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IMG 4885coupleThere is not a day that goes by in my practice as a GYN nurse practitioner that I have not brought up the issue of sexual activity with a least one or more of my patients. Though many other concerns are addressed at a variety of visits, sexual intercourse is probably the least comfortable topic of conversation for most women. This may be partly due to the social mores and a woman’s upbringing. She may say, “Sex is just something that was not talked about back when I was growing up.” Or “I’m a little embarrassed to ask, but……..” While I am not a sex counselor, and am not trained in relationship issues, I do discuss the issues of safe sexual activity with my patients of all ages.

The youth of my generation, the Baby Boomers, felt that they had invented sex. Or at least they coined the word, “Free Love.” With the advent of the birth control pill, women were no longer afraid of unwanted pregnancies and proclaimed their sexual freedom. And while pregnancy may not have been a worry, “Free Love” often came at the expense of sexually transmitted infections (STIs). Among some of the most common of these diseases are gonorrhea, chlamydia and trichomoniasis. Other STI’s such as syphilis, hepatitis, HIV, herpes and human papilloma virus (HPV) are gifts that keep on giving and giving and giving………

Many widows and widowers may have had only a few sexual partners before finding their soul mate to whom they had been married for many years before the tragic loss of that spouse. And now after decades, they are braving the dating scene once again. Just the idea of having sex with a new partner may be overwhelming, not to mention dealing with the anxiety of performance, acceptance and body image. And there is, unfortunately, another anxious fear…….that of getting a disease, a sexually transmitted infection.

coupleWith the exception of HIV/AIDS, not much has changed in the list of sexually transmitted diseases that have been around for centuries, millennium even. What has changed is the recognition of how diseases are diagnosed, treated and may be prevented. Today, most dating men and women, who are considering having sex, are upfront about disease prevention. They may discuss their sexual histories and decide that they will get tested and share each other’s results before progressing to that “next step.”

So what are the tests a clinician would likely order when their patient asks to be “tested for everything?” Though most often seen in a younger population, gonorrhea and chlamydia can be detected through a cotton swab culture or a urine sample. Testing may be obtained during the annual Pap smear visit for women when the cervix is swabbed. Urine sampling for both men and women is most accurate using a specimen of the first morning urine or a specimen collected one hour after the last voiding. Test results are immediate in urine testing but may take a few days if collected from the cervix or by swabbing the urethral opening of the penis for men. Symptoms for these infections are usually silent for women, but may cause discomfort during intercourse or spotting afterwards. Men usually have a penile discharge and burning with urination. If left untreated a woman may experience a tubal pregnancy, develop infertility or pelvic inflammatory disease and men can experience acute or chronic prostatitis. Both gonorrhea and chlamydia are easily treated with antibiotics. Infections, like the parasite-caused trichomoniasis, present with significant symptoms such as an irritating, itchy discharge with a foul odor. It is tested directly with a swab of vaginal or penile discharges and can often be seen under a microscope slide in the office and is treated with antibiotics. It must be stressed, however, that both partners of the all the above infections MUST be treated at the same time to avoid re-infection of each other or further transmission to other partners. All of these infections may be prevented by consistent condom use.

Syphilis, hepatitis and HIV/AIDS are diagnosed with specific blood tests. These infections are often seen in high risk populations with risky sexual behaviors such as unprotected sex with multiple partners or IV drug use. Further discussion of these diseases is beyond the scope of this article.

The final two STIs which a clinician may test a patient for would be herpes simplex virus (HSV) and HPV. There are two types of HSV that can be sexually transmitted. HSV 1 is the cold sore herpes. It prefers the mucous membrane of the mouth but can be transmitted to the genital area by autoinoculation or by oral sex with a partner with an active “fever blister.” However, a person may be shedding the virus prior to a herpes outbreak when they experience the prodromal symptoms of burning, tingling and itching at the site of eruption. It is estimated that approximately 70-80% of the general population possess the antibodies of HSV 1, the cold sore herpes, whether they manifest symptoms of blisters or not. That is, if 10 people were tested at random, about 7-8 of those would be positive for the HSV 1 antibodies. This virus is often passed during childhood through direct skin to skin contact with a close friend or relative while kissing or hugging when that relative has an active sore or is shedding the virus prior to an outbreak.

Genital herpes is HSV 2. Both herpes infections can be difficult to diagnose unless the person has a tender open sore on the genitalia. The usual presentation is an “exquisitely tender” cluster of tiny blisters which then break open and crust over within a week to ten days. Treatment may include topical analgesics and oral antivirals. A primary outbreak often makes the person feel like they are coming down with the flu with general aches, pains and fever. Subsequent outbreaks are usually not as serious. Some clinicians may offer a blood test, called Herpes Select 1 & 2, which can identify if a current infection is the very first infection for an individual or if they have been exposed to the virus in years past. However, this test in no way can indicate exactly when or by whom a person was infected. The best way to prevent herpes is to avoid any skin to skin contact when a person is symptomatic with prodromal symptoms listed above. HSV 1 or 2 in the genital area can be suppressed with daily antiviral medication.

HPV is perhaps the most illusive STI as it has very little symptoms to announce its presence. Beginning in the mid-20th century, Georgios Papanikolaou developed the Pap smear to screen for cervical cancer, which at that time was one of the foremost causes of death for women worldwide. Since then scientists have made great strides in identifying numerous strains of HPV responsible for multiple genital diseases. There are two main HPV sub-groups related to sexual activity: high risk HPV and low risk HPV.

It is estimated that about 70% of sexually active adults are infected with HPV. In women, a Pap smear or special DNA swab can detect HPV, but unfortunately science has yet to develop an HPV test for men. While bothersome, the low risk HPV can never cause cancer, but are able to cause abnormal Pap smears in women and genital warts in both genders. The high risk HPV, however, causes abnormal Pap smears and has the potential to cause cervical cancer as well as other genital cancers of the vagina, vulva, rectum, penis and scrotum. It is suspected now that some of these high risk viruses may be linked to some head and neck cancers as well. Again, condom use may help prevent the transmission of HPV.

Symptoms of the other STIs discussed in this article usually appear within months of exposure, but HPV sometimes takes years to cause enough changes to be detected. It is unclear how long an individual harbors the virus, but it is thought that younger persons can fight off the virus easily due to their healthy immune systems, whereas older individuals may have more difficulty shedding the virus. The good news is that once a woman is diagnosed with HPV, she is closely monitored through frequent Pap smears so that changes may be detected long before cancerous cells develop.

Most of the above information may discourage many widows and widowers to even consider pursuing intimate relationships. But in spite of these ominous sounding sexually transmitted infections, many couples can enjoy a safe and rewarding sexual relationship if they first arm themselves with knowledge of prevention and transmission and take precautions to avoid exposure as they take that “next step.”

In addition to your local nurse practitioner or physician, more information can be obtained through the following websites: www.cdc.gov/std ; www.webmd.com

Merrilyn Harden McNatt, APRN, FNP-BC has been in practice with Robert Spitz, MD at Montauk GYN since November 2000. She holds certification from the North American Menopause Society as a certified NAMS menopausal practitioner. She also is certified through the ASCCP, American Society for Colposcopy and Cervical Pathology. Although a board certified Family Nurse Practitioner, Merrilyn has focused in women’s health issues for most of her 40 + year nursing career. Prior to becoming an NP in 1998, Merrilyn taught Lamaze childbirth and breastfeeding classes at L&M Hospital and was one of the first three Connecticut IBCLC (International Board Certified Lactation Consultant) in1985. After receiving her Master’s Degree in Nursing in 1989 from UCONN, she taught maternity nursing for almost 10 years at a number of nursing schools including Wilcox College of Nursing and Three Rivers Community College. She lives in East Lyme, CT with Terry, her husband of 44 years.

By Merrilyn Harden McNatt, APRN

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