Sexually transmitted infections in adolescents

Sexually transmitted infections (STIs) occur disproportionately in adolescents. According to the Youth Risk Behavior Surveillance of 2011, 47% of high school students reported having been sexually active. High-risk sexual behaviors such as nonuse or incorrect use of barrier methods and multiple partner selection are common in adolescents.¹ To optimize treatment and prevent sequelae of STIs in adolescents, screening and diagnosis must be tailored to their unique needs.

What are the most frequent STIs in adolescent females?

Chlamydial and gonococcal infections are the 2 most commonly reported bacterial STIs in the United States, and their prevalence is highest among females aged 15 to 24. Surveillance data from 2010 showed that gonorrhea had a slightly higher prevalence in the 15-to-19 age group, and chlamydial infections were slightly more prevalent in the 20-to-24 age group.² Human papillomavirus (HPV) infection, trichomoniasis, and herpes simplex virus (HSV) infections are also common in adolescents.^2-5 High-risk sexual behaviors also place adolescents at risk of acquiring syphilis and HIV infection. 

When should an adolescent be screened for STIs?

Adolescents should be screened confidentially about the initiation of sexual intercourse at each clinic visit.^5,6 For sexually active females younger than age 25, the Centers for Disease Control and Prevention (CDC) recommends yearly screening for chlamydia and targeted screening for gonorrhea (for those at increased risk).⁵ Testing for HIV is recommended for sexually active and at-risk youth, and should be repeated annually for those at high risk of infection.⁷ Screening for additional STIs such as syphilis or hepatitis should be based on symptoms and the presence of additional high-risk factors (prostitution, drug use, incarceration). It should be routine among certain populations with high rates of seropositivity.

Rescreening should occur with the initiation of intercourse with a new partner. In patients who have tested positive for gonorrhea or chlamydia and have been treated, the CDC recommends repeat screening after 3 months because the rate of reinfection is high.

Is an internal pelvic exam required to test for gonorrhea or chlamydia?

No. In sexually active adolescents, endocervical swabs are usually reserved for those who are symptomatic, and require an internal pelvic exam. However, screening for gonorrhea and chlamydia with nucleic acid amplification tests (NAATs) is also possible through vaginal swabs (which can be collected by the provider or the patient) or urine testing (which has a slightly lower detection rate than endocervical and vaginal sampling).^7-9 

When and how should an adolescent be screened for genital herpes infection?

Routine screening for HSV is not indicated. Testing should be performed if genital ulcers or other mucocutaneous lesions are present. Viral culture is the preferred method of testing, but its sensitivity is low. Polymerase chain reaction assays are increasingly used and have higher sensitivity than viral culture. NAAT testing is also available. 

Recurrence rates for genital HSV-type 1 infection are significantly lower than for type 2 infection. The CDC and the American College of Obstetricians and Gynecologists (ACOG) recommend glycoprotein

G-type specific antibody testing in asymptomatic patients who report possible exposure, patients whose partners have histories of genital herpes, and those who have histories of symptoms concerning for HSV infection.^7,10

When is testing for HPV indicated in an adolescent?

There is no role for HPV testing in adolescents.¹¹ Diagnosis of genital warts is performed by visual inspection. Biopsies are reserved for cases in which the diagnosis is uncertain, or in cases of atypical or worsening lesions.⁷ Current ACOG guidelines support initiation of cervical cytology testing at age 21 for immunocompetent patients.¹¹ If cervical cytology is performed earlier than age 21, HPV testing should not influence management. In addition, HPV testing is not required before administration of the HPV vaccine. 

How is trichomoniasis diagnosed?

Diagnosis of trichomoniasis is usually performed in the office by saline microscopy of vaginal secretions, but sensitivity is low. For those with suspected infection but negative microscopy results, additional testing options are available (culture, rapid antigen, or NAAT).¹² 

What are the consequences of an untreated STI?

Untreated STIs can cause pelvic inflammatory disease (PID, which can lead to infertility), adverse pregnancy outcomes,^13,14 and anogenital and cervical cancers.¹¹ In addition, the presence of other STIs increases the likelihood of both transmitting and acquiring HIV.^15,16

How can STIs cause infertility?

Up to one-third of untreated cases of chlamydia or gonorrhea will progress to PID, an inflammatory process of the upper genital tract. Scarring of the fallopian tubes from PID can lead to infertility, chronic pelvic pain, and increased rates of ectopic pregnancy.¹⁷ Increased screening for gonorrhea and chlamydia is associated with fewer hospitalizations for PID and ectopic pregnancy.¹⁴ 

Can STIs in a mother affect her newborn?

Yes. Perinatal transmission of gonorrhea and chlamydia can lead to conjunctivitis, infant pneumonia, and rarely, disseminated gonococcal infections in neonates.⁷ HSV infection in the newborn can be limited or present as encephalitis or disseminated disease.18 Perinatal HPV transmission can lead to cutaneous or laryngeal papillomas in infants or children.⁷ Congenital syphilis can lead to stillbirth, premature delivery, and a wide spectrum of clinical manifestations, including developmental delay and seizures.¹⁹

Are condoms effective in preventing all STIs?

Barrier methods of contraception reduce the risk of STI transmission.²⁰ Male latex condoms are highly effective in preventing transmission of HIV when used consistently and correctly. Condom use also reduces the risk of other STIs, including those transmitted by genital secretions and, to a lesser degree, genital ulcer diseases and HPV infection. 

Studies have found that barriers to condom use may include younger age, inability to pay for/obtain condoms, STI risk perception, number of partners, partner support of condoms, educational factors, and the presence of other types of short- or long-acting contraception.^21,22 In general, use of condoms with and without other contraception methods is lower in the United States than in Western European countries.²³

As a provider, how can I help adolescents prevent STIs?

Adolescents should be screened confidentially at every visit for initiation of sexual activity, sexual contacts and behaviors, and sex of partner(s). Age-appropriate education about sexuality, contraception, and STI prevention should occur. Several organizations, such as the Society for Adolescent Health and Medicine (SAHM) and the CDC, offer sample screening questionnaires on their websites for use in office practice (Table).^24,25

Once an STI is diagnosed, both the patient and her partner(s) should be treated according to the latest CDC guidelines to prevent reinfection and further disease transmission. Additionally, ACOG and the CDC recommend vaccination against HPV for all males and females aged 9 to 26 years. Both vaccines are most effective prior to any exposure to HPV, but even sexually active teens can benefit from vaccine administration.^26,27

How can a provider help prevent reinfection and continued transmission of STIs?

Adolescents with a diagnosis of STI should be encouraged to notify their sex partners and urge them to seek medical evaluation and treatment. Expedited partner therapy (EPT) is the practice of treating the sex partners of patients with STIs without medical evaluation.²⁸ Its use is recommended by the CDC for heterosexual partners of patients with a diagnosis of chlamydia or gonorrhea if it is unlikely that the partner will seek treatment. The usual implementation of EPT is through patient-delivered partner therapy (PDPT). Other methods, such as a prescription for the partner, may be employed, but EPT is useful only for oral medications. 

Since the routine use of oral medication for gonorrhea is no longer recommended by CDC guidelines, sex partners should be preferentially evaluated and treated with the recommended intramuscular regimen.29 However, if this is not possible, the CDC recommends that EPT still be considered with the alternative oral regimen, since the risks of no treatment are greater than the risk of EPT. Because EPT may be prohibited in some states and is the topic of ongoing legislation in others, providers should visit www.cdc.gov/std/ept to obtain updated information for their states.^2,28

What barriers do adolescents face in seeking care for STIs?

In an exploratory study, adolescents expressed social stigma, fear of positive results, negative consequences of testing, clinician gender, lack of knowledge about STIs and their treatment, and comfort with the physician as major barriers to STI care.³⁰ Adolescents are less open to providers and less likely to return for care if they are uncertain about confidentiality.³¹ Some may be unable to pay for services independently of a parent-funded insurance plan. 

Are there limits to confidentiality when treating adolescents with STIs?

In all states, minors are allowed to consent to services for STI care. There are minimum age requirements in 11 states, and 18 states allow physicians to notify parents that services were sought.³² However, there is risk of breach of confidentiality in some office practices (printing of admission or discharge paperwork, privacy of the electronic medical record, literature distribution to patients), and in payment for services. 

Billing confidentiality differs depending on the insurance provider. Federal programs such as Title X and Medicaid provide confidentiality protection for services rendered under these programs, but confidentiality with private insurance plans is subject to state laws. Providers may be able to refer patients to clinics that operate with Title X funding for confidential services. The SAHM has several resources that assess office confidentiality and explain billing for adolescent contraceptive services on its website: www.adolescenthealth.org/Clinical_Care_Resources/4032.htm.²⁴

References

1. Eaton DK, Kann L, Kinchen S, et al; Centers for Disease Control and Prevention (CDC). Youth risk behavior surveillance-United States, 2011. MMWR Surveill Summ. 2012;61(4):1-162.

2. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2010. Atlanta: US Department of Health and Human Services; 2011.

3. Krashin JW, Koumans EH, Bradshaw-Sydnor AC, et al. Trichomonas vaginalis prevalence, incidence, risk factors and antibiotic-resistance in an adolescent population. Sex Transm Dis. 2010;37(7):440-444.

4. Forhan SE, Gottlieb SL, Sternberg MR, et al. Prevalence of sexually transmitted infections among female adolescents aged 14 to 19 in the United States. Pediatrics. 2009;124(6):1505-1512. 

5. Huppert JS, Biro FM. Adolescents and sexually transmitted infections. In: Sanfilipo JS, Lara-Torre E, Edmonds K, Templeman C, eds. Clinical Pediatric and Adolescent Gynecology. New York: Informa Healthcare; 2009:263-276.

6. Committee opinion no. 460: the initial reproductive health visit. Obstet Gynecol. 2010;116(1):240-243.

7. Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR-12):1-110.

8. Cook RL, Hutchison SL, Østergaard L, Braithwaite RS, Ness RB. Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Ann Intern Med. 2005;142(11):914-925.

9. Shrier LA. Sexually transmitted infections: chlamydia, gonorrhea, pelvic inflammatory disease, and syphilis. In: Emans SJ, Laufer MR. Emans, Laufer, Goldstein’s Pediatric and Adolescent Gynecology.

6th ed. Philadelphia, PA: Wolters Kluwer/Lippincott, Williams & Wilkins; 2012:325-348. 

10. ACOG Committee on Practice Bulletins-Gynecology. ACOG practice bulletin: clinical management guidelines for obstetrician-gynecologists, number 57, November 2004. Gynecologic herpes simplex virus infections. Obstet Gynecol. 2004;104(5 pt 1):1111-1118.

11. American College of Obstetricians and Gynecologists. ACOG committee opinion no. 463: cervical cancer in adolescents: screening, evaluation, and management. Obstet Gynecol. 2010;116(2 pt 1):469-472.

12. Pattullo L, Griffeth S, Ding L, et al. Stepwise diagnosis of Trichomonas vaginalis infection in adolescent women. J Clin Microbiol. 2009;47(1):59-63.

13. Haggerty CL, Gottlieb SL, Taylor BD, Low N, Xu F, Ness RB. Risk of sequelae after Chlamydia trachomatis genital infection in women.

J Infect Dis. 2010;201(suppl 2):S134-S155.

14. Anschuetz GL, Asbel L, Spain CV, et al. Association between enhanced screening for Chlamydia trachomatis and Neisseria gonorrhoeae and reductions in sequelae among women. J Adolesc Health. 2012;51(1):80-85.

15. HIV prevention through early detection and treatment of other sexually transmitted diseases-United States. Recommendations of the Advisory Committee for HIV and STD prevention. MMWR Recomm Rep. 1998;47(RR-12):1-24.

16. Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm Infect. 1999;75(1):3-17.

17. Soper DE. Pelvic inflammatory disease. Obstet Gynecol. 2010;116(2 pt 1):419-428.

18. Straface G, Selmin A, Zanardo V, De Santis M, Ercoli A,

Scambia G. Herpes simplex virus infection in pregnancy. Infect Dis Obstet Gynecol. 2012;2012:385697.

19. De Santis M, De Luca C, Mappa I, et al. Syphilis infection during pregnancy: fetal risks and clinical management. Infect Dis Obstet Gynecol. 2012;2012:430585. 

20. Centers for Disease Control and Prevention. Condoms and STDs: Fact Sheet for Public Health Personnel. www.cdc.gov/condomeffectiveness/latex.htm. Updated March 6, 2013. Accessed March 14, 2013.

21. Joffe A. Adolescents and condom use. Am J Dis Child. 1993;147(7):746-754.

22. Kaplan DW, Feinstein RA, Fisher MM,et al; Committee on Adolescence. Condom use by adolescents. Pediatrics. 2001;107(6):1463-1469.

23. Higgins JA, Cooper AD. Dual use of condoms and contraceptives in the USA. Sex Health. 2012;9(1):73-80. 

24. Society for Adolescent Health and Medicine. Clinical Care Resources. www.adolescenthealth.org/Clinical_Care_Resources/4032.htm. Accessed March 14, 2013.

25. Centers for Disease Control and Prevention. A Guide to Taking a Sexual History. www.cdc.gov/std/treatment/SexualHistory.pdf. Accessed March 14, 2013.

26. Committee opinion no. 467: human papillomavirus vaccination. Obstet Gynecol. 2010;116(3):800-803.

27. Centers for Disease Control and Prevention (CDC). FDA licensure of bivalent human papillomavirus vaccine (HPV2, Cervarix) for use in females and updated HPV vaccination recommendations from the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2010;59(20):626-629. Erratum in: MMWR Morb Mortal Wkly Rep. 2010;59(36):1184.

28. Centers for Disease Control and Prevention. Expedited partner therapy in the management of sexually transmitted diseases. Atlanta, GA: US Department of Health and Human Services; 2006.

29. Centers for Disease Control and Prevention. Guidance on the use of expedited partner therapy in the treatment of gonorrhea. http://www.cdc.gov/std/ept/GC-Guidance.htm. Updated November 19, 2012. Accessed March 13, 2013.

30. Chacko MR, von Sternberg K, Velasquez MM, Wiemann CM,

Smith PB, DiClemente R. Young women’s perspective of the pros and cons to seeking screening for chlamydia and gonorrhea: an exploratory study. J Pediatr Adolesc Gynecol. 2008;21(4):187-193.

31. Ford CA, Millstein SG, Halpern-Felsher BL, Irwin CE Jr. Influence of physician confidentiality assurances on adolescents’ willingness to disclose information and seek future health care. A randomized controlled trial. JAMA. 1997;278(12):1029-1034. 

32. Guttmacher Institute. State policies in brief: minors’ access to STI services. http://www.guttmacher.org/statecenter/spibs/spib_MASS.pdf. Published March 1, 2013. Accessed March 14, 2013.

The North American Society for Pediatric and Adolescent Gynecology (NASPAG) is a nonprofit organization dedicated to educating healthcare professionals in pediatric and adolescent gynecology. For more information, visit www.naspag.org.