Ask the Experts: STDs/STIs

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You Be The Influence


Below are some of the questions sent to ASHA about sexually transmitted infections. Click on the + to see the answers from our experts.

After having lots of pain when I’d urinate, I was worried I might have something like gonorrhea so I went to my clinic and was diagnosed with Mycoplasma genitalium. What is it? I never heard of it! How do you get it? They gave me some pills and said it would be ok, so does it go away? What can it do to you?

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Mycoplasma genitalium, or M gen as it’s sometimes called, is a bacterial infection that’s overlooked (but getting more attention). M gen is transmitted through sexual contact and can be found in the urethra (the tube through which urine passes), cervix, anus, and throat. Men often experience inflammation of the urethra (urethritis) which can involve symptoms just like you describe: burning, painful urination and sometimes a discharge from the penis. Women generally don’t have symptoms with M. gen although they may experience pain with urination, vaginal discharge, or discomfort with sex.

Diagnosis with men involves a swab or the urethra or a urine test. M gen is usually detected in women from a swab of the cervix. The infection is curable with antibiotics, typically azithromycin or moxifloxacin.

As for the effects: urethritis in males (including the hard to shake variety) is probably the best documented condition associated with M gen. Less is known about the effects of M gen in women, but evidence suggests the infection may be associated with inflammation of the cervix (cervicitis) and Pelvic Inflammatory Disease (infections involving the uterus, fallopian tubes, or ovaries). There may also be a link with infertility in females, but this isn’t well established. Similarly, more research is needed to understand the impact of M gen on pregnant women and their infants.

--The STI Resource Center Staff

References:

Manhart L, Broad J, Golden M. Mycoplasma genitalium: Should we treat and how? CID, 2011. 53(S3):S129-142.

Mycoplasma genitalium Factsheet. New South Wales Government Health. Accessed online at http://www0.health.nsw.gov.au/factsheets/sexualhealth/mycoplasma_genitaliu.html


As a gay man I hear a great deal about testing for HIV and hepatitis; what about other STIs? Please tell me what tests I should be thinking about.

 

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The Centers for Disease Control and Prevention (CDC) recommend the following tests at least once each for men who have sex with men (MSM):

HIV

  • Syphilis
  • Gonorrhea and chlamydia of the urethra (tube in the penis)
  • Gonorrhea and chlamydia of the rectum – the “butt”- for those who had insertive anal sex in the last year
  • Gonorrhea of the throat for anyone who performed oral sex in the last year

MSM are also recommended to be tested for hepatitis B, and to get vaccines against hepatitis A and hepatitis B. Additionally, HPV vaccines are recommended for both males and females up to age 26.

Depending on your own risk factors, more frequent testing may be recommended. Talk to your healthcare provider about sexual health, and ask them what tests they think you should have. For help finding a clinic in tune with your needs, visit the Gay and Lesbian Medical Association online.

--The STI Resource Center Staff


I’m confused about trichomoniasis. The ASHA site and others say it’s one of the most common infections out there, but I’ve never heard of it. I’ve had STI tests done in the past, for HIV and chlamydia, but no one has ever mentioned trichomoniasis with me. How can it be so common if I’ve never heard of it? How do you test for it?

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Trichomoniasis or “trich” is actually a parasite (called Trichomonas vaginalis) and is perhaps the most common, curable sexually transmitted infection among young women. An estimated 7-8 million cases of trich occur in the U.S. each year. Trich doesn’t get much as much publicity as other STI because we’re just beginning to learn how important it is.

Trich probably deserves more attention. It can cause an unpleasant discharge, and a lot of vaginal irritation. Trich always stays in the vagina so it doesn’t cause infections in other parts of a woman’s body. However, trich is associated with both premature delivery and low birth weight babies. Also, people with trich get infected more easily with STIs like chlamydia and HIV, and trich makes it easier to transmit these infections to others. Untreated trich infections can last months or even years, without causing any symptoms.

One of the things we’ve learned about trich is how to do a better job with diagnosis. For many years, the diagnosis was made by using a microscope to look for the parasite in the vaginal fluid. Unfortunately, this test often misses the diagnosis. More recently, much more accurate tests have become available. Men get trich too but usually don’t have any symptoms. So, men usually find out from a sex partner.

Trich is curable, but it can come back unless both partners are treated before they have sex again. Treatment should be taken even if there are no symptoms of trich. The antibiotics used to treat trich (they are called metronidazole or tinidazole) work very well. However, some trich has become more resistant to these antibiotics, so it’s important to take all of the medication that is prescribed, make sure partners are treated, and get checked again if the symptoms come back (or don’t go away).

Click here to learn more about trich, including diagnosis, treatment, and prevention.

--J. Dennis Fortenberry, MD, MS


I am a 23-year old woman, one steady partner now but a couple of lovers in the last year or so. I had a urine test for chlamydia that was (thankfully) okay and said I don’t have it. I’ve had anal sex, too, and didn’t mention that to the people at the clinic. Would the test I had also pick up on chlamydia in the anus or rectum?

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Chlamydia is perhaps the most commonly reported infectious disease in the U.S., with over a million cases reported to the CDC annually. In reality, many cases of chlamydia are undiagnosed and unreported, so the true number of new cases each year (known as “incidence”) is probably closer to 3 million.

This bacterial infection is especially common in young women and is also common in young men. Sexually active adults with multiple sex partners and those who do not use condoms regularly also have increased rates of infection. Usually there are no tell-tale signs nor symptoms of infection to let you know, so you were smart to get tested. In fact, it’s recommended that all sexually active females under age 26 be tested each year for chlamydia.

We now have very accurate swab and urine tests for chlamydia using Nucleic Acid Amplification Technology (NAAT). However, a urine test will only detect chlamydia infection of the urethra or genital tract; to check for chlamydia infection in someone who has had receptive anal intercourse, a swab sample must be taken from the rectum which can be done easily and with little or no discomfort. The same NAAT test can be used to test this swab and tell you if you have a rectal infection. A different swab can also be used to test the throat to see if there is a chlamydia infection due to oral sex if you have had that exposure as well.

It can be hard, I know, but it would be a good idea to let your healthcare providers know you’ve had anal sex and/or oral sex (believe me, you won’t be the first to tell them that!) so additional tests can be ordered. Also, an HIV test is always a good idea for anyone who’s sexually active, for example.

--Gary Richwald, MD, MPH


My doctor tested me for trich by taking a swab from my vagina, and then tested my urine for chlamydia. I don’t understand why I needed two tests. My friend was tested for a bunch of STIs and said they used a swab for her to test for trich, chlamydia, and gonorrhea.

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There are several ways to test for Trichomonas (“trich”) and different providers may use different methods. Trichomonas is a motile one-cell parasite which can be viewed in a “wet preparation” of a vaginal swab on a slide under the microscope by the clinician. It is diagnosed by its motion on the slide under the magnification of the microscope.

Another way to detect it is to take a vaginal swab and send it to the laboratory for culture, which is a method to grow it; it is a little more sensitive than viewing it directly on a wet prep.

Recently, there is a new molecular test that is much more sensitive (more accurate) than “wet prep” or culture that amplifies the DNA from the swab or urine or a liquid PAP specimen. This is much like PCR or polymerase chain reaction that is powerful method for diagnosing infections. Tests for chlamydia, gonorrhea, and trichomonas can all be performed from a single swab or from urine using the new molecular method. Your doctor may have needed a separate swab for trichomonas if she/he was using a wet prep or culture method. The number of swabs (or use of urine) all depends on the type test the doctor is using.

--Charlotte A. Gaydos, DrPH, MPH, MS



How does a person get hepatitis C? I thought it had to be inherited or you had to come into contact with someone who has it, like with an open wound. I was told I tested positive for hepatitis C but we have no family history of this infection?

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You are correct you have to come in contact with someone who has it. There are several types of hepatitis and unlike some other conditions (such as high blood pressure or diabetes, for example) none of them –including hepatitis C - are infections you get because a family history makes you more susceptible. Because hepatitis C virus is a virus it can be transmitted through exposure to infected blood. For example, when injecting drug users share needles or syringes. The virus can be transmitted mother-to-child if a pregnant woman is infected. Rarely, hepatitis C is transmitted through sexual contact (hepatitis B is much more likely to be acquired sexually). It’s also possible to contract hepatitis C thorough blood or organ transplants, although this is rare in the U.S. since updated precautions went into place in the early 1990s.

Most individuals with hepatitis C (about 80%) do not have signs or symptoms. Hepatitis targets the liver. Liver disease progresses so slowly that a person can have hepatitis C for years without having symptoms. Many individuals with chronic hepatitis C have mild to moderate liver damage but do not feel sick. The possible symptoms for an acute infection (newly acquired or short-term) and a chronic (long-term or persistent) infection are different.

Unlike hepatitis B, there is no vaccine for hepatitis C. Treatment may differ depending on the stage of illness at the time treatment is sought. Your healthcare provider can help you make the best decisions about your treatment based upon your individual health needs. People with acute viral hepatitis experience a self-limited illness (one that runs a defined, short course) and go on to recover completely. Relatively few people seek medical care for acute HCV, since most individuals are have no symptoms or have only mild, flu-like symptoms. Contact your healthcare provider for more information.

--Versie Johnson-Mallard, PhD, RN, APRN, WHNP-BC



I just took the treatment for chlamydia yesterday (I think azithromycin). I forgot about the doctor's instructions and drank a bit of beer, about half a cup. Is this going to affect the treatment?

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The short answer to your question is that a small quantity of alcohol (beer) taken about the same time as a dose of azithromycin should not cause a problem or make the treatment less effective.

Azithromycin (common trade name, Zithromax® or Z-Pak) may be taken either with or without food, but should not be taken within 2 hours of using antacids that contain aluminum or magnesium.

Your concern and question are good because alcoholic beverages do cause interactions with some medications, and you should know this information and follow the instructions of your doctor or pharmacist carefully.

--James Allen, MD, MPH



My partner and I were both treated with two antibiotics for gonorrhea. We took the meds at the same time. We were not told how long to abstain from sex and we had sex with a condom 4 days after treatment. Should we be ok or could we have reinfected one another?

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Co-infection with chlamydia occurs frequently among those who have gonorrhea, hence the two antibiotics. Most experts advise waiting a week after treatment, but you and your partner were both likely to have enough antibiotics in your system to have cured gonorrhea and avoid reinfection. Consistent condom use is a good idea and highly effective in preventing future infections. The 2010 CDC STD Treatment Guidelines recommend retesting for gonorrhea three months following treatment, so this is something you can do.

--Versie Johnson-Mallard, PhD, RN, APRN, WHNP-BC



I was reading a fact sheet on bacterial vaginosis (BV) and it stated "BV can increase a woman's susceptibility to other sexually transmitted infections (STIs) such as herpes, chlamydia and gonorrhea." I don't understand how BV can increase susceptibility to STIs. Please advise.

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One of the hallmarks of BV is the absence of a specific type of bacteria that defines the healthy vagina: certain species of lactobacillus (sometimes also called lactobacilli). The lactobacilli found in the healthy vagina are generally found only in humans (meaning you can't get them by eating or douching with dairy products, like yogurt!) and often produce chemicals that act like antibiotics to fend off foreign invaders, including STDs like chlamydia and gonorrhea. One of these chemicals is hydrogen peroxide.

In BV, the normally robust population of vaginal lactobacilli essentially disappear, for reasons that are not completely understood, and are replaced by large numbers of bacteria that characterize BV, including Gardnerella vaginalis. While we think that some behaviors probably increase a woman's risk of BV, including douching (which probably reduces the good lactobacilli if it's done frequently) and unprotected sex (sometimes with a specific partner, and especially between female sex partners), we don't really know what causes BV.

The best way to avoid getting BV is to avoid douching, use precautions to increase sexual safety as you would to protect yourself against any STD, and to seek care if you notice abnormal vaginal discharge or an unusual genital odor. BV usually responds well to antibiotic therapy, which can be given as oral medication (pills) or vaginal gel or cream for 5-7 days; however, many women will experience a repeat episode, and some might need to go on long-term suppressive therapy (usually vaginal antibiotic gel twice a week) to keep it at bay.

--Jeanne Marrazzo, MD, MPH



Would you please tell me how long a person can have trichomoniasis and carry it? Could it have been passed on almost three months with only light symptoms?

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This is such a common question that it is surprising how little we know about the answer. No one knows exactly how long someone can have vaginal trichomoniasis with few or no symptoms. We do know that women can have this infection for at least three months without symptoms of any kind, and we know that it can be transmitted to a sex partner even when it is causing no symptoms.

The diagnosis of trichomoniasis often raises questions for couples about their partner's faithfulness. Although trichomonas is always transmitted by sexual contact, the fact that trichomonas can survive for several months, maybe even longer, means that an infection could have been acquired in a previous sexual relationship that ended several months earlier.

It's also important to remember that men can have trichomonas but almost never have symptoms. And, we know next to nothing about how long some men may have trichomonas. It's also important to know that making a diagnosis of trichomonas infection in men can be very difficult. Click here to learn more about trichomonas infection.

--J. Dennis Fortenberry, MD, MS




Somebody I was with told me he has chlamydia and that his clinic said I should be tested. I don't have any symptoms and don't want to spend the money to test for something I may not even have. Do I really need to get tested?

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It’s always a good idea to get tested if you learn that a current or previous partner has been diagnosed with a sexually transmitted infection (STI). Testing is particularly important for chlamydia because it is a common STI, especially in younger people, and most women don’t experience symptoms, so there really is no way of knowing if you have it. For this reason ASHA, the CDC, and most experts recommend that women 26 years and younger have annual chlamydia screenings – or more frequently if they are at high risk for an STI (such as having unprotected sex, multiple partners, or even a new partner).

Testing for chlamydia is easy; most often the specimen is a urine sample or swab. Chlamydia is easily treated, but if it goes undiagnosed over time it can cause fertility problems - something you might not be thinking about right now but will want to protect for the future. Your partner's clinic was right to advise that you get tested, and you can be thankful that your partner told you he had been infected. You should also notify any other partners you have been with recently.

Please don’t let the costs of medical care stand in the way of taking care of yourself and your future. Your local health department probably has an STI clinic, or you may want to contact community resource centers to learn about free clinics or subsidized health services that can offer lower rates for these tests (you can search here). Also, prevention of chlamydia and other STIs continues to be important for you and your partner.

--James Allen, MD, MPH

 


I’ve heard that gonorrhea can’t be cured anymore. Is this true and if so, what do people do when they’re diagnosed? 

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Some strains of gonorrhea have been found to be resistant to certain drugs (known as antibiotic resistance), so much so that only one class of antibiotics (called cephalosporins) is now recommended to treat the infection. The Centers for Disease Control and Prevention’s (CDC) STD Treatment Guidelines call for most cases of gonorrhea to be treated with a single 250 mg injection with the antibiotic ceftriaxone. If this is not an option, two antibiotics from the cephalosporin class of drugs can be used (one delivered as an injection and the other as an oral medication).

Resistance is a worry, to be sure, and CDC monitors resistant gonorrhea each year through reports from each region of the country. To date (summer 2013) there are no reports of treatment failures in the U.S. with medications currently recommended for gonorrhea.

So while gonorrhea can still be effectively treated and cured, public health officials continue to keep a close watch on the issue. The latest information is available at  http://www.cdc.gov/std/Gonorrhea/arg/basic.htm