Attention All Sexually Active Women

According to a recent report from the Centers for Disease Control and Prevention (CDC), less than half of sexually active women ages 16 to 25 in the U.S. are being screened for chlamydia. Because screening for gonorrhea is often done at the same time as chlamydia, we can assume that screening rates for gonorrhea are equally low. To put this in context, the U.S. Preventive Services Task Force (USPSTF) recommends that all sexually active women ages 16 to 25 be routinely screened for chlamydia and gonorrhea.  For women ages 26 or older, screening is recommended in women who have one or more of the following risk factors: new or multiple sexual partners, inconsistent condom use, sex workers, or history of previous infection with chlamydia, gonorrhea or other sexually transmitted infections. While screening rates in women ages 26 and older are not well known, the general consensus is that women in this age group are also under-screened for these infections.

These guidelines are not new. So much changes in preventive medicine it’s actually surprising that these guidelines have been essentially unchanged since 1989. So what’s the problem? Why are so many women not getting screened for these serious, yet completely treatable infections? In its report, the CDC identified five barriers to screening:

• Physician barriers
  1. lack of reimbursement for the time required to conduct screening tests and to counsel patients
  2. lack of awareness that patients are sexually active and at risk for STD
  3. lack of knowledge that chlamydia screening can be performed without a pelvic examination
• Patient barriers
  1. inability to pay the copayment of a screening test
  2. lack of knowledge of the asymptomatic nature, high prevalence, and possible adverse long-term reproductive effects of chlamydia infection

(I would add the following to the list of patient barriers: stigmatization of sexual behaviors and sexually transmitted infections.)

Looking at these barriers, one can begin to think of potential solutions. The following identifies some approaches that doctors and patients can take to improve screening rates:

- Whenever in doubt screen: All preventive health services have benefits and risks that need to be balanced. With chlamydia and gonorrhea screening the risks are very low. Screening is highly accurate and so false positives (being told you have the disease when you don’t) and unnecessary exposure to antibiotics is rare. At the same time, because patients are reluctant to share their sexual behaviors and tend to minimize their risk of infection, increased screening is likely to have significant benefits.

- Use alternative screening tests: In the past, chlamydia and gonorrhea screening required doing a pelvic exam, which is time-consuming for doctors and a source of discomfort for patients. Today urine testing and self-vaginal swab are accepted alternatives that do not require pelvic examination yet are just as reliable. To be fair many women receive their screening for gonorrhea and chlamydia at the same time as their annual Pap smear, which does require a pelvic exam. However, even when there is no other reason to do a pelvic examination many doctors, either out of habit or lack of awareness, do not use these alternative screening tests.

- Simplify the guidelines: While the guidelines are not new, many people are unaware of them. Part of the challenge is that the guidelines are somewhat unwieldy to remember. Let’s translate them to keep them as simple: if you’re a sexually active woman ages 25 or younger, you need to be screened at least once a year for chlamydia and gonorrhea. If you’re older than age 25 and not in a mutually monogamous long-term sexual relationship, you also need to be screened regularly for chlamydia and gonorrhea. These simplified guidelines have an additional advantage for doctors – they make asking women about their sexual risk factors less daunting and the work of determining if a woman requires screening easier.

- Breakdown stigmas: Screening for chlamydia and gonorrhea is not just for “certain types of women.” Chlamydia affects nearly 3 million Americans each year – that’s 1 in every 300. Among younger women the rates of infection are even higher. That’s why the guidelines for screening are so inclusive. All sexually active women 25 years of age and younger should be screened, regardless of their sexual practices. For sexually active women ages 26 or older women not in long-term monogamous sexual relationships need routine screening. At the same time, chlamydia and gonorrhea often do not cause any symptoms, especially in women. They are referred to as “silent” diseases, because they can cause complications and be spread between sexual partners without causing any symptoms. That’s why the absence of symptoms is falsely reassuring and why routine screening is so important.

- Increase awareness of testing sites: For women who are reluctant to go to their doctor for screening or who cannot afford medical care, there are STD clinics available around the country, many of which provide low-cost or free testing. To help find a testing site in your area visit www.hivtest.org, a CDC-sponsored website.

Perhaps the most important solution is you the patient. Don’t wait for a doctor to screen you. If you are sexually active and ages 25 or younger or are older and not in a mutually monogamous long-term sexual relationship, get tested. Only half the women in this country are getting appropriately screened for gonorrhea and chlamydia – make sure you are in the right half.

- Shantanu Nundy, M.D.