1. Common STD’s in Women
Bradley H. Alger MD
St. Joseph FP Residency

2. Objectives of talk
Cover Chlamydia, Herpes, Gonorrhea, Trichomonas, PID
Briefly touch on Syphilis, HPV, HIV
Present Cases from Private Practice
Review treatment options from 2002 CDC treatment Guidelines

3. Chlamydia Cervicitis
Case: A 17y/o presents for routine WWE. New sex partner(unprotected) in last 4 months. You discuss and do a GC/CHL DNA probe at time of PAP and note normal cervix, no tenderness. 4 days later her positive chlamydia report is on your desk. How do you proceed? Phone management vs Appt. What issues do you discuss?(partner treatment, HIV screening, abstinence period, test of cure, future prevention, fertility issues, PID, follow up)

4. Chlamydia cont.
Estimated 3 million cases per year, 75% of women are asymptomatic
complications of PID(40% if untreated), subsequent infertility(20% of those who get PID), and risk of tubal pregnancy(9% of those who get PID), chronic pelvic pain(18% of those who get PID)
1 in 10 adolescent females who are tested are infected
By age 30, 50% of sexually active women have evidence that they have had chlamydia at some point in their lives
Generally it is easily treated and cured
Medication generally so effective that test of cure not necessary, except in pregnancy. If symptoms persist or reinfection occurs, retesting done best 3 weeks later. Abstain from sex for 7 days.
Evaluate and treat all sexual partners of the preceeding 60 days, or any partner prior to 60 days if the only sexual contact of the index case.
Consider rescreening all patients at next presentation within 12 months, esp. teens.

5. Treatment of Chlamydia
Azithromycin now preferred 1g single dose($20)
preferred in pregnancy
Doxycycline 100mg bid for 7 days($5)
alternatives(look them up!) – erythro,oflox,levoflox

6. Genital Herpes
Case1: You receive a refill request for Famvir for a 38 year old married female who you saw for a WWE 9 months ago. Your notes acknowledge she takes it for episodic outbreaks. Do you a) refill the med b) call and ask about her history, pattern of symptoms, efficacy of the drug c) ask her to schedule a brief appt to discuss further.
Case 2: A 43 y/o asian female( and her husband of the past 10yrs) presents with 8d hist. resolving painful perineal ulcer. 5 yrs ago she was hsv culture +. Her husband was not aware she had hsv and he’s never had symptoms. They have done research on the internet and they have many questions, including about antibody testing. Which topics do you cover?(asymptomatic shedding, transmission rates, etc.)
Case 3: After 4 years of occasional HSV outbreaks, a 32 y/o now has monthly 4-6 day outbreaks. Suppression is offered. Duration? Success rates?

7. Genital HSV Key concepts to explain to all patients:
Transmission rate and manner, natural history, asymptomatic shedding, permanent infection, what antiviral therapy may do, perinatal transmission, condom use, suppression indications.
Antiviral therapy may decrease the severity and duration of an HSV outbreak
data marginal for episodic outbreaks(except in HIV), good for primary outbreak, good for suppression(75% reduction of frequency of recurrences if 6 or more outbreaks).
Best to treat in first 24 hours/prodrome. Remind Patients. If presenting late in primary outbreak, drug may not do much.
Topicals never helpful and CDC says not recommended.
Regimens look them up.

8. Primary herpes, female

9. Genital HSV(cont.) Asymptomatic shedding concept.
Suppression not proven to prevent shedding.
Transmission rate unknown when suppressed.
HSV-2 more likely to shed than HSV-1
Shedding more likely to occur in first year after primary outbreak.
If suppressive therapy used, re-eval every year with patient whether to continue (given age and tendency to improve with time).
Acyclovir only one studied for long-term safety beyond 1 year. Safety established for up to 6 years.

10. Genital Herpes First Clinical Episode
Acyclovir 400 mg tid or
Famciclovir 250 mg tid
Valacyclovir 1000 mg bid
Duration of Therapy 7-10 days

11. Genital Herpes Episodic Therapy
Acyclovir 400 mg three times daily x 5 days or
Acyclovir 800 mg twice daily x 5 days
Famciclovir 125 mg twice daily x 5 days
Valacyclovir 500 mg twice daily x 3-5 days
Valacyclovir 1 gm orally daily x 5 days

12. Genital Herpes Daily Suppression
Acyclovir 400 mg bid or
Famciclovir 250 mg bid
Valacyclovir mg daily

13. Gonorrhea
Case: 16y/o female presents with pelvic pain and discharge. T 101, cervix draining pus, +CMT. What do you treat her with empirically? Gonorrhea + on Swab 2 days later. Follow up plan? Further testing, education?

14. Gonorrhea(cont.) 600,00 new cases per year in U.S.
Women often asymptomatic, so screening encouraged in high risk women.
Co-infection with chlamydia common so treat for both awaiting culture.
Five single-dose regimens now available(suprax 400mg, ceftriaxone 125mg IM, Cipro 500mg, oflox 400mg, levo 250mg) plus azithro 1g or doxy x 7d if chl not ruled out)
DGI (Disseminated GC) - pustular acral skin lesions, assymetirc arthralgia, tenosynovitis, septic arthritis, perihepatitis, endocarditis, meningitis). Hospitalize for i.v. Rocephin(1gq24), especially if compliance a concern.

15. Disseminated gonorrhea - skin lesion

16. Disseminated gonorrhea - skin lesion

17. Pelvic Inflammatory Disease
One million experience PID annually, 100,000 become infertile annually, 150 women die.
10% women develop PID in reproductive years.
May be mild enough(esp Chlamydia) to go undetected by patient and provider(2/3 cases go undetected)
Be aware of atypical PID(maintain low threshold)
abnormal bleeding, dyspareunia, or vaginal discharge.
Upper tract - Endometritis, salpingitis, tubo-ovarian abscess, pelvic peritonitis
Parenteral therapy for women pregnant, immunodeficient, intolerant to orals, tubo-ovarian abscess or severe illness.

18. PID cont.
Criteria:
Minimal - lower abdominal tenderness, adnexal tenderness, cervical motion tenderness.
Additional - t>101, abnormal vag or cervical discharge, elevated ESR or CRP, + culture for GC or Chlamydia.
Management: outpatient therapy with oral antibiotics for majority of patients, but follow up in 72 hours important to evaluate response to treatment(I.e. repeat pelvic exam)
Indications for hospital: pregnancy, cannot exclude surgical emergency, failing outpatient regimen, tubo-ovarian abscess, immunosuppressed, severe illness, high fever, n/v.

19. PID treatment
Coverage: GC, Chlamydia, anaerobes, streptococci, gr- facultative bacteria.
Outpatient:
ofloxacin 400mg BID x 14d or levo 500mg QD x14d, plus /minus metronidazole 500mg BID for 14d
Rocephin 250mg IM plus Doxycycline 100mg BID x 14d plus /minus metronidazole 500mg BID for 14d.
Other regimens look up.
Inpatient:
Cefotan 2givq12hr,or Mefoxin 2givq6hr plus Doxycycline 100mg iv or po q 12hr. (doxy po=iv bioavail), go 14 days on doxy
Clindamycin 900mg q8hr plus Gent 2mg/kg load then 1.5mg/kg q8hr. Or single daily dosing ok.
Alternatives look them up.

20. Pelvic Inflammatory Disease Management of Sex Partners
Male sex partners of women with PID should be examined and treated for sexual contact 60 days preceding pt’s onset of symptoms
Sex partners should be treated empirically with regimens effective against CT and GC

21. Trichomonas
Frothy yellow-green malodorous discharge. wet-prep evidence of motile pear-shaped protozoa, wbc’s, nit green
Treat partners as well. Incubation 5-28d.
metronidazole 2g single dose or 500mg bid for 7 days. (cure rate 90-95%). Not metrogel!!

22. Trichomoniasis Treatment Failure
Re-treat with metronidazole 500 mg twice daily for 7 days
If repeated failure occurs, treat with metronidazole 2 gm single dose for 3-5 days
If repeated failure, consider metronidazole susceptibility testing through the CDC

23. Noncervical HPV
20million currently infected, 5.5million new cases/yr.
Weeks to months to appear after sexual contact.
No evidence to support that treatment decreases infectivity, changes the natural course, or the risk for development of cervical cancer. No cure for HPV.
Goal to eliminate visible warts.
Patient-applied treatment:
podofilox(.5% sol or gel) BID 3d off 4d for four cycles
aldara 5% cr. Apply qhs 3 times a week, wash off 6-10 hrs, for up to 16 weeks. Warn pt mild to moderate local irritaton prior to resolution.
Physician-applied: cryotherapy, TCA. Q 2-3 weeks.

24. Papillomavirus Treatment
Primary goal for treatment of visible warts is the removal of symptomatic warts
Therapy may reduce but probably does not eradicate infectivity
Difficult to determine if treatment reduces transmission
No laboratory marker of infectivity
Variable results utilizing viral DNA

25. Papillomavirus
Source of therapy guided by preference of patient, experience of provider, resources
No evidence that any regimen is superior
Locally developed/monitored treatment algorithms associated with improved clinical outcomes
Acceptable alternative may be to observe; possible regression/uncertain transmission

26. Syphilis 35,600 cases reported in 1999. 2.5/100,000
Prevalence high in the South, 75% of cases in African Americans(16%whites, 8% hisp)
Be able to recognize it, but get ID involved treating it.
2-5 fold increase in acquiring HIV(ulcer makes transmission easier).
3 stages, treatmnet stage-dependent.

27. Primary syphilis - chancre

28. Secondary syphilis - papulosquamous rash

29. Secondary syphilis

30. Populations to Target Adolescents
Of the 12 million new cases of STDs annually, 3million of them occur in adolescents.
Annually, 1 in 4 sexually active teens gets an STD.
By the 12th grade, 70% of adolescents have had sexual intercourse. One quarter of all students have had sex with 4 or more partners.
Chlamydia is more common among teens than among older men and women.
Gonorrhea rate is highest among females age years.
Up to 15% of sexually active teenage women are infected with HPV, many with subtypes associated with cervical cancer.

31. Teen Vist
Remember to inquire about adolescent health issues at any teen visit, and especially cover STD’s at every adolescent WCC. Ask sexual behavior and identify risk!
Vaccine preventible STD’s (HBV especially)should be a part of every teen visit. Offer and start HBV series.
Remember confidentiality!!

32. HIV
Individuals infected with STDs are at least two to five times more likely than uninfected individuals to acquire HIV if they are exposed through sexual contact.
Co-infected persons are more likely to transmit HIV
ulcers efficiently tranmit, STD provide target cd4 cells.
Screen & consent. Screen repeat in 6 months.