PULL-OUT SECTION                                     

                                                                                                                                                               Bacterial STIs and

                                                                                                                                                               Genital herpes


                                                                                                                                                               Genital warts

                                                                                                                                                               The author

                                                                                                                                                               CATRIONA OOI,
                                                                                                                                                               director, sexual health, Hunter
                                                                                                                                                               New England Area Health
                                                                                                                                                               Service, Newcastle, NSW.

This week’s How to Treat comprises the second part of a two-part series on STIs. Last week Part 1 focused on
screening, while this week Part 2 is a discussion of investigation and management.

TESTING for STIs should be guided                                            resulting in increased acceptability     first-line treatment modalities and
by individual sexual risk assessment,                                        and allowing for limited screening in    local resistance patterns. STI testing
local epidemiology, and whether the                                          non-clinical situations.                 and management is an ideal opportu-
patient falls within a particular at-                                          Clinicians need to be aware of         nity to effect behaviour change by
risk group. With the widespread                                              sampling options, test limitations and   way of education, safe-sex messages,
availability of nucleic acid amplifica-                                      associated window periods, and           and harm-minimisation counselling.
tion tests (NAATs), more sampling                                            counsel patients appropriately. Simi-
options are available for patients,                                          larly, clinicians need to be aware of                            cont’d page 24

                                                                                                                   30 October 2009 | Australian Doctor |    21

     Bacterial STIs and syndromes
 Chlamydia                                                 Table 6: Treatment of bacterial STIs and syndromes                                   with rising rates of resistance   under 35, common causative
 Testing                                                                                                                                        worldwide.          However,      organisms are chlamydia and
 WITH the widespread use of            Infection             First line                 Second line            Notes                            NAATs are more robust             gonorrhoea; in those over 35
 NAATs for chlamydia, such             Chlamydia                                                                                                than other options, as sensi-     epididymo-orchitis may be a
 as PCR and ligase chain reac-         Uncomplicated         Azithromycin 1g stat       Doxycycline 100mg      Test of cure is                  tivity does not rely on the       complication of a UTI.
 tion, testing can be non-inva-                                                         bd for seven days      recommended for                  viability of the fragile gono-    Enteric organisms may be the
 sive, self-collected or clinician     Rectal                Azithromycin 1g stat,      Doxycycline 100mg      single-dose treatment of         coccus. On the other hand,        causative organism in MSM.
 driven. Increased sampling                                  repeat day 7               bd for 10 days         rectal infection                 culture offers 100% speci-        Rarely, haematological spread
 options have resulted in              Lymphogranuloma       Doxycycline 100mg                                                                  ficity, whereas specificity       or drugs such as amiodarone
 broader acceptance of test-           venereum              bd for 21 days                                                                     may be a concern with PCR         may be responsible.
 ing, which is particularly rel-       (serovars L1-3)                                                                                          testing due to false-positive        Examination may reveal an
 evant for young people under          Gonorrhoea
                                                                                                                                                results with closely related      acute scrotal swelling, unilat-
 25, for whom speculum                                                                                                                          non-gonococcal Neisseria          eral redness and oedema. In
                                       All sites             Ceftriaxone 500mg IM       Ciprofloxacin          Consider co-infection with
 examination may render test-                                                                                                                   species.                          some cases the scrotum may
                                                             stat in 2mL of 1%          500mg stat             gonorrhoea and chlamydia;
 ing prohibitive. PCR is pri-                                                                                                                      Like chlamydia NAATs,          be exquisitely tender, and
                                                             Iignocaine                                        when suspicious treat both
 marily used in Australia and                                                                                                                   gonorrhoea PCR is only val-       urgent ultrasound or urgent
 is both highly specific (99-          Epididymo-orchitis                                                                                       idated for urine, urethral and    surgical assessment may be
 100%) and sensitive (83-              Gonorrhoea            See above                                         Consider co-infection with       cervical samples, although it     required to exclude testicular
 88%).                                                                                                         gonorrhoea and chlamydia;        has been evaluated at other       torsion.
    Studies comparing collec-                                                                                  when suspicious treat both.      sites. One study found that          When an STI-associated
 tion sites in women have              Chlamydia             Doxycycline 100mg          Azithromycin           Stat doses may be                in high-prevalence popula-        organism is causative, concur-
 shown comparable perform-                                   bd for 14-21 days          1g orally stat,        considered in poor               tions, the newer-generation       rent urethritis is often asymp-
 ance for clinician-collected                                                           repeat day 7           compliance but there             PCR tests have a sensitivity      tomatic, although the Gram
 endocervical swabs, self-col-                                                                                 are no clinical trial data       and specificity of 100% in        stain features inflammatory
 lected vaginal swabs and                                                                                      assessing this                   all sites, including orophar-     cells. Urine dipstick may be
 tampons.10-12 However, vari-          Enteric organisms     Norfloxacin 400mg          Ciprofloxacin 500mg                                     ynx and rectum.16 Previous        positive when epididymo-
 able sensitivities (72%+) have                              bd for five days           bd for 10 days                                          data indicate poor specificity    orchitis is secondary to UTI.
 been reported for first-void          UTI organism          Trimethoprim 300mg         Norfloxacin 400mg                                       (<80%) in oropharyngeal           First-void and midstream
 urine compared with other                                   daily for 14 days or       bd for 14 days                                          samples, and culture should       urine samples should be col-
 sites.11,13 Pharyngeal swabs are                            cephalexin 500mg                                                                   be considered here.17 Speci-      lected, and patients screened
 not recommended.                                            bd for 14 days or                                                                  mens for culture should be        for gonorrhoea, chlamydia
    Despite validation for                                   amoxycillin 500mg +                                                                collected for patients not        and UTI bacteria.
 urine, cervical and urethral                                clavulanate 125mg                                                                  receiving first-line treatment,      Empirical treatment based
 samples only, the chlamydia                                 bd for 14 days                                                                     and are useful for both con-      on the likely causative organ-
 PCR test is also acceptable           Non-gonococcal        See under chlamydia.                              For treatment of                 firmation and test of cure.       ism/s should be given to all
 for rectal and vaginal sam-           urethritis            If gonorrhoea test is                             Mycoplasma genitalium                                              patients (table 6). Age, sexual
 ples. In fact, self-obtained                                pending, consider                                 contact a sexual health          Management                        history and local epidemiol-
 vaginal swabs are the pre-                                  co-infection and                                  specialist                       When gonorrhoea is sus-           ogy will help guide this deci-
 ferred self-collected specimen                              treat for both                                                                     pected, patients should be        sion. Patients should avoid
 in American women for sev-            PID                   Doxycycline 100mg bd                                                               treated immediately while         sexual contact until all sexual
 eral STIs, including chlamy-                                for 14 days                                                                        awaiting test results.            partners are traced and
 dia, as recommended by the                                  +                                                                                  Untreated infection in            treated. Rest, scrotal elevation,
 US National Institutes of                                   Metronidazole 400mg                                                                women may extend proxi-           supportive underwear and
 Health.                                                     bd for 14 days                                                                     mally to the endometrium          analgesia with NSAIDs are
    The use of NAATs has ren-                                +                                                                                  and lead to PID. In men,          recommended when required.
 dered previously used testing                               Azithromycin 1g stat                                                               untreated infection may           Patients who do not respond
 methods such as immunoflu-                                  +                                                                                  result in epididymo-orchitis.     may require hospitalisation
 orescence and ELISA largely                                 If gonorrhoea suspected,                                                           Systemic dissemination of         and IV antibiotic therapy.
 obsolete. Cell culture,                                     ceftriaxone 500mg                                                                  infection occurs in 1-3% of
 although expensive with poor                                IM stat in 2mL of                                                                  those infected, affecting         Non-gonococcal urethritis
 sensitivity, is 100% specific                               1% lignocaine                                                                      women more commonly               Non-gonococcal urethritis
 and is primarily used in                                                                                                                       than men, and often present-      (NGU) is defined as urethri-
 medicolegal cases. Chlamy-                                               treated empirically. Test of          Similarly, many Australian      ing without genital symp-         tis not associated with gon-
 dia serology is useless for                                              cure is not routinely recom-       patients were HIV co-              toms.                             orrhoea. C. trachomatis is a
 diagnosis because of high                                                mended but should be con-          infected. While most pre-             Most recent national sur-      common causative organism.
 baseline prevalence of anti-                                             sidered in pregnancy to            sented primarily with              veillance data showed 38%         Characterised by dysuria
 bodies in the sexually active                                            avoid complications. Re-test-      ‘anorectal syndrome’ — typi-       of gonococcal isolates were       and discharge, NGU may be
 population and cross-reactiv-                                            ing is advised when compli-        cally, acute proctitis — there     resistant to penicillins, and     asymptomatic and if not
 ity with Chlamydia pneumo-                                               ance concerns exist and for        are reports of ‘inguinal syn-      49% resistant to quinolones.      treated may progress to epi-
 niae.                                                                    patients whose regular             drome’ — presentation with         About 1% of isolates              didymo-orchitis and, rarely,
                                                                          sexual partners have not           inguinal lymphadenopathy,          showed decreased sensitivity      reactive arthritis (Reiter’s
 Management                                                               been tested and treated. It is     ulceration and positive LGV        to ceftriaxone, and to date       syndrome).
 First-line treatment for                                                 important to remember that         serotypes on first-void urine.     there is no known resistance         Mycoplasma genitalium is
 uncomplicated urethral and                                               NAATs may remain positive             LGV differs from the            to spectinomycin.18 Current       emerging as a significant
 cervical infections is                                                   for 4-6 weeks despite suc-         common urogenital chlamy-          first-line treatment and med-     contributor of infection;
 azithromycin 1g stat (table                                              cessful treatment, due to          dia D-K infections, tending        ication availability reflects     however testing is limited
 6). This is well tolerated,                                              nucleic acids from non-            to be invasive and destruc-        these findings (table 6). As      and optimal treatment yet to
 with few side effects, the stat                                          viable organisms.                  tive. Untreated, LGV may           for those with other STIs,        be determined. Adenoviruses
 dose ensuring compliance.                                                                                   mimic Crohn’s disease and          patients should be advised to     and genital herpes have been
 Azithromycin is safe and                                                 Lymphogranuloma venereum           cause complications, includ-       abstain from sexual contact       identified as other significant
 effective in pregnancy. An                                               While C. trachomatis               ing strictures, chronic fistu-     for one week and until            causative pathogens.
 Edinburgh study of men                                                   serovars D-K are responsible       las, abscesses and genital ele-    sexual partners are tested           Discharge may be mucoid
 who have sex with men                                                    for common urogenital infec-       phantitis. Routine PCR             and empirically treated.          or mucopurulent, and gono-
 (MSM) reported unaccept-                                                 tion, serovars L1-3 cause          testing does not distinguish                                         coccal infection cannot be
 able rates of treatment fail-                                            lymphogranuloma venereum           between serovars and, if LGV       The syndromes                     excluded on examination
 ure (up to 13%) associated                                               (LGV) — an STI previously          is suspected, genotype testing     Epididymo-orchitis                alone. When possible, ure-
 with single-dose azithro-                                                seldom seen in developed           must be requested. Identifi-       Epididymo-orchitis (inflam-       thral swab and Gram stain
 mycin for treatment of rectal                                            countries. Since 2003, LGV         cation is essential for ade-       mation of the epididymis ±        may be useful for immediate
 infection. 14 Test of cure                                               has emerged in populations         quate management (table 6).        inflammation of the testicle)     diagnosis of gonorrhoea, but
 should be considered in                                                  of MSM in Europe and                                                  most commonly results from        NAAT testing for gonor-
 cases of rectal infection for                                            America, and several years         Gonorrhoea                         retrograde spread of a ure-       rhoea and chlamydia is
 patients receiving single-dose                                           later the first cases in MSM       Testing                            thral infection. Infection usu-   required for confirmation.
 treatment.                                                               were reported in Australia.        Despite varying sensitivity,       ally begins in the tail and          It should be noted that in
    Ideally, patients should                                              Cases abroad were associated       culture remained the gold          spreads, involving the rest of    more than 50% of cases no
 abstain from sexual contact                                              with high-risk sexual prac-        standard test for gonorrhoea       the epididymis and testicu-       causative organism is identi-
 for one week after treatment                                             tices such as unprotected anal     for many years. Culture is         lar tissue and may result in      fied. Treatment should not
 and until all current sexual                                             sex, fisting and group sex. Up     valuable, as it allows for         abscess formation, infarction     be delayed while awaiting
 partners have undergone                                                  to 80% of those diagnosed          antibiotic sensitivity testing,    and infertility if untreated.     results. Contact tracing
 screening and have been                                                  with LGV were HIV positive.        an important consideration           In sexually active men          should also be performed.

24   | Australian Doctor | 30 October 2009                                          
  Further NAATs testing for         broad, ranging from asymp-                                                                                  abdominal pain with cervi-         stream urine dipstick may be
other pathogens such as M.          tomatic infection in up to                                                                                  cal motion tenderness and/or       helpful to exclude a UTI.
genitalium is warranted in          60%, to severe infection in                                                                                 adnexeal tenderness.               Patients may be febrile and
patients who present with           4% requiring hospitalisation                                                                                  Laparoscopy, the gold            tachycardic in severe cases
recurrent symptoms despite          and IV therapy. Patients with                                                                               standard, is neither practi-       and hospitalisation is
adequate treatment, who are         mild to moderate infection                                                                                  cal nor possible for most          required when tubo-ovarian
not at risk of reinfection.         are most likely to present to                                                                               cases and the clinician is left    abscess is suspected.
                                    GPs, typically with symp-                                                                                   with sexual history, clinical         Treatment should be
Pelvic inflammatory disease         toms of deep dyspareunia                                                                                    presentation and examina-          started presumptively (table
PID is a clinical syndrome          and acute pelvic pain.                                                                                      tion findings on which to          6). Ideally, patients should
resulting from the ascending           In young women, gonor-                                                                                   base the diagnosis. Given          be reviewed several days
spread of infection to the          rhoea and chlamydia are                                                                                     the wide clinical spectrum         after starting treatment, to
upper genital tract from the        responsible for 30-50% of                                                                                   and significant sequelae of        monitor improvement. Con-
vagina and/or cervix. It encom-     PID. As well as ascending                                                                                   untreated or missed infec-         tact tracing and empirical
passes infection of all upper       the genital tract themselves,        obic      organisms       and       hence unreliable and esti-         tion (ectopic pregnancy,           treatment for sexual part-
genital tract sites and             these STIs damage the cervi-         mycoplasmal organisms,              mated to be incorrect in one-      chronic pelvic pain and            ners is necessary in all cases,
abdomen, such as endometri-         cal epithelium, allowing for         including M. genitalium,            third of cases. There are no       infertility), many clinicians      regardless of patient test
tis, salpingitis, oopheritis and    the ascension of vaginal             have been isolated in women         pathognomonic signs or             have a low threshold for           results. If Neisseria gonor-
infection spilling into the peri-   flora. One study found that          with PID. While polymicro-          symptoms of PID, and set           diagnosis.                         rhoeae is isolated, contacts
toneum (eg, peritonitis, peri-      the presence of micro-organ-         bial isolates are often found,      criteria may miss cases if too       Tests should be conducted        should be treated with cef-
appendicitis and peri-hepatitis     isms associated with bacter-         no organisms are isolated in        strict, and result in over-        to exclude pregnancy and           triaxone. Azithromycin 1g
[Fitz-Hugh-Curtis syndrome]).       ial vaginosis doubled the risk       20-30% of cases.                    treatment if too broad. Most       bacterial STIs (gonorrhoea         stat is appropriate for con-
   The clinical spectrum is         of PID. Indeed, both anaer-            Diagnosis is clinical and         guidelines suggest lower           and chlamydia). A mid-             tacts in all other cases.

 Genital herpes
MOST cases of genital                                                                                                                                                              Both famciclovir and valaci-
                                                                                           Table 7: Herpes treatment
herpes remain undiagnosed.                                                                                                                                                         clovir have greater bioavail-
While asymptomatic infec-            Medication First episode                   Recurrence                       Suppressive              Immuno-          Notes                   ability than aciclovir, as
tion accounts for about 20%                                                                                                               compromised                              reflected in the dosing sched-
of cases, for about 60% of                                                                                                                                                         ule (table 7).
cases non-classical symptoms         Aciclovir      400mg tds for 5-10 days 800mg tds for two days               200mg bd                 400mg bd         Most extensive             Presumptive treatment is
such as itch, redness, burn-                                                or                                                                             use in pregnancy        recommended for all sus-
ing and irritation occur.                                                   400mg tds for five days                                                                                pected first episodes. Patients
These symptoms are com-              Famciclovir 250mg tds for 5-10 days* 1g bd for one day                      250mg bd                 500mg bd for     *Famciclovir not        with primary infection may
monly misdiagnosed.                                                       or                                                              seven days       available on the        require simple analgesia and,
   Asymptomatic shedding                                                  500mg stat then 250mg                                           (episodic) or    PBS for this            despite lack of data, may
occurs sporadically regard-                                               bd for three doses                                              ongoing          indication              benefit from an extended
less of symptoms, and most                                                or                                                              (suppressive)                            antiviral treatment course.
transmission occurs at these                                              125mg bd for five days                                                                                   Hospitalisation is rarely nec-
times, as patients are                                                                                                                                                             essary for urinary retention
unaware of increased trans-          Valaciclovir   500mg bd for 5-10 days      500mg bd for three days          500mg daily              500mg bd                                 or IV aciclovir in extensive
mission risk and thus do not                                                                                                              (suppressive)                            infection.
avoid sexual contact or take         Notes          •   Simple analgesics       • Short courses shown in       • Microbiological                                                      In established infection,
additional precautions.                             •   Topical anaesthetic gel   ITALICS                        confirmation                                                      treatment may be suppressive
                                                    •   Saline bathing          • Supportive therapy             required for authority                                            or episodic. Episodic treat-
Testing                                             •   Extended treatment        may be adequate                prescription                                                      ment may be more appropri-
Clinical diagnosis should be                            course may be required • Start treatment at first      • Reassess                                                          ate for patients who:
confirmed. Definitive diag-                             in severe disease         signs of recurrence            requirement                                                       • Have infrequent recur-
nosis will help guide man-                                                        (microbiological confirmation every 6-12 months                                                    rences.
agement, and herpes simplex                                                       is required for authority                                                                        • Are able to recognise out-
virus (HSV) group typing                                                          prescription but treatment                                                                         breaks.
provides valuable prognos-                                                        can and should begin                                                                             • Are reluctant to take ongo-
tic information. Direct detec-                                                    while awaiting results)                                                                            ing medication.
tion swab tests (PCR, culture                                                                                                                                                         Prompt treatment at the
and immunofluorescence)                                                                                                                                                            first indication of an out-
are preferred for herpes diag-      Figure 3: Penile herpes                 repeat swabs are negative.         Clinicians should bear in           Recurrent genital herpes is     break holds the greatest ben-
nosis, as they permit HSV           simplex virus (HSV).                  • For patients whose part-         mind that the positive pre-        milder than the first episode,     efit for the patient, and
typing and are both site and                                                ners have proven genital         dictive value of HSV serol-        becoming less frequent over        patients may be able to abort
symptom specific.                                                           herpes.                          ogy will decrease in low-          time. Patients may opt for         an episode before lesion for-
   The NAATs have become                                                  • When there may be a risk         prevalence populations.            treatment following diagno-        mation if medication is
the standard of care, with                                                  of new infection in preg-          The serological gold stan-       sis, however depending on          administered within 24
HSV PCR both specific and                                                   nancy.                           dard test for herpes is the        the future pattern of recur-       hours. Early studies indicated
sensitive. Use of this method                                                It is important to counsel      western blot, which is             rences, they may choose to         that five days of treatment
has been estimated to                                                     the patient as to the limits of    expensive and available            manage their infection with-       was necessary; however,
increase the rate of virus                                                testing — that although type-      only from reference labora-        out treatment thereafter. Thus     recent studies have shown
detection by nearly 70%                                                   specific, serology only detects    tories.                            patterns of antiviral use may      shorter courses to be equally
compared with the previous                                                previous exposure to infec-          Serology may be positive         change, with many options          as effective, giving the indi-
gold standard (culture), with                                             tion. For many asympto-            at two weeks post exposure         now available to suit the indi-    vidual greater choice and
superior sensitivity for both                                             matic patients HSV serology        but the window period may          vidual’s lifestyle and relation-   greater control (table 7).
atypical and older lesions.                                               may be of limited benefit, as      extend to three months or          ship status.                          Suppressive treatment is
   When herpes is suspected,        Figure 4: Vulval ulcer, due to        it may cause undue distress        longer.                               Three antiviral products        available:
those with lesions (figures 3       HSV.                                  without influencing behav-                                            are currently available — aci-     • For those who have more
and 4) should be tested with                                              iour or management.                Management                         clovir; its pro-drug, valaci-        frequent recurrences.
direct swabbing: patients                                                    HSV group-specific serol-       Recurrence rates vary. Most        clovir; and famciclovir. All       • For those who have severe
should be encouraged to                                                   ogy provides little informa-       patients with mild infrequent      are effective in decreasing          episodes.
return when symptomatic,                                                  tion and is not recom-             recurrences will not require       frequency of recurrences,          • When the risk of transmis-
or supplied with swabs for                                                mended.         Type-specific      treatment. After the first         preventing new lesions, abat-        sion to sexual partners is of
self-collection. False-negative                                           serology tests (enzyme             episode the median recur-          ing symptoms and prevent-            significant concern.
results will occur while                                                  immunoassay and ELISA)             rence rate for HSV1 infection      ing complications of infec-           It should be noted that the
patients are asymptomatic,                                                are widely available and vary      is about once a year, signifi-     tion. All agents are effective     risk of transmission in the
although PCR is superior to                                               in specificity and sensitivity.    cantly lower than for HSV2,        in decreasing asymptomatic         absence of medication has
culture in this respect.                                                  False-positive and false-nega-     at four a year. Indeed, for        viral shedding and hence           been estimated at about
   Serology is available and                                              tive results do occur as a         HSV1 and HSV2, both shed-          transmission, although only        10% per annum in HSV2-
may be useful in some cir-                                                result of cross-reactivity with    ding frequency and recur-          one study (using suppressive       serodiscordant monogamous
cumstances, for example:                                                  HSV type 1 (HSV1)/HSV              rence rates are highest in the     valaciclovir) has been con-        couples.
• If herpes is suspected but                                              type 2 (HSV2) antibodies.          6-12 months after infection.       ducted to demonstrate this.                       cont’d next page

                                                                                                                                       30 October 2009 | Australian Doctor |   25

 Testing                                                                                                                                                                                                  treponemal antibody absorp-
                                                                                               Table 8: Syphilis treatment
 APART from the ongoing                                                                                                                                                                                   tion test (FTA-Abs) — are
 syphilis epidemic in MSM,                                  Early syphilis (<2 years of infection)                                        Late syphilis (>2 years of infection)                           used for diagnostic confir-
 most patients are diagnosed                                Primary                     Secondary                   Early latent          Late latent                    Tertiary syphilis                mation. After primary infec-
 at screening and are asymp-                                                                                                                                                                              tion, sensitivity approaches
 tomatic. Serology remains             Clinical features    • Chancre, classically      Presentation                Asymptomatic          Asymptomatic                   • Neurosyphilis                  100%. Specific tests will
 the mainstay of diagnosis in                                 single, painless          may include:                                                                     • Cardiovascular                 remain positive for life in
 all stages, although recognis-                               indurated ulcer.          • Generally unwell,                                                                syphilis                       about 80% of people
 ing the various signs and                                    Clean base                  lymphadenopathy                                                                • Gummatous                      regardless of treatment or
 symptoms associated with                                   • Regional                  • Rash (hands                                                                      syphilis                       disease activity.
 primary and secondary                                        lymphadenopathy             and soles)                                                                     • The above                         False-negative results from
 stages may expediate treat-                                                            • Condylomata lata                                                                 presentations                  treponemal-specific tests
 ment (table 8).                                                                        • Mucocutaneous                                                                    may coexist                    may arise when testing in
    With sensitivity of 82-                                                               lesions                                                                                                         primary infection. The
 100% and specificity of 97-           Treatment            Benzathine penicillin 1.8g IM single dose                                     Benzathine penicillin          Specialist referral              window period for serology
 100%, treponemal-specific                                  or                                                                            1.8g IM weekly for                                              has been reported at up to
 EIAs have largely replaced                                 Procaine penicillin 1g IM daily for 10 days                                   three weeks                                                     six weeks. For patients pre-
 the use of the non-specific                                or                                                                            or                                                              senting with a suspected pri-
 tests in screening; however a                              Doxycycline 100mg po bd for 14 days                                           Procaine penicillin                                             mary chancre, swabs may be
 combination of both tre-                                                                                                                 1g IM daily for 15 days                                         collected for NAATs, such as
 ponemal and non-trepone-                                                                                                                 or                                                              syphilis PCR, available from
 mal tests is required to cor-                                                                                                            Doxycycline 100mg po                                            reference laboratories. Dark
 rectly diagnose and stage                                                                                                                bd for 28 days                                                  ground microscopy is rarely
 infection.                            Follow-up            • Contact tracing and presumptive treatment for all contacts                  Evaluate contacts
    The non-treponemal tests                                • Review clinically and serologically at six and 12 months                    clinically and
 — rapid plasma reagin                                      • Fourfold titre drop in six months                                           serologically and treat
 (RPR) and venereal disease                                                                                                               appropriately
                                                                                                                                                                                                          Treatment recommendations
 research laboratory (VDRL)                                                                                                                                                                               have varied little since wide-
 tests — are reported as titres        Special              • Consider penicillin desensitisation in penicillin-allergic patients, in pregnancy or if HIV positive                                        spread use of penicillin after
 and serve as markers of               considerations       • Missed doses in pregnancy — restart full course                                                                                             World War II (see table 8).
 infectivity and re-infection.                              • Review HIV-positive patients with early syphilis at three, six and 12 months                                                                Alternative regimens have
 Titre falls are used to moni-                              • Doxycycline is NOT recommended in pregnancy                                                                                                 been considered in previous
 tor treatment response.                                    • Consider HIV testing in those diagnosed with syphilis                                                                                       studies, with varying results.
    False-positive results occur                                                                                                                                                                          Intrinsic macrolide failure has
 in 1-2% of the population                                                                                                                                                                                been linked with azithromycin
 and have been reported in                                                known as the ‘prozone phe-                After treatment, non-specific                Treponemal-specific tests                and, although ceftriaxone
 pregnancy, HIV infection                                                 nomenon’, may occur in the                tests may become non-reac-                 — Treponema pallidum par-                  appears to be effective, ideal
 and other medical condi-                                                 non-specific tests in individu-           tive, but may remain posi-                 ticle/haem agglutination                   dosing regimens are yet to be
 tions. False-negative results,                                           als with very high titres.                tive at a low titre for life.              (TPPA/TPHA), fluorescent                   determined.

     Genital warts
 TRANSMISSION of human                 Figure 5: Genital warts.                                                                           Table 9: Wart treatment*
 papillomavirus (HPV) is by
 direct skin-to-skin contact.                                               Treatment type        Use                  Regimen            Clearance       Recurrence Advantages and                 Use in    Notes
 Pregnancy and immune sup-                                                                                                                rate (%)        rate (%)   disadvantages                  pregnancy
 pression are associated with                                               Provider
 higher rates of clinical expres-                                           administered
 sion of latent virus, with                                                 Cryotherapy           Keratinised          Apply weekly. 27-88                21                Cheap, quick,      Yes
 smoking a possible factor in                                                                     warts; external      Freeze                                               allows ongoing
 persistent infection.                                                                            anogenital           wart and                                             monitoring and
    Diagnosis of genital warts                                                                    warts; can be        surrounding                                          immediate clinical
 is made clinically (figure 5).                                                                   used for             skin to 2mm.                                         evaluation. May
 As a manifestation of low-               necrosis and wart destruc-                              vaginal,             Thaw.                                                be painful. Often
 risk HPV types, warts are a              tion                                                    cervical, anal       Repeat twice                                         requires
 largely a cosmetic problem             – surgery: direct removal of                              and meatal                                                                repeated visits
 and, as such, the treatment              wart tissue                                             sites
 goal is resolution of symp-            – laser and electrosurgery:         Surgical              All warts,           Single             35-72           19-29             Expensive. Longer Yes                  Good for large
 tomatic infection and a pos-             thermal disruption to wart        excision              dependent            treatment                                            recovery time.                         pedunculated
 sible decrease in infectivity.           tissue via electrical energy,                           on provider                                                               Risk of infection                      warts. Large-
    Lesion resolution does not            resulting in tissue protein                                                                                                       and scarring.                          volume warts
 guarantee resolution of                  coagulation and necrosis.                                                                                                         Immediate result                       may require
 infection, as these viruses          • Antimitotic agents:                                                                                                                                                        general anaesthetic
 tend to be transient. Subse-           – podophyllotoxin (Condy-           Cautery/              All warts,                              61-94           22                                        Yes            Useful when other
 quent lesions may re-present             line paint/Wartec solution        diathermy             dependent                                                                                                        modalities have
 either as new HPV infection              0.5%, Wartec cream                                      on provider                                                                                                      failed
 or symptomatic recurrence.               0.15%): stops cell division       Laser                 All warts,                              23-52           60-77                                     Yes
 However, spontaneous                     at metaphase, inducing                                  dependent
 regression does occur, with              local tissue necrosis.                                  on provider
 up to one-third disappearing         • Immune modulation:                  Patient
 within six months, although            – imiquimod (Aldara cream           administered
 some reports suggest regres-             5%): stimulates both the          Podophyllotoxin       External             Twice daily     37-91              4-91              Local irritation.       No             Most useful in
 sion may take years.                     innate and acquired               0.5% paint,           anogenital           for three days,                                      Allows home                            multiple, easily
                                          immune          pathways.         0.15% cream           warts                four days off.                                       treatment                              accessible lesions
 Treatment                                Imiquimod locally induces                                                    Use up to
 All treatments for genital warts         cytokines, TNF and inter-                                                    four cycles
 are associated with recurrence           leukins, which in turn acti-      Imiquimod             External             Nocte three     33-72              9-19              Expensive. Skin         No             Consider in recurrent
 and should be individualised             vate natural killer cells, T-     cream 5%              anogenital           times per                                            irritation. Allows                     or recalcitrant warts
 to suit the patients’ needs              cells, polymorphonuclear                                warts                week, wash                                           home treatment
 (table 9).                               neutrophilic leukocytes                                                      after 6-10
    Wart treatment falls into             and macrophages, thus                                                        hours. Use
 several categories:                      increasing antitumour                                                        for up to
 • Ablation:                              activity.21,22                                                               16 weeks
   – cryotherapy: freezing                                                  *Derived from Maw R. Critical appraisal of commonly used treatment for genital warts. International Journal of STD & AIDS 2004; 15:357-64.

     causes cytolysis at the          Follow-up
     dermal–epidermal junc-           Routine follow-up is not            resolved. Patients should be              matic. Contact tracing is not              warts. HPV vaccination                     young women and considered
     tion, resulting in tissue        required after warts have           advised to return if sympto-              recommended for genital                    should be encouraged for                   in others at risk.

26   | Australian Doctor | 30 October 2009                                              
 Other common sexual health conditions                                                                                                                         References and
                                                                                                                                                               further reading
                                                                                                                                                               Available on request from
Molluscum contagiosum                     Table 10: Amsel’s criteria for diagnosis of bacterial vaginosis              ever, in most cases, no precipitat-
virus                                                                                                                  ing factor can be identified.
A MEMBER of the pox virus               Criteria                       Notes                                             Three of four Amsel’s criteria is
family, molluscum contagiosum                                                                                          diagnostic (table 10). Although the     Online resources
                                        Discharge                      Thin, grey, homogenous                                                                  2006 National HIV Testing Policy.
virus (MCV) is a benign virus,                                                                                         disease tends to be self-limiting,
classically presenting as smooth        Vaginal pH >4.5                Use pH indicator paper at bedside.              treatment is recommended for  
genital papules or nodules with a                                      Collect high vaginal swab (HVS) and roll        symptomatic women and before            ublishing.nsf/Content/F4F093E1E2
distinguishing umbilicated centre                                      directly onto pH indicator. Normal vaginal      invasive gynaecological proce-          2A7478CA256F1900050FC7/$File/
overlying the viral core. These are                                    pH is 4-4.5                                     dures. Bacterial vaginosis has been     hiv-testing-policy-2006.pdf
often misdiagnosed as warts and         Positive KOH ‘whiff test’      Collect an HVS and directly add to a slide      associated with complications in
confused for pimples. Transmission                                                                                     pregnancy.                              STIs in general — for GPs
                                                                       with a drop of 10% KOH. A fishy (amine)
is via skin-to-skin contact and                                                                                          First-line treatment of metron-       STIs Resources for General
                                                                       smell is a positive test
fomite spread.                                                                                                         idazole 400mg bd for five days          Practice:
                                        Clue cells visualised          Epithelial cells covered with mixed flora                                     
  MCV is common, with peak                                                                                             achieves up to 80% cure at four
                                        (Gram stain or wet mount)      via microscopy
prevalence in children under five                                                                                      weeks. Metronidazole 2g stat may
years, in whom lesions tend to be                                                                                      be offered to poorly compliant          STIs in general — patients
non-genital. In adults transmission                                                                                    patients but is less effective.         NSW Health — Get Tested:
is mostly via sexual contact.          Bacterial vaginosis is                    Culture, and microscopy of a          Regardless of treatment, recur-
                                                                                                                                                               NSW Health — Sexually
Lesions are self-limiting, but                                                 wet preparation, are available for      rence is common.
release of the viral core with
                                       the most common                         diagnosis but lack sensitivity. Pap                                             Transmissible Infections (STIs) and
squeezing and trauma means             cause of abnormal                       smear may also be considered.           Candidiasis                             Blood Borne Viruses (BBVs)
autoinoculation is common.                                                     Although not widely available,          Most women will experience at
  Management includes single
                                       vaginal discharge in                    PCR testing is the most sensitive       least one episode of vulvovaginal
cryotherapy treatment or eviscera-     women of                                and specific. Treat with metron-        candidiasis or thrush. Candida          h/sexualhealth/sex_factsheets.asp
tion. Podophyllotoxin and              childbearing age                        idazole 2g stat.                        albicans is the causative organism
imiquimod have been used with                                                                                          in up to 90% of cases, occurring        HIV — for GPs
varying results.                       worldwide.                              Bacterial vaginosis                     as a commensal in about 30% of          HIV information, guidelines and
                                                                                                                                                               resources: Australasian Society for
                                                                               Although not an STI, bacterial          women.
                                                                                                                                                               HIV medicine:
Trichomoniasis                                                                 vaginosis is a polymicrobial condi-       Although transmission may be
Trichomoniasis is uncommon in                                                  tion that is the most common            sexual, thrush is not traditionally
urban areas. The highest prevalence                                            cause of abnormal vaginal dis-          considered an STI. While classical      HIV — for patients
in Australia is in remote communi-                                             charge in women of childbearing         presentation of vulvovaginal itch,      National Association of People
ties, where rates have been esti-                                              age worldwide. Women typically          inflammation and a ‘cottage             Living with HIV/AIDS (NAPWA),
mated at up to 25%.                                                            present with irritation, fishy odour    cheese’ discharge is common,            the national peak organisation
   While many infections are                                                   and increased vaginal discharge,        other signs such as erythema,           representing people living with
asymptomatic, more than 50% of                                                 although about half remain              oedema, excoriation and fissuring       HIV/AIDS in Australia:
women develop clinical features,                                               asymptomatic.                           also commonly occur. Diagnosis is
including malodorous frothy green                                                The condition is characterised        made via microscopy, with visual-       Australian Federation of AIDS
vaginal discharge, pruritus, dysuria                                           by an increase in vaginal pH and        isation of fungal elements, or by       Organisations (AFAO) — the peak
and dyspareunia. Vaginal pH will                                               subsequent increase of mixed-flora      culture.                                non-government organisation
be high, and speculum examination                                              commensals due to the decrease of         About 5% of women will expe-          representing Australia’s
may reveal a ‘strawberry’ cervix or                                            hydrogen-peroxide-producing lac-        rience chronic candidiasis, unre-       community-based repsonse to
colpitis macularis — punctuate                                                 tobacilli. As a result, bacterial       sponsive to treatment. These            HIV/AIDS. AFAO’s work includes
haemorrhages on the cervix. Ure-                                               vaginosis has been associated with      women should be investigated to         education, policy, advocacy and
thritis and balanoposthitis may                                                practices that disrupt the vaginal      confirm diagnosis and exclude           international projects:
occur in men, but most men remain                                              ecosystem, such as douching and         other causes, including resistant
asymptomatic.                                                                  intravaginal foreign bodies; how-       non-albicans species.
                                                                                                                                                               Herpes simplex virus — for doctors
                                                                                                                                                               and patients
                                                                                                                                                               Australian Herpes Management
 Author’s case study                                                                                                                                           Forum:

SIMON presented to the clinic for      found that this was associated            of previous infection.                mary chancre. Simon was advised
a sexual health screen. He had         with risky sexual practices. He         • HIV window period and the poten-      to start treatment for syphilis with
recently had unprotected anal          denied ever sharing needles and,          tial extension of this with PEP.      1.8g benzathine penicillin IM stat.
intercourse (both insertive and        although expressing concern,            • The increased risk of HIV trans-      Contact tracing was raised, with
receptive) with a casual male part-    denied that there was a                   mission with concomitant STI          Simon preferring to defer this until
ner and had started HIV post-          problem.                                  and broken ulcerated skin.            his next visit.
exposure prophylaxis (PEP) one            Examination revealed an erythe-         The testing process was dis-           Simon returned a week later.
week previously.                       matous perianal area. There were        cussed, including collecting results,   The RPR was reactive 1:64, and
   He had accessed HIV PEP at          several small, well circumscribed       contact tracing and ongoing care.       the FTA-Abs was positive. We
the local emergency department         ulcerated lesions of several mil-       He was advised to continue HIV          explained to Simon that the
and was keen for the results of        limetres in diameter. They had a        PEP and to return in one week for       syphilis tests (treponemal specific)
the baseline blood tests that had      clean, soft base. A clinical diagno-    results of STI screening.               would remain positive for life
been collected there: HIV anti-        sis of herpes genitalis was made           Simon returned one week later        despite successful treatment.
body/antigen (HIV Ab/Ag), hepa-        and a swab of the ulcer base was        for review and results. He                Contact tracing methods were
titis C antibody, hepatitis B core     collected for confirmation with         reported that the perianal skin felt    discussed, including both partner
antibody.                              HSV PCR. Rectal swabs for both          improved, and on examination it         and provider notification.
   On questioning, Simon reported      gonorrhoea and chlamydia were           was noted that the lesions had          Resources and information were
that he had noticed a few days of      collected for PCR testing, as well      decreased in size and were heal-        provided to assist this process,
anal irritation but had attributed     as first-void urine for chlamydia       ing. The syphilis EIA screening test    including website details for send-
this to his most recent sexual         PCR and a pharyngeal swab for           was positive, but further syphilis      ing named or anonymous notifi-
encounter. He was otherwise            gonorrhoea culture.                     tests (RPR, TPPA, FTA-Abs) were         cation by SMS and email
asymptomatic. His last sexual             Results of serology testing con-     pending. Much to his relief, Simon      (
health screen and HIV test had         ducted at the emergency depart-         had tested negative to HIV, gonor-        It was emphasised that sexual
been conducted toward the end of       ment were accessed and delivered.       rhoea and chlamydia at all sites.       contacts should be treated empiri-
a long-term relationship two years     Simon had indeed been exposed           He demonstrated immunity to             cally. A follow-up visit was
ago. All tests were negative. Since    to hepatitis B and was immune.          hepatitis A and so did not require      arranged for 2-4 weeks (after com-
that time, Simon had had few           The hepatitis C result was non-         vaccination. The HSV PCR                pletion of PEP medication) to
casual sex partners, reporting that    reactive, while the HIV Ab/Ag           from the perianal area was nega-        assess compliance and contact
he used condoms 99% of the time        result was pending. Further serol-      tive.                                   notification. Serological follow-up
with anal sex.                         ogy for hepatitis A virus total anti-      We spoke with Simon and dis-         was scheduled six months post
   He was generally well. He had       body and syphilis, and a repeat         cussed the syphilis result and the      treatment for syphilis, to monitor
no side effects associated with        HIV Ab/Ag was collected.                current epidemic in homosexually        RPR drop and for post-window-
PEP. He reported he had been              Simon was treated with antiviral     active men. As Simon’s last nega-       period HIV testing. Simon was
exposed to hepatitis B in the past     medication for first-episode genital    tive syphilis test was two years        referred to the sexual health coun-
but was unsure of his hepatitis A      herpes. He was counselled regard-       ago, he was diagnosed with early        sellor to explore risk-taking
status. Simon injected ampheta-        ing HIV:                                syphilis, the perianal ulcers a pos-    behaviour and injecting drug use
mines every few months and             • Previous risks and the possibility    sible atypical presentation of pri-     harm minimisation.                                             cont’d page 28

                                                                                                                         30 October 2009 | Australian Doctor |   27

     GP’s contribution
                                      KEESHA, 32, is well, new to                                                                                     syphilis serology profile will           aware of her results and test
                                      the practice and attending                                                                                      give an indication of dura-              the infant as required.
                                      for antenatal care. She has                                                                                     tion and stage of infection.
                                      lived in the local area for five                                                                                                                         The situation has significant
                                      years since relocating from                                                                                     What treatment is indicated              implications for the relation-
                                      the NT, where she grew up                                                                                       in the first trimester of preg-          ship at a time when they are
                                      within a mining family. She                                                                                     nancy and how should this                already facing the challenges
         DR SUE PAGE                  is fully vaccinated and has                                                                                     be followed up in later preg-            of a first child. How is con-
        Lennox Head, NSW              no past history of note,                                                                                        nancy? Does the infant need              tact tracing best managed
                                      other than having had glan-                                                                                     testing?                                 and whose responsibility is
                                      dular fever about six months                                                                                       Treatment will depend                 it?
                                      ago.                               ling a lot with work and has        any correlation with the                 upon the stage of infection.                Contact tracing will need
                                         Her first trimester screen-     had a number of recent trips        recent glandular fever? How              Regardless of stage however,             to be approached with deli-
                                      ing tests were arranged by         to south-east Asia.                 could the result be con-                 a penicillin-based therapy is            cacy. Keesha should be
                                      your partner just before he                                            firmed?                                  recommended. While some                  counselled as to all the vari-
                                      left on holiday, and she has       Questions for the author               An isolated TPHA may be               argue that procaine penicillin           ous possibilities the results
                                      returned today to you for          What is the potential for           a false-positive reaction. The           is first-line in pregnancy               may represent, and the risks
                                      the results. Her TPHA test         contracting syphilis despite        result may be confirmed                  because of placental trans-              of reinfection to herself and
                                      is recorded as “reactive”.         use of condoms?                     with further serology, includ-           fer, benzathine penicillin may           her pregnancy. Depending
                                         After discussing the result       Condoms are not 100%              ing both treponemal-specific             be preferred in women for                upon her childhood and
                                      there is a period of stunned       protective against syphilis         (FTA-Abs, EIA) and non-                  whom compliance may be                   experience in the NT,
                                      silence. This is Keesha’s first    infection. Condoms will only        specific (RPR or VDRL) test-             an issue.                                syphilis of unknown dura-
                                      pregnancy and she is now at        cover the penile shaft and,         ing. The non-specific tests                 If Keesha is treated at 12            tion, for example, may have
                                      12 weeks’ gestation. She           as syphilitic lesions (primary      will also give an indication             weeks’ gestation there is                been endemically acquired
                                      cannot remember being              chancre, condylomata lata,          of the stage of the syphilis.            little risk to the infant; how-          from childhood and not sex-
                                      tested for STIs before. She        secondary syphilitic rash,                                                   ever, although rare, cases of            ually transmitted.
                                      admits to having had a             mucous patches, etc.) may           Is there any way to deter-               congenital syphilis have been               It is the diagnosing clini-
                                      couple of different partners       occur in other genital and          mine the duration and stag-              reported even in women                   cian’s responsibility to initi-
                                      in her early 20s but is            non-genital areas, they are         ing of the illness?                      who have undergone recom-                ate contact tracing; however,
                                      adamant they always used           not 100% protective.                  Good sexual history, and               mended treatment regimens.               this is best managed in con-
                                      condoms. She immediately                                               examination to elicit any                Reinfection may also be a                sultation with Keesha and
                                      questions her husband’s            Is it possible this is a false-     signs or symptoms of                     risk. The clinician attending            may be done anonymously
                                      fidelity. He has been travel-      positive result and is there        syphilis together with full              Keesha’s delivery should be              if she feels the need.

                                How to Treat Quiz                                                            Complete this quiz online and fill in the GP evaluation form to earn 2 CPD or PDP points. We no longer accept quizzes
                                                                                                             by post or fax.
                                                                                                             The mark required to obtain points is 80%. Please note that some questions have more than one correct answer.

                                Managing STIs — 30 October 2009                                               ONLINE ONLY
                                                                                                     for immediate feedback

 1. Which TWO statements about testing for              c) False-positives do not occur with PCR testing        all suspected first episodes of genital                      does not occur
 chlamydia are correct?                                    for gonorrhoea                                       herpes                                                    b) All treatments for genital warts are
 a) PCR testing is both highly specific and             d) First-line treatment for gonorrhoea is            b) Both viral shedding frequency and                            associated with recurrence
    sensitive for chlamydia                                ciprofloxacin 500mg stat                             recurrence rates are highest in the 6-12                  c) Podophyllotoxin is not suitable for self-
 b) Self-collected vaginal swabs are inferior to                                                                months after infection                                       administered home treatment of anogenital
    clinician-collected endocervical swabs for          4. Which TWO statements are correct?                 c) Episodic treatment of outbreaks requires a                   warts
    detecting chlamydia                                 a) Enteric organisms are a common cause of              minimum of five days’ therapy                             d) Surgical excision may be helpful for large
 c) Chlamydia serology is useful when there is             epididymo-orchitis in heterosexual men under      d) Risk of transmission of genital herpes in the                pedunculated warts
    any doubt about the diagnosis of genital               35                                                   absence of medication is estimated at 30%
    chlamydia infection                                 b) There are no significant sequelae if non-            per annum in HSV-2-serodiscordant                         9. Which TWO statements about bacterial
 d) If lymphogranuloma venereum (LGV) is                   gonococcal urethritis (NGU) goes untreated           monogamous couples                                        vaginosis are correct?
    suspected, genotype testing of Chlamydia            c) Gonorrhoea and chlamydia are the cause of                                                                      a) Typical symptoms of bacterial vaginosis are
    trachomatis must be requested                          30-50% of PID in young women                      7. Which TWO statements about syphilis                          increased vaginal discharge, fishy odour
                                                        d) Treatment should be started presumptively in      testing are correct?                                            and irritation
 2. Which TWO statements about treatment of                suspected PID                                     a) The non-treponemal tests — rapid plasma                   b) Bacterial vaginosis is characterised by a
 chlamydia are correct?                                                                                         reagin (RPR) and venereal disease research                   decrease in vaginal pH
 a) First-line treatment for uncomplicated urethral     5. Which TWO statements about genital                   laboratory (VDRL) tests — serve as markers                c) Amsel’s criteria include the presence of
    and cervical chlamydia infections is                herpes simplex virus (HSV) infection are                of infectivity and re-infection                              clue cells on microscopy
    azithromycin 1g stat                                correct?                                             b) Treponemal-specific tests — Treponema                     d) Recurrence of bacterial vaginosis after
 b) Patients should abstain from sexual contact         a) Direct detection swab tests (PCR, culture and        pallidum particle/haem agglutination                         adequate treatment is uncommon
    for one week after treatment of chlamydia              immunofluorescence) are preferred for                (TPPA/TPHA) tests, and fluorescent
 c) Test of cure is routinely recommended in all           diagnosis of genital HSV infection                   treponemal antibody absorption test (FTA-                 10. Which TWO statements about
    patients who have been treated for chlamydia        b) Culture remains the gold standard test for           Abs) — are used for diagnostic                            trichomoniasis are correct?
    infection                                              genital HSV infection                                confirmation                                              a) Clinical features of trichomoniasis may
 d) A positive nucleic acid amplification test          c) Type-specific HSV serology may be useful if       c) The non-treponemal tests are 100%                            include a ‘strawberry’ cervix or colpitis
    (NAAT) three weeks after treatment for                 herpes is suspected but repeat swabs remain          specific for syphilis                                        macularis
    chlamydia indicates a failure of treatment             negative                                          d) For a patient presenting with a suspected                 b) Trichomoniasis does not cause any
                                                        d) The window period for HSV serology is up to          primary chancre, a swab for dark ground                      symptoms in men
 3. Which TWO statements about gonorrhoea                  two weeks                                            microscopy remains the test of choice                     c) Microscopy of a wet preparation and
 are correct?                                                                                                                                                                culture are the most sensitive tests for
 a) Gonorrhoea PCR is only validated for urine,         6. Which TWO statements about genital                8. Which TWO statements about genital                           trichomonas
    urethra and cervical samples                        herpes are correct?                                  warts are correct?                                           d) The treatment of trichomoniasis is
 b) Culture for gonorrhoea offers 100% specificity      a) Presumptive treatment is recommended for          a) Spontaneous regression of genital warts                      metronidazole 2g stat

 The RACGP now requires that a brief GP evaluation form be completed with every quiz to obtain category 2 CPD or PDP points for the 2008-10 triennium. You
 can complete this online along with the quiz at Because this is a requirement, we are no longer able to accept the quiz by post            HOW TO TREAT Editor: Dr Wendy Morgan
 or fax. However, we have included the quiz questions here for those who like to prepare the answers before completing the quiz online.                                  Co-ordinator: Julian McAllan
                                                                                                                                                                         Quiz: Dr Wendy Morgan

 NEXT WEEK The next How to Treat looks at the latest in management of the menopause. The authors are Dr Amanda Vincent, consultant endocrinologist, menopause unit, Southern Health, Clayton, and
 research fellow, Jean Hailes Foundation Research Centre, Monash University, Clayton, Victoria; and Professor Henry Burger, consultant endocrinologist, Jean Hailes Foundation, Clayton, and emeritus
 director, Prince Henry’s Institute, Clayton, Victoria.

28   | Australian Doctor | 30 October 2009                                          

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