Everything you want to ask about STIs but maybe haven't yet

In Canada, rates of syphilis, gonorrhea and chlamydia are on the rise, and have been for the last decade. In July, Alberta's syphilis rates were the highest level the province had seen since 1948.

There are many factors playing a role in this increase, but a lack of education is believed to be one of the big ones. So we jumped at the opportunity to ask ob-gyn and women's health myth-buster Dr. Jen Gunter all our nagging questions about sexually transmitted infections (STIs). She sent us these very detailed and informative answers — and what we learned may surprise you. 

How do you know if you have an STI, and who should you consult about it?

Most people don't know when they have a sexually transmitted infection, as they typically produce few or no symptoms, especially for women. That's why screening (testing when you have no symptoms) is important, as well as seeing your doctor for an evaluation if you feel you may have been exposed to an STI. 

When and how often should you get tested?

Some testing is part of routine screening, meaning a person is tested whether they have symptoms or not. This is done based on age and other risk factors.

The basic recommendations for screening for STIs include the following: 

• Everyone between the ages of 13 and 64 should be tested at least once for HIV. People with more risk factors may need to be tested every year, or even every 3-6 months. Some risk factors for HIV include having multiple partners, engaging in unsafe sex practices and sharing injection drug equipment. 

• Women who are younger than 25 years old and who are sexually active should be tested for gonorrhea and chlamydia every year. 

• Any person with a new partner or multiple sex partners or who feels they may have been exposed to an STI should be tested for gonorrhea, chlamydia and syphilis. HIV testing is almost always recommended as well. 

• Pregnant women should be tested for syphilis, HIV and hepatitis B early in their pregnancy. Most providers also recommend testing for chlamydia and gonorrhea starting early in pregnancy. In higher-risk situations, this testing may be repeated. Repeat testing for syphilis in the third trimester and at delivery is often recommended as we're seeing an increase in congenital syphilis, and early treatment is very beneficial.

• Any person with a cervix who is 21 years of age and older should start cervical cancer screening. As cervical cancer is almost exclusively due to the human papilloma virus (HPV), this could also be considered a form of STI testing. 

What is the testing like? Is it invasive?

A blood sample is needed to test for syphilis, hepatitis B and HIV, however, there are some HIV tests using a swab from the mouth.

Testing for gonorrhea and chlamydia involves a urine sample. More invasive testing — a swab in the cervix (a speculum must be inserted vaginally to collect the specimen) or a swab inserted in the penis — is another option, although this can almost always be avoided. A swab from the throat or rectum may be needed to test for gonorrhea or chlamydia in those locations. 

Other STIs require different testing. For example, trichomonas testing for women is performed with a vaginal swab, although this can often be done without a speculum. [Trichomoniasis is a common STI caused by infection with a protozoan parasite called Trichomonas vaginalis.] Herpes is diagnosed with a swab from the ulcer. We do not recommend testing for human papilloma virus outside of cervical cancer screening for women. 

Although STIs are frequently asymptomatic, what are some symptoms you should watch out for in yourself or your partner?

Some common symptoms of STIs include visible genital warts, a painful or painless sore, vaginal discharge for women and penile discharge for men. Bleeding after sex can also be a symptom of chlamydia for women.  

Gonorrhea and chlamydia for women are almost always asymptomatic, although trichomoniasis can produce a heavy vaginal discharge and chlamydia can cause vaginal bleeding after sex. 

Men may get a penile discharge with gonorrhea or chlamydia, but most men have no symptoms.

Genital herpes can cause an ulcer or an itch, although most people who are positive for herpes don't know it because they have never had an outbreak. Even when women do get a sore, if it's in their vagina or on their cervix, they may have no symptoms and therefore be unaware they even had an outbreak. 

Genital warts, caused by HPV, have a cauliflower-like appearance. They are usually skin-coloured or whitish-grey and can appear on the vulva, rectum, penis and scrotum. Women can also get genital warts in the vagina and on the cervix. 

Every STI can be transmitted when there are no symptoms.

What is a 'bacterial STI'? Is it easier to treat?

There are two bacterial STIs, chlamydia and gonorrhea, and they are both treated with antibiotics. Chlamydia is treated fairly easily with a single dose of an antibiotic called azithromycin, although sometimes a week of an antibiotic called doxycycline is indicated. 

Gonorrhea is much harder to treat as we have a growing problem with antibiotic resistance,  meaning gonorrhea has evolved mechanisms to render many antibiotics ineffective. Since the 1930s, gonorrhea has defeated multiple classes of antibiotics. Currently, treatment for gonorrhea requires taking two antibiotics, one by injection and one by mouth, on the same day. 

As resistance patterns for gonorrhea can vary depending on where you live, it's important that your doctor follow the local recommendations for therapy and that you take any antibiotics exactly as prescribed.  

Aside from antibiotic resistance, what else is playing a role in higher rates of gonorrhea?

There are many other factors contributing to the increase in gonorrhea (rates more than doubled in Canada between 2010 and 2016) including the following:

• Lack of screening for people at risk. 

• Failure to screen the mouth and rectum (in these sites, gonorrhea is even more likely to have no symptoms). 

• Gonorrhea acquired during travel. Travel is associated with sexual risk-taking, and it's been estimated that 20 to 34 per cent of international travelers have casual sex while abroad. They may be in contact with populations that have a high rate of gonorrhea or other STIs. People exposed to gonorrhea while traveling may be at greater risk of being exposed to a resistant strain.

• Not receiving the correct therapy. Again, gonorrhea requires that doctors give two antibiotics, and guidelines can change based on region. Unfortunately, not everyone is given the right antibiotics.

People may be aware of the risks of HIV, but should we take other STIs equally seriously?

All STIs need to be taken seriously, but what that means depends on the STI. For example, doctors are concerned about herpes because having a sore can increase your risk of catching HIV if exposed, and herpes outbreaks at the end of pregnancy can cause a serious infection for newborn babies. 

The human papilloma virus can cause cancer. Gonorrhea and chlamydia can cause serious infections for women and lead to infertility. These infections can also cause serious complications in pregnancy as well as for the newborn. Syphilis can lead to serious neurological damage and cause serious health issues for a developing fetus if acquired during pregnancy. HIV can cause serious health problems and death if untreated. 

Early, appropriate treatment reduces the complications of almost all STIs. And screening for HPV (as part of cervical cancer screening) can save lives by allowing treatment of pre-cancers so cancer doesn't develop. 

Research points to declining condom use as a factor in the rise of STIs. What's behind this?

Alcohol use is associated with reduced use of condoms. Also, the increasing use of long-acting reversible contraception (such as IUDs and implants) are playing a role. This doesn't mean women with long-acting reversible contraception are engaging in riskier sexual behaviour, but rather that they switch from condoms to this option, hence losing the protection condoms afforded.

People who are sexually active after long periods of monogamy may have less familiarity with condoms. Lack of access to early, quality sex education is also a factor.  

Dating apps may also change how people engage sexually. This is really unstudied, but there is some data that suggests sexting outside of a committed relationship may be a marker for riskier sexual behaviour.

Early access to pornography without the benefit of having comprehensive sex education may also play a role. Male condoms are only used three per cent of the time in heterosexual pornography, and dental dams are almost never used. People with less sexual experience or less knowledge about safe sex may be less inclined to use condoms after viewing pornography versus those who have already used condoms or who received quality sex education.

STI rates are rising steeply among older populations (one study found that gonorrhea rates among 30- to 39- year-olds went up by over 128 per cent between 2010 to 2015, while another reported a 51 per cent increase in chlamydia rates for Canadians over 40 during that same period). What's behind this?

Many factors are likely involved in the rising STI rates for people over the age of 30, including:

• People being outside the age range for screening recommendations (so the idea of getting tested isn't discussed with them).

• People not thinking of themselves as being at risk.

• Providers not thinking their patients are at risk and missing opportunities to discuss both testing and safe sex practices. 

• Entering the dating pool after a long period of monogamy — so post-divorce or after the death of a partner — and not being prepared for discussions about condoms and safe sex practices with partners, thus increasing the risk of exposure.  

• Difficulties using male condoms due to erectile dysfunction (more of an issue for men over the age of 40).

• The ability of men and women to have more sex at an older age, given erectile dysfunction medications for men and vaginal estrogen for women. 

This interview has been edited and condensed.

Eva Voinigescu is a freelance journalist and producer. She writes about health and science, careers, and culture.