Sexual Health Flashcards
What are the federal and provincial guidelines for STIs?
PHAC STBBI Guides (National Guideline)
Communicable Disease Control Manual (section on STIs, adapted from PHAC)
What are STI (Sexually Transmitted Infections)?
Infections are passed from one person to another through sexual activity, including vaginal, oral, or anal sex as well as genital skin-to-skin contact.
Some STIs are spread through the blood
What are the three catagories of STIs?
- Viral: HPV, HIV, herpes simplex (HSV)
- Bacterial: chlamydia, gonorrhea, syphillis
- Parasitic/Fungal: Trichomoniasis
What are some risk activities for STI infection?
- Multiple partners (concurently or over time)
- Casual sex
- Sex without protection
- Sex with infected person
- Previous STI
- Substance use
- Viagra/Cialis use
- Sexual violence
- Social environments
What populations are at greater risk for STI infection?
- Indigenous people
- Gay, bisexual, and MSM
- Transgender people
- Youth and young adults
- People who use drugs
- Incarcerated people
- Sex workers and those who receive their services
How do pharmacists help prevent the spread of STIs in the community?
- Assessing and discussing risk
- Educating people about signs and symptoms and the asymptomatic nature of infections
- Helping individuals recognize and minimize their risk
- Providing treatment, follow up and counselling to individuals and their partners
What are some barriers to getting tested for STIs?
- Underestimate personal risk
- Perception that STIs are not serious
- Fearful of procedures
- Self-conscious about genital exam
- Perceived and anticipated attitudes of HCPs and clinic staff
-Stigma - Impact of COVID-19
What are the different types of barrier protection?
- External condom
- Internal condom
- Dental dams
What are the effects of using barrier protection when having sex?
Decrease risk of acquiring and transmitting the majority of STIs, including HIV, Hepatitis B virus, chlamydia, gonorrhea
Do not provide full protection against syphillis, HPV, or HSV
What are goals of therapy when treating a STI?
- Treat the infection
- Abolish symptoms
- Decrease spread to sexual partners
- Decrease vertical transmission to newborns (fetal and breastfeeding)
- Reduce transmission of HIV
- Decrease the probability of complications, such as infertility, chronic pain, sepsis
Are all STIs incurable?
No, some can be treated and cured
But there are still some STIs that are lifelong infections, but can be managed
How are STIs transmitted between people?
- Contact with semen, vaginal fluid, or other body fluids during vaginal, anal, or oral sex without a condom
- Skin-to-skin contact during sexual activity
- Sharing sex toys
Some STIs are blood-borne (blood transfusions, transplants, fetal, breastfeeding, sharing needles or tattooing equipment)
What are some impacts of an STI during pregnancy?
STIs can negatively affect fertility and pregnancy, and can also be harmful to baby
- Chlamydia: pre-term birth, conjunctivitis and pneumonia in newborns
- Gonorrhea: endometritis and pelvic sepsis, systemic infection in newborn
- Syphillis: Systemic symptoms, fetal loss
When should pregnant women be tested for STIs?
Early in pregnancy and again in third trimester
Are the symptoms of an STI infection obvious?
No, many STIs are either asymptomatic or present as syndrome with a diverse set of symptoms
This is why empiric treatment is so common
What are some symptoms seen in patients infected with STIs?
- Vaginitis
- Urethritis and Cervicitis
- Anogenital Ulcers & Warts
- Epididymitis
- Proctitis
What are the three STIs that can cause abnormal vaginal discharge?
- Vulvovaginal candidiasis (white, clumpy, curdy discharge)
- Trichomoniasis (Off-white or yellow, frothy discharge)
- Bacterial Vaginosis (Grey or milky, thin, copious discharge)
What is used to treat vulvovaginal candidiasis?
Fluconazole 150mg PO x single dose
Topical azole antifungals
No need to treat asymptomatic patients
What is used to treat Trichomoniasis?
Metronidazole 2g PO x single dose
OR
Metronidazole 500mg PO BID x 7 days
Treat sexual partners
What is used to treat Bacterial Vaginosis?
Metronidazole 500mg PO BID x 7 days
OR
Metronidazole 2g PO x single dose
Same treatment as patients with trichomoniasis
No need to treat asymptomatic patients
What is the etiology of Chlamydia?
Caused by Chlamydia trachomatis (gram-negative)
What are some characteristics of Chlamydia?
Most common nationally reported STI in Canada
Likely underreported incidence because most people with infection are asymptomatic
Empiric treatment given without lab testing (treatment also offered to partner or patient has gonorrhea)
What are the symptoms of Chlamydia?
Most patients are asymptomatic
Most common symptoms:
- Dysuria (painful urination)
- Urethritis (seen more often in men)
- Cervicitis (abnormal bleeding, discharge, painful intercourse)
- Proctitis (diarrhea, bleeding, discharge)
- Conjunctivitis (swelling or redness of eye)
What are some complications of Chlamydia in women?
Pelvic inflammatory disease
Ectopic pregnancy
Infertility
Reiter syndrome (reactive arthritis)
What are some complications of Chlamydia in men?
Epididymo-orchitis (Pain/swelling in epididymis, testicles)
Reiter syndrome (reactive arthritis)
What are the preferred agents in the treatment of chlamydia?
Azithromycin 1g PO x single dose (preferred due to dosing frequency)
OR
Doxycycline 100mg PO BID x 7 days
What agents are used in the treatment of chlamydia in pregnant women?
Azithromycin 1g PO x single dose (use this one due to its versatility for treating chlamydia in different patient groups, but review local antibiograms)
OR
Amoxicillin
OR
Erythromycin
What are some counselling points for Doxycycline?
Take with food
Do not take with iron or calcium
Abstain from sexual activity with barrier protection until treatment of person and partners is complete
When should pharmacists follow up with patients after chlamydia infection?
Perform test of cure (TOC) 3-4 weeks following a positive result
Repeat testing in all individuals 6 months later as re-infection is high
What is the etiology of gonorrhea?
Neisseria gonorrhoeae
What are some characteristics of gonorrhea?
Second most common nationally reported STI in Canada
When left untreated, infection becomes chronic
HIgh rates of concurrent infection with chlamydia (treat for both)
What are some symptoms of gonorrhea in women?
Vaginal discharge
Abdominal pain
Dysuria (painful urination)
Dyspareunia (painful sex)
What are some symptoms of gonorrhea in men?
Urethral discharge
Dysuria
Testicular pain (epididymitis)
Rectal pain with discharge
What is the preferred treatment for gonorrhea?
Combination therapy required (3rd gen cephalosporin plus azithro. or doxy.)
Ceftriaxone 250mg IM x single dose & azithromycin 1g PO x single dose
OR
Cefixime 800mg PO x single dose & azithromycin 1g x single dose
How is gonorrhea treatment monitored?
Test of cure (TOC) cultures are performed 4-5 days after treatment
Repeat testing 6 months post-treatment (due to high reinfection risk)
What is the etiology for syphilis?
Treponema pallidium (spirochete)
What are some characteristics of Syphilis?
- Rates of infection are increasing rapidly (861% increase over 4 years)
- Transmission via contact with chancres
- Untreated syphilis has many complications (neurosyphilis, ocularsyphilis)
- Universal screening recommended in pregnancy
How does primary syphilis manifest?
-Painless lesions (chancre)
- Regional lymphadenopathy
Usually occurs for the first 3 weeks after transmission
How does secondary syphilis manifest?
Occurs within 2-12 weeks of transmission
Systemic symptoms present in this stage
- Flu-like symptoms
- Lymphadenopathy
- Mucous lesions
- Alopecia
- Meningitis
How does latent (early and late) syphilis manifest?
Occurs after more than 6 months of transmission
They are asymptomatic
We often treat patients as if they have late latent syphilis despite their actual status
Is tertiary syphilis common?
No, very few patients are seen even by specialists
What are the main types of tertiary syphilis?
- Neurosyphilis (1-20 years)
- Ocular syphilis (1-20 years)
- Cardiovascular syphilis (10-20 years)
- Gumma (1-46 years)
What is gumma?
Syphilis induced tissue destruction of any organ
What are the two types of congenital syphilis?
- Early (onset under 2 years)
- Late (persistance after 2 years of age)
What are the characteristics of early congenital syphilis?
2/3 may be asymptomatic
Anemia, neurosyphilis, rhinitis, mucocutaneous lesions
What are the characteristics of late congenital syphilis?
Similar to early congenital syphilis (symptoms just last more than 2 years after birth)
Anemia, neurosyphilis, lyphadenopathy
What are the new syphilis screening guidelines from the federal authorities?
Universal screening for all sexually active adults with multiple partners
Retest every few months (opt-out testing)
What is the preferred treatment for earlier forms of syphilis?
For primary, secondary, and early latent syphilis
Pencillin G-LA (Bicillin) 2.4 million units IM as a single dose (into both gluteal cheeks)
What is the preferred treatment for later forms of syphilis?
For late, late latent, gumma, and cardiovascular syphilis
Similar drug as earlier forms, but need 3 doses (1 dose per week) instead of a single one time dose into each gluteal cheek
Penicillin G-LA (Bicillin) 2.4 units IM x 1 dose/week x 3 weeks
What is the preferred treatment for neurosyphilis?
Refer to neurologist (given IV antibiotics)
What are some counselling points for syphilis treatment?
- Avoid sexual contact until the lesions are completely healed and it has been 7 days since they received their final dose of treatments
- Condoms should be advised and encouraged for all sexual encounters
How is syphilis treatment monitored?
Treatment repsonse based on clinical picture (symptom resolution) and nontreponemal test (NTT) results over the next 3, 6, 12, and 24 months
NTT values should reduce four-fold every 6 months
What is Jarisch-Herxheimer Reaction?
- Occurs within first 24h of starting therapy (endotoxins released by spirochete following destruction by antibiotics)
- Acute febrile reaction accompanied by headache, myalgia, chills, and rigors
- Manage with NSAIDs
What are some characteristics of HPV?
- Widespread (over 200 types have been identified)
- Most common STI in the world
- Majority of infections are self-limited, asymptomatic, unrecognized
What types of HPV are responsible for lower/no cancer risk?
HPV 6 and 11 are responsible for anogenital warts, cervical lesions
What types of HPV have higher oncogenic risk?
Persistent HPV 16 and 18 infections may lead to cancer (cervical, oropharyngeal, vulva, vagina, penis, anus)
Virtually all cases of cervical cancer are attributable to HPV
What are some symptoms of genital warts caused by HPV?
- Asymptomatic
- Cauliflower-like warts on penis or vulva
- Discomfort during intercourse (potential for bleeding)
What are some symptoms of cancer caused by HPV?
- Cervical cancer causes little to no discomfort, hence regular screening (pap test)
- Lesions can bleed, itch, cause pain wherever located
What are some treatment options for HPV genital warts?
Topical:
- Imiquimod cream (3.75% cream daily and wash off after 8 hours)
- Sinecatechins 10% ointment (apply 0.5cm strand TID, washing off not needed
Ablative:
- Cryotherapy
- CO2 laser
- Electrosurgery
- Surgical excision
What are some counselling points to tell patients going through genital wart therapy?
- Avoid contact with healthy skin
- Refrain from sexual activity while undergoing treatment
What is the efficacy of the HPV vaccine (Gardasil 9)?
Very effective and safe (97% vaccine efficacy for preventing cervical cancer)
IM injection (deltoid preferred)
Multivalent (9 types of HPV) vaccine provides coverage for most common HPV types that cause genital warts and cervical cancer
Who can benefit from the HPV vaccine?
Everyone (even patients that already have HPV, but will not see the same level of benefits as the target population)
But, its efficacy is best studied in HPV-naive patients between the ages 16-26
This is why early vaccination is important
Who can receive public funding for the HPV vaccine?
- Females and males in Grade 6
- Those that did not receive vaccine in Grade 6 until they are 26 years old
- Immunocompromised females and males aged 9-26
What is the etiology of Herpes Simplex Virus (HSV)?
HSV-1 is primarily associated with oral infection (but growing trend of more genital warts)
HSV-2 is primarily associated with genital infection, but may also present orally
What are some characteristics of herpes simplex virus infection?
- Transmitted by unprotected sex and via delivery of baby
- Higher risk with open sores, also asymptomatic viral shedding
- Common in adolescents and adults (women more than men)
- Virus establishes itself intracellularly with host cell ganglia for life (but can be well managed)
What is a primary genital HSV infection?
This is the first time a patient is exposed to HSV
Presentation:
-Extensive, painful, bilateral anogenital lesions
- Flu-like symptoms
- lymphadenopathy
- Lasts 17-20 days
How does a recurrent genital HSV infection present?
This is a flare-up of the previously exposed HSV
Presentation:
-Prodromal symptoms for 1-2 days
- Unilateral localized (bilateral in primary HSV infection)
- Lasts 9-11 days
How are primary genital HSV infections treated?
Famiciclovir 250mg PO TID x 5 days
OR
Valacyclovir 1000mg PO BID x 10 days
OR less common due to dosing frequency
Acyclovir 200mg PO five times per day x 5-10 days
Topicals are not effective
How are recurrent genital HSV infections treated?
Valacyclovir 500mg PO BID x 3 days or 1g PO x 3 days (treat within 12h of onset for best effect)
OR
Famciclovir 125mg PO BID x 5 days (treat within 6h of onset for best effect)
OR less common due to dosing frequency
Acyclovir 200mg PO x five times per day x 5 days
How does suppressive therapy for genital therapy work?
Daily dosing of antivirals
Indicated for patients with 6 or more recurrences/yr, significant complications, and those with risk factors (multiple partners)
Famciclovir 250mg PO BID daily
OR
Valacyclovir 500mg PO daily (can increase to 1000mg if more than 9 recurrences/yr)
What is neonatal herpes?
Occurs when baby is delivered through an infected vagina
Initial symptoms seen 4 weeks after birth (generalized systemic infection)
Mortality in nearly 60% of cases, 70% will experience sever or fatal complications
What are some counselling points for antivirals?
- Use as early as possible (preferrably within 6h of prodromal phase) and until lesions are fully healed
-Abstain from sexual contact during symptomatic episodes until lesions are completely healed
- Always use a condom as asymptomatic viral shedding can occur
-Lifelong condition (encourage patient to seek support)
What is monkeypox?
Viral zoonotic disease caused by orthopoxvirus
Not necessarily an STI, but it can be transmitted via direct contact with lesions, body fluids., mucosal surface of infected patients
