lOMoARcPSD|17706574
Sexual Health
Sexually transmitted infections (STI) screening diagnosis:
All women who are sexually active should be screened for STIs regularly through history,
physical examination, and laboratory studies based on risk factors. To identify those women
at increased risk, specific questions should be asked during the collection of a health history:
The Five P’s of Sexual Health:
Partners
Do you have sex with men, women, or both?
In the past 2 months, how many partners have you had sex with?
In the past 12 months, how many partners have you had sex with?
Is it possible that any of your sex partners in the past 12 months had sex with someone else
while they were still in a sexual relationship with you?
Practices
To understand your risks for sexually transmitted infections, I need to understand the kind of
sex you have had recently.
Have you had vaginal sex, meaning “penis-in-vagina sex?” If yes, do you use condoms never,
sometimes, or always?
Have you had anal sex, meaning “penis-in-rectum/anus sex?” If yes, do you use condoms
never, sometimes, or always?
Have you had oral sex, meaning “mouth-on-penis/vagina?”
For condom answers:
If “never”: Why don’t you use condoms?
If “sometimes”: In which situations (or with whom) do you use condoms?
Prevention of Pregnancy
What are you doing to prevent pregnancy?
Protection from Sexually Transmitted Infections
What do you do to protect yourself from sexually transmitted infections and HIV?
Past History of Sexually Transmitted Infections
Have you ever had a sexually transmitted infection?
Have any of your partners had a sexually transmitted infection?
Additional questions to identify HIV and viral hepatitis risk:
Have you or any of your partners ever injected drugs?
Have your or any of your partners exchanged money or drugs for sex?
Is there anything else about your sexual practices that you would like to discuss?
Reproduced from Centers for Disease Control and Prevention. (2015). Sexually transmitted
diseases treatment guidelines, 2015. Morbidity and Mortality Weekly Report, 64(3), 1–137.
Gynecologic History Questions to Assess Risk of Sexually Transmitted Infections
Do you experience now or have you ever experienced the following:
Frequent vaginal infections
Unusual vaginal discharge or odor
Vaginal itching, burning, sores, or warts
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, lOMoARcPSD|17706574
STIs (ask about individual infections)
Abdominal pain
Pelvic inflammatory disease (PID)/infection of the uterus, tubes, or ovaries
Sexual assault/rape
Physical, emotional, or sexual abuse
Abnormal Pap test
Pain or bleeding with intercourse
Severe menstrual cramps occurring at end of period
Ectopic pregnancy
The physical examination begins with careful visualization of the external genitalia,
including the perineum. Erythema, edema, distortions, lesions, trauma, and any other
abnormalities are noted. Palpation can locate areas of tenderness. During the speculum
examination, the vagina and cervix are inspected for edema, thinning, lesions, abnormal
coloration, trauma, discharge, and bleeding. Thorough palpation of the inguinal area and
pelvic organs through bimanual examination, milking of the urethra for discharge, and
assessment of vaginal secretion odors is essential.
Appropriate laboratory studies will be suggested, in part, by the history and physical
examination results. These tests include microscopic examination of vaginal secretions (wet
mount), chlamydia and gonorrhea testing, treponemal tests with reflex to Venereal Disease
Research Laboratory (VDRL) or rapid plasma reagin (RPR) testing for syphilis, and a hepatitis
B and C panel. When an STI is diagnosed, testing for other STIs is essential. The woman
should be notified that HIV testing will be performed unless she specifically declines it (see
the section on HIV testing later in this chapter). Other laboratory tests, such as a complete
blood count, urinalysis, and urine culture and sensitivity, should be obtained only if
indicated. If the history or physical examination indicates possible pregnancy, a urine human
chorionic gonadotropin (hCG) test should also be performed because treatment for STIs can
differ in pregnant and nonpregnant women and because certain antibiotics are
contraindicated in pregnancy.
Common Sexually Transmitted Infections
Infection Causative Organism
Chancroid Haemophilus ducreyi
Chlamydia Herpes Simplex Virus
Genital warts Human papilloma virus (HPV)
Gonorrhea Hep B, Hep C
HIV infection and AIDS HIV
Molluscum contagiosum Molluscum contagiosum virus
Pubic lice Phthirus pubis
Syphillis Treponema pallidum
Trichomoniasis Trichomonas vaginalis
Downloaded by Nicholas Marks ()
, lOMoARcPSD|17706574
Treatment
HPV (including the vaccine): The most clinically significant HPV types can now be prevented
with vaccination. The bivalent vaccine (HPV2, Cervarix), the quadrivalent vaccine (HPV4,
Gardasil), and the 9-valent vaccine (HPV9, Gardasil 9) (Gardasil is the only HPV vaccine
available in the US) all protect against HPV types 16 and 18, which cause the majority of
cervical cancers. In addition, the quadrivalent and 9-valent vaccines protect against HPV
types 6 and 11, which cause the majority of genital warts, and provide some protection
against vulvar and vaginal cancers and precancers. The 9-valent HPV vaccine protects against
another five strains of HPV (31, 33, 45, 52, and 58) that are responsible for an additional 15
percent of cervical cancers. Routine HPV vaccination is recommended for girls and boys
aged 11 to 12 years. HPV vaccines can be given to girls as young as age 9 and are also
recommended for adolescents, women, and men aged 13 to 26 years who were not
vaccinated or did not complete the series earlier. In 2018, the FDA expanded the use of the
9-valent HPV vaccine to include men and women through the age of 45, which will allow for
increased vaccination beyond previous recommendations. Ideally, vaccination should occur
before an individual becomes sexually active and therefore has the potential for HPV
exposure; nevertheless, previous sexual activity does not preclude receiving the HPV9
vaccine through age 45.
The dosing schedule for 9-valent HPV vaccine is dependent on age. Prior to age 15, a two-
dose schedule is followed in which an initial dose is given, and the second dose is given 6 to
12 months later (0, 6–12-month schedule). If vaccination is initiated after the 15th birthday,
a three-dose schedule is followed, in which the second dose is given 1 to 2 months (and at
least 4 weeks) after the first dose, and the third dose is given 6 months (and at least 12
weeks) after the second dose (0, 1–2, 6-month schedule). The series does not need to be
restarted if the second and third doses are delayed, and the next vaccine can be given even
if years have elapsed. The 9-valent HPV vaccine can be used to complete a vaccine series
that was started with either the bivalent or quadrivalent formulations.
9-valent HPV not recommended during pregnancy, ok during lactation. Not necessary for
routine pregnancy prior to vaccination. If given during vaccine, no interventions require, the
remaining vaccines should be delayed and the clinician should report to vaccine
manufacturer.
Primary treatment for visible genital warts are removal of warts and relief of s/s, not
eradication of HPV. Untreated genital warts may resolve, remain unchanged, or increase in
size or number. Multiple office visit for clinician-administered regimes. Patient-applied
treatments need to be repeated for months, and even with treatment, recurrence is
common.
Treatment of External Genital Warts
Patient-Applied Regimes Clinician-Administered Alternative Regimens
Regimens
Podofilox 0.5% soln or gel Cryotherapy with liquid Intralesional interferon
nitrogen or cryoprobe,
repeat applications every 1-
Downloaded by Nicholas Marks ()
, lOMoARcPSD|17706574
2 weeks
Imiquimod 3.75% or 5% Trichloroacetic acid or Topical cidofovir
cream bichloracetic acid 80-90%
Sinecatechins 15% ointment Surgical removal by Podophyllin resin 10-25% in
tangential scissor excision, a compound tincture of
tangential shave excision, benzoin
curettage, or electrosurgery
Although various options exist for treating genital warts, not all are safe during pregnancy.
Specifically, podophyllin, sinecatechins, and imiquimod should be avoided in women who
are pregnant.
Genital Herpes:
Signs/symptoms including subjective findings:
A history of viral symptoms, such as malaise, headache, fever, or myalgia, is suggestive of HSV
infection. Likewise, local symptoms, such as vulvar pain, dysuria, itching, or burning at the site
of infection, and painful genital lesions that heal spontaneously are very suggestive of HSV
infection. The clinician should also ask about prior history of a primary infection, prodromal
symptoms, vaginal discharge, dysuria, and dyspareunia.
incurable viral infection characterized by painful vesicular eruptions of the skin and mucosa of
the genitals. Two types of HSV have been identified as causing genital herpes: HSV-1 and HSV-2.
HSV-2 is usually transmitted sexually, whereas HSV-1 is transmitted either nonsexually or
through oral–genital contact.
Physical exam findings: An initial or primary genital herpes infection characteristically has both
systemic and local symptoms and lasts approximately 3 weeks. Flu-like symptoms with fever,
malaise, and myalgia first appear about a week after exposure, peak within 4 days, and subside
over the next week. Multiple genital lesions develop at the site of infection, which is usually the
vulva, but lesions may be present anywhere in the anogenital area. Other commonly affected
sites are the perianal area, vagina, and cervix. The lesions begin as small painful blisters or
vesicles that become unroofed, leaving behind ulcerated lesions.
During the physical examination, the clinician should assess for inguinal and generalized
lymphadenopathy and elevated temperature. Carefully inspect the entire vulvar, perineal,
vaginal, and cervical areas for vesicles, ulcers, or crusted areas. A speculum examination may be
very difficult for the patient because of the extreme tenderness often associated with genital
herpes. Genital lesions, especially those that are extremely tender, should be tested for HSV
even if the appearance is not consistent with classic herpes lesions.
Ulcerative lesions last 4 to 15 days before crusting over, and new lesions may develop over a
period of 10 days during the course of the infection. Cervicitis is also common with initial HSV-2
infections. The cervix may appear normal, or it may be friable, reddened, ulcerated, or necrotic
if cervical lesions are present. A heavy watery to purulent vaginal discharge is possible.
Extragenital lesions may be present because of autoinoculation. Urinary retention and dysuria
may occur secondary to autonomic involvement of the sacral nerve root
Think 3 Ps (Patho, Physical exam, Pharmacology):
Downloaded by Nicholas Marks ()
Sexual Health
Sexually transmitted infections (STI) screening diagnosis:
All women who are sexually active should be screened for STIs regularly through history,
physical examination, and laboratory studies based on risk factors. To identify those women
at increased risk, specific questions should be asked during the collection of a health history:
The Five P’s of Sexual Health:
Partners
Do you have sex with men, women, or both?
In the past 2 months, how many partners have you had sex with?
In the past 12 months, how many partners have you had sex with?
Is it possible that any of your sex partners in the past 12 months had sex with someone else
while they were still in a sexual relationship with you?
Practices
To understand your risks for sexually transmitted infections, I need to understand the kind of
sex you have had recently.
Have you had vaginal sex, meaning “penis-in-vagina sex?” If yes, do you use condoms never,
sometimes, or always?
Have you had anal sex, meaning “penis-in-rectum/anus sex?” If yes, do you use condoms
never, sometimes, or always?
Have you had oral sex, meaning “mouth-on-penis/vagina?”
For condom answers:
If “never”: Why don’t you use condoms?
If “sometimes”: In which situations (or with whom) do you use condoms?
Prevention of Pregnancy
What are you doing to prevent pregnancy?
Protection from Sexually Transmitted Infections
What do you do to protect yourself from sexually transmitted infections and HIV?
Past History of Sexually Transmitted Infections
Have you ever had a sexually transmitted infection?
Have any of your partners had a sexually transmitted infection?
Additional questions to identify HIV and viral hepatitis risk:
Have you or any of your partners ever injected drugs?
Have your or any of your partners exchanged money or drugs for sex?
Is there anything else about your sexual practices that you would like to discuss?
Reproduced from Centers for Disease Control and Prevention. (2015). Sexually transmitted
diseases treatment guidelines, 2015. Morbidity and Mortality Weekly Report, 64(3), 1–137.
Gynecologic History Questions to Assess Risk of Sexually Transmitted Infections
Do you experience now or have you ever experienced the following:
Frequent vaginal infections
Unusual vaginal discharge or odor
Vaginal itching, burning, sores, or warts
Downloaded by Nicholas Marks ()
, lOMoARcPSD|17706574
STIs (ask about individual infections)
Abdominal pain
Pelvic inflammatory disease (PID)/infection of the uterus, tubes, or ovaries
Sexual assault/rape
Physical, emotional, or sexual abuse
Abnormal Pap test
Pain or bleeding with intercourse
Severe menstrual cramps occurring at end of period
Ectopic pregnancy
The physical examination begins with careful visualization of the external genitalia,
including the perineum. Erythema, edema, distortions, lesions, trauma, and any other
abnormalities are noted. Palpation can locate areas of tenderness. During the speculum
examination, the vagina and cervix are inspected for edema, thinning, lesions, abnormal
coloration, trauma, discharge, and bleeding. Thorough palpation of the inguinal area and
pelvic organs through bimanual examination, milking of the urethra for discharge, and
assessment of vaginal secretion odors is essential.
Appropriate laboratory studies will be suggested, in part, by the history and physical
examination results. These tests include microscopic examination of vaginal secretions (wet
mount), chlamydia and gonorrhea testing, treponemal tests with reflex to Venereal Disease
Research Laboratory (VDRL) or rapid plasma reagin (RPR) testing for syphilis, and a hepatitis
B and C panel. When an STI is diagnosed, testing for other STIs is essential. The woman
should be notified that HIV testing will be performed unless she specifically declines it (see
the section on HIV testing later in this chapter). Other laboratory tests, such as a complete
blood count, urinalysis, and urine culture and sensitivity, should be obtained only if
indicated. If the history or physical examination indicates possible pregnancy, a urine human
chorionic gonadotropin (hCG) test should also be performed because treatment for STIs can
differ in pregnant and nonpregnant women and because certain antibiotics are
contraindicated in pregnancy.
Common Sexually Transmitted Infections
Infection Causative Organism
Chancroid Haemophilus ducreyi
Chlamydia Herpes Simplex Virus
Genital warts Human papilloma virus (HPV)
Gonorrhea Hep B, Hep C
HIV infection and AIDS HIV
Molluscum contagiosum Molluscum contagiosum virus
Pubic lice Phthirus pubis
Syphillis Treponema pallidum
Trichomoniasis Trichomonas vaginalis
Downloaded by Nicholas Marks ()
, lOMoARcPSD|17706574
Treatment
HPV (including the vaccine): The most clinically significant HPV types can now be prevented
with vaccination. The bivalent vaccine (HPV2, Cervarix), the quadrivalent vaccine (HPV4,
Gardasil), and the 9-valent vaccine (HPV9, Gardasil 9) (Gardasil is the only HPV vaccine
available in the US) all protect against HPV types 16 and 18, which cause the majority of
cervical cancers. In addition, the quadrivalent and 9-valent vaccines protect against HPV
types 6 and 11, which cause the majority of genital warts, and provide some protection
against vulvar and vaginal cancers and precancers. The 9-valent HPV vaccine protects against
another five strains of HPV (31, 33, 45, 52, and 58) that are responsible for an additional 15
percent of cervical cancers. Routine HPV vaccination is recommended for girls and boys
aged 11 to 12 years. HPV vaccines can be given to girls as young as age 9 and are also
recommended for adolescents, women, and men aged 13 to 26 years who were not
vaccinated or did not complete the series earlier. In 2018, the FDA expanded the use of the
9-valent HPV vaccine to include men and women through the age of 45, which will allow for
increased vaccination beyond previous recommendations. Ideally, vaccination should occur
before an individual becomes sexually active and therefore has the potential for HPV
exposure; nevertheless, previous sexual activity does not preclude receiving the HPV9
vaccine through age 45.
The dosing schedule for 9-valent HPV vaccine is dependent on age. Prior to age 15, a two-
dose schedule is followed in which an initial dose is given, and the second dose is given 6 to
12 months later (0, 6–12-month schedule). If vaccination is initiated after the 15th birthday,
a three-dose schedule is followed, in which the second dose is given 1 to 2 months (and at
least 4 weeks) after the first dose, and the third dose is given 6 months (and at least 12
weeks) after the second dose (0, 1–2, 6-month schedule). The series does not need to be
restarted if the second and third doses are delayed, and the next vaccine can be given even
if years have elapsed. The 9-valent HPV vaccine can be used to complete a vaccine series
that was started with either the bivalent or quadrivalent formulations.
9-valent HPV not recommended during pregnancy, ok during lactation. Not necessary for
routine pregnancy prior to vaccination. If given during vaccine, no interventions require, the
remaining vaccines should be delayed and the clinician should report to vaccine
manufacturer.
Primary treatment for visible genital warts are removal of warts and relief of s/s, not
eradication of HPV. Untreated genital warts may resolve, remain unchanged, or increase in
size or number. Multiple office visit for clinician-administered regimes. Patient-applied
treatments need to be repeated for months, and even with treatment, recurrence is
common.
Treatment of External Genital Warts
Patient-Applied Regimes Clinician-Administered Alternative Regimens
Regimens
Podofilox 0.5% soln or gel Cryotherapy with liquid Intralesional interferon
nitrogen or cryoprobe,
repeat applications every 1-
Downloaded by Nicholas Marks ()
, lOMoARcPSD|17706574
2 weeks
Imiquimod 3.75% or 5% Trichloroacetic acid or Topical cidofovir
cream bichloracetic acid 80-90%
Sinecatechins 15% ointment Surgical removal by Podophyllin resin 10-25% in
tangential scissor excision, a compound tincture of
tangential shave excision, benzoin
curettage, or electrosurgery
Although various options exist for treating genital warts, not all are safe during pregnancy.
Specifically, podophyllin, sinecatechins, and imiquimod should be avoided in women who
are pregnant.
Genital Herpes:
Signs/symptoms including subjective findings:
A history of viral symptoms, such as malaise, headache, fever, or myalgia, is suggestive of HSV
infection. Likewise, local symptoms, such as vulvar pain, dysuria, itching, or burning at the site
of infection, and painful genital lesions that heal spontaneously are very suggestive of HSV
infection. The clinician should also ask about prior history of a primary infection, prodromal
symptoms, vaginal discharge, dysuria, and dyspareunia.
incurable viral infection characterized by painful vesicular eruptions of the skin and mucosa of
the genitals. Two types of HSV have been identified as causing genital herpes: HSV-1 and HSV-2.
HSV-2 is usually transmitted sexually, whereas HSV-1 is transmitted either nonsexually or
through oral–genital contact.
Physical exam findings: An initial or primary genital herpes infection characteristically has both
systemic and local symptoms and lasts approximately 3 weeks. Flu-like symptoms with fever,
malaise, and myalgia first appear about a week after exposure, peak within 4 days, and subside
over the next week. Multiple genital lesions develop at the site of infection, which is usually the
vulva, but lesions may be present anywhere in the anogenital area. Other commonly affected
sites are the perianal area, vagina, and cervix. The lesions begin as small painful blisters or
vesicles that become unroofed, leaving behind ulcerated lesions.
During the physical examination, the clinician should assess for inguinal and generalized
lymphadenopathy and elevated temperature. Carefully inspect the entire vulvar, perineal,
vaginal, and cervical areas for vesicles, ulcers, or crusted areas. A speculum examination may be
very difficult for the patient because of the extreme tenderness often associated with genital
herpes. Genital lesions, especially those that are extremely tender, should be tested for HSV
even if the appearance is not consistent with classic herpes lesions.
Ulcerative lesions last 4 to 15 days before crusting over, and new lesions may develop over a
period of 10 days during the course of the infection. Cervicitis is also common with initial HSV-2
infections. The cervix may appear normal, or it may be friable, reddened, ulcerated, or necrotic
if cervical lesions are present. A heavy watery to purulent vaginal discharge is possible.
Extragenital lesions may be present because of autoinoculation. Urinary retention and dysuria
may occur secondary to autonomic involvement of the sacral nerve root
Think 3 Ps (Patho, Physical exam, Pharmacology):
Downloaded by Nicholas Marks ()
