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Chlamydia is one of the most common sexually transmitted infections (STIs) worldwide. In Ontario alone, there were nearly 42,000 cases of this “silent” bacterial infection reported last year.
But these numbers don’t tell the whole story.
Chlamydia often doesn’t cause symptoms, so it’s important to screen for infection. And if you develop symptoms — such as discharge, burning when you urinate or pelvic pain — it may not happen for weeks after exposure. For women, untreated chlamydia can cause serious health problems such as infertility, pelvic inflammatory disease and ectopic pregnancy; in men, health problems include urethritis, epididimitis and infertility. Most worrying is that infection rates are rising.
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Years ago, a swab test from inside the vagina in women or urethra in men was the main way to screen for STIs such as chlamydia and gonorrhea. But that’s no longer the case. A simple urine test can now detect these two common STIs. As you can imagine, a urine test is much less invasive and unpleasant than the swab test.
Pap tests, which screen cells from the cervix for changes linked to cervical cancer, used to offer an annual opportunity for doctors to screen for infections such as chlamydia by taking separate samples from the vagina while the Pap test was done.
The guidelines for cervical cancer screening changed in 2012 and we now recommend women have a Pap test every three years after age 21 if they have been sexually active.
As a family doctor, I wondered if less frequent Pap tests resulted in reduced testing for chlamydia and fewer patients being diagnosed.
Recently, I was part of a research team from Mount Sinai Hospital’s Academic Family Health Team, Public Health Ontario and the Institute for Clinical Evaluative Sciences that looked at this question.
As an unintended consequence of women needing less-frequent Pap tests, thousands of women haven’t been screened for chlamydia, resulting in fewer cases being diagnosed. And because most women are unaware they are infected, these women miss the opportunity for treatment — and pass the STI along to their partners. Furthermore, we found that teenage girls, who no longer require Pap tests until after age 21, have had the largest drop in chlamydia testing.
This change in practice opens the door to find new opportunities for STI testing. Primary care providers like me need to be more proactive and look for other chances to offer screening and discuss safe sex practices.
One idea is to allow doctors’ offices to leave urine test containers out, allowing people who want to be screened to discreetly pick up a container during their appointment.
Another idea is to add reminders to electronic medical records to prompt physicians to ask patients if they’d like to be screened or whether they have questions.
There’s a misconception that less-frequent Pap testing is a cost-cutting measure, but that’s not the case. There’s good evidence to support scaling back Pap tests to every three years if the results are normal. More-frequent tests may detect changes that prompt unnecessary followup treatments for things that will ultimately resolve on their own. Less-frequent testing reduces this risk.
In my clinic, patients often ask me how to protect themselves against STIs. And the questions don’t just come from young adults.
Older people re-entering the dating world after their long-term relationships end also want to know how to be safe as they become involved in new relationships. Our understanding of STIs and safer sex has evolved since baby boomers were students in sexual education classes.
Online dating and dating apps have made it easier than ever to connect with new partners. And these often casual encounters can put you at additional risk for contracting an STI.
Earlier this year, research showed middle-aged men and women who are single, divorced or widowed often skip condoms. And between 2003 and 2012, there was a 154-per-cent increase in the number of chlamydia infections in Canadians between the ages of 40 and 59.
No matter your age, if you have a new partner, talk to them about getting tested and practising safer sex.
And the conversations shouldn’t end there.
If you’re sexually active and under the age of 25, or an older woman or man with a new sex partner, don’t be shy to talk to your doctor about being tested.
Your own risk factors will determine how often you might need to be screened for STIs, which may include chlamydia, gonorrhea, HIV, Hepatitis B and C, HPV and syphilis.
For women, the bottom line is that they need to speak to their doctors about STI screening — whether or not a Pap test is due.
Dr. Michelle Naimer is an associate professor in the Faculty of Medicine’s Department of Family and Community Medicine at the University of Toronto. She is also a family physician and clinical director of the Mount Sinai Academic Family Health Team. Doctors’ Notes is a weekly column by members of the U of T Faculty of Medicine. Email firstname.lastname@example.org .