Highlights from the Australasian Sexual Health Conference Part One: STIs and Contraceptives

After a year almost devoid of sexual health (breast surgery and hepatology were as close as I could get to it at SCGH), I was very excited to finally be attending the 2016 Australasian Sexual Health Conference.

Here is some of the information that tickled me most:


Human Papilloma Virus

The human papilloma virus (HPV) is an extremely common STI that affects both men and women. Most sexually active people will become infected with HPV at least once in their lives, but fortunately most of these infections are spontaneously cleared without symptoms ever developing. There are approximately 100 types of HPV virus, some of these causing warts (e.g. HPV types 6 and 11), while others (e.g. HPV types 16 and 18) have the ability to cause cancer.

There were several talks at the conference about HPV, the majority of which came from Associate Professor Amber D’Souza from the Johns Hopkins Bloomberg School of Public Health. While it’s well known that HPV causes cervical cancer, the research Amber presented focused on oral and anal cancers, which (while contributing to less of the overall HPV cancer burden) are on the rise.

Probably the most interesting piece of information to come from Amber’s talks can be summarised as follows: men who perform cunnilingus are at increased risk of oral HPV infection (and therefore oral cancer) compared to both women who perform cunnilingus and women/men who perform fellatio. This is likely due in part to men having a decreased immune response to HPV, which is why similar trends aren’t seen in women who have oral sex with other women.

Amber’s research was recently discussed on an episode of The Science Show, the link to which can be found here.

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Don’t forget that there is a fabulous vaccine for HPV! Image from The Guardian.

 


National Cervical Screening Program

On the topic of HPV, from May 1 2017 cervical cancer screening by Pap smear is out, and HPV testing is in. The new program is just as safe, more effective and involves less frequent testing (hooray!)

Here is a summary of the changes:

  • Just like a pap smear, the cervix will be visualised with a speculum and cervical cells collectedwith a brush. However, instead of these cells being transferred onto a slide, they will be placed into a liquid medium.
  • The new test looks for HPV DNA with partial genotyping to see if the HPV identified is ‘oncogenic’ (cancer causing).
  • If the HPV DNA test is positive a liquid cytology test will take place. This test is done on the original specimen and allows the cervical cells to be examined for pre-cancerous or cancerous changes.
  • Screening will start at age 25 and finish at 74, with a screening interval of five years unless HPV detected (or three years for immunocompromised women).
  • There is a self-sampling option for never or under screened women aged over 30 who are late for screening by two years.
  • There will be a traffic light system for results:
    • Low risk (green)
      • No HPV DNA detected.
      • Repeat test in five years.
    • Intermediate risk (yellow)
      • HPV detected (not 16 or 18) with either no or low-grade cell changes.
      • Repeat test in 12 months.
    • High risk (red)
      • HPV 16 or 18 detected OR HPV detected (not 16 or 18) but high-grade cell changes present.
      • Colposcopy referral required.

This picture pretty much summarises the above information:

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The proposed cervical screening pathway. Image from NPS MedicineWise.

 


LARCs

Long acting reversible contraceptives (or LARCs) are brilliant. They have the highest satisfaction and continuation rates of any contraceptive method, and are even better at preventing pregnancy then having your tubes tied!

One of the topics covered at the conference was the myths surrounding IUDs, which include them not being appropriate for nulliparous women and increasing infection risks.

Let’s debunk these now:

  • IUDs are a brilliant option for women of any age.
  • The rate of IUDs causing pelvic inflammatory disease is very low (about 1.6 cases per 1000 women years of use). There is a small increased risk of PID post insertion of the IUD, but this goes back down to the level of a non-IUD user after twenty days.

Other barriers to LARC use discussed at the conference include:

  • Lack of patient knowledge of benefits
  • Misconceptions about side effects
  • Lack of knowledge from GPs
  • Lack of insertion skills by GPs
  • Long waiting times at LARC insertion clinics
  • Initial costs (although they are cheaper in the long run)

And here are some other interesting facts about LARCs:

  • You can have an IUD inserted at the time of caesarian section.
  • You can have an IUD inserted straight after a surgical termination, or following a medical termination once it has been confirmed that you are no longer pregnant.
  • You can have an Implanon inserted directly after a surgical or medical termination (giving mifepristone and progesterone together has shown no decrease in the efficacy of medical termination).
  • Copper IUDs are the most effective form of emergency contraception.

You can read more about how obsessed I am with LARCs in my piece for Eat More Cake here.

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LARCs are amazing. Get one. Image from LARC First.

Mycoplasma genitalium: the STI you’ve never heard of

It was great to see so many different sessions about Mycoplasma genitalium at the conference, as I for one knew virtually nothing about it.

M. genitalium is a recently identified STI that is estimated to affect about 1-3% of the population. Its symptoms are very similar to those chlamydia and include painful urination, urethral or cervical discharge, pelvic pain, testicular pain, and abnormal bleeding in women.

Sample collection involves a first void urine for men, a high vaginal or cervical swab for women, and an anal swab if the person has participated in anal sex. Diagnosis is by nucleic acid amplification test (where the DNA of the pathogen is detected and amplified), although testing has not been widely available due to the lack of commercial assays (this is likely to change in 2016/2017 though).

The current treatment regime is 1 g of azithromycin (the same treatment as chlamydia) or moxifloxacin when the organism is resistant to macrolide antibiotics. For those organisms with dual macrolide and fluoroquinolone resistance, pristinamycin has been trialled.

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M. genitalium is much prettier under the microscope. Image from HNGN.

Ulipristal to the rescue!

Prior to 2016 there were only two emergency contraceptive types available: the levonorgestrel pill (LNG) and the copper IUD. However, as of April 2016, a new tablet – ulipristal acetate (UPA) – became available on the market.

So what do you need to know about UPA?

  • It’s a single dose 30 mg tablet that has been used effectively all over the world before approval in Australia.
  • It is a selective progesterone receptor modulator that, like LPG, works by preventing or delaying ovulation. Unlike LNG however, UPA can do this even after the LH surge has begun, making it far more effective.
  • Unlike the LNG pill, which is licensed for use up to 72 h post- sex, UPA is licensed for use up to 120 hours.
  • There are very few contradictions to UPA and there is no evidence of harm in pregnancy. However, for those women using progesterone-containing contraceptives (such as the combined pill, mini pill, Mirena or Implanon), contraceptives use should be delayed for five days after taking UPA (progesterone can reduce the efficacy of UPA).
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Ulipristal acetate (brand name ellaOne) is on the market and ready for women Australia-wide! Image from ellaOne.

Next up: porn and abortion!

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