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.