Rates of sexually transmitted infections continue to rise, disproportionately affecting young people, as do pregnancy rates among teens of color. So providing good care is crucial – but talking to young patients about sex isn’t easy. Adolescent medicine specialist Javay Ross, MD, discusses key questions and how to ask them; offers time-saving tips on taking histories, screening appropriately and prescribing wisely; and explains how to guide patients to their best birth control options.
so happy to be here. Um, next slide please. So today we're going to do a little bit of talking about stds, there's been some recent updates and STD treatment and screening recommendations from the CDC. So we'll dig into that a little bit and then talk about some adolescent con reception. Um, I have no disclosures to reveal for this presentation. It is fully voluntary and I'm not getting paid by nobody. Just so you know, next life. And the objectives for today is we'll talk a little bit about how to take a good sexual history. Um especially considering a lot of um you know what, what we're seeing now is push a real move, a movement really to be inclusive in as many ways as possible. And so we'll try and dig into how to take a gender inclusive, culturally aware sexual history. Um, I want, I pray that you will be able to name at least one S. T. I. Treatment update. Um, that has come out of the new CDC guidelines and then hopefully you'll be able to identify three maybe more contraceptive options for adolescents by the end of this talk. Next life. So I have to give a big shout out to doctor in a park shi a couple of weeks ago gave a phenomenal grand rounds at our institution in Oakland and she basically cracked open the S. T. I. Treatment guideline updates from the CDC and she said feel free to use whatever slide you want for any presentations coming up. And I was like, oh thank you Lord. So if you see you can tap next, if you see this California Prevention Training center emblem on any slide, which will be the vast majority of the slide you see? No, that that came from dr Anna Parks talk um and she gave my she gave her permission for me to use it today. Thank you next black. So we're gonna start with a little case came across this case in my my research and I was like this is still relevant um because I feel like as a PCP I see this is pretty often. Um so the case is Angela. Angela is a 16 year old cis gender female who has been your patients since she was little. So since she was a baby um and you haven't seen her in a few years and that is like perfectly fitting what we're seeing today, especially with Covid and you know, not having access to our patients like we typically do, but I feel like this actually happens just because in adolescents they don't go to the doctor like they should. But you haven't seen another couple of years you want to come in for sports, physical. And so I have a couple of rhetorical questions for the group today to ponder as we go through some of this one is what portions of the visit will you need to spend more time on today than you would have, let's say a couple of years ago when you saw her and I think um we'll get into that. And then another question is what questions do you need to make sure you ask her today? So, you know, from the pc ps perspective, you take a step back and you're like a 16 year old here for sports physical. I'm supposed to see 12, 15 patients in this half clinic day. This is gonna take up a chunk of my time, how I'm gonna make this happen. And this is how I think um as I'm managing my own clinic panel. Um so I think it's good to have some key things to dig into um in that day and then think about things you want to maybe bring them back for next flag. So when you get into, you know, taking your sexual history, I think it's important to you have to kind of be aware of the intersectionality, intersection S. E. S. S. E. S. C. Intersectionality of all of the things that contribute to sexual health. So you have your sexual orientation, your sexual attraction. Who you know, what's gender are you attracted to by a lot, your biological sex? What were you born? And then what do you identify? They're all different pieces of the paradigm that create sexual health. So, I think that's important to kind of like build that framework before you kind of dig into the questioning. So you have a good understanding next life and I really love um this this concept of um an inclusive spectrum. This is this was actually really helpful for me to get an um more solidified kind of concrete idea of like where sex and gender kind of meat and where they're different and where people fall in that spectrum because you will come across adolescents who, you know, maybe in one visit, identify when one way, and then when you see them a few months later, they feel they like they identify in a different way. And so I I think it's important to remember that it's a spectrum that is ever changing and that's normal and it's healthy and for us to be aware and affirming and um uplift that for them next way. So I think this has been helpful for us, at least in our school based clinics, um when we get our registration staff involved in like the first steps and that kind of takes a little bit off of your plate in the visit as well to kind of already know before you go into the room how your patient is identifying that day. So, um there are often times when we get patients who come into our clinic who, you know, have a certain name on the chart, and when they come in we'll ask for their preferred name and it will be something different. Um and we also ask for the preferred pronouns and so that that is identified. So when you go into the room, you go into the room kind of already one step ahead and I think that takes a little bit of of um of that, you know, need to dig into that off of your plate and just makes it a little more general, Izabal. I think it's also helpful to remember that sexual orientation and gender identity are really important for medical care. So, you know, if you have a patient who identifies as transgender knowing what their sex of was at birth and then what they identify with now can be very helpful in guiding how you how and what you offer for them for testing for example. Um and in remembering that gender identity is independent of sexual orientation. And so remembering that there's that spectrum, um even though there's intersectionality, there is a spectrum where you know, things can be, you know different along the spectrum next life. So the heads the ever handy heads assessment actually think, I mean the heads was developed in the 70s. Um and I actually think the heads is a really, really awesome um and useful tool to dig into psycho social history and I think that's part of the reason why it's not changed and you know, the past 50 years basically is because it is really helpful and useful and is patient centred. Um I think one area where we can build on evolving the assessment is considering using a strength based heads approach. Um and it's something that I try work with. Um I'm the medical director at juvenile the Alameda County juvenile justice center. And so I do a heads assessment I would say at least I'm doing them like 5 to 6 times a week. And so I've noticed that if I lead off with something that is a little bit empowering and and strength building, tell me something you're good at what you really love to do, What's your favorite you know thing to do when when you're like um if you're feeling down even if you can start with something that's like you know if they seem in J. J. C. They're often you know not in the best mood. So when you're when you're feeling down, what do you usually do to kind of build yourself back up? How do you feel your cup wellness questions questions we should be answering but it's something that strength based that gets them to identify things that they are good at and capable of. I think it is a helpful approach um next life. So um you know there are different ways to go about executing the heads or the shreds if you want to start with the strength based questions. Um So considering asking the less sensitive questions first um might kind of just like you know set the stage and and be a soft open and and create a more enriching environment. You can also, I mean for a time saving kind of tip is we use what's called a staying healthy assessment in our clinic that asks a fair amount of questions that are on the heads just as a yes or no um kind of check box and I find that most of our teams are are pretty, I would say for the most part they're pretty good at answering honestly on those questionnaires. I think it's important to provide and you'll see this kind of like woven in the next couple of slides, a level of confidentiality and some degree of privacy. So they do feel comfortable being able to answer honestly. But if you can use a questionnaire in the waiting room, it gets some time out of the room that you can spend on other more important things and then um it's a it's a pretty good tool to use that can be accurate. Um, so you know, and then if you get red flags that come up, of course this just happened to me a couple of weeks ago, there was some sexual abuse history revealed on one of the questionnaires, you have to make sure you have the resources to be able to follow up those things. So having a connection to social work, being able to reach out cps if you have to but also making sure that the young young person and the patient you're working with knows that you know with certain questions when they answer a certain way there there is that obligation, um, you know, to report certain things. Um So as as as mentioned the time limitations. Make a true heads assessment of limitation and it makes it more difficult, but you know, there are ways that you can try and squeak out um trying to make it more efficient providing that confidentiality. I try my best to remember to start off a conversation about psychosocial history with this is a confidential space. I want you to feel confident that I will keep this private. But if you tell me something that makes me concerned about your safety or the safety of someone else or if you're going to hurt someone. And I say that so routinely that a lot of my patients are like, I know if I'm gonna hurt somebody like they're over it, they've got it. Um But I think it's really important to just make sure you set the stage with that talking in terms of adolescent want to understand. I think that's important too. So um I will say things at J. J. C. In particular. Are you sexually active in? And there are a good cohort of patients who are like, what do you mean by that? Like they don't know what that means. Um So I've learned a little to reframe that and say, have you ever had sex before? Um and I find that they received that a little a little easier. Um and that can be a way to that they can understand it better. Um I talk a lot um Unfortunately that's that's one of the areas that I've been working on with how I provide medical care is too be a little bit more culturally humble and be quiet ask a question. Try and make it an open ended question and let them work it out and listen. And so I think that can be really helpful in their heads when you have the time. Um As well remembering it's not a converse it's a conversation, it's not an interrogation. And we're like we're digging into their like most private private parts of their lives. Um And for it to just be like question after question without like taking a lead from a question. Um I think it's important so I'll just say this and then we can go on because I could spend forever on the slide. But one thing I like to do and that I see kind of like softens their heads a little bit especially with a lot of my male patients at J. C. Is um sinks. If they if they were talking about diet for example and they say oh yeah I eat this and that and I'll say oh do you eat home cooked food? Oh yeah I do most of the time do you ever cook and then like I see a light go off. Yeah I cook or what do you could tell me what you cook, you're not a fried chicken. You know how to make tacos like what are you doing? And then like it just really kind of softens the blow of the now, what are you doing? Um when you by yourself with your partner next flag. Um So a couple more tips. So you know, we've already kind of established this, but I just want to emphasize that adolescents should have a sexual history at all preventative care visits. Um and that's like even if you have a more, you know, complicated patient who you're seeing maybe, you know, two or three times a year and not annually for not necessarily a preventative care, but like let's say they come for their second HPV. It might be good to just check in because um just like I said that spectrum of identity sexual health can change the risks can change within a matter of weeks to months, months. So it's important to reassess where they are and reassess if they need, you know, more support around certain screening or you know, options to use and and then we talked about confidentiality. Um I thought this was great. I came across this and I don't often do this because the workflow and art and some of our clinics when it happens is for patients to get changed into a gown after they've gotten their vitals before the doctor comes in the room. Um but I do find that patients are a little more, he's talkative and we're both about more sensitive subjects when they're in there close. Um And so what I tried to do when I can is have them talk to me about their head to do their heads assessment and then leave for a few minutes and then pop back in um after they've changed um to do the exam and the rest of the visit. And then we kind of mentioned assessing development structure. The question appropriately avoid assumptions of heterosexuality. This is a tough one for me at J. J. C. Because if I ask um you know, have you uh you know, are you sexually active or have you ever had sex? Are you attracted to males or females are both As soon as I put out the option of them being attracted to you? Someone of the same sex. It's just like, oh, the homophobia is intense. So I mean, you don't want you want to avoid assumptions heterosexuality. But then like I feel like once I do that, sometimes it shuts them down. So it's just and I've asked is in preparation for this talk. Actually had to ask like, what's the best way to ask that without you getting offended? And I really think it's just like people we just have to keep doing it. Honestly. That's how I feel because there's no way to break the chains of homophobia and discrimination until we normalize that it's OK it's ok for somebody to be attracted to somebody who's your same gender and sex And that's that's just how life is in. We all need to get used to it. So I don't think we need to change that anyways. Next flag. So sexual history, the five piece. So the CBC actually put out this year, I think they've been doing it. But this year they updated um a guy to taking a sexual history and they refer to the five p. Method. And it's basically what we've been talking about but a quick way to remember it. So you want to get an assessment for the patients, partners with the partners gender is. And then what practices they use, what sexual practices they use with that partner? Are they using any protection for stds? And then have they ever had any past S. T. I. S. And then the addition of pregnancy intention. So that's something that um I come across fairly commonly is um You know I guess you can add that you can't assume someone is heterosexual. You also can't assume that a teenager does not want to get pregnant. And so I think getting some um information about intentionality is important, especially if you since you're getting resistance to like the contraception conversation. Um Just saying, well, are you interested like is this something that you feel like you're ready for right now? And getting a sense of like are you intending to get pregnant because if that's the case. Um Not that I necessarily want to blatantly discourage that. But I want to talk about it some more and do some motivational interviewing around it and maybe, um, in the meantime put you on a prenatal vitamin and start to get a sense of like who your support system in is in your resources because if things do happen, I wanted to be in the best way possible. But you know, just working through that a little bit and not assuming everyone who's a teenager doesn't want to get pregnant next time. So I'm being trauma informed I think is also really important and is also a fine line to walk. Um, because this means that if you're sensing that when you're digging into the sexual history, you're getting a little bit of resistance or that the patient is seems to be uncomfortable. I think it's important to read that and to pause because we don't, I mean, you know, it is a good history to document and it's important for documentation purposes and for medical decision making. But it also is you have to meet that patient where they are. And if you're sensing that there's something that's triggering, then maybe it's best to just not ask all the details in that moment And then just say, hey, you know, we want to keep you safe and healthy and I don't want you to feel uncomfortable at in any parts of this process. So these are the things that I can offer you today. These are the tests, these are the different types of you know contraception I can offer you today and you let me know what you might be interested in. So sometimes I think that could help. I think it's a fine line though because you know if there's something that's triggering past trauma and it hasn't been managing, it hasn't been addressed and it's continuing worst case scenario then we you know are obligated to do something about that. So I think you have to take it on a case by case basis but being trauma informed just in general when you're taking a sexual history I think it's just important to be cognizant of next life. So back to our girl Angela. So she tells you that in fact she does she is in a relationship, she's had a boyfriend that they've been dating for about six months. Um They had their first sexual encounter about a month ago and they've been inconsistently using condoms and she is not on any other form of birth control. So the risk rhetorical questions I'm going to throw out today that now that she has graciously agreed to do some routine STD testing is what should you send and then what birth control options could we offer her today or maybe at our next visit? But do we want to wait until our next visit next slide. So every um I guess update every annual update about S. T. I. S. In this country is like worse than the next year. So like 2018 was worse was the worst year on record, like it's just getting worse. Um And it's so unfortunate because that means antibiotic stewardship is getting worse. Um And that's the biggest thing to take from this. But in 2019 it was the worst year on record for reported S. T. I. S. Um 1.8 million cases of commedia this blows my mind. 56% increase since 2015 in cases of gonorrhea. Oh my goodness. And then syphilis and congenital syphilis is just like out of control right now. And I mean I've seen cases in my clinic of babies with congenital syphilis and that's something I hadn't seen um during my training honestly and in the past 10 years so frequently and I've seen a couple of cases I'm in the past year or so. Um So this is real, I'm not going to really get into the congenital syphilis. I'm not gonna get into syphilis at all for this talk because all the updates are in regards to pregnancy management of syphilis. And I thought that was kind of out of the scope of what we're getting into today. But the CDC has a bunch of awesome information on the changes for syphilis management next slide. Um So this just refers to what I've been talking about. So the CDC released updated testing and treatment guidelines this past summer. So in july so this is fresh hot off the presses and then more to come about HIV prep. Um and but in the past 1-2 years I would say the access the accessibility to prep has improved significantly. We have a health educator here in R. F. Q. H. C. Who has broken down some barriers for prep um for our patients and our patients have been like responding to it. People are taking it. Um So more to come on prep soon enough. Next slide I'm sorry? Okay so this is the quick and dirty version of the updates. So there's updates on the treatment for gonorrhea, trichomoniasis, chlamydia and P. I. D. And then there's some changes in how to test um and manage mycoplasma genitalia um which is kind of like this new to us um S. C. I. That we're seeing in males with persistent discharge. Um And then there's some recommendations for HSV testing and then like I mentioned the syphilis and pregnancy um updates. Next lack. So I just wanted to mention Dr Park had this in her presentation and I thought that was important for us to kind of just make sure everyone was on the same page. Um with the fact that You have to be 12 years old at least to consent for STD services in the state of California. And that includes not only testing and treatment but it also includes immunization of sexually transmitted um from sexually transmitted diseases which are hep B and HPV. So a 12 year old could consent for their own HPV vaccine if that was something that presented as an opportunity for you and your clinic next slide. So dr Park got into um a lot of details around how what screening to offer um based off of a person's gender identity and their sexual partners. Um I'm not gonna go into as much detail because you can easily reference this on the C. D. C. S. T. I. Screening guidelines online. Um But I did want to point out that hepatitis C screening has been added um as a recommendation to the routine STD testing for patients who are sexually active in 18 and over. So I started adding this. So what I do is I send an HIV test. Our pr this is not on the C. D. C. Recommendation just so you know but this is what our group does in Oakland um for a higher risk patient population. Um So we do a C. Excuse me an HIV and a RPR serum testing blood tests every six months we like to have one on file every six months. And of course if they had something happened that was a high risk situation or if the patient is requesting it or they have new partner will do it more frequently than that but at least every six months for those two. Now I'm adding a hep C. Um at least once in life. Um for my 18 and older patients. And then we do gonorrhea and chlamydia Screening probably every 3-6 months. But we'll talk about this more on another slide. So next live. Thank you. Um Oh this is the slide. So uh this uh kind of breaks down based on gender and sexual um orientation, what to send. Um And the update is that in adolescence they recommend now to consider sending rectal and differential screening based on the reported sexual behavior. Um So that was not previously recommended and it came with this update. Um And I think that that is something to do with what we're seeing with the resistance patterns and infection rates going up next slide. So first we're going to kind of jump into clay media next slide. So the change that has been made for chlamydia that we're seeing is basically azithromycin isn't as great um of a treatment for chlamydia as it once was. Um comedy is becoming smart and resistant. And so now the recommendation is to is to treat chlamydia with doxycycline 100 mg twice day for a week. Um As you can imagine this could be really challenging for a lot of patients. Doxy is can upset your stomach. Two for two, expect a team to take something twice a day for a week. Um and really complete that and be adherent with that I think is also a challenge. Um So um oh and you'll also see on here that there's an asterix doxycycline delayed release 200 mg um Once daily dosing for seven days is also effective. Um It's pricey though and I don't even think any of the insurance plans that I we see over in Oakland um as far as medical and management covers that. Um So anyways next slide. So this is the reason why the recommendation was made. So uh there was a meta analysis that showed the efficacy of Zithromax versus doxy for euro genital chlamydia. Um It's actually not terrible. You see like the average difference between doxy and his death row is like 3 to 4% which isn't terrible. So I actually think um and dr Park mentioned this it it can be if you're in a higher risk population. So for example at J. J. C. We do routine gonorrhea chlamydia testing for every youth who comes through our doors And it's not uncommon that they'll get released before there um results can come back and so we have to kind of track them down and turns into a public health issue. And so a lot of times what we'll do is because we know they won't be there for a week for us to like make sure they get doxy twice a day for seven days we give the remission um in those instances so I would say share decision decision making with your patient is a reasonable thing to do for euro genital chlamydia. Next slide for rectal commedia totally different story as you can see. Um the differences between efficacy and doxy and the Cipro is significant. I mean up to 2530% in some of these um studies and so the recommendation would be to treat with doxycycline for seven days um for rectal. Excuse me, rectangle media next slide. So I did a little digging um Just because this is something that we've come up with, this is an issue that we've recognized in some of our treatment uh situations. Sorry, I don't know why I couldn't get that out. Um but like who covers what I think is relevant for a PCP because having to do a prior authorization and you know all of the ups and downs that come with prescribing medicines that you don't typically prescribe can be challenging. Um So I just looked at the formularies for Alameda alliance for blue cross and for san Francisco health plan and luckily doxy is covered by everybody. You'll come across a difference between mono hydrate and hike late. I hope I'm saying that right hike late doc c cycling. So hike late is actually um it has better scalability than the mono hydrate um but it's a little tougher on the tummy. So mono hydrate is more tolerable and so we prescribe the mono hydrate in our institution. Um so we can hopefully keep them on it. Um But I think either one is fine. Next slide. So gonorrhea is what we'll talk about next and you go to the next slide. So the update for gonorrhea is that it is also becoming more resistant unfortunately. Um So we used to give half of this dose for the treatment of gonorrhea of subtract zone and now it's 500 mg. I am times one. Um And then the other update that came outside of the this this actual increase in the dose came in the end of 2020. So I'm like december. So this came out prior to the july um mmr mmwr update. Um But um the other thing to recognize is that you don't. So we used to give subtraction tough tracks on and azithromycin together for for gonorrhea. Now if you have tested for both gonorrhea and chlamydia and you have a negative chlamydia test and in the setting of a positive gonorrhea test you no longer have to co treat. Um And that was given for a couple of reasons it was like to catch the chlamydia that you may not have tested for scene. And then also um as a treatment for the gonorrhea but now it's not recommended what is recommended is a test of cure if you're treating for forensic jal gonorrhea um a week or two after you treat test of cure is not necessary for you know you're a genital or rectal but for differential it is recommended. Um And then now if you have co infection with gonorrhea committee or you're gonna do step tracks on and doxycycline for seven days next slide. Um And then there's a new alternative gonorrhea treatment. And I think this is pretty relevant when we're seeing you know this wave of telehealth that has been actually I think a true blessing um for many of our patients and helped to increase health equity um and access to care for a lot of patients. But like treating something that requires an intramuscular injection, his challenge can be challenging. So you can if you're treating your a genital or um rectal gonorrhea you can give to fixing um which is super pacs 800 mg P. O. Times one. And the same rule still applies with the if the committee is negative you don't need to treat committee of its positive treat with doxy. Um I think the caveat here is that if you're treating rectal gonorrhea you have to bring them in a third generation cephalosporins. The only thing that works. I think that's oh next live etc. So I did a little digging about the soup racks because I very rarely prescribe it but it was good for me to at least know if it's covered. Um And it's a little spotty looks like sf health plan for you. Lucky sf. Uh huh. Yeah pediatricians you have easy accessibility to it a little harder for us over on the on the East Bay side next slide. Um So the concept of expedited partner therapy or patient delivered partner therapy um has come up and this was actually commented on in the new updates. So it looks like what what they now are saying is that shared decision making can be made to provide expedited partner therapy for men who have sex with men. Um And that wasn't um previously the case. Now all 50 states including Texas um it is allowable to do this. Um And I think it could be I think if it's done the right way. So we have done a couple of different versions. We've actually written prescriptions for patients to give to their partner either in the patient's name, hope nobody's watching this or the prescription in the partner's name. And I think there's been studies to show that that's not super effective. And those prescriptions actually I know there's been a study by family packed um in California that shows that those prescriptions very rarely get filled. Um So the best way to approach it is to provide prepackaged oral medication to the patient to give to their partner. Um And there are groups, there's a group called Essential Health Access um that's local. I think they're actually national but um that you can work with to to provide this service if you're serving a population that would need it often. I'm not sure if it's you know useful for the everyday PCP but something to consider if you're seeing a lot of this next slide. So we're going to dig into discharge causing diagnoses next thank you. Um So I learned so much about this and DR parks talk, I was like, I have to share this, it seems so it's not relevant to the everyday PCP but I think it actually is because as I listened to her talk about MG thought about patients who I'm like this is what they had and I had no idea in retrospect. Um so non gonna conquer your arthritis, the number one culprit has been um found to be michael plasma genitalia. And they did this big study, the magnum study a couple of years ago. It looked at different sites across the country and basically the outcome of that was that greater than 900 it took greater than 900 men with 33 itis. Of those 900 men, 900 plus men, almost 30% had mycoplasma genitalia. So it was in many cases, men who had already been empirically treated because whatever you see a male with discharge you treat that's just like you just give them a treat for gonorrhea and chlamydia empirically before they walk out the door. So most of them have been empirically treated and they have persistent your arthritis, persistent discharge, 28.7% had my co plasma genitally. Um um The demographics of that group were like my patients, black men who have sex with men who are young um of those who had the my mycoplasma genitally um 64% were resistant to macro lights which I find crazy next slide please. Um So the treatment for this is like antibiotic pie. It's crazy. You're giving them doxycycline 100 mg twice a day for a week followed by a one week course of moxie flock season. I mean my goodness. Um So that is the way you treat these patients. Um Next slide right now we don't have um a great way of diagnosing MG. There is an FDA approved. I'm sorry don't mean to go this live to talk about this. There is an FDA approved um N. A. T. Test the PCR test. And I touched base with my lab um here in Oakland and they said it's in the pipeline. So I can only imagine if Oakland is gonna get its SAN Francisco probably already got it or is going to have it soon sooner than us. Um So look out for that but I think that would be super helpful um in managing and mitigating this A. B. V. I felt like we definitely had to throw in the BV slide because I feel like we probably see more than we realize um Right now we're relegated to just using a wet mount for diagnosing BV. Um Which you know a wet mount is very subjective um And um can can we can miss a lot because we're looking for clues sales were with test to ph um white blood cells like we're not looking for. You know we need a better test. So there is an FDA approved test for this that I also found out that our lab will be getting soon. Um And it's an N. A. T. Test so that's great um fingers crossed. Um But I did want to mention from this slide that what else? Oh yes BV can increase your risk um to other S. C. I. S. And M. G. Is included in that group. And then um there's certain BV. Associated bacteria that can increase your HIV susceptibility. So it's important to treat it and to not you know ignore it. Um We get patients who come back over and over with the same complaints and it can be very frustrating. Um next slide we'll talk about in terms of sleep treatment recommendations. The recommendation has not changed. You still treat with fragile 500 mg twice a day for a week. Or you could use the metro jail or clindamycin cream and then they've added other alternative regimens um that are highlighted right there for you. Next slide So Canada um I think Canada also be very frustrating and I think this slide actually speaks to that so um there's no good FDA approved test for Canada right now. We are relegated to using our web mount. Um I think for the PCP who doesn't have a microscope. You usually are just kind of stuck using patient symptoms. Um which can be very classic. Sometimes the white discharge clumpy lots of vaginal irritation or itching. You know you get your classic symptoms but I think where we run into issues that recurrence rate is so high, that has at least been my experience. Um With a lot of the patients that I treat for Volvo can vulva, vaginal candida diocese. Um And so the newest recommendations are to treat little longer. Um So you don't get that recurrence as much. So if you're doing a topical you'll do it a week to two weeks of topical. If you're doing Diflucan or a 150 mg. We used to do one tab P. O. Times one. Now you do it Q three Days Times three Doses. So that's the biggest recommendation difference for the candidate treatment. Next slide. So next we're going to get into HSV. The update for HSV really is about how to diagnose it. Um And there's a lot on this slide and I just go summarize it for you to say that if you have a lesion of suspicion, a sore or ulcer a bump or something that's like new and funky in the genital area, it's best to swab it and send that swap for pcR because that's your highest chance of getting a positive of anything because if you don't swap something that you have no lesion of like the there's the lesions that are gone or they never had a lesion and you just kind of like trying to chase the patient's immune system for evidence, it gets tricky and sticky. Um So really only do serology is if there is a true history of symptoms, tingling waves of that you know cycles or I had a sore something that was real because otherwise it's like not helpful and you can go to the next slide so we can kind of look at the evidence behind that. Um So the FDA approved Sterile logic essay to differentiate between HSV one and 2 isn't great. So I mean I've had patients have um serology is done in the setting of Guiyu history, guiyu lesion history, nothing I could swap but they just had a history of it and then their apology comes back for a just be one and you're like uh I mean it's possible but it's just like you know a little off for what you expect. So um there's you know and and there you go. I didn't even read that false positives are more likely at a lower index value and an HSV one serial positive person. So you can have this like low specificity um Next slide. So the recommendation now from the CDC is to do what's called a two step testing for HSV. Um And basically you're gonna send um your C. I. A. Which is your enzyme immuno essay. Um And if it's high you're good you don't need a confirmatory tests but if it's low then you're going to do a second step which is sending one of these two confirmatory test options. Um And that kind of helps to kind of narrow down what is truly HSV and what is just causing people to have sleeplessness and like hopelessness because people respond to HSB diagnosis and like its tortuous. Um So we want to make sure if we're diagnosing it we're confident and that diagnosis. That's what I gather from that next slide. And then I'm really quickly going to talk about P. I. D. Um The biggest change that came with the P. I. D. Treatment recommendations is that there was a question on whether flah jal Metro night is all should be added um to the regimen and and um the studies that they did on this said yes and when you add fragile to your third generation selfless born plus your doxycycline for two weeks. My goodness. Um You should there has been evidence of decreased endometriosis um bacterial load I believe as well as uh decreased duration of symptoms. When you add fragile for two weeks. And I would say throw on some uh cam Boucha uh some yogurt with live cultures like I just um is so terrified by what this is doing to our normal floor in our health. Uh huh. Next slide we got through it. Thank you goodness. Okay so all of that was a lot and nobody is ever gonna remember it all. Um So good things to reference to help you with this when you're like boots on the ground ready to treat. And seeing Angela in your clinic is to go to the C. D. C. This C. D. Summary of the C. D. C. S. T. I. Treatment guidelines Um for 2021 is super helpful and is a good reference and you can just print it out. It's like a one page handout and just have it in your clinic. They also have like a pocket guide and then they have a mobile app that's like in the works since coming out soon. So things to reference right there. Next slide. Okay contraception we're gonna whip through this because I really didn't have enough time to dig into it like I wanted to and we're running out of time. Only got like a few minutes. So um The reason why we talk about it so listen to just say contraception use has increased. So over the past 25 years or so this started in the 80s. So this is like 40 years almost now, 2030, years ago um things have gotten better so that's great but we still got room to grow next five. This is the reason why we have room to improve. Um If you really look at this in detail this is for 2018 2019. These high bars are all bodies of color. Um And that's the reason why it matters and that's the reason why it makes sense. Teen pregnancy continues even though it's gotten better. Teen pregnancy continues to affect the most disenfranchised and marginalized communities in our country. And that's part of the reason why there hasn't been enough um support around it. Um So this is why we want to make sure that to create an environment a culture of health equity and uh that's that eliminates the social determinants of health. We must be able to provide adequate contraception, contraceptive options to our patients. Point blank period. All of them they need to have the ability to access it. Next slide. So your options um The UCSF school medicine bixby center um has these great handouts. We these are like our go to handouts in our clinic. We have them like um on a on a ring of laminated handouts in each room um because they're really useful, their visual perfection and they show like in real life like how effective things are. And you can get these off of the website. Um And I would say would be good to just have to just pull out for a clinic patient like Angela. Um So those are the options next slide I think another thing to be able to reference um is the C. D. C. Medical eligibility criteria for contraceptive use. Especially if you're seeing more complex patients who have underlying diseases let's say migraine for example. Um That's something that people often think of like what can I use in a patient who has like real migraines. If you pull up this chart, it will tell you of all the options, what's the best next slide. Um So I'm gonna go over these quickly, we all know the options. But I just want to highlight like the things I think you should know um when you're prescribing condoms like our sex education and I'm assuming our health educators who do a lot of self sex education with our school based health centers are big on giving condoms with lube. Um And I know that terminology can be off putting a little bit too like older people like even me, but like that's just like how it's used used that term with blue because it increases the utility of it because I think there's more pleasure involved in the sexual act as well as it decreases the risk of there being a tear in the condom. Um So you want to do that. Two main types of oral emergency contraception. And I wanted to make sure everybody knew about this. There's your plan B. Um which is a progestin emergency contraception and then which we all are pretty aware of. And then there's Ella. So Plan B. You can prescribe it as the practitioner or patients can buy it at the pharmacy. Um We tell them, I try and tell my patients don't buy plan B. Let me prescribe it for you. So you just keep that prescription in your pocket because that's money that you can be putting towards so many other things. So try and prescribe an advanced prescription if you can. So they just have it just in case. Um It happens on the weekend and then Ella um Billy Crystal is the other one. So um you can take both of them. It's Plan B. Is not FDA approved to be taken more than three days after unprotected sex. But it can be and it can be still effective. So we tell patients if it's up to five days you can take both L. A. Or plan B. But L. A. Is actually FDA approved and works better in patients who are larger. So if there be any is greater than 26 it's further out from the un protect sex. Um So that's good to remember. And then if it's a two pill pack, have them take both pills at the same time and give them a little warning that it may disrupt their next cycle. But that's normal. And that's okay. And then it's good to get a follow up pregnancy tests a week or two after they have the unprotected sex and take the emergency contraception next slide. Um So your hormonal contraception options. You've got your patch, you got your pill, you've got your ring patch pill ring are both are all excuse me combined hormonal contraceptive with estrogen and progesterone depot which is the shot you it is just progesterone only. I don't know why I'm like struggling on this slide because I'm trying to like make sure I run through it. I'm sorry. Um Just want you to know if estrogen is involved, then you're less likely to have difficulties with bleeding. As soon as you remove estrogen from one of these options, you're more likely to hear patients complain of a change in bleeding in some way. Um So just know that um and council your patients on that. Um If you can also depot, increases the appetite. A lot of people say, oh I got devil and I blew up. Like the shot is what led to the weight gain. When really is the shot lead to stimulating receptors in your brain that increase your hunger and you ate more probably unknowingly and you probably ate more things that you that are quick and easy that aren't good for you and you gain weight. And so I try and counsel patients on it's going to increase your appetite. So if you can make sure you're accessing foods that are fresh so hard. I mean we could go into this um in the whole another talk but healthier foods if you can exercise if you can. But some girls are like I want to gain weight so you're like great Depot is great. Um Ayman Arria may not always be desired. Oh goodness. Um Sorry my computer's giving me feedback and I think that's novel because I feel like who does who wants a period. But there are girls who do. And so talking to them about changes in period is good to review. Next slide. So this is what I want you all to take home, take home message, take home message long acting, reversible. Contraception is the best option for adolescent females. Or adolescents who have a uterus. This is the best or or who are desiring to not have bleeding you. I mean, they could be um identify as a different gender and desire not to have uterine bleeding. This is the best option. Um You won't always get a stopping bleeding, but you don't have to worry about thinking about taking something every day. There are methods. So um with the marina for example, the um you d that has hormone, you can see changes in bleeding that are, you know, eventually lead to maybe a Maria or less bleeding. Um Not guaranteed, but you can see that. And it could be a good option in those situations. Next plan in which is the device that goes in the arm um is also progesterone. Only. These the ones that have hormones on this page are progestin, only hormones. There's no estrogen and with with the next one. And so I would like to say that we see patients um gain weight because it is similar to depo in this way, even though it's not marketed that way. I see a lot of girls gain a lot of weight on this so it's increasing their appetite as well. Um I'm a big fan and I'm not getting paid to say this a pair guard because I find when you throw hormones into somebody who already has hormones, it really makes stuff up for some people, not everybody but hormone free option to me just seems right now. There are some unwanted side effects with para guard. You have um you know, potential to have heavier bleeding, potential to have worse cramps. Um But that doesn't happen for everyone and so I think it's a really good option for someone you're like, I'm not sure what hormones are going to do to you and I want to make sure that you um you know are protected from an unplanned pregnancy. Okay, so I just want to give next items. Try a shout out to my crew. Um There's uh almost everybody on here who says adolescent medicine. Those are U. C. S. F. Dr. In the adolescent med department. Um And anybody on here that says pediatrician or adolescent health is in Oakland