Managing the silent STI: chlamydia

Chlamydia, a sexually transmitted bacterial infection (STI), often goes undiagnosed because it is largely asymptomatic, particularly in cisgender women. And yet it remains the most prevalent STI in the United States.                                        

In 2017, the CDC reported more than 1.7 million cases in the U.S., with 45 percent of that comprised of girls and women ages 15 to 24.

Anita Ravi, MD, MPH, MSHP, a practicing family physician in New York City, urges physicians to make STI screenings a routine part of patient care so as to help catch and treat chlamydia, which can have long term health repercussions if not treated.

“You could have chlamydia for years and not know it,” Ravi says. “That’s one of the scariest parts about it-people will say ‘I haven’t had sex in a long time’ and I have to explain that they won’t always have symptoms.”

If left untreated, chlamydia can lead to pelvic inflammatory disease in cisgender women, which can include scarring of the fallopian tubes and fertility problems. In men it may cause epididymitis, an inflammation of the coiled tube (epididymis) at the back of the testicle where sperm is stored and carried, as well as foul-smelling discharge from the penis.

The treatment for chlamydia is typically an oral antibiotic such as azithromycin, which will usually clear up the infection 1 to 2 weeks after medication begins. A person with the STI is recommended not to engage in sexual activity for up to two weeks after the medication is finished, Ravi says.

Though chlamydia has often flown under the radar due to its common lack of symptoms, Ravi says that recommended screening guidelines via the United States Preventative Services Task Force, there are more family medicine and primary care physicians now beginning to use a “triple screen” for chlamydia. “Now we’re looking for chlamydia not just in the usual places, like the vagina, but we’re doing anal swabs and throat swabs,” she says.

Chlamydia, like the human papilloma virus, can infect multiple tissues through sexual contact. “I’ve definitely diagnosed oral chlamydia and anal chlamydia in my practice. It’s becoming a standard of care [to test all places] because we never know who has sex where.”

The importance of this kind of testing, she adds, is that even people who have not had penetrative vaginal sex or who consider themselves virgins, but who have had oral or anal sex, could acquire chlamydia through those methods.

And while prophylactic contraceptives are the only surefire way to prevent chlamydia spreading, Ravi points out that not everyone who is having sex is doing so in a way where condoms are an option. This could be transactional sex for money or housing, people who are victims of “stealthing,” in which a male partner removes a condom during sex without informing his partner, other forms of sexual assault, or partners who have sex with other infected partners but don’t disclose.

While she acknowledges that discussing STI screenings can be uncomfortable for some patients, particularly those who have religious or cultural taboos around discussing sex, it is still important to do so in a way that normalizes it as a part of regular care. “I ask everyone in my practice because I don’t want to miss anything.”

Making it standard also bypasses any assumptions a physician might make about a person’s sexual activity due to age, gender, or sexual history, and helps patients who are uncomfortable discussing their sexual health see it as a normal part of healthcare.

In her practice, Ravi is able to offer patients the option of doing self swabs in her office, which gives an extra measure of privacy to the screening. First morning urine can also be collected at home to test for it.

“I think even opening the door [to talk about STIs] at a first visit can help lift any assumptions,” Ravi says.