Chicago Tribune - November 10, 2004
Merry Mayer, Special to the Tribune

Much is said of patients feeling comfortable enough with their doctors to raise questions and concerns about their health care. But when it comes to discussing sexually transmitted diseases, perhaps it's the doctors who need encouragement.

Whether it's social barriers, poor interviewing skills or fear they might offend their patients, many doctors are not recommending or discussing STD testing with patients, and women in particular may pay the costs with their health.

Anne Borkowski, a doctor of reproductive endocrinology at North Shore Fertility in Skokie, regularly sees the damage done by unchecked STDs in her practice.

"In approximately 10 percent of my patients, their infertility is secondary to a sexually transmitted disease," she says. Usually the STD is chlamydia and about half of those patients had no idea they had an STD, she adds.

Although several national guidelines recommend routine screening for chlamydia, only 22 percent of doctors said they tested patients under 20 for the disease and only 9 percent tested women 20 to 25, according to a recent survey of doctors conducted by the Baylor College of Medicine in Houston.

Yet, chlamydia in women has no symptoms and is curable with antibiotics if caught early. But if the disease is left to progress, women can develop pelvic inflammatory disease, which can result in chronic pelvic pain, ectopic pregnancy or infertility. Among the diseases required to be reported to the government, chlamydia is the most commonly reported infectious disease in the U.S., according to the Centers for Disease Control and Prevention.

But it's not just chlamydia that is being ignored. Testing for all STDs is less than what it should be. A survey conducted by the Henry J. Kaiser Family Foundation found that only half of doctors discuss STDs with all or most of their patients. More alarming, among the half of doctors mentioning STDs to patients, only 10 percent were specifically mentioning human papillomavirus (HPV), which is strongly linked with cervical cancer and is the most common of all STDs. Only 5 percent of these doctors tested and advised on genital herpes, which the CDC estimates infects 20 percent of all Americans.

Then consider that the U.S. has the highest rate of STD infection in the industrialized world, according to the CDC's National Prevention Information Network Web site.

"We are told about having Pap smears, but [then we] don't talk about these other important parts of our sexual health," says Michele Megregian, associate medical director for Planned Parenthood in Chicago.

Part of it is social, observers say.

"As a culture, we are majorly in denial. [We are] repressed about having this kind of discussion and there is a lot of shame attached to it," says Mimi Kravitz Omilinsky, a licensed clinical social worker based in Northfield.

Doctors agree that social barriers may hinder some physicians from discussing STDs. "My No. 1 thought would be awkwardness," says Dr. Bryan R. Hecht, who chairs the gynecological practices committee at the American College of Obstetricians and Gynecologists and practices in Ohio.

Doctors may worry about offending patients, says Dr. Loren Hutter, medical director of Links-Northshore Youth Health Service in Northfield. "At Links, we concentrate on having [doctors] hone their interview skills," he says.

But the silence on STDs is especially harmful for women. Women are biologically more susceptible to becoming infected if exposed to an STD and most STDs are less likely to produce symptoms in women than in men, says the National Academy of Sciences' Institute of Medicine in Washington, D.C.

Making it even more difficult is that most people tend to underestimate the risk of getting an STD.

"They are a nice person, live in a good community, partner would never do that to them," Hutter says. "There is also a false notion that there is a cure for anything they get. You get people slipping back into a pattern of behavior that puts them at risk."

But by age 24, roughly one in three sexually active people will have contracted an STD, the Kaiser Foundation estimates.

"Any woman who has had unprotected sexual intercourse, meaning without a condom, and has not been tested, should get tested," says Planned Parenthood's Megregian, who also adds that herpes and HPV can be contracted through oral sex and sexual play.

If increased testing is a solution, there are still a lot of barriers to reaching that goal. Insurance for one. "Not everything seen as necessary is always covered," Hecht says.

For patients under 25, who are most at risk, many either have no insurance or rely on their parents for insurance, Hutter says. If they are on their parents' insurance, they may not want to be tested because their parents may then realize they are sexually active, he says.

There also isn't just one all inclusive test for STDs. Gonorrhea and chlamydia are done with a cell sample of the urethra or cervix; HIV and syphilis require a blood test; Herpes, a swab; and genital warts is usually detected by either a pap smear or a visual exam, Megregian says. Planned Parenthood offers all patients the chance to get tested.

Doctors need to talk to their patients, experts say. But what questions should they be asking?

"Current and past sexual practices, high-risk behaviors, number of partners, any symptoms suggestive of current or past STDs, current and past use of barrier protection, and a history of an STD in themselves or their partners," Hecht says. "If you don't screen universally, how would you decide who is at risk? Anyone sexually active is."

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By the numbers

Estimation of new STD cases annually in U.S.

HPV 5.5 million

Trichomoniasis 5 million

Chlamydia 3 million

Herpes 1 million

Gonorrhea 650,000

Hepatitis B 120,000

Syphilis 70,000

HIV 20,000

Source: Henry J. Kaiser Family Foundation

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E-mail ctc-woman@tribune.com

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