[Question #8493] unprotected vaginal sex and fellatio

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43 months ago
Hello, I am a female in the US and had unprotected vaginal sex and gave unprotected fellatio to a male of unknown std/sti status. I am very confused and anxious as to which tests to get done to not put my usual partner at risk for any std/sti's. I would like to know what std/sti testing I should have done before resuming unprotected sex with my long-term partner and when to have them done. Which std's can infect the throat and which tests should I get done? I read about some std's such as trich, lgv, and mycoplasma genitalium, can these infect the mouth? Should I be concerned about chancroids? I also plan on having children in the future and would like to know which std's cause PID, so I can be tested. Many thanks in advance. 
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H. Hunter Handsfield, MD
43 months ago
Welcome and happy new year. Thanks for your question.

In general, testing after any single sexual exposure should be quite limited. Many (sometimes most) tests in the various online "comprehensive" panels are entirely unnecessary, or use tests that are not highly reliable. In addition, for most STIs the risk of infection after only one exposure is quite low It would be reasonable for you to have a vaginal swab (or urine) test for gonorrhea and chlamydia and a throat swab for gonorrhea. (Almost all labs automatically test for chlamydia along with gonorrhea, but oral chlamydia is rare and testing really isn't necessary -- but you can expect it to be done. Gonorrhea/chlamydia testing is valid any time more than 4-5 days after exposure. Optionally you also could have blood tests for syphilis and HIV, which achieve 100% accuracy at 6 weeks. (You can test earlier, but if tested at all, it should also include 6 week tests.) 

Chancroid doesn't currently exist in the US, and there is no test for it anyway. LGV is a form of chlamydia -- the standard chlamydia tests detect LGV, and a negative result will prove you don't have it. Vaginal trichomonas is possible but probably very rare after any single exposure. But you could include a urine or vaginal swab test if you wish. If so, be sure it's a DNA test (i.e. PCR), not culture or a microscopical test of vaginal fluid (these miss half of all infections). M genitalium testing is not recommended or done routinely except in special circumstances -- but here too, if you find a provider or lab that includes M gen testing, a vaginal swab test could be done for reassurance. Oral infection doesn't occur with M genitalium or trichomonas, and no oral tests for them have been validated.

Chlamydia and gonorrhea are the only proved causes of sexually acquired PID and are the only tests needed for PID prevention. (The jury is still out on M genitalium and PID; but as already stated, it's fine to be tested if offered by the doctor or lab that you use.

We recommend against testing asymptomatic persons for HSV, viral hepatitis, CMV, EBV, or HTLV (sometimes offered in comprehensive panels), especially after a single exposure. The risk is low for all of these, and the test results -- whether positive or negative -- often are unreliable. There is no test for HPV, except in conjunction with Pap smears -- but there is no need of Pap smear just because of a new sexual exposure. 

Women in this situation should see a knowledgeable physician, i.e. not rely on self-selected testing through a laboratory. Personal exam for vaginal discharge, genital lesions, and so on is an important part of STI screening.

Finally, an alternative or additional approach is to speak with your partner and ask him to be tested for common STIs. You may find he is as concerned as you are, and simultaneous mutual testing can be very reassuring. For example, if you both test negative now for HIV and syphilis, you'll know you could not have been infected, with no need to wait 6 weeks for conclusive results.

I hope these comments are helpful to you. Let me know if anything isn't clear.

HHH, MD
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43 months ago
Thank you for your reply, this helps incredibly. I will be seeing my gynecologist this week. I understand that hepatitis risk was low, but am still a bit concerned. Is this type of exposure ofrisk for Hepatitis A, B, C and/or E? If so, when would results be conclusive? And lastly should I test for scabies and crabs, or are they diagnosed when symptoms are present? Please excuse my many questions as I am very regretful and anxious. Thank you.
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H. Hunter Handsfield, MD
43 months ago
I have to apologize. I don't know how or why I missed this follow-up question for a full two weeks. I'm really sorry. I hope you see this.

Despite common statements in STI education materials and the media about sexual transmission of viral hepatitis, it's really quite uncommon, especially in men having sex with women and vice versa. Hepatitis B virus (HBV) is commonly transmitted sexually in men who have sex with men (MSM). However, it is becoming quite rare since childhood immunization against HBV became the norm in the past 15-20 years. And for that reason as well, even the frequency of heterosexual transmission has declined. If you were vaccinated, for sure you are not at risk. Hepatitis C virus actually is not appropriately considered an STD in heterosexuals:  sexual transmission is extremely rare, except in MSM who participate in potentially traumatic anal sex practices, and then the risk is because of exposure to blood, not genital or anal fluids. For hepatitis A, there is no chronic carrier state -- so that outwardly healthy persons (i.e. without hepatitis) virtually never are infected and therefore do not transmit it, sexually or otherwise. There are few data about hepatitis E (or D, which you don't mention), but they probably are transmitted primarily in MSM as well and rarely in heterosexual relationships.  Finally, the risk of scabies or pubic lice (crabs) is low -- and as you suggest yourself, there are no screening tests in absence of symptoms.

By now you probably have seen your gynecologist. I apologize again for this long delayed reply -- I hope you see it. Let me know if you have any further questions. 
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42 months ago
No worries. I see that my gynecologist ordered the trichomoniasis vaginalis cv/tv test and the syphilis rpr. Are these two accurate and conclusive after 6 weeks? Thank you.
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H. Hunter Handsfield, MD
42 months ago
I'm not sure I understand "cv/tv test" for trichomonas. If it was a test for trich DNA (i.e. PCR or similar technology), a negative result is conclusive. In contrast, trich culture misses at least half of all infections.

Negative RPR at 6 weeks is conclusive in ruling out syphilis.
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