Hi everyone! My name is Dr. Lena Shankar Nathan. I’m a UCLA Health OBGYN physician located out in Westlake Village. I have a talk for you today called Straight Talk about Sexually Transmitted Diseases. You can ask questions during this presentation using the hashtag #UCLAMDChat on Twitter. So, the hard facts–no pun intended– according to studies by the CDC, 47.4% of high school students have had sex, 39.8% did not use a condom, and nearly half of the 19 million incidents of STDs per year occur in the ages 15 to 24. So, this is a very important subject for young people to know about. The facts, continued–a study showed that 40% of women ages 14 to 19 who have had sex have at least one STD, with the most common one being HPV, or human papillomavirus. Other STDs include chlamydia, gonorrhea, trichomonas, and herpes. There’s a high rate of reinfection. Once you’ve had an infection of this sort, even if you’ve been treated, there’s a good chance you’ll get reinfected–about 40%–or be infected within just a few months, and rRepeated STD infections are a risk factor for HIV infection. So, who needs to know? I want to discuss briefly the California minor consent laws. So, if you’re an adolescent and you’re concerned about one of these issues, such as pregnancy, STD testing, or birth control, in most cases, you do not have to tell your parents, and you can seek medical care on your own. So, for instance, if you would like birth control, minors of any age can come to a doctor or a clinic and be counseled and receive a prescription, and by law, the provider cannot reveal this information to the parents due to privacy laws. Similarly, for pregnancy care and abortion, minors of any age can seek care on their own without parental consent. And, again, the parents, by law, are not informed unless the patient actually gives permission to the provider. For STD testing and treatment, for HIV testing, minors over the age of 12 do not require parental consent. If you’re younger than 12, you will need to have your parent approve of your evaluation and treatment. And again, once you’ve been evaluated and treated, your parents, by law, will not be told unless you give permission to your provider to do so. For sexual assault care, minors of any age can seek care without their parents knowing about it. In this case, though, we are required by law to inform your parents, and oftentimes law enforcement as well. This being said, talking to your parents, we actually encourage you to discuss things with your parents of this nature, and if not your parent, another trusted adult because they can usually give you a good advice, and they have your best interests at heart. So it’s best if you have a relationship where you can discuss with your parents, even though by law you can see care without telling them. So, when is sex reported as child abuse? So, for instance, when would we have to report an intercourse to law enforcement? So, when the sex is not voluntary, or the victim is unconscious or so intoxicated that he or she cannot resist, this mandates that the provider must inform law enforcement. Also, based on age difference between the partner and the patient–so, in this grid where you see the CJ– here– that means the provider will use their clinical judgment. And where you see the letter M, it means that it’s mandated reporting for the provider. So, for instance, if a twelve-year-old has intercourse with fourteen-year-old, this is mandated by law that the provider must report it. However, incredibly, in California, if a fourteen-year-old has intercourse with somebody who is even up to 20 years old, It’s not required by law. However, it is a clinical judgment, it is on the part of the provider to report it. So, this is essentially specific to the state, and this is what California has mandated. So if you go to the doctor with a concern about a sexually transmitted disease, what will the doctor do? The doctor will talk to you about your concerns in your medical history. If your parent is with you, we will usually ask him or her to leave to ask your questions, ask you some more questions in private. Usually, this is done during the exam portion of the visit. If you are a virgin, a pelvic exam is not required, and if you have any symptoms, you may need a speculum exam, and this is specific to females. The meaning is that the speculum exam is to examine the vagina or the cervix. So, here’s a picture of what a speculum looks like, and here is the way that we position patients in order to do the female pelvic exam. I want to first talk about human papillomavirus. This is the most common sexually transmitted disease. There are many different strains. There are high risk strains, which includes 16, 18, 31, and 33, and these are associated with cervical cancer. There’s also the group of low risk HPV strains, which includes 6 and 11, and these are associated with genital warts. If you have one strain or the other, it doesn’t predispose you to developing the other disease. For instance, if you have a low risk strain, you’re not at high risk of cervical cancer. And if you have a high risk strain, you’re not at risk of genital warts unless you’re infected with the other strain as well. What a pap smear does is it checks the cells of the cervix for cervical changes, which include cancer or pre-cancer. We can also do an HPV test at that time. It’s important for young people to know that no pap smear is needed until age 21 for most patients, regardless of sexual activity, and this is because young people clear the virus quite quickly, and even if there are changes in the cervix, these usually go back to normal without any further treatment. So, HPV is ugly. Here in the upper corner, you can see a picture of how HPV can cause changes in cervical cells over time. So, there’s an image of normal cells and then pre-cancer cells and then cancer cells, which look very different from the normal cells. There’s also a diagram here of what cervical cancer does to the actual cervix. So, this is the uterus, or the womb, where the baby grows, and then this is the cervix, which is the opening to the uterus, and you can see that as time goes on, HPV can affect changes to cause cervical cancer. On the other side, I have some pictures of genital warts. So, you can see here some images of genital warts in men as well as women. So, HPV can actually be prevented. There’s a vaccine called Gardisil, which is approved for ages 9 to 26. It protects against strains 6 and 11, which cause genital warts, and strains 16 and 18, which are the most common to cause cervical cancer. It’s a series of three shots over six months, and it’s available for boys and girls. Condom use can also help prevent HPV, but it’s not 100% effective. The best time to receive the vaccine is prior to initiation of any sexual activity. Chlamydia is the most common bacterial sexually transmitted disease. It’s frequently asymptomatic, which means you have no symptoms, and there is a recommendation that we should screen sexually active women ages 25 or less universally. Women can develop an infection of the cervix or the urethra, which is the tube where the urine comes out of the bladder. Women can also develop pelvic inflammatory disease, which can cause infertility in the future, so it’s very important to diagnose this infection if you have it and have it treated so that you don’t have issues with fertility in the future. For men, they can develop a urethritis, which is a discharge of the penis, epididymitis, which is an infection of the testicles, or prostatitis, which is an infection of the prostate. The test for chlamydia is a swab of the cervix, or a urine test for men. Prevention and treatment of chlamydia–so, prevention is linked to education, which is, in part, watching things like this presentation. So, delaying age of first intercourse is key to preventing sexually transmitted diseases, including chlamydia. Using condoms can help with prevention, and reducing the number of sexual partners. Treatment includes antibiotics, such as azithromycin or doxycycline, and these are taken by mouth. Gonorrhea is the second most common bacterial sexually transmitted disease. Women are usually asymptomatic, but the men are not, and in men, it can cause urethritis, prostatitis, or epididymitis. In women, you can develop cervicitis, which would give you unusual vaginal discharge, or pelvic inflammatory disease, which can lead to infertility. Gonorrhea can also give you a throat infection related to oral sex, and you can have symptoms of a sore throat from gonorrhea. Ocular transmission is also possible, so this means there’s possibility of transmission to the eye, and Neisseria gonorrhoeae can actually infect the eye, and there’s a picture down here below of what gonorrhea looks like within the context of the cells. That’s where the arrows are. Gonorrhea: diagnosis, treatment, and prevention. So, the testing involves using a swab of the cervix, of the throat if we suspect a throat infection, or a urine test, and the treatment includes ceftriaxone, which is actually an intramuscular injection, plus azithromycin or doxycycline, and this is because there’s increasing resistance of Neisseria gonorrhoeae to antibiotics, so it’s a recent recommendation to try to use two antibiotics to treat this infection. Prevention, again, is linked to education, so delay up the age of first intercourse, using condoms, and reducing the number of sexual partners. So, how about your partner? In California, we can actually assist with expedited partner therapy, and what this means is if you have been diagnosed with an infection, particularly chlamydia, we can actually give you a prescription for your partner as well without having evaluated your partner, and this is in order to prevent reinfection of the patient. It’s not appropriate for gonorrhea because part of the treatment for gonorrhea is an injection, and for that the partner must come in to see the provider, and the other issue with expedited partner therapy is that the partner is never evaluated for all the other sexually transmitted diseases, so we may be missing some infections by doing this. However, it is still important to treat partners, even if they don’t want to come in to the doctor, in order to prevent reinfection of the patient. We also recommend avoiding sex for seven days after initiating treatment. Next, I want to touch on genital herpes. It’s caused by herpes simplex virus, type 1 or type 2. It can be transmitted by vaginal sex, anal sex, and by oral sex, and there’s a high rate of carriers for herpes virus in general, whether it be oral or genital. Primary infection of herpes will give you flu-like symptoms where you can have a fever, headaches, fatigue, body aches, and you will also develop painful genital ulcers, which will cause burning with urination and enlarged lymph nodes in the groin. This infection is a permanent infection. Your body will always the virus, and you will be at risk for recurrence. The recurrence, however, can be less painful and shorter in duration. Again, you will have painful ulcers with the recurrences, and it is important to also note that even if you have no ulcers, you can still shed the virus, and you can still transmit this disease to your partners. So, here’s a picture of genital herpes–a couple of pictures of penile genital herpes and a couple of pictures of genital herpes on the labia, and it is as painful as it appears on the screen here. Herpes diagnosis, prevention, and therapy. So, it’s diagnosed by a viral culture of the ulcer. Blood testing is less sensitive, and prevention–condom use can help reduce the transmission by about 50%, but because condoms don’t cover the entirety of skin that is exposed to your partner, it’s definitely possible, with skin-to-skin contact, to still have transmission despite the condom. We treat this infection with acyclovir, famcyclovir, or valcyclovir, which can help improve the symptoms but does not cure the virus. And if you have frequent recurrence of ulcers, we can give you medication to take every day to prevent the ulcers from forming. It’s also important to note that in pregnancy, this can be a dangerous condition because if babies are born through the birth canal when they’re shedding off the virus, the babies can actually get very sick from this, and for that reason we give prophylactic antibiotics towards the end of pregnancy, in order to reduce the occurrence of ulcers or also of shedding. So, HIV is caused by a virus, which attacks your immune system. The primary infection symptoms are mono-like, or you may have none at all. If you have a mono-like reaction, you will have fevers, body aches, sore throat, fatigue, enlarged lymph nodes, or possibly a rash. However, the diagnosis can be missed because so many people may think that they just have the flu or mono and never think that this is a primary HIV infection. The diagnosis is usually made once the patient develops opportunistic infections, and what this means is that because your immune system is lower, you’re more susceptible to infections that people with a good immune system would normally not get, so if you have one of these rare infections, then HIV is suspected and tested for. Transmission of HIV can be by sex–oral, vaginal, or anal– IV drug use, and rarely blood transfusions. So, we diagnose HIV with a blood test. Universal screening is recommended for ages 13 to 64 because it may be asymptomatic, or maybe the symptoms were passed off as the flu, as I previously mentioned. Prevention includes condom use and treatment of a partner who’s known to have HIV because that will reduce their viral levels and help reduce transmission. The treatment is a complex multi-drug regimen called HAART, or highly active antiretroviral therapy. It can never be cured but only controlled with medications, and death is usually caused by these opportunistic infections. AIDS is a late stage HIV infection where your T-cell count drops to less than 500, and in pregnancy it is possible to transmit HIV from mother to child, and we call this vertical transmission. However, we do treat with medications in order to try to prevent this from occurring. Next, I want to talk about syphilis. This is caused by a bacteria, and there are different stages of syphilis, which cause different symptoms. You can have a primary syphilis infection, which occurs 2-3 weeks after exposure. You’ll notice a raised red bump and then a sore where the infection has occurred, and this is usually painless. Secondary syphilis infection can occur weeks to months after infection, and only 25% of people will actually have these symptoms, which include a rash and flu-like symptoms. Latent syphilis is when you have no symptoms at all, and then tertiary syphilis is a very serious condition where you can have damage to the heart, brain, eyes, and other organs. Here are some pictures of both the genital sores associated with syphilis. You can see one here on the penis as well as here, and then you can see these are some pictures of the rash that syphilis can present with. Syphilis is diagnosed with a screening blood test and then a confirmatory blood test. The treatment is quite simple. Penicillin shots will take care of this infection, and doxycycline can be used as well. Prevention includes the use of condoms as well as limiting the number of sexual partners. So, most importantly, please take care of yourself and your partner. You should disclose your history of any sexually transmitted diseases and any treatments you have received. I also recommend to my patients to get tested for STDs prior to having sex with a new partner, and you can get tested at various clinics, like Planned Parenthood or free clinics, if you can’t see a regular doctor for this issue. Thank you for your attention. So, I have some questions here I would like to address. The first question is “If you have come into contact with herpes but never show symptoms, are you a carrier? Can you still pass it on?” So, it’s definitely possible to be infected with herpes but to not actually have the primary outbreak, and it is possible, in that case, to still be shedding. The next question is “How can I prevent spreading a sexually transmitted disease?” So, it depends on which disease it is. Condoms are effective for prevention of the spread of sexually transmitted diseases in most cases. However, in skin-to-skin contact type diseases, such as herpes or genital warts, it can be less effective. The other key to prevention is the education, which I commend all of you for watching this presentation, and delaying the age of first intercourse, reducing the number of partners–that can definitely help with reducing the incidence of sexually transmitted diseases. The next question is “How should I talk to my kids about sexually transmitted diseases?” This is a great question because it can be uncomfortable for parents to talk about sex and these diseases with their children. However, it’s very important to maintain open lines of communication, and having a frank discussion with your children is a very good idea. You may want to do it over possibly a meal or at a time when you and your child are feeling relaxed, where you can just open up the discussion about, you know, what may be going on with your child, with their friends, and give your good advice to your children. They are looking for advice from whomever they can find it, and I think parental support and guidance is very important in this situation. The next question is “Does viagra protect against sexually transmitted diseases?” I have not seen any research related to that, so my understanding is that it does not protect against any of these. “As a teen, where can I get tested for sexually transmitted diseases?” So, this is a very good question. You can go to your own pediatrician or doctor to get tested and treated, and as I mentioned before, it is confidential, and your parents don’t have to know about it. Sometimes there can be issues if you use your insurance, that your parents may receive something in the mail about this, and If that could be a potential issue, we do recommend that people receive care somewhere such as a Planned Parenthood, which is completely anonymous and confidential as well, or free clinics, so there are definitely places where you can receive evaluation and treatment for these diseases. “Can Estella protect me from sexually transmitted diseases?” So, Estella, I believe, is one of the hundred different kinds of birth control pills out there, and birth control pills will protect you against pregnancy, but they will not protect you against sexually transmitted diseases. So if you’re still concerned about STDs, you should use condoms in addition to the pill. “How can I get a sexually transmitted disease if I’m still a virgin?” So, first we should define virgin. If you’ve had oral sex or anal sex, you may still consider yourself a virgin. However, you have had sex that can expose you to sexually transmitted diseases, so it’s not just vaginal sex that leads to sexually transmitted diseases, but oral and anal as well, so if you’re a virgin, yet you’re engaging in oral or anal sex, you can definitely contract STDs that way. Other than that, you know, as a virgin where you’ve having no sexual contact whatsoever, it would be very difficult to be infected with a sexually transmitted disease. “How often should I be screened for sexually transmitted diseases?” So as I mentioned in the lecture, anytime you change partners, you should be screened for sexually transmitted diseases, and I at least recommend to my patients once a year when they come in for their well-woman visit to be screened, and similarly for men as well. When you have your annual physical, you should request screening if your doctor doesn’t initiate that discussion. But it is very important, because so many of these diseases can be asymptomatic, to be screened at a regular basis. And “Can sexually transmitted diseases cause testicular cancer?” I have not heard that, but to be honest, because I’m OBGYN, I’m not as well-versed with male sexual health. In terms of any sexually transmitted diseases causing testicular cancer, I’ve not heard any reports or studies in my education, training, and experience, but that’s not to say that it doesn’t exist. So, “How do human papilloma virus vaccines work?” So, what a vaccine does is it actually exposes you to the antigens of the virus so that your body can build an immune response to the actual virus strains, and by doing, that you actually form antibodies, which will then fight off any sort of initial exposure to the virus itself. And “How do I protect myself from HPV while engaging in oral sex?” That is a very good question. Condom use can definitely help with this, but again, as I mentioned, if there’s skin-to-skin contact, there’s always a possibility of transmission. Those are all the questions I have here. “Are there any genetic or hereditary risks associated with CIN and HPV?” So, HPV can cause CIN–so, CIN is a cervical intraepithelial neoplasia, which is a precancerous change in cervical cells– in terms of genetic or hereditary risks, some people can be predisposed to developing changes in their cervix more easily with the HPV infection than other people, so some people are infected with HPV and they never develop any sort of precancerous changes, whereas other people do. It’s usually related to your immune system, so, for instance, if you’re a smoker, or if you have an HIV infection, if you’re on steroids, or other immunosuppressive medications, then you’re at increased risk of having cervical cancer or precancerous changes from the human papilloma virus. In terms of genetic or hereditary risks, not so much. “If you have unprotected sex while using an IUD for birth control, does that increase a chance of getting an STD?” This is a great question. So, many years ago, there was a concern that if you have an IUD and you contract a sexually transmitted disease like gonorrhea or chlamydia, that you are at higher risk for pelvic inflammatory disease. The current day IUDs, particularly the Mirena IUD, which has a little bit of a progesterone hormone called levonorgestrel, you actually develop thicker cervical mucus, which actually prevents pelvic inflammatory disease. So I guess my answer to this question is that if you are using an IUD for birth control, it does not increase your chance of developing an STD, and in fact, it could be protective against pelvic inflammatory disease. An IUD is an excellent form of contraception, so highly recommended and you’re interested. This concludes my presentation today. If you have any further questions or comments, please feel free to contact us through the web. Thank you so much.