Taking a sexual history without judgement
- Normalise it: 'I ask everyone about sexual health.' Then partners (number, gender), practices (which sites are exposed: genital, oral, anal), protection, past infections, and pregnancy intention. The five Ps are a checklist, not a script.
- Ask about symptoms the patient may not volunteer: discharge, dysuria, intermenstrual or postcoital bleeding, pelvic pain, dyspareunia, sores, rashes, and in partners.
- Ask about consent and safety in the relationship. Coercion, violence and reproductive coercion (sabotaged contraception) are common and rarely disclosed unasked.
- Confidentiality, including for adolescents, within the limits the law sets where you practise; say what those limits are.
Who to test and how
- Test all exposed sites. A pharyngeal gonorrhoea infection is usually asymptomatic and is missed by a genital test alone.
- Point-of-care and syndromic management exist where laboratories do not; test-of-cure is needed for pharyngeal gonorrhoea and in pregnancy.
| Infection | Test | Who, and how often |
|---|---|---|
| Chlamydia and gonorrhoea | NAAT on a self-taken or clinician-taken vaginal swab (first-void urine is acceptable but less sensitive); pharyngeal and rectal swabs by exposure | All sexually active women under 25 yearly, and older women with new or multiple partners; retest 3 months after treatment for reinfection |
| Syphilis | Serology (treponemal screen with a non-treponemal titre) | By risk, in pregnancy at booking (and again later where prevalence is high), and whenever another STI is found |
| HIV | Fourth-generation antigen and antibody test | Everyone at least once; yearly or more with ongoing risk; in every pregnancy |
| Hepatitis B and C | HBsAg (and anti-HBs for immunity), anti-HCV | Pregnancy, risk, and once for hepatitis C in adults where recommended |
| Trichomonas | NAAT (microscopy is insensitive) | Symptoms, or screening in higher-prevalence settings |
A vaginal swab the patient takes herself is as sensitive as a clinician's for chlamydia and gonorrhoea NAAT, and many prefer it.
Treatment and the partner
- Expedited partner therapy (a prescription for the partner without a visit) is lawful in many places for chlamydia and gonorrhoea and reduces reinfection.
- Pelvic inflammatory disease is the reason the threshold to treat is low: see the discharge and PID module.
- Prevention: HPV vaccination (ideally at 9 to 14, catch-up to 26 and by shared decision to 45), hepatitis B vaccination, condoms, and HIV pre-exposure prophylaxis (PrEP) for women at substantial risk, with the same three-monthly testing as any PrEP user.
| Infection | First-line treatment (CDC 2021) | Partners and follow-up |
|---|---|---|
| Chlamydia | Doxycycline 100 mg twice daily for 7 days (azithromycin 1 g single dose in pregnancy or if adherence is doubtful) | Treat partners of the last 60 days; abstain 7 days; retest at 3 months |
| Gonorrhoea | Ceftriaxone 500 mg intramuscular once (1 g if 150 kg or more); add doxycycline if chlamydia not excluded | Treat partners; test of cure for pharyngeal infection; resistance is rising, so follow local guidance |
| Syphilis (early) | Benzathine penicillin G 2.4 million units intramuscular once (three weekly doses for late latent or unknown duration) | Titres at 6 and 12 months; partners by stage; in pregnancy penicillin is the only treatment, desensitise if allergic |
| Trichomonas | Metronidazole 500 mg twice daily for 7 days (women) | Treat partners; retest within 3 months |
| Genital herpes, first episode | Aciclovir or valaciclovir for 7 to 10 days | Counsel on shedding, suppression, and disclosure; matters in late pregnancy |
Check
A 22-year-old asks for 'a check-up' after a new partner. She has no symptoms. What is the best chlamydia and gonorrhoea test?
Her test is positive for chlamydia. She is not pregnant. Which is first-line?
On the modelCervixVaginaFallopian tubes