We’re diving into another ‘taboo’ topic with Dr. Rebecca Brightman
Big news everyone… the doctor is in the house! That’s right, our favorite women’s health expert Dr. Rebecca Brightman is back, and this time we’ll be diving right in on another “taboo” topic: sexually transmitted infections (STIs). From HPV info for women of all ages to why it’s crucial for post-menopausal women to use protection, Dr. B is here to answer it all. Something else to remember: Covid-19 is still spreading rampantly. So if you choose to be intimate with a new partner, consult your doctor.
Wake-Up Call: So Dr. Brightman, what type of STIs do you see most in your practice, and what should the average woman be most concerned about?
Dr. Rebecca Brightman: In my younger patients, who usually come in annually, we generally screen for gonorrhea and chlamydia, but HPV [Human papillomavirus] is probably the most common STI. Most of my young patients have received Gardasil, which is the HPV vaccine [approved by the FDA in 2006]. It protects against the most aggressive forms of HPV, which are responsible for the overwhelming majority of cervical cancer.
Even if a woman has been vaccinated, there are multiple HPV subtypes out there, so we start doing pap smears [cervical screenings used to detect signs of cancer or precancer, frequently caused by HPV] on women starting at age 21. If the results show any degree of abnormality, that may dictate further management. We now know that mild abnormal cervical changes due to HPV will typically resolve on their own, particularly in younger women in their 20s. So only if a pap smear shows something very high grade, or something that may be highly correlated with cancer, will we do additional testing.
For older women who have not had a Gardasil vaccination, what concerns should they have about HPV?
Initially [Gardasil] was recommended for women between the ages of nine and 26, because the younger a woman is, the more robust of an immune response she’ll have. But we’ve stretched out that age range, and it’s now recommended that women up to age 45 should get Gardasil. Regardless of age, you have to look at someone’s social history. I could have a patient who’s 47, newly divorced, has had the same sexual partner for 20 years but now wants to go out into the dating world. And for that woman, it may make sense to give her Gardasil. So there’s no official age cutoff, but if you’re going to look at insurance reimbursement, you may not be covered if you’re over 45.
What about pap smears? Is there an age when a woman should stop getting pap smears?
By the book: age 70. But if a woman over 70 has recently had an abnormal pap, or has a new sexual partner, I would still recommend getting one. People are living longer, and it’s not unusual for a woman over 70 to have a new sexual partner. So in theory, if you are over 70 and have unprotected sex with a new partner, you’re putting yourself at risk of STIs including HPV, and that age population is likely not vaccinated against it.
If you develop HPV at an older age and you’ve never had it before, it’s something that you have to make sure that your gynecologist keeps an eye on to make sure it doesn’t develop into cervical cancer. It’s also very important to know the HPV subtype you have, and that’s something your doctor can determine. If certain subtypes are present, such as 16, 18 and 45, that patient needs to be followed very vigilantly.
When a patient asks for a full STI screening, what can they expect to be screened for?
When one considers a comprehensive STI screening, in addition to gonorrhea and chlamydia, you should also be tested for syphilis, hepatitis C, hepatitis B (for which most people are already vaccinated) and HIV. Depending on the woman, she may also be tested for trichomoniasis or mycoplasma. In the state of New York, every pregnant woman must be screened for HIV, and that test may be repeated based on certain risk factors. If you think you’ve been exposed to HIV, I would suggest waiting eight weeks to get blood work done. If you think you’ve been exposed to gonorrhea or chlamydia, which just require a cervical swab, you can get that test done within a couple of days.
The other STI that may not be on people’s radar is herpes. We don’t generally test for herpes, because unless a patient is shedding [meaning, they are in a state where they are more likely to actively spread the virus], the yield is quite low [ie: the herpes test may result in a false negative]. With herpes, there’s an incidence of what we call asymptomatic shedding, which means you can have an outbreak of the virus without showing any symptoms. Herpes can come out of nowhere from an asymptomatic partner. It is not unusual for me to see women who are in relationships, and they call and say, “Oh my gosh, I’m very itchy, and I have sores.” And lo and behold, they have herpes. This does not imply that their partner was not faithful. A partner in a committed relationship could have a period where the virus is dormant, and then suddenly have a period of asymptomatic shedding and pass it on without even knowing.
Herpes can be controlled with antiviral drugs but can’t be cured. That said, it isn’t something that is generally dangerous if it goes undetected, the way gonorrhea or chlamydia or HPV can be. Chlamydia left untreated may result in a pelvic infection that can impair fertility. That’s why it’s so important to get regular STI screenings when you’re sexually active. Herpes is not associated with any long term health ramifications, like cancer or infertility, but psychologically it can really take its toll. So I try to reassure my patients that it’s very common. Some people may have one outbreak, and never have one again for their entire life. Everybody’s different.
For heterosexual women who are no longer worried about pregnancy, what is the best way to protect against STIs?
Condoms. There is also a female condom, and there are silicone sheets that are made for oral sex [these can also be used in same sex relationships]. I have talked to so many women who are beyond their reproductive years and are reentering the dating pool, whether it’s because they’re widowed or divorced or have just remained single. They all have to protect themselves. I have seen chlamydia, gonorrhea, herpes, and HPV in this population. These are women who weren’t vaccinated for HPV, so I’ll much more frequently see HPV 16, 18 and 45, which are the types which carry greater clinical significance. So condoms really are the best bet.
The problem with condoms, particularly among an older population, is when men have erectile dysfunction (ED). The more anxious or concerned a man gets about ED, the worse it becomes. So many older men have trouble wearing condoms, and might say they refuse to wear a condom, and that may be because they can’t maintain their erection [which would cause a condom to fall off]. So really, it all comes down to trust. In any relationship, you have to trust your partner. You have to have a conversation about sexual history. So I suggest that mature women who are embarking on new relationships to get screened. It’s worth it to get a baseline anytime you are sleeping with a new partner, so there’s no finger pointing. That way if you have a disease, you can take care of it before you have unprotected sex. It also means you can tell your partner, “Hey, I got screened. Will you do the same?” I think that’s very fair. It really makes the conversation that much easier.
I would be remiss if I didn’t mention that dating is very different right now, during the pandemic. It’s crucial, particularly among vulnerable populations, to make sure people have taken precautions and are healthy before getting physically involved. I think one good thing the pandemic has taught people is that right now, it’s ok to ease into a relationship, and actually get to know and trust someone before becoming physically involved. That goes a long way.
Dr. Rebecca Brightman is an assistant clinical professor of Obstetrics, Gynecology, and Reproductive Sciences at the Icahn School of Medicine at Mount Sinai. Dr. Brightman is also a certified provider with the North American Menopause Society.