrhea, Trichomonas
- Syphilis: Screening and Diagnostic Challenges
- HPV and Vaccination: Preventing Cancer
- HSV and HIV PrEP Management
- STI Testing Recommendations and PID
- Case Discussion and Conclusion
References:
- NASPAG Essentials of Pediatric and Adolescent Gynecology: Chapter 20
- Human Papillomavirus Vaccine Efficacy and Effectiveness against Cancer by Supitcha Kamolratanakul and Punnee Pitisuttithum
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What is PAG?
Pediatric and Adolescent Gynecology is a subspecialty of OBGYN (2 year fellowship) focusing on reproductive healthcare for children and young adults. It fills the overlap between general gynecologists and pediatricians. It is a multi-disciplinary field involving work with pediatric endocrinology, dermatology, hematology, surgery, ect. Go to NASPAG.org for more PAG educational resources.
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A 15-year-old patient comes to clinic in distress because her boyfriend cheated on her three weeks ago. They stopped using condoms six months ago. She does not have any vulvovaginal symptoms. What STI testing should be performed? Hi everyone and welcome to another episode of Pagover Pastries, a 20 to 30 minute review podcast regarding all things pediatric and adolescent gynecology. I'm Camille Imbo, a second year pediatric and adolescent gynecology fellow at Phoenix Children's Hospital, and today we have
Alla Vash:I am Alla Vash- Margita and I am faculty at Yale University School of Medicine Pediatric, Adolescent Gynecology.
Aliah Fonteh:And my name is Aliah Fonteh and I'm a second year resident in the Obstetrics and Gynecology Department at Yale School of Medicine.
Camille Imbo:Today we'll be talking about sexually transmitted infections. Our reference is Chapter 20, Sexually Transmitted Infections, HIV Pre-Exposure, Prophylaxis and Expedited Partner Therapy, which is written by Dr Cynthia Holland-Hall and Lauren Matera in the Essentials of Pediatric and Adolescent Gynecology, released by NASPAG. So what are your favorite pastries?
Aliah Fonteh:My favorite pastry is a white chocolate chip macadamia nut cookie. So good.
Alla Vash:I will go for apple turnover.
Camille Imbo:It's not a very popular one, but that's one of my favorite ones as well. All right, let's get started. So, sexually transmitted infections a very big problem, but unfortunately carry a lot of stigma, especially in our teens. So, Alah, can you tell us a little bit more about the background on STIs?
Alla Vash:STI stands for sexually transmitted diseases and although it affects all ages, our young patients are at increased risk because they may not know the proper behavior when they engage in sexual encounters. They may also inconsistently use condoms and may have increased number of partners. We all know that STIs can definitively be prevented only by abstinence. There is nothing 100% effective, but there are means to prevent them. We all know in pediatric adolescent gynecology that we have not one patient, but we have two patients, sometimes three, so we have a patient and usually parent. So it behooves us to earn the trust of the patient and part of taking care of adolescents is to offer an opportunity for confidential interview and that's sort of mainstay of the visit, especially for new patients.
Alla Vash:We always offer confidential interview where we pledge confidentiality to the adolescent and I always I will tell my patient that this all stays between you and me and electronic medical record. The only time I have to disclose is if I find out that you want to harm yourself or hurt someone else. I would say 99% of parents/ guardians are okay with that and this interview is offered ages 13 and above. They see us as a partner, meaning patient sees us as a partner. They are likely to disclose any activities that they may have been engaged in and also seek advice. We'll often tell my patients this is a no judgment zone. You're safe Now be aware that each state has its own laws and practitioners should be familiar with those laws. Gottmacher Institute, which is a research institute on reproductive health, is a great resource that has a separate section on laws in each state.
Camille Imbo:I'm pretty sure we have another podcast that's just focusing on the confidential interview At our office, We grab their number directly so we can call them directly with results. But even when we tell them the results, if it is positive and they need to pick up antibiotics, it might go on mom's insurance. So if you don't drive yourself at that point, moms might start to question things. So at some point the truth might come out and it's always best to be honest. But from my end I will not be exposing as best as I can. So, going back to STIs, aliah, do you want to break down some of these different types of infections, starting off with the big one, chlamydia?
Aliah Fonteh:Chlamydia is one of the most common reportable bacterial infections in the United States. It actually remains the highest amongst female adolescents and young adults age 15 to 24. And what we know about chlamydia is that the symptoms typically include vaginal discharge, spotting, post-coital bleeding, pelvic pain or dysuria. The cervix could be normal or be associated with some friability or oozing of purulent and peering fluid from the os. Gonorrhea is the second most common reportable bacterial infection in the United States.
Aliah Fonteh:Oftentimes, patients might be asymptomatic, and if not asymptomatic, their symptoms are actually similar to chlamydia
Camille Imbo:and I want to emphasize something you mentioned because, yes, there's all these possible symptoms. My own experience it seems like 90% plus of people who've tested positive were asymptomatic.
Alla Vash:And, as we've previously discussed, it can be through genital, anal or oral encounters. It's also important for patients who end up becoming pregnant, because it can be passed from the pregnant person to their infant during childbirth. First and foremost, we want to make sure they're aware that we recommend very strongly treatment of not just themselves, with the full course of their treatment, but also their partners. Trichomonas is a tricky one, and when you think about trichomonas, imagine a cervix that has this pathognomonic finding of a quote, unquote strawberry cervix. What you're thinking about for this typical presentation is a patient that has frothy vaginal discharge with friable cervix. They also typically might have vaginal pruritus, dysuria. They might have pelvic pain, lower abdominal pain.
Aliah Fonteh:I think that's like most exciting day in the OBGYN clinic. If somebody looks under the microscope and there's like the protozoa swimming, everybody gets called to look at the wet map.
Camille Imbo:That's what we find fun as gynecologists. And another symptom I think you mentioned but I want to bring up again is also abnormal bleeding is a really big one. That's often missed as a sign of STDs because we go down the route of abnormal uterine bleeding and other periods ambulatory all of that.
Camille Imbo:But that's another big thing to look for and test for STDs
Alla Vash:the only other thing I forgot to mention was expedited partner therapy that the patient's partners are treated and their prescriptions are provided, and that they have all of the instructions regarding the diagnosis as well, and that the patient is rescreened within three months for a test of cure.
Camille Imbo:Now diving a little bit more. Let's talk about like syphilis.
Aliah Fonteh:Yes, there has been a resurgence of syphilis and we are really needing to be very intentional about screening, diagnosing, treating Syphilis is caused by spirochete bacteria. There are many manifestations of syphilis it could be early, it could be secondary, it could be late syphilis, it can have a neurological involvement called neurosyphilis, or it can fall into a category called late in syphilis. And so when we think about primary syphilis, this is a patient who typically presents with a painless ulcer called a chancre. This presentation of syphilis typically is only about three to six weeks. Honestly, with serologic testing it might be negative, but diagnosis can either be made through dark field microscopy of the lesion or by blood work.
Aliah Fonteh:You do need to treat this patient with penicillin I am and if they have an allergy, they actually require desensitization
Camille Imbo:and the other thing that's really important that actually had this happen to a patient recently he went to the emergency room is that syphilis has a two-step screening process. Tpa is the primary and then you can confirm with the RPR. And so this patient had a positive TPA. But of course this was the emergency room so the RPR didn't return in time. So they basically told her you have syphilis, you need penicillin, follow up with GYN and scare this poor 15 year old to death. And you know it's important to realize TPA can come back positive from a whole slew of other things and actually, for taking her history, it actually sounded like she may have lupus or something .
Camille Imbo:I sent her to a rheumatologist for workup from that perspective. So of course it's a serious enough disease that you don't want to not tell someone that they tested positive, and you never know in the emergency room if they're going to follow up or not.
Camille Imbo:So I understand where they came from, but I think it's important to still mention there is a possibility that this is a false positive
Aliah Fonteh:For the patients that are at highest risk, like the adolescents who unfortunately might be unhoused or are victims of sex trafficking or engage in transitional sex or who have recently been incarcerated. This is a unique population that we don't want to miss and hopefully they are not lost. To follow up, even if we have, like you said, dr Imbo, like precursor tests, but we don't have the final result with that secondary screening.
Camille Imbo:Absolutely. I trained in Florida and I'm now in Arizona, which are both high syphilis states. Funnily enough, in Florida a lot of it was because of the elderly population. We have the villages I don't know if you've heard of it and syphilis is actually rampant over there. So opposite population from PAG. But that was the big thing. And the other unfortunate thing that these two states have in common, exactly like you mentioned, is human trafficking. We talked about this a little bit when talking about HPV, how it fits the STD world, because that's how it's transmitted, but not quite and kind of. Can you talk to us a little bit more, alla, about what it is and what different ways we have to go about preventing HPV?
Alla Vash:So, yeah, hpv is one of the STIs that we can actually prevent. We'll talk about vaccine in a bit, but it is the most common STI in adolescents and young adults, although it is mostly asymptomatic and patients is unaware for a long time or forever until they clear the infection. So the ones that they may become aware, the manifestation of non-oncogenic subtypes of HPV, which are most commonly cited as 6 and 11,. These serotypes will cause anogenital warts, otherwise known as condyloma acuminatum, and so these are not dangerous. They're not cancerous, but they are visible and they can be usually located around introital entrance, posterior fourchette. They can spread into the cervix, vaginal wall, urethra. The distress that comes with those lesions is immense. The other type of HPV subtypes are oncogenic and most commonly known are type 16 and 18. They will not cause visible lesions, but they can cause in a long-term cancer, and that is a cervical, vulvovaginal, anal cancer, also head and neck cancers. We touched on oral sex and that is how it's transmitted. So now we get to the HPV vaccine, because this is the only vaccine that we as medical establishment have to prevent cancer, and I named a couple of types of cancers.
Alla Vash:The vaccine was actually approved in 2006. So if people have reservations and worry about new vaccines. I tell them this vaccine has been out for decades now and millions and millions of boys and girls have been vaccinated. Any serious side effects are really negligible. So vaccine is approved starting at age nine. The target age is really 11 to 12. When in discussion I take facts out of the equation because many parents are worried about giving this vaccine as a sort of a free ticket to sexual activity, so I do not discuss sexual activity really associated with this vaccine I say this is a vaccine that prevents cancer that can be deadly. I also say that if you're younger than 15, you only need two shots. 15 and older it's three shots.
Camille Imbo:One parent asked me how effective is this?
Camille Imbo:I pulled up an article from the Vaccines Journal called the Human Papillomavirus Efficacy and Effectiveness Against Cancer by, and I apologize if they hear this if I say this wrong but, Drs . So it's been shown to have a 90% reduction in HPV 6 through 18, a 90% reduction in warts, a 45% reduction in LSIL type abnormalities so low-grade cervical abnormalities and 85% reduction in HSIL, the high-grade and had about a 70% to 80% reduction in cervical cancer. Altogether and overall effectiveness, depending on how many doses they received, was between 83% to 96%, of course, best when given before they've gotten their first infection, which is why, as you've mentioned, I point out why we give it so early, despite the association with sexual activity, and also the risks of adverse events and anaphylaxis are extremely low less than one per million doses.
Aliah Fonteh:So exciting that we get to share about this vaccine and that they extended it even up to age 45.
Camille Imbo:Absolutely, and then we jump into some different ones.
Aliah Fonteh:Yes, let's talk about HSV, also known as herpes simplex virus. So, first and foremost, hsv can be broken down into HSV1 or into HSV-2. The most important thing to know is that, yes, we have treatments that we provide when someone has an outbreak, or long-term treatment, but it's never 100% curative. Hsv-1 is transmitted typically via oral contact and it will manifest with oral or cutaneous lesions, but it can still also cause genital ulcers, and HSV-2 is associated with genital ulcers and it's also important to mention we are taught of like which one is an oral versus genital, but really nowadays either one presents in either place, so it doesn't necessarily matter.
Aliah Fonteh:When we think about primary versus secondary infection. A patient who is about to have their first ever infection typically will have painful, small, less than one centimeter vesicles that have this red, irritated, angry base that over some time will ulcerate. They may or may not have systemic symptoms, including fever, malaise, swollen lymph nodes, and then this primary infection can typically last about two weeks after that initial exposure and then after that the virus becomes latent in the sacral ganglia. Consecutively, a patient might believe that they are starting to have the re-manifestation of the virus because they'll have prodromal symptoms which are tingling, burning, itching or shooting in the region where an ulcer is going to form. And it's very important, if someone is starting to have prodromal symptoms, for us to go ahead and initiate treatment to reduce the severity of their outbreak.
Aliah Fonteh:For transmission and shedding, which are other important aspects, patients with known HSV first and foremost, we will counsel them that they are actively having the virus or shedding within that period of time that we discussed, that they are at risk of transmitting this orally or through genital encounters.
Aliah Fonteh:Most important thing that we never want to forget is pain control for these patients and, as long as the patient doesn't have any contraindications to non-steroidal agents that is one of the first lines as well as topical analgesics. And then we can discuss suppressive therapy, which can be either a daily treatment with antiretrovirals, which is typically prevalent and available for HSV-2, but there's no evidence of daily suppression for HSV-1 at this time and then the other way that we can treat HSV is through an episodic treatment of the outbreak, and there's a great chart in the textbook that talks about what you do for an initial outbreak, what you do for an initial outbreak, what you do for recurrent outbreaks and what you would do for daily suppressive therapy. In a very brief summary, you can take a Ciclovir or Valsiclovir for a course of seven to 10 days. I'll be honest.
Camille Imbo:I always look it up when I have a patient, whether they're initial or recurrent, because I cannot for the life of me keep track of these and of course I want to be right. And then a huge personal pet peeve of mine is how we screen for it. It's meant to be tested by scraping the active lesion, which of course is unfortunate if they come in way too late after the lesion has been presented but to not do it via blood testing, because about 60% of people will be seropositive for HSV and then never have had a lesion. And then in the OB world where, if they've ever tested positive or have been told they're positive, we now have to treat them and do the preventative treatment in pregnancy. And of course we think about how we can make patients anxious and those types of things. So I absolutely hate whenever I see that someone was told they have herpes but it was from a blood test.
Alla Vash:Yeah, same, I sign on to that. So IgG is notoriously not accurate for HSV and it's actually it's discouraged by ACOG from routine screening via blood or serum testing. So, yes, it's a lesion testing or clinical presentation or both.
Camille Imbo:Alright, do you want to talk about HIV Aliah?
Aliah Fonteh:This is actully an area of interest to me. When we think about Human immuno-deficency Virus. It is something that we can encourage our patients to consider preventing not just through safe sex practices, but also if they are a candidate
Aliah Fonteh:Pre-exposure prophylaxis or after an event, post-exposure prophylaxis PrEP or pre-exposure prophylaxis is 99% effective in reducing the risk of a patient attaining HIV when it is taken as prescribed. I feel like you can just drop the mic after hearing that it's so powerful. A patient who has risk factors for attaining HIV, such as they have an HIV positive partner. They've tested and received a diagnosis of an STI within the last six months. They might have some behavior patterns that put them at risk for multiple STIs and or HIV, but they are currently HIV negative. They do not have any acute signs of HIV infection and they are at least greater than 35 kilograms.
Aliah Fonteh:These are patients who would be a candidate for PrEP. And specifically talking about Truvada and also talking about the risk for patients who are participating in receptive vaginal intercourse, and so for patients who are interested in PrEP, we would recommend that every three months that they are having testing for HIV, and then every six months we need to check their kidney function. We need to do bacterial screening gonorrhea, chlamydia, syphilis and then every year we check for things like lipids, again reassessing their kidney function and making sure that they are still a good candidate for PrEP.
Camille Imbo:Yes, that's wonderful and it's so important to minimize the stigma around HIV. And what's wonderful is there's a lot of different forms of PrEP coming out that don't have to be taken as often anymore, so the amount of options out there are absolutely incredible. So it's really important that we bring it up and give those options to our patients. I'm assuming you're not necessarily doing the A through F of testing every single time. I'm interested to hear how you present these and decide what they need.
Alla Vash:The guideline by ACOG is that a sexually active cisgender woman younger than 21 should be offered screening at least once a year for chlamydia and gonorrhea with a vaginal swab. Now if they have apprehension or don't want to have a vaginal exam by a physician, they can either self-swab We've had very great successes with picking up infections or they can also do first catch urine. Swabs are preferred because of slightly higher sensitivity, but again, if they have any kind of reservation, self-sw swap or urine sample is sufficient. That is chlamydia gonorrhea. For trichomonas, recommendation is to screen in populations with high prevalence and again, knowing your state, speaking with your infectious disease specialist, they will know exactly whether you need to screen for trichomonas or not. We use a highly sensitive testing called NAAT and that stands for nucleic acid amplification test. We can also use this testing for chlamydia gonorrhea, not just genital sources, but places like throat. Teens can engage in other types of sexual activity, such as oral sex, and so in that case we would need to swab someone's throat.
Camille Imbo:Yeah, I'm glad you mentioned the throat swab because I'll admit, earlier on in my stages of training I wasn't great at specifying what kind of sexual activity. So I've tried to bring that up a little bit more. And when I offer testing, I say once a year or anytime you've had a new partner. A lot of patients say, well, I've had STD testing, everything was negative, not realizing that they probably only got chlamydia, gonorrhea.
Aliah Fonteh:Now. Syphilis is rare, but now it's on the increase and we need to be aware of syphilis screening and also offer it via blood test in areas of high prevalence.
Alla Vash:Human papillomavirus is the most common STI in the United States. We don't screen until age 21. And even then we don't screen for it. We do pap smear, we do cytology Right.
Camille Imbo:That one's a funky one because you'll have, of course, patients all the way, even thinking of adults who've been in a committed relationship, and HPV is one of those that can pop in and out randomly and explaining yes, it's sexually transmitted, but it doesn't quite fall in the same category as the other STDs, because you didn't work on them, or something like that. So I try to explain that one a little bit differently, for peace of mind if it pops up in a pap smear.
Alla Vash:The really important thing about chlamydia, gonorrhea and most of these sexually transmitted infections is that we want to detect it early so that we can treat the patient, treat their partners and reduce the risk of future sequelae. Sequelae for patients who unfortunately might not have treatment or who have recurrent risk of getting these infections can down the line, include pelvic inflammatory disease, tubal scarring, infertility, and some of these patients can be at increased risk for ectopic pregnancy and chronic pelvic pain.
Camille Imbo:PID is a very common way that we see presentation of STDs. Do you want to touch on that a little bit?
Alla Vash:We hope to prevent PID. That's why we're doing this amazing work to prevent any STIs. But if a patient gets infected she may develop a pelvic inflammatory disease, which is infection of the uterus, fallopian tubes and or the ovaries. They may present even with a lesion in the adnexa with formation of pus around it, something called TOA, tubovarian abscess. So historically they've been attributed to Neisseria gonorrhea or chlamydia trachomatis, but more recently we culture them in 25 to 50% of cases.
Camille Imbo:I've had so many conversations with hospitalists of no, you do not automatically need a sexual abuse or a child protective team console just because someone has TOA or PID, because it's not always related to an STD.
Alla Vash:Typical presentation. Obviously patient will have systemic illness, fever, chills, malaise then localized abdominal pelvic pain, vaginal discharge. Some patients can be treated as outpatients. Some, if they're too ill, they need admission and treatment as an inpatient.
Camille Imbo:The other big thing is TOA kind of presents like a cyst type formation is not something that we operate on unless it's really not responding to antibiotics. Give her the antibiotics. Give her 24 to 48 hours and we should start to see resolution of symptoms. And it can take several weeks for the TOA to completely go away, if not months but at least for the fever to go away. About IUDs do you want a quick statement about that?
Alla Vash:So IUDs. Many will use IUDs as a reliable method of contraception. If a patient has an IUD in place and has a TOA or PID, that is not indication to remove an IUD, unless, of course, patient desires removal. But aside from that, we may leave IUD in place and treat PID as directed. Obviously, if patient is not responding, she's not defervescing, she's not clinically better, she still has leukocytosis, then yes, maybe we need to remove it or talk about removal of an IUD.
Camille Imbo:That kind of covers all of it. Sti seems like such a simple topic, but there's a lot of different kinds, a lot of different symptoms, presentations, treatments. But going back to our initial case, we had a 15-year-old who came in because she was cheated on by her boyfriend, unfortunately, and they hadn't been using condoms for six months. She's asymptomatic, but, like the lovely pediatric gynecologist that we are, we talked to her about STI testing. So, Aliah, what kind of tests would you want to offer her?
Aliah Fonteh:I would offer her vaginal swabs, if she's amenable whether it's a self-swab or myself for gonorrhea, chlamydia, and then, if she's in an endemic region, I'd also recommend trichomonas. And then I would tell her that this is not the full spread of everything and, depending on her symptoms and anything else presenting, we could add other tests.
Alla Vash:We will also talk about use of condoms and reliable birth control, because she's 15 and she's engaging in intercourse with male partner.
Aliah Fonteh:And then, of course, we could offer her the HPV vaccine Gardasil, if she has not already had her first dose.
Camille Imbo:Educate, educate, educate. That's what it comes down to. Despite this unfortunate situation of her being cheated on, hopefully she comes out of it more protected for future relationships. Well, that concludes our podcast on STIs.
Camille Imbo:For more information, visit PAG over Pastries page, which is available on the NASPAG website. It'll include transcript of this podcast and all the other ones, links to the references that we discussed today, and once you access the book you can see the helpful pictures, the references that we discussed today, and once you access the book you can see the helpful pictures and tables that we've mentioned. We also are doing a survey trying to see who is listening to this podcast, what your background is in, trying to get more information about that. So, if you're able to get onto the website, there's a very short survey available on there. If you have any questions or concerns for myself or any of our speakers, or feedback, or you want to be a guest in the feed to Pag over Pastries, we'll see you at pagoverpastries@ gmail. com.
Aliah Fonteh:I just want to say thank you so much for this opportunity
Camille Imbo:. Yes
Alla Vash:thank you, dr Imbo
Camille Imbo:This has been a pleasure it was such a pleasure talking to the both of you. Well, thank you for listening to PAG Over Pastries. We'll see you next time.
