Phelps Health Physicians Discuss Sexually Transmitted Diseases (STDs)

Paige Heitman, director of marketing at Phelps Health, talks with Phelps Health physicians Nathan Ratchford, MD, a gynecologist, and Cory Offutt, MD, a family medicine doctor, about sexually transmitted diseases (STDs), or sexually transmitted infections (STIs) on The Scope at Night podcast.

Paige Heitman: I'd like to go ahead and introduce our two guests tonight: Dr. Nathan Ratchford, chief medical officer of Phelps Health Hospital and a gynecologist with Phelps Health, and Dr. Cory Offutt, one of our primary care providers at Phelps Health as well. We're really excited to have both of you here. Today, we are talking about STDs, which is a taboo topic, and we're super excited to have this conversation with everybody. Just to kick us off, what is an STD?

Dr. Nathan Ratchford: Actually the current nomenclature that we use for this is sexually transmitted infections [STIs]. It was STDs whenever I was in training. I don't know when that changed, but we currently call them sexually transmitted infections. Basically, these are typically bacterial or viral infections that are passed through sexual intercourse. As we're going to discuss, some of them don't have any symptoms, and some do. Some can cause other health concerns. I know it's a sensitive topic to discuss, but it’s definitely an important one.

Paige: Dr. Offutt, what are some of the most common STDs and their risks?

Dr. Cory Offutt: Some of the most common STDs out there are going to be gonorrhea and chlamydia. Genital herpes is also one of the more common ones. I would say also HPV [human papillomavirus] is a fairly common STD, as well. All of them can be tested for, which we'll get into later, but they all have their own unique risks. Some are curable; some are not. Some cause fertility issues, and some of them can lead to certain types of cancers. HPV can lead to cervical cancer. Some of them are just extremely painful and can be spread more easily.

Paige: I love asking this question because I have a sibling who gets cold sores pretty often. Are cold sores an STD?

Dr. Ratchford: Well, cold sores are caused by an HSV virus. Historically, we've thought of HSV-1 as an oral virus that is passed with skin-to-skin contact from one person to another. We're talking about kissing, for example. And then HSV-2, historically, was thought to cause similar lesions –  what people are familiar with when they see cold sores on a mouth [rather] than in the genital area. Over time, that distinction has become less important, and to be frank, with modern sexual practices, with skin-on-skin contact on different parts of the body, you can get HSV-1 or 2 in either of those areas. So I would give this question a solid yes and no. It is a sexually transmitted infection in that it can be passed with sexual intercourse, but it doesn't necessarily require intercourse. It's really that skin-to-skin contact.

Paige: So be careful when you're kissing is what I'm getting from that.

Dr. Ratchford: Definitely. When somebody has a cold sore, that's when they're most contagious. Their viral load is the highest, and the lesion that you see on their lips is where the virus is actually at. But even when somebody doesn't have an active herpes lesion, they can still be contagious. Their viral load is just a lot less. If you're somebody who is prone to getting cold sores and you are intimate with somebody who does not get cold sores or has never been exposed to HSV, you would definitely want to avoid that skin-on-skin contact when you actually have an active lesion.

Paige: Great advice. Dr. Offutt, anything to add to that?

Dr. Offutt: One thing to also keep in mind is that you don't always have to have the active lesion. Sometimes you'll start to actually have symptoms prior to the lesion showing up and you are still very contagious during that period as well.

Paige: What are some of the symptoms that you’re talking about?

Dr. Offutt: Well, every patient's different. Sometimes it can just be like a tingling sensation. Sometimes it can be a burning sensation. Sometimes it can even show up as almost what looks like a pimple on the lip to start with and then it breaks out into more of the cold sore that we all have pretty much seen on multiple people whenever we're just walking around.

Paige: Great information. So a question for Dr. Offutt…how serious are STDs? Should someone be concerned if they have one? Let's say there's a person who has a cold sore and then maybe somebody who has something a little bit more severe.

Dr. Offutt: Like you alluded to, there are various STDs. Some of them are quite serious and some of them are not as serious, but they can all have their long-term complications that can be more permanent. Some of them are more permanent and some of them are curable. With the cold sores and the genital herpes, those are lifelong [conditions]. There's no actual cure for those. Even though you can treat the acute symptoms and get them to go away quicker, there's no actual cure for those. Now there are [treatments] for gonorrhea, chlamydia and things like that, but if left untreated or go on for a long enough period of time, they can lead to infertility issues or pelvic inflammatory disease. HIV [human immunodeficiency virus], which is much more serious, has no cure, but it can be easily treated. If you're on the proper medications, you can actually have a fairly normal, long life with a normal life expectancy. It just depends on the specific sexually transmitted disease that you're talking about, whether you should be concerned or not. If you ever have any symptoms, whatsoever, you definitely need to talk to either your OB/GYN or your primary care provider to get evaluated and treated.

Paige: How many people have STDs?

Dr. Offutt: In the United States, one in five people, per CDC [Centers for Disease Control and Prevention] information, actually has a sexually transmitted disease of some kind. So they're fairly common.

Paige: I think that destigmatizes [STDs] because more people have [STDs] than we think they do. Dr. Ratchford, is it true that only people with a lot of sexual partners get STDs?

Dr. Ratchford: No, that is definitely not true. Certainly, risky sexual behaviors make it more likely for somebody to have a sexually transmitted infection. For people who are exposed to more partners, if you're not using protection like condoms, for example, your risk of transmitting or acquiring an STD from somebody is definitely going to be higher. But honestly, it just takes one exposure to acquire an STD.

Paige: So definitely be careful. I heard you mention…that protection is really important. Making sure that you have condoms, making sure that you're protected and maybe even having a conversation with somebody who you might be sexually active with or even kissing [are important]. It might even be worth just asking them [about STDs].

Dr. Ratchford: Sure. As a gynecologist, I see a lot of adolescent women…younger girls who have not had intercourse for the first time yet. I phrase it in terms of who they're sharing their body with. I frequently tell patients, “Who you share your body with can have health implications for basically the rest of your life.” And we've all been there. Relationships – they can be tough sometimes; they can be interesting. Especially for teens, the hormones are going and it feels like a natural thing. It's something you want to pursue. But that frank discussion about the possible consequences from their actions, that's important for patients to hear.

Paige: Well, I agree. Dr. Offutt, were you going to say something, too?

Dr. Offutt: Yeah. One thing that people really should keep in mind, too, is [that with] oral sex, [STDs] can also be easily transmitted. Different STDs, including gonorrhea, chlamydia and even genital herpes, can be spread via oral sex. Using protection or a barrier contraception of some kind during oral sex is extremely important in preventing STDs.

Paige: I think that's great advice. I think we have to continue to have these conversations. That way, people, even if they're younger people, feel comfortable having these types of conversations with their partner in whatever format they choose. Can a person have an STD and not know it?

Dr. Offutt: A lot of STDs are actually asymptomatic. The most common asymptomatic STD that I could think of would probably be HPV. There's really no symptoms of HPV until something happens, [such as] if a woman develops cervical cancer. You can have multiple STDs, [which] actually can be present without you having symptoms – particularly, in males. Males, a lot of times, won't have any symptoms, whereas females are more likely to have symptoms of certain ones. Gonorrhea and chlamydia are probably the two more common, well-known [STDs], but then there's also trichomoniasis that has pretty significant symptoms that a lot of women will have, but men won't have any symptoms of.

Paige: What's the difference between men and women and their symptoms? Why is there a variance in that?

Dr. Offutt: It depends on their physiology. Women are constantly producing a lot more cervical mucus and vaginal lubrication. And then women also are more prone to have pain and burning with urination, just because of anatomy, with shorter urethras.

Paige: Great information. Dr. Ratchford, can a person contract an STD from a tattoo or a body piercing?

Dr. Ratchford: Yeah, definitely you can. That's why it's important that if you're going to seek out a piercing or tattoo, you want to go to a reputable location that's using sterile and safe practices.

Paige: I love hearing you say that because I'm somebody that has a couple of tattoos, and one of the things I think is really important to know is if they're opening up stuff, make sure it's in front of you, so you know that it's fresh, it's clean and it's been sanitized. Don't let them do it in a backroom where you don't know what's going on.

Dr. Ratchford: They're piercing the barrier that you have with your skin. It'd be really no different than going to your doctor's office and them giving you a medicine or a vaccine of some kind. You would expect sterile precautions with that, and this would be no different.

Paige: Absolutely. Moving right along. What are the symptoms of STDs? What are some of those common symptoms that might prompt somebody to go and see their primary care provider?

Dr. Offutt: In males, [symptoms may include] pain and burning with urination and redness around the urethra. Urethral discharge is fairly common in a lot of the STDs in males, as well. If it's left untreated long enough, you can actually get testicular pain and swelling, leading to epididymitis, which is a little bit harder to treat, but it's still very treatable depending on the STD that's causing it. With females, [symptoms may include] vaginal discharge, pain and burning with urination and sometimes vaginal bleeding, depending on the severity of the inflammation in the vagina as well as different vaginal odors, depending on which STD it is.

Paige: Can you explain, in more detail, what epididymitis is?

Dr. Offutt: So the epididymis is a small sac that sits on top of the testicle that houses the sperm and the seminal fluid. Basically, the infection can get into the epididymis and cause inflammation and a lot of pain.

Paige: That definitely sounds painful. Dr. Ratchford, how soon might symptoms of an STD appear?

Dr. Ratchford: It's going to be several days to weeks or months. My general advice to patients – when they might be in a new relationship or they may have a new partner – is if somebody does have a new partner, there really shouldn't be any stigma around getting checked. Depending on what the exposure was, or if there's some specific concern, there may be more testing they would have to do down the road because some of the viral infections, like hepatitis C or HIV, for example, might not actually show up on a blood test for months. But in general, if somebody had an exposure and they were concerned about something common, like chlamydia and gonorrhea, those are actually checked with DNA probes, which are extremely sensitive. You could test immediately for something like that, but somebody might not have symptoms for several days.

Paige: It's really important, again, like you said, to proactively have those conversations before you enter into any type of physical stuff. So, Dr. Offutt, are most STDs treatable?

Dr. Offutt: Some are; some aren't. Most are manageable, but they may not be curable. Like Dr. Ratchford had said, gonorrhea and chlamydia are both treatable and curable, whereas herpes and HIV are not curable, but they are manageable and can be suppressed with different medications to where you won't be able to detect the virus or have outbreaks of herpes. There are actually now cures for hepatitis C, which is a huge breakthrough. That's actually relatively recent. And by recent, I say in the last 10 to 15 years, it is recent in the medical field. Now, they are starting to, hopefully, find some potential cures for HIV as well, but there are medications that you can use to suppress the herpes virus…where you don't have frequent outbreaks and won't have such a high viral load to where you can spread it to others. Trichomoniasis is very treatable and curable. I am trying to think of any others that are common that we see. Can you think of any others, Dr. Ratchford?

Dr. Ratchford: Syphilis isn't common anymore, but it's treatable, as well.

Dr. Offutt: We are actually seeing more syphilis recently because penicillins aren't used as commonly anymore for ear infections and strep. People were incidentally getting treated with penicillins for a long time, whenever amoxicillin was so readily prescribed and penicillin was so readily prescribed. People were just having their syphilis treated without knowing it because they never have been symptomatic.

Paige: That's a good reason to go in and see your primary care provider. Do STDs cause infertility? And which ones cause it? What are the levels of infertility, Dr. Ratchford?

Dr. Ratchford: I can't speak for males, but for women, the big [cause of infertility] is going to be untreated chlamydia and gonorrhea infections, especially if someone has an infection that leads to what's called pelvic inflammatory disease, or PID, which is basically an infected fluid collection involving the fallopian tubes. [PID can be found in] the upper genital tract in a woman, and the damage, the inflammation and the scarring that you can get from that can damage the fallopian tubes, which can lead to infertility.

Paige: If someone has an STD and they are pregnant, how will the fetus be affected?

Dr. Ratchford: For most women who acquire an STD during pregnancy, the overwhelming majority have a healthy, normal pregnancy. However, certain infections, especially the viral infections, can cause severe issues with pregnancy. Especially if it's in the second trimester, [an STD] can cause fetal demise and birth defects. Part of routine care for obstetrical patients is to do an STD screening as part of the new OB visit. For somebody who's pregnant and is concerned that they might have been exposed, there's no harm at all in repeating that. I would definitely encourage somebody to speak to their OB provider if that's a concern.

Dr. Offutt: Toward the end of pregnancy, if they've had a history of herpes, [we might recommend that they start taking] prophylactic medicines to hopefully prevent an outbreak. If you have active lesions whenever you deliver vaginally, you can transmit it to the baby. I've actually seen somebody transmit herpes to a baby, and the baby ended up with herpes meningitis right after birth.

Paige: Wow. If someone has HPV, does that affect their ability to become pregnant or does that affect the fetus at all?

Dr. Ratchford: Not directly like what Dr. Offutt was talking about with herpes, but if someone does have HPV that has caused them to have an overwhelming burden of genital warts, that can cause an issue with either blocking the birth canal or if it's on their cervix, with their cervix dilating or just the structural changes in their cervix. HPV can also cause abnormal cervical cells and even cervical cancer, like Dr. Offutt had said earlier. It's important for women who are pregnant to be up-to-date on their cervical screening, because if somebody had a cervical lesion like that, that could also cause issues with the pregnancy.

Paige: Thanks so much for taking the time to the answer that. Moving right along, when should someone visit a doctor if they're concerned that they might have an STD?

Dr. Offutt: As soon as possible, particularly with herpes. If you think you might have herpes or even if you know you have a history of herpes and have a herpes outbreak, usually, you have to start on the medications to reduce the outbreak within 48 hours of the onset of symptoms. Even if you have the pre-symptoms of tingling, you can actually get started on the medications beforehand and hopefully even prevent the outbreak. I always recommend anybody who is sexually active to get routine screening if they're having more high-risk behaviors – if they're having multiple sexual partners or not using protection. Now, if you're in a monogamous relationship and you've had your testing at the start of your relationship…that's perfectly fine to not get yearly testing at that point or regular routine testing at that point. But if you're having multiple partners without protection, then I generally recommend routine screening.

Paige: Dr. Offutt, how often should somebody who is sexually active with lots of different partners go in and get screened? Whenever you say routinely, what do you mean?

Dr. Offutt: It depends on the behaviors, how many partners and how frequent you're changing partners. If you have a partner who has come to you and said that they had a previous positive test – if they came back and said, “Hey, I had chlamydia and I tested positive for chlamydia,” obviously, you should get in and get tested and treated appropriately. It depends on the person. I've had some people come in every six months to get tested because they're having regular frequent [sex with] different partners, and then I've had some people who will get tested just yearly.

Paige: Great information. So, let's say a person doesn't have a PCP established. Can they just go into an immediate care clinic every time they want to get tested, or should they really establish care with a primary care provider to begin that process?

Dr. Offutt: I always recommend having a primary care [provider], especially with COVID-19, because there were so many ERs and urgent cares and immediate cares just being overrun with four-, five- and six-hour waits at times because there weren't enough providers and nurses to manage the patient load. Having that follow-up for the repeat testing to make sure everything's cleared up is super important, so that's where primary care comes into play.

Paige: Thanks so much for answering that. Moving right along, do primary care doctors automatically screen or test for STDs in an annual wellness appointment?

Dr. Offutt: We ask about, at the annual wellness appointments, if [patients have] any concerns for any STDs and if they're having any risky sexual behaviors. Otherwise, we don't routinely screen, other than just asking to see if we need to go ahead and do testing for [STDs] or even recommend testing. All we can do is make recommendations. We can't actually make anybody do any particular screening.

Dr. Ratchford: I would agree. I think that asking about a patient's sexual behavior and assessing those risk factors – that's just due diligence. I don't think that a patient should automatically anticipate [STD screenings] when they go in for their regular yearly check-up, which may or may not involve a general exam. If they have an expectation that they're being tested for a sexually transmitted infection, they really need to come out and ask that to make sure that that's being done.

Dr. Offutt: I would say the only [STD screenings] that we probably routinely do would be the HPV testing, which is just [following guidelines].

Paige: Thanks, guys. Are STD appointments with the doctor confidential?

Dr. Ratchford: Every visit is confidential. Certainly, [we’re] trying to get away from the stigma of talking about sexually transmitted infections. For anybody out there who's concerned about that, there is nothing that your doctor has not heard before. No one is going to be talking about you or gossiping about this. I can tell you from my personal experience that if one of my patients I've known for years or if somebody who just came in off the street came in requesting to be evaluated for a sexually transmitted infection or even talk about risks, that's part of my job. Someone should have confidence that they're going to be treated with respect and it'll be a confidential discussion.

Dr. Offutt: Teenagers are probably one of the higher risk groups who are not likely to seek care because a lot of teenagers won't have those safe home environments to be able to come to their parents or to come to the doctors. Even those visits are actually kept confidential. If the teens decide that they don't want their parents to know about that visit, we actually can't divulge that information to the parents either if the teen specifically requests us not to.

Paige: I think that's really great information and a good resource to know about. What should people expect if they need to get tested for an STD? What does that process look like?

Dr. Offutt: Basically like a normal office visit. We'll go through all of the questions and everything else to figure out what kind of risky behaviors they're having, what symptoms they're having and why they're concerned about potentially having an STD. If they've been told that they've been exposed to a specific STD, that helps. A lot of times they'll just want to be tested for all of the more common STDs. Some of those would be a blood test, like with HIV and hepatitis. Many more can actually be a urine test, with the exception of HPV testing. With gonorrhea, chlamydia and trichomoniasis, those can all be tested from the urine. It just depends on what we're testing for and the depth of testing that we're doing.

Paige: So this next question, Dr. Ratchford, I think is a perfect segue. What happens if a person tests positive for an STD?

Dr. Ratchford: It's really going to depend on what the STD is. If it's something common and treatable, like chlamydia or gonorrhea, they should expect to have a prescription for some antibiotics that they're going to get. There may be some follow-up discussion about getting their partner or partners treated. If it's something like…HPV, for example…a lot of times…further testing [is required] to check for abnormal cervical cells. Another thing that needs to be discussed is if that person is contagious. We've talked about herpes lesions and how somebody might be contagious even if they don't have an active lesion. There's medicine that people can take to suppress the recurrence of outbreaks of those lesions. It also makes it less likely for them to transmit the virus to a partner, for example. There is really no one-size-fits-all [treatment]. It depends on what the actual infection is and what the patient's expected outcomes and what the relationship might be.

Paige: Absolutely. So, Dr. Offutt, why are STDs not something to be ashamed of?

Dr. Offutt: Because they're so common. I really wish people would just get rid of this stigma. It's no different than any other disease that you can acquire. There's just such a big stigma around them, but STDs are part of human life in general. A large majority of the people out there are having sex or will have sex at some point in their life. One in five Americans – that's a pretty high amount of people who actually have an active STD. A lot of them…don't even know it. By getting rid of that stigma, we could easily reduce that number. If people would just be more open and have a conversation with their partners about any STDs that they have and where they can take the proper precautions to hopefully prevent that transmission, it would help significantly and allow people to get treated.

Dr. Ratchford: I agree with everything Dr. Offutt just said, and I'd like to add that these infections don't care about your age or your gender, or your sexual practices, or your race, or anything that you could think of. These infections can really affect anyone.

Paige: I love that. So in the spirit of destigmatizing these types of conversations, you guys have mentioned “risky behavior” a few different times throughout the show tonight. Let's define what those risky behaviors are. Is it the type of sex that you're having or is it just the frequency of partners? What do you mean whenever you say risky behaviors?

Dr. Offutt: One would be not having that conversation with your partner. If you are not having those conversations or you're not asking, “Hey, have you ever had any STDs or do you have any symptoms?” that alone puts you at risk if you're not willing to have that conversation. Frequent sexual partners and not using protection are all very high-risk behaviors.

Dr. Ratchford: I would agree with that. Basically, [risky behaviors include] the more partners you have and not using protection. It’s a sad commentary, and there's actually been criminal cases with this, but there are people out there who have infections that intentionally have unprotected intercourse to get other people infected. All of these would fall under the umbrella of risky behaviors.

Paige: We've got one more question before we wrap up. How can someone avoid getting an STD?

Dr. Offutt: Basically, avoid those risky behaviors. Have those conversations. Use condoms. Use any kind of barrier or contraception. The most definitive way would be to avoid sexual activity.

Dr. Ratchford: I would also add, if you are in a new relationship and you have a new partner, don't be afraid to get tested. It's not something that should be viewed as a negative thing to do, and it's not pointing fingers or accusing your partner. I tell patients all the time, “Nobody's going to watch out after your health better than you, and staying informed and getting appropriate testing, that's going to help protect you."

Dr. Offutt: I've even had partners actually come in together, and both of them have an appointment at the same time, just so they could both get tested simultaneously.

Paige: I think that's fantastic.

Dr. Ratchford: Hey, Paige, we left out one really important thing earlier on when we were talking about HPV, which is HPV vaccination. For male and female patients older than age 9, there has been vaccination in place for HPV since the late 2000s. HPV, in addition to everything that we've talked about so far, is the type of infection that is preventable with a vaccination. So I would definitely encourage men and women to seek that out if it's appropriate.

Dr. Offutt: If the HPV vaccine is given [to adolescents] under the age of 14, then it's actually only a two-dose series instead of a three-dose series. Australia…actually implemented [the HPV vaccine] as one of the mandated vaccines, and they've almost completely eradicated cervical cancer in their entire country.

Paige: Wow, that's amazing. Thank you so much to everyone for tuning into The Scope at Night. A huge thank you for Dr. Ratchford and Dr. Offutt for joining us today to talk about this taboo topic. We do appreciate all of the insights that each of you have been able to share with our community. It also can be re-watched on our Facebook page and shared with family and friends who may have missed the show. If you liked the show and would like to know more, check out our other episodes of The Scope on YouTube. Have a great evening everyone, thanks so much.