When it comes to sexually transmitted infections (STI), a woman’s best protection is knowledge — combined with generous doses of compassion and self-respect. In our article Safe sex in midlife, we encourage women to place a high value on their sexual health, offering practical guidance as well as information on how to avoid sexually transmitted diseases (STDs) in the first place. But if it’s too late for that, don’t waste time feeling guilty. Get testing and treatment, and move forward to create better health.
When it comes to symptoms and basics about getting tested, here’s what you should know:
Commonsense guidelines on STD screening and testing
- Many STDs can be silent or asymptomatic.
- Regular Pap smears and pelvic exams are an important self-care measure for all sexually-active women.
- When you have a new partner, we recommend getting STD testing as soon as possible — don’t wait for your annual Pap smear.
- If you don’t already know how, learn to have “The Talk” about STIs with others, so any soon-to-be partners will be comfortable and easy to talk with about this topic.
- Whenever one infection is found it’s best to be tested for as many other STIs as possible because having one STI can make the body more prone to others.
- If someone is being treated for any type of STI, treatment of their partner, along with any other partners they might have, at the same time is strongly advised.
- General info: Bacterial STDs are relatively easy to treat and cure — once identified. However, antibiotic resistance is a growing concern in some areas. Bacterial STDs are of greatest concern only if they go unidentified and untreated.
- Testing and diagnosis of bacterial STD’s as a group: Healthcare providers evaluating a woman for bacterial STDs will perform a pelvic exam, checking for tenderness, inflammation, swollen lymph glands, and vaginal discharge. They will collect vaginal and/or urine samples, and possibly draw blood to send to a laboratory. At the lab, the specimens themselves may be examined for identification by microscopy, or possibly cultured out for positive identification.
Specifics on common bacterial STDs:
Caused by the spirochete bacterium Treponema pallidum.
Symptoms of syphilis
- Many signs and symptoms of syphilis are difficult to distinguish from other diseases.
- Primary symptoms: The indication of infection is a lesion at the point of contact (typically the genitalia), appearing anywhere from 10–90 days after exposure. This lesion, known as a chancre, is generally quite firm in consistency, typically painless, and may heal completely within 4–6 weeks. Another primary symptom of syphilis is swelling of lymph nodes in groin. Since these symptoms are relatively benign, people with syphilis may be unlikely to seek treatment at outset of infection.
- Secondary symptoms are much more noticeable, beginning anywhere from 1–6 months after contracting the disease, and vary widely. These include changes of the skin, such as a red or pink non-itchy rash, broad whitish lesions in moist areas of the body, and mucous patches in the mouth or genitalia. These areas are highly infectious. Other symptoms may include fever, sore throat, weight loss, headache and neck stiffness.
- Latent syphilis: Signs and symptoms of latent syphilis are not obvious, but it is still possible to detect an infection by examining a blood sample at this stage.
- Tertiary syphilis: If not caught and treated at an earlier stage, tertiary syphilis symptoms generally develop anywhere from 1–10 years after initial infection, producing a chronic inflammatory state in the body that may progress to painful joint disease and debilitating neurological problems. At this point the infection is extremely difficult to treat, as the immune system may have become unable to clear the body of the organism.
Notes on syphilis: Even though syphilis is easily treated, unsafe sexual behavior can cause it to spread rapidly within population subgroups.
Caused by the bacterium Neisseria gonorrhoeae.
Symptoms of gonorrhea
- In women, the most common symptoms are pain with urination, vaginal discharge, and bleeding between periods or after sex. Since the urethra and endocervical tissue are the most common targets of infection for this bacterium, these are the areas that characteristically become inflamed (urethritis and cervicitis). More advanced symptoms may include cramps, pain, vomiting or fever, all potential indicators of pelvic inflammatory disease (PID), which if left untreated can lead to damage of the reproductive organs, and ultimately to infertility in some cases.
- Between 30–60% of women with gonorrhea are asymptomatic or have “subclinical” disease, meaning the illness remains undetectable by most healthcare clinicians.
- Secondary symptoms are much more noticeable, beginning anywhere from 1–6 months after contracting the disease, and vary widely. These include changes of the skin, such as a red or pink non-itchy rash; broad whitish lesions in moist areas of the body, and mucous patches in the mouth or genitalia. These areas are highly infectious. Other symptoms may include fever, sore throat, weight loss, headache, and neck stiffness.
- Left untreated, gonorrhea can increase HIV acquisition risk and cause serious health problems in women and men.
Notes on gonorrhea: Though gonorrhea in the US had been on a downward trend, recent statistics show it is increasing again. Additionally, gonorrhea resistance to conventional antibiotics has gone up, and it’s now included on the list of superbugs with strong resistance.
Caused by sexually-transmitted bacterium Chlamydia trachomatis.
Symptoms of Chlamydia
- In women, the most common symptoms are pain with urination, pain with sex, lower abdominal pain, and vaginal discharge.
- Chlamydia is of significant concern to women because it’s often “silent” — as many as 70–80% of women infected with it are asymptomatic. One reason regular pelvic exams are so important is that you can be exposed to this over and over, and again, if it’s left untreated, chlamydia may progress into PID.
Notes on Chlamydia: Reinfection is possible, so it’s important for all partners to be treated.
Bacterial vaginosis (BV)
Caused by disruption in the balance of normal protective vaginal microflora, with colonies of odor-producing bacteria such as Gardnerella taking over. These odor-producing bacteria typically prefer a high vaginal pH so activities and changes that upset the normal vaginal “ecology” are linked with higher incidence. These include vaginal douching; a sudden increase in frequency of sex (semen has a high pH); and having an IUD placed. Low estrogen can also disrupt vaginal pH balance.
Symptoms of BV
- Malodorous or otherwise abnormal vaginal discharge; vulvar burning, itching and irritation; burning with urination (similar to trichomoniasis ).
- Increased susceptibility to other STDs, including HIV, herpes, chlamydia and gonorrhea.
Notes on BV: BV can cause inflammation of the cervix and increased vulnerability to STD infections. While BV is related to sexual activity, it is not considered an STD because men do not carry the causal organism, and male partners of women with BV do not require treatment.
General info about sexually transmitted viral infections: Unlike bacterial STDs, which can be cured, viral STIs remain in the body without necessarily showing any symptoms, even after treatment. That means that once you become infected, even if you do get testing and treatment, you may continue to carry the virus and possibly infect others. There have been cases where, with good nutritional and immune support, these viruses remain fully dormant.
Here are some specifics on common viral STD’s:
Herpes simplex virus (HSV)
- Type I HSV (oral herpes)
- Type II HSV (genital herpes)
Caused by either type I or type II herpes simplex virus (HSV) strains.
Symptoms: In its characteristic form, herpes causes painful, blister-like sores. Primary symptoms are itching, tingling or burning at the infection site before sores or blisters appear. Blisters, or ulcers, may appear at any time within days of exposure or years later, possibly accompanied by flu-like symptoms. The blisters crust over and drop off in about 2 weeks. The virus then lies dormant in the body, but outbreaks may recur. It may be infectious even when there are no symptoms.
- Type I appears mostly on the mouth and face as oral herpes or cold sores, but can infect the genitals as well.
- Type II generally occurs on the genitals, but can affect the face following contact.
Notes on HSV: We now know that contact with the infected tissue region can spread the virus at any time, not just when sores are present. Oral sex can pass both types of herpes from oral to genital tissues and back again. While herpes is one of the most stigmatized STDs, there are no fatal results to herpes.
Testing/diagnosis for herpes
- If an active herpes ulcer is present, a healthcare provider can swab it and send the sample to a diagnostic laboratory. At the lab, these cells can be cultured out; or immediately stained and examined for definitive features; or used to conduct what is known as a PCR, or polymerase chain reaction test. The PCR test is the most sensitive and accurate of these three because only tiny amounts of the virus are needed to produce a positive result. However, because it is not widely available and is more expensive than other tests, you may need to ask specifically for this more definitive test. A negative culture does not necessarily mean absence of infection.
- Sometimes an asymptomatic or mildly symptomatic patient in the earlier stages may be asked to return for testing when they experience an outbreak.
- Alternatively, a blood sample can be drawn and checked for antibodies against the HSV-2 virus. This type of testing is called serology. In the past, HSV antibody tests, or assays, were unable to distinguish between HSV-1 and HSV-2, but today there are newer assays that distinguish the two. Again, not all laboratories conduct these tests, so you may need to ask your provider for a definitive test. Another, newer finger-prick test is also now available for clinicians to use in their offices at the time of visit, providing results within 15 minutes.
- Testing for herpes is not common in routine STD screening, so you may need to ask specifically to be tested.
Genital warts or Human Papilloma Virus (HPV)
Caused by certain strains of the human papillomavirus. Of over 100 strains of HPV, over 30 affect the anogenital region. Genital warts are associated with types 6 or 11. In the US, cervical cancer is most strongly associated with high-risk HPV types 16, 18, 31, 33, and 35.
Symptoms of HPV: This can manifest as changes of the cervix, detected via abnormal Pap smear results, or as condylomata (warts).
Testing/diagnosis of HPV: Atypical changes on a Pap smear are usually indicative of infection with high-risk types. However, detection of actual viral genetic material or protein is the definitive means of diagnosis. Women with abnormal results on Pap smear will be counseled to return for additional sampling of cervical cells.
Notes on HPV: The new HPV vaccine Gardasil targets only strains 16, 18, 6 and 11, and must be given prior to exposure to any of these strains in order to be effective.
Caused by a lentivirus (“slow virus”) that is transferred through blood, semen, vaginal fluid, or breast milk. AIDS is a syndrome that is believed to develop over time as a result of HIV infection.
Symptoms of HIV
- Many people do not experience any symptoms when first infected by HIV. Others may experience a set of acute, flu-like symptoms known as acute HIV syndrome. Symptoms include fever, fatigue, headache, nausea, diarrhea, and possibly enlarged lymph nodes, all of which can be easily mistaken as being caused by some other virus. At this stage, there is a high level of viral particles present as they spread throughout the body, particularly through the lymphatic system.
- It takes the immune system time to rally and develop antibodies against the infection. These antibodies generally develop within the first three months, a process by which their numbers increase as the number of viral particles in the system decreases. Most people then become asymptomatic for a period of time that can last from several months to 10 or more years.
- Over time, the body’s immune mechanisms become worn down and the virus prevails. At that point other “opportunistic” infections can gain a foothold when they might not have been able to in someone who wasn’t immunocompromised. This state eventually leads to the stage known as acquired immunodeficiency syndrome (AIDS), where the body’s immune system becomes unable to fight off opportunistic infections and other life-threatening illnesses.
Testing/diagnosis of HIV
- A healthcare provider will draw a blood sample to evaluate for HIV antibodies. HIV-testing may require several steps before positive confirmation can be made.
- Two basic types of antibody tests are available: the enzyme immunoassay (EIA) test is used for initial screening, and rapid HIV antibody tests which use blood, oral fluid, or urine to detect HIV antibodies. If either of these tests is positive, a second test called the Western blot is used to confirm the presence of the disease.
- Both the above can return false-negative results for up to three months following exposure.
- Other types of tests that are less commonly available can be used to more definitively diagnose infection and determine how far advanced the infection may have become, including measuring the number of viral particles themselves, and the number of white blood cells known as CD4.
- At the University of Maryland School of Medicine’s Institute of Human Virology, research scientists have developed a more sensitive test, called immuno-PCR, that can detect the presence of HIV virus particles earlier and at much lower levels, providing better opportunity to treat and monitor infection.
Notes on HIV/AIDS
- Testing positive for HIV does not mean you have AIDS. A diagnosis of AIDS is made by a medical professional in accordance with the CDC AIDS case definition.
- Many people do not know they have HIV. As of 2014, there are almost 1.1 million people with HIV in the United States, and it’s estimated that 1 in 5 do not know they have the virus.
Hepatitis B virus (HBV)
Caused by the blood-borne DNA virus Orthohepadnavirus. Transmission occurs with exposure to infectious blood or other body fluids containing blood, such as unprotected sexual contact.
Symptoms of hepatitis B
- In some people, the infection may be completely asymptomatic.
- Primary symptoms of an acute infection are flu-like, and may include mild fever, headache, body aches, fatigue, loss of appetite, nausea, vomiting, diarrhea and dark urine.
- Symptoms may progress to jaundice, with yellowing of the skin and eyes, and clay-colored stools.
- Chronic infection may be asymptomatic or cause inflammation of the liver, which can progress to cirrhosis.
Testing/diagnosis of HBV
- Because hepatitis B induces the body to produce different antibodies or other biochemicals in the blood depending on the stage of infection, different types of tests, or assays, may be required for definitive diagnosis, depending on how long it has been since a person was exposed.
- The hepatitis B surface antigen (HBsAg) test looks for substances in the blood that show whether a hepatitis infection is active, ongoing (chronic), or has occurred in the past. This is the first and most frequently used test. It may not give an accurate response in the earliest stages of infection, before this viral antigen is manufactured, or when more than six months have passed since infection in a person who has cleared the infection. There are other antigens and particles in the blood that can be used to confirm diagnosis.
Notes on HBV
- This is one of numerous unrelated viruses causing what we refer to as viral hepatitis (A, B, C, D, E, and delta factor).
- In some people, the virus is self-limiting, meaning it clears itself within weeks to months, with the person making a full recovery and developing protective immunity against the virus. In others, the virus becomes a longstanding problem.
- Up to a third of the world’s population has been exposed to hepatitis B, with only 3–6% of the population becoming infected.
- Incidence is relatively low in the US (~2%) compared to certain parts of South America, Africa and Asia.
- Individuals who continue for six months to test positive for HBsAG are considered hepatitis B carriers.
- This disease can be prevented by having the recombinant hepatitis B vaccine.
- HBV is not usually included in routine blood tests, so patients may need to specifically request the test.
Other types of sexually transmitted infections
Caused by the sexually-transmitted protozoan parasite Trichomonas vaginalis.
Symptoms of trichomoniasis
- Main symptoms in women include malodorous, yellow-green discharge; inflammation of the vaginal canal; and vulvar burning, itching and swelling. Burning with urination can also occur.
- It is estimated that up to half of women with trichomoniasis are asymptomatic.
- Most men infected with Trichomonas do not experience symptoms, so they are usually only treated if they have unusual swelling or discomfort with no other detected cause, or because a female partner has been found to have it.
Testing/diagnosis of trichomoniasis: To screen for this disease, the healthcare provider performs a pelvic exam and collects vaginal samples with a swab. The samples may be inspected immediately under a microscope, though the Trichomonas organism is often missed because sensitivity of this method is approximately 60–70%. The specimen may also be sent out for culture, which is the most sensitive, widely available method of diagnosis, generally requiring 3-7 days. Some labs have developed their own PCR tests (polymerase chain reaction) for Trichomonas. This method is the most sensitive (approximately 84%) but these tests are not widely available.
Notes on trichomoniasis:
- Trich is very common and highly underdiagnosed. The World Health Organization (WHO) refers to it as an “orphan pathogen,” meaning it is poorly understood, underfunded, and often untreated.
- The inflammation associated with trichomoniasis has been connected with increased susceptibility to other STDs, including HIV.
- Reinfection is possible, so it’s important that both partners get immediate treatment before resuming sexual activity.
- Trich is very easy to cure.
Pubic lice (“crabs”)
Caused by a species of parasitic insect known as Pthirus pubis. Humans are its only known host.
Symptoms of crabs
The first and most obvious symptom is itching in the genital area, though lice can colonize other areas of the body. Visible signs include:
- Yellow-to-white ovoid nits (eggs), about the size of a pinhead
- Slightly larger nymphal stages (of which there are three)
- Somewhat larger still, the grayish-white adult lice that may appear more red-brown after feeding on blood. Nymphs and adults resemble tiny crabs under the microscope.
- Most infestations are also characterized by grey-blue or slate-colored skin at the feeding site.
Testing/diagnosis of crabs: It’s hard not to notice that you have crabs. If you’re itchy, take a closer look. Crabs can be treated initially with an over-the-counter product, but the longer you have them, the harder they can be to get rid of. See your practitioner if you need confirmation or if your efforts at treating them without a prescription aren’t successful.
Notes on crabs: Reinfection is a concern, so any sexual partners — and everyone in the family — should be checked and treated.
Molluscum contagiosum (MC)
Caused by the common, benign virus Molluscum contagiosum, or MC, that affects adults and children. It is readily transmitted via skin-to-skin contact with infected individuals as well as from inanimate objects such as the surfaces of chairs and toilet seats. Since it can also be sexually transmitted, it is included as an STD though transmission is not exclusively through sexual contact.
Symptoms of Molluscum contagiosum: Small, pearly, wart-like skin bumps, sometimes with a dimpled or pored center that may produce a white curd-like secretion or “exudate”; may be itchy and may lead to secondary bacterial infection if left untreated, particularly in moist areas such as the genitals.
Testing/diagnosis of MC: The wart-like bumps have a distinctive appearance and identification can be confirmed by skin biopsy or, less commonly, by stained smears of expressed cores. Though not common, MC may be confused with warts, chicken pox, moles or other skin conditions.
Notes on MC: Even though the virus typically resolves by itself within a few months to years, treatment is preferable to prevent spread, both to other areas on the body and to other people. MC is not listed as an STD by the Centers for Disease Control and Prevention.
If you suspect an STD or STI: see a qualified healthcare provider right away
Sexually transmitted infections have been around for at least as long as we have. They’ve had plenty of time to evolve and diversify. Those listed here are just a few of the most common but there are numerous other types, with more to know about them than we can cover here. For further reading, check out some of the links listed in our references below.
If you suspect or worry that you have picked one up or been exposed to one despite your best efforts at protection, don’t beat yourself up about it. Instead, take care of yourself by getting appropriate diagnosis and treatment.
Your next best step is to see a qualified healthcare provider, whether it’s your primary care provider, gynecologist, Planned Parenthood or an STD clinic. And if you do test positive, remember that these infections are very common. Anyone who is sexually active is at risk of getting one —or more. Everyone deserves to receive the best, most effective testing and treatment available in a nonjudgmental atmosphere.
To put things in perspective, think of STDs simply as bugs you don’t want, and bugs you don’t want to pass along to anyone else. With adequate prevention, treatment and
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Department of Health and Human Services. 2012. HIV Test Types. URL: http://aids.gov/hiv-aids-basics/prevention/hiv-testing/hiv-test-types/ (accessed 07.17.2014)
American Sexual Health Association. 2014. Hepatitis B. URL: http://www.ashasexualhealth.org/std-sti/hepatitis/hepatitis-b.html (accessed 07.17.2014)
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