STI checks for women

STIs under diagnosed — often missed as may have no symptoms or minor symptoms that clear quickly

• Can be at any age but are more common under 35 years
• If under 18 years — consent and child protection issues
• If 14–18 years — first see STI checks for young people
• If under 14 years — see Child sexual abuse
• STI checks routinely recommended in 15–34 year age group
• Times to offer an STI check include
• As part of another consultation (opportunistic) if 15–34 years
• As part of Adult Health Check
• Community-wide screening and outbreaks
• If symptoms and/or risk factors suggest STI
• If asked for by person even if not long since last check
• All pregnant women
• Opportunistically to young person especially if from outside community
• Offer opportunistic Standard STI check every 6 months (twice a year) and use a recall system

Risk factors for STIs

• Living in community with high STI rates
• Age
  
• High risk — sexually active under 35 years
• Highest risk — sexually active under 25 years
• STI or PID in past 12 months
• New sexual partner in past 3 months or more than 1 partner in past 6 months
• Drug or alcohol use — increases high-risk behaviours (eg multiple sexual partners, unsafe sex)
• Recent travel

Additional risk factors for HIV

• Existing STI
• Behavioural risk factors — person or their partner is a man who has sex with men, is transgender and/or sistergirl, from overseas or person who injects drugs

 Point of care (POC) testing for STIs

• POC testing for chlamydia/gonorrhoea/trichomonas is available in some clinics
• POC and laboratory tests are completed on the same collection site (single urine sample is usually enough volume for all tests, additional POC swabs are required for other sites) 
• Always do syphilis serology and other laboratory tests regardless of POC result
• Syphilis POC testing is only suitable in restricted situations and can only be carried out by trained operators — refer to your health service guidelines or trained colleague 

Three types of STI checks

• Standard — pathology testing, no detailed history or examination
• Full — pathology testing plus history and examination, contact tracing
• Pregnancy — series of checks with additional tests at different times during pregnancy and postnatal

Standard STI check

Full pathology testing, no detailed history or examination. 

Indications

• Opportunistic
• Adult Health Check, yearly STI check, community screening
• 3 month re-test following a positive test result
• 6 week postnatal check

Sometimes there is not enough time or only some samples that can be collected. It is still useful to do some tests from Standard STI check

Do

• Ask about symptoms — abnormal vaginal discharge, lower abdominal pain,  abnormal vaginal bleeding, sores/ulcers
• If symptoms — see relevant protocol

Collect

• Self-collected lower vaginal swabs x 2 (NAAT and MC&S)
• OR urine if woman does not want to collect swabs
• OR if cervical screening due and/or doing genital examination — endocervical swabs x 2
• Samples for POC Test if available
• Send for
• NAAT for chlamydia, gonorrhoea, trichomonas
• MC&S for gonorrhoea culture

• Take blood for HIV serology, syphilis serology
• Also do syphilis POC Test test if indicated
• If hepatitis B status unknown or not immune (no evidence of previous infection or immunisation) — take blood for HBsAg, Anti-HBc, Anti-HBs

Follow-up

• Tell woman to come back for results from laboratory or POC Test
• If any positive result — do rest of Full STI check including history, examination, treatment, contact tracing
• When giving results for STI check — be very clear about what has been tested for and what conditions the results relate to. Do not say things like 'You have the all clear' or 'You don't have an STI'

Full STI check

Indications

• Symptoms — vaginal discharge, pain on passing urine, lower abdominal pain
• Asks for a check
• If positive result from Standard STI check — for additional assessment
• Contact (partner) of someone with an STI

Check file notes

• Date and results of last STI check
• Treatment offered and completed
• Hepatitis B status
• Date and result of last cervical screening
• Contraception use

Ask

• Last menstrual period and any abnormal bleeding
• Pregnant or planning to be
• Lower abdominal pain, pain with sex
• Vaginal discharge, itching, soreness
• Pain on passing urine
• Sores, rash, lumps on genitals
• Sexual partners
• Regular or casual partners, do partners have other partners
• New partners in past 3 months
• Number of partners in past 6 months
• Any concerns (eg non-consensual or unwanted sex) 

Check

• Urine pregnancy test especially if no record of contraceptive use
• If positive and woman has symptoms of STI — medical consult — see STI management
• Rash including hands and feet or hair loss
• Mouth for ulcers
• Groin for enlarged or tender lymph nodes
• If present — check lymph nodes at other sites
• Groin, vulva, anus for sores, other lesions, rashes
• If present — see Genital ulcers and lumps

Collect — for all women

• Self-collected lower vaginal swabs x 2 (NAAT and MC&S)
• OR urine if woman does not want to collect swabs
• OR if cervical screening due and/or doing genital examination — endocervical swabs x 2
• Collect samples for POC Test if available
• Send for
• NAAT for chlamydia, gonorrhoea, trichomonas
• MC&S for gonorrhoea culture
• If abnormal discharge — MC&S from low or high vaginal swab
• Take blood for HIV serology, syphilis serology
• Also do syphilis POC Test test if indicated
• If hepatitis B status unknown or not immune (no evidence of previous infection or immunisation) AND all pregnant women — take blood for HBsAg, Anti-HBc, Anti-HBs
• If genital sore — use NAAT swab to swab base of ulcer (sore, scab, lump) or fluid from blister
• Request — NAAT for herpes, syphilis, donovanosis

Do

• Ask for name/s of partner/s for contact tracing if syndromic or presumptive treatment given or pathology positive
• If symptoms of STI — offer immediate syndromic treatment
• If discharge — see Vaginal discharge
• If sores, ulcer — see Genital ulcers and lumps

• In communities with high STI rates — think about presumptive treatment (immediate treatment even if no symptoms). Treat for gonorrhoea (will also treat chlamydia) if 
  
• Asks for treatment or thinks she has put herself at risk
• At high risk and unlikely to return for results
• If behavioural risk factors for HIV consider medical consult for PrEP
• If symptoms of PID (eg lower abdominal pain, deep pain with sex) — see Pelvic inflammatory disease
• Offer STI and safer sex education
• Consider talking about contraception
• Tell woman to come back for results

Follow-up

• If positive results — see STI management
• When giving results for STI check — be very clear about what has been tested for and what conditions results relate to. Do not say things like 'You have the all-clear' or "You don't have an STI"

Pregnancy and postnatal STI checks

• Pregnancy STI check always includes syphilis serology
• Additional tests are carried out at different times during the pregnancy 
• STIs in pregnancy can have serious consequences for mother and baby, including miscarriage, neonatal illness and death
• Regular testing, prompt management and prioritised contact tracing are important

Pregnancy STI check

Ask

• Symptoms — abnormal vaginal discharge, lower abdominal pain, abnormal vaginal bleeding, sores/ulcers. If symptoms — see relevant protocols
• If history of herpes — see Genital herpes – Do in pregnancy

Check

• Vulva for sores, scars, abnormalities at first visit
• Collect
• Lower vaginal swabs x 2. Best collected by clinician at first visit, otherwise self-collected
• OR urine
• OR if cervical screening due and/or doing genital examination — endocervical swabs x 2
• Collect samples for POC Test if available
• Request
• NAAT for chlamydia, gonorrhoea, trichomonas
• Gonorrhoea culture
• Take blood for HIV serology, syphilis serology
• Also do syphilis POC Test if indicated
• If genital sores
  
• Dry swab base of ulcer (sore, scab, lump) or fluid from blister
• Request — NAAT for herpes, syphilis, donovanosis
• Treat straight away — could be syphilis. See Genital ulcers and lumps

Do

• If any positive results from Pregnancy STI check — do Full STI check