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[7 min read] STI and cervical screening in Australian general practice
Sexually transmitted infections
Sexually transmitted infections (STIs) are common, with around 16 per cent of Australians reporting having an STI at some point in their lifetime. The most common STI is chlamydia; other STIs include gonorrhoea, genital herpes (herpes simplex virus, HSV), genital warts (human papilloma virus, HPV), hepatitis B, human immunodeficiency virus (HIV), and syphilis.
The general population may present for an asymptomatic STI screen at any point, and it’s important to be comfortable taking a sexual history, assessing risk and offering appropriate testing. A sexual history should cover timing of sex, gender of partners, condom use, and type of sex (i.e. vaginal, oral, anal).
For most patients presenting for an asymptomatic screen, they should be tested for gonorrhoea and chlamydia and offered serum testing for HIV, hepatitis B and syphilis. Swab samples for chlamydia and gonorrhoea can often be self-collected by female patients, avoiding the need for examination, and for male patients a first pass urine is sufficient.
Patients may present with a wide range of symptoms that may indicate STI. In women, vaginal discharge, pelvic pain and unusual vaginal bleeding are some of the most common symptoms. In men, dysuria is the most common presenting complaint. Patients may also present with skin manifestations such as ulcers or warts. Most patients who are symptomatic merit examination.
Chlamydia can be asymptomatic in men and women, or may cause vaginal discharge, bleeding or pelvic pain in females; and dysuria in males. Gonorrhoea typically causes a discharge in both men and women. Genital warts appear as painless fleshy lesions around the anogenital region. Herpes appears as painful ulcers on the genitals. HIV and hepatitis can be asymptomatic for many years, and typically don’t cause visible genital symptoms. Syphilis can cause a painless ulcer known as a chancre, and thereafter can be entirely asymptomatic.
When testing for STIs, it’s important that window periods and limitations of testing are explained, and that the patient knows how and when they will receive their results. On receipt of a positive result, contract tracing should be initiated based on the patient’s recent sexual contacts.
Cervical screening in Australia
The National Cervical Screen Program in Australia invites all people with a cervix for screening every five years from the age of 25 to 74. During cervical screening, a sample of cells from the ectocervix is obtained via speculum examination, and this sample undergoes “primary screening” for the presence of human papilloma virus (HPV). Certain strains of HPV, particularly types 16 and 18 are associated with a significantly increased risk of cervical cancer.
For those who do not have evidence of HPV infection, routine screening is performed again in five years. For those in whom type 16 or 18 HPV is detected, referral to colposcopy is indicated. For those where an oncogenic type of HPV is detected, but not type 16 or 18, liquid based cytology is performed to assess for an evidence of neoplasia.
Women are then categorised as intermediate or high risk based on cytology. Those at higher risk will go on to have colposcope examination, and those at intermediate risk will be invited back in 12 months. The rationale is that most HPV infections will spontaneously clear within a period of 12 months, and this process aims to avoid unnecessary colposcopy in women who will spontaneously clear a HPV infection.
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- Australian Government Department of Health. Sexual Health. https://www.health.gov.au/health-topics/sexual-health
- Australian Sexual Health Alliance (2018). Australian STI Guidelines. http://www.sti.guidelines.org.au/
- New South Wales Government (2019). STI/HIV Testing Tool. https://stipu.nsw.gov.au/wp-content/uploads/STI-HIV-Testing-Tool-online-version-2.pdf
- British Association for Sexual Health and HIV (BASHH)(2018). Sexually Transmitted Infections in Primary Care. https://www.bashh.org/documents/Sexually%20Transmitted%20Infections%20in%20Primary%20Care%202013.pdf
- Australian Government Department of Health. National Cervical Screening Program. https://www.health.gov.au/initiatives-and-programs/national-cervical-screening-program
- Cancer Council Australia Cervical Cancer Screening Guidelines Working Party (2021). National Cervical Screening Program: Guidelines for the management of screen-detected abnormalities, screening in specific populations and investigation of abnormal vaginal bleeding. https://wiki.cancer.org.au/australia/Guidelines:Cervical_cancer/Screening