Vaginal atrophy and genital pain in women on depot medroxyprogesterone acetate contraceptive injection.

Depot medroxyprogesterone acetate causes a hypo-estrogenic state in over half of users although clinical vaginal atrophy causing superficial dyspareunia is thought rarely to occur. This is a case series of ten women using depot medroxyprogesterone acetate who presented with superficial dyspareunia and clinical vaginal atrophy. The women were treated with vaginal estriol cream and their contraception was discontinued or changed. All patients had either a complete resolution of symptoms or a substantial improvement at follow-up, and the clinical and laboratory findings of vaginal atrophy had resolved. This case series demonstrates that vaginal atrophy may occur more frequently than previously thought.

Demographics of New Zealand women with vulval lichen sclerosus: is specialist care equitable?

AIM: Vulval lichen sclerosus is an inflammatory genital skin condition associated with poor quality of life, sexual dysfunction and risk of squamous cell carcinoma. The aim of this study was to document the demographics of women with lichen sclerosus seen at specialist vulval clinics. METHOD: We performed a retrospective review of women with lichen sclerosus seen at a tertiary combined gynaecology/dermatology vulval clinic over 12 months and Auckland Regional sexual health vulval clinics over five years. Data were collected for age, ethnicity, skin biopsy, treatment, referral source and time from symptom onset to diagnosis. Ethnicity was compared with Census data for the Auckland region. DISCUSSION: Three hundred and thirty-five women were included; 273 from the gynaecology/dermatology clinic and 62 from sexual health. Women seen at sexual health were younger than those seen by gynaecology/dermatology (mean age 45 and 64, respectively; p<0.0001). Most referrals were from general practitioners (54%), although self-referrals made up 42% of sexual health consultations. The most common ethnicity was European (82%) followed by Asian (10%), Maori (4%) and Pacific Peoples (3%). Compared with Census data, European women were over-represented and Maori, Pacific and Asian women were under-represented. CONCLUSION: We found inequitable ethnic representation of women with vulval lichen sclerosus seen at our institution. Causes may include sociocultural beliefs, variations in access to care or ethnic differences in the prevalence of lichen sclerosus. A deeper understanding of underlying issues would enable planning of initiatives to ensure equitable access to specialist care for all New Zealand women with vulval conditions.

Trends in genital warts diagnoses in New Zealand five years following the quadrivalent human papillomavirus vaccine introduction.

AIM: To investigate whether changes in rates of genital warts diagnosis at Auckland Sexual Health Service (ASHS), pre and post the quadrivalent human papillomavirus (4vHPV) vaccine introduction in late 2008, differed between clients vaccine-eligible and not eligible. METHOD: All new clients attending ASHS from 2007 to 2013 were categorised as having genital warts or not. Generalised linear mixed models were used to compare differences in rates of change in diagnoses. RESULTS: Overall, 43,480 were seen with genital warts diagnosed in 13.1%. The difference in rate of change over time in diagnosis pre- to post-vaccine differed in females vaccine-eligible to not (p=0.004). The relative risk of diagnosis per year pre-vaccine was 0.98 (0.84, 1.13) and post-vaccine 0.77 (0.74, 0.81) in those eligible compared to 0.87 (0.80, 0.95) and 0.95 (0.91, 0.98), respectively, in those not eligible. This difference in change, between vaccine eligible or not, differed between males and females (p=0.02), with males considered eligible if the same aged female would have been. In males, no difference in rate change pre- to post-vaccine could be shown in those eligible or not (p=0.53). CONCLUSION: In this study a population effect for women of the 4vHPV vaccine was demonstrated.

A case series of young women with spontaneous regression of vulval intraepithelial neoplasia: Demographics and associated HPV genotypes.

OBJECTIVE: To review the clinical features, demography and human papillomavirus (HPV) genotype in a group of young women with usual type vulval intraepithelial neoplasia (VIN) whose lesions regressed spontaneously. MATERIALS AND METHODS: A retrospective case note review was made of the records of women with a diagnosis of usual type VIN whose lesions resolved spontaneously. The clinical features, demography, associated conditions, time to regression and follow-up data were extracted. Stored paraffin-embedded biopsy tissue was tested for the presence and genotype of HPV. RESULTS: Fifty-four women were identified. The median age at diagnosis was 19 years. Forty-four women (81%) were of non-European ethnicity. The median time to regression was 9 months. In 44 (81%) cases, the lesion was an incidental finding during clinical examination. The majority of lesions were multifocal and pigmented (44 (81%) and 48 (89%), respectively). HPV was detected in 40 (87%) of the 46 available biopsy samples, and HPV genotype 16 was identified in 33 (82.5%). Recurrences of usual type VIN occurred in three women, and these all resolved spontaneously. CONCLUSION: Women diagnosed with usual type VIN which resolves spontaneously are very young, mainly non-European, and usually present with multiple, asymptomatic pigmented lesions. HPV genotypes and their frequencies are similar to those detected in older women with usual type VIN. This clinically defined group of women may be managed by observation alone if follow-up is assured.

Enhanced surveillance of infectious syphilis in New Zealand sexual health clinics.

Following a rise in cases of infectious syphilis in New Zealand, national enhanced surveillance at sexual health clinics was initiated. All public sexual health clinics reported monthly on the number of cases seen, and completed a coded questionnaire on each case. Monthly reports to routine surveillance were compared and discrepancies reconciled. During 2011, 72 cases of infectious syphilis were reported. The majority (83%) were among men who have sex with men who were mainly infected in New Zealand and had an ethnic profile similar to all New Zealanders. Most heterosexual infections occurred overseas, among people of non-European non-Maori ethnicity. About half the cases had symptoms on presentation. Overall, 18% of men who have sex with men were HIV positive. Resurgent syphilis in New Zealand disproportionally affects men who have sex with men, amongst whom HIV is prevalent. Men who have sex with men should be aware of the risks and symptoms of syphilis and encouraged to have regular sexual health checks including serology testing. Control of syphilis should be included in the strategy to check HIV spread. Syphilis serology should continue to be part of routine immigration and antenatal screening, and where clinically indicated. Enhanced surveillance was easily initiated for an uncommon condition seen at sexual health clinics, and provided valuable information.

Impact of the human papillomavirus (HPV) vaccine on genital wart diagnoses at Auckland Sexual Health Services.

AIM: To review cases of genital warts diagnosed at Auckland Sexual Health Service (ASHS) and to document any change following the introduction of the human papillomavirus (HPV) vaccination. The national HPV immunisation programme, using the quadrivalent vaccine Gardasil, commenced on 1 September 2008. The publically funded programme provides for the ongoing vaccination of girls in year 8 with an initial catch-up programme for young women born after 1 January 1990 until the end of 2010. Monitoring rates of diagnosis of genital warts should provide the earliest clinical indicator of a population response to the vaccine. METHOD: The proportion of new clients attending ASHS who were diagnosed with genital warts from 1 January 2007 to 31 December 2008 was compared to the proportion diagnosed from 1 January 2009 to 30 June 2010. RESULTS: 40,793 new clients attended the ASHS between 2007 and June 2010 and genital warts were diagnosed in 3125 (7.7%). Genital warts were diagnosed in 9.2% of new clients in 2007 decreasing to 6.6% for the first 6 months of 2010. Analysis of the subgroup of clients under the age of 20 years, found genital warts in males decreased from 11.5% in 2007 to 6.9% in 2010 while in females the rates decreased from 13.7% to 5.1% over the same time period. In comparison, the rates decreased from 7.5% in 2007 to 5.9% in 2010 for females aged 20 years and over. Thus there was evidence of a significant difference, in the pre to post vaccination era, in the proportion of female clinic visits for genital warts in those aged less than 20 years and those aged 21 years or older (p=0.02) and further a borderline significant difference for males aged less than 20 years (p=0.05). CONCLUSION: A significant decline in the incidence of genital warts in the target population suggests an early response to the HPV vaccination programme with some evidence of an effect for males aged less than 20 years.

Topical imiquimod treatment of aciclovir-resistant herpes simplex disease: case series and literature review.

Infection with herpes simplex virus (HSV) is extremely common worldwide. In immunocompromised patients anogenital HSV disease may have atypical features and may be very severe. Treatment of aciclovir-resistant anogenital HSV disease is challenging, as resistance to alternative treatments may occur, and effective treatment generally involves intravenous therapy with relatively toxic agents such as foscarnet. This case report presents three immunocompromised patients with presumed aciclovir-resistant anogenital HSV disease who were successfully treated with topical imiquimod. Imiquimod promotes local immune activation, which results in resolution of viral lesions such as anogenital warts and HSV disease. It is convenient to use and avoids the necessity for intravenous treatment with substantial systemic toxicity. In addition, as the mode of action of imiquimod is related to immune stimulation rather than direct antiviral activity, it may be used repeatedly without resistance developing.

Prevalence of sexually transmitted infections in men who have sex with men presenting to Auckland Sexual Health Service.

AIM: Reported incidence of HIV infection and infectious syphilis in New Zealand has been increasing in recent years in men who have sex with men (MSM) but there is no recent published data about prevalence of other sexually transmitted infections (STIs) in this group. Therefore we decided to collect data on prevalent STIs and possible risk factors in a sample of MSM presenting to Auckland Sexual Health Service (ASHS). METHOD: All MSM presenting to ASHS during the study period were eligible for enrollment. Data on demographics, sexual behaviour, use of recreational drugs and STI diagnoses was collected and entered into a data collection form after verbal consent was obtained. RESULTS: Eighty-seven men participated in the survey. A third of the men were symptomatic (n=26) and 44% (n=38) were diagnosed with a new STI including 2 with infectious syphilis and 3 with HIV. The Internet (65%) was the most common method used for meeting sex partners (n=55) and 46% of men (n=37) reported use of recreational drugs within the previous 6 months. Sixty percent (n=52) of men reported more than 5 sexual partners within the previous 6 months and 52% were engaging in concurrent sexual partnerships with both casual and regular partners(n=45). Participants were more likely to use condoms for insertive and receptive anal sex with casual than with regular partners (p=0.0004, p=0.005), however a history of consistent condom use did not rule out diagnosis with a new STI or HIV. CONCLUSION: There was a high prevalence of STIs (44%) in this sample of MSM presenting to a sexual health clinic. Many were presenting with problems rather than attending for routine screening. Possible explanations for the high STI rate include high rates of concurrent sexual partnerships (52%), lower rates of consistent condom use within relationships and use of recreational drugs. Internet use was a common method for meeting sex partners and offers future potential for health promotion interventions for MSM. STI screening should be regularly offered to sexually active MSM regardless of whether they report consistent condom use.

Audit of cervical screening in women with HIV infection in the Auckland and Northland regions of New Zealand.

AIM: We aimed to review our current cohort of women with HIV infection to document the number of women who had received a yearly cervical smear since their diagnosis of HIV infection and the number of women who were likely to have had undiagnosed HIV infection at the time of their first abnormal cervical smear. METHOD: This audit was a retrospective review of the cervical smear history of all adult women (> or =16 years) with HIV infection who were under active follow-up by the Infectious Diseases and Sexual Health Services at Auckland City Hospital on 31 December 2007. RESULTS: Sixty-nine of the 123 (56%) women in this audit met the definition for yearly cervical smears. The factor associated with not receiving yearly cervical smears was women who had received cervical smears from their general practitioner (GP). Taking into account the women's CD4 count at the time of the diagnosis of their HIV infection, it is very likely that seven women had undiagnosed HIV infection at the time of their first abnormal cervical smear. CONCLUSION: The proportion of women with HIV infection in the Auckland and Northland regions who received a yearly cervical smear during the audit period was low. We have put a number of interventions in place that we expect will improve this rate. These interventions include informing GPs of the need for yearly cervical smears for women with HIV infection, informing the National Cervical Screening Unit that these women are immunocompromised which will result in a yearly recall comment and informing these women of options for obtaining a cervical smear at little or no cost. Cervical smear takers should consider offering an HIV test to all women with an abnormal cervical smear who have resided in areas with high rates of HIV infection.

Increase in incidence of infectious syphilis in Auckland, New Zealand: results from an enhanced surveillance survey.

We instigated an enhanced voluntary surveillance system to determine the epidemiology of infectious syphilis in Auckland because it is not a notifiable condition. The study took place over a 12-month period from July 2006 to July 2007. We identified 92 cases of infectious syphilis, of which 71 were male (77%). Forty-four (48%) cases were in men who have sex with men, who made up the biggest proportion. Forty-eight cases (52%) acquired their infection in New Zealand and only 48 of all identified cases were symptomatic (52%). Our results confirm that infectious syphilis incidence is currently under-reported.

Risk factors and characteristics of patients with gonorrhoea presenting to Auckland Sexual Health Service, New Zealand.

AIMS: A case-control study of patients with gonorrhoea presenting to Auckland Sexual Health Service was carried out to determine specific risk factors and to look more closely at the transmission of ciprofloxacin-resistant Neisseria gonorrhoeae in the Auckland region. METHODS: Patients who tested positive for gonorrhoea during a 6-month time period from September 2003 till March 2004 were included in the study. A control group was selected from patients who presented during the same time period but who had negative sexually transmitted infection (STI) screens. A selection of N. gonorrhoeae isolates were sent to ESR for typing by pulsed-field gel electrophoresis (PFGE). RESULTS: 204 cases of gonorrhoea were identified during the study period; 50% of the diagnosed cases were in people aged less than 26 years. Gonococcal infection was strongly associated with being of either Maori or Pacific ethnicity (p<0.001). A history of consistent condom use was found to lower the risk of acquisition of gonorrhoea (p=0.009). Thirty-three percent of cases had ciprofloxacin-resistant gonococcal infection and the majority of these acquired their infection in New Zealand (88%). Comparison of PFGE genotyping data with results from an audit in 2001 indicated that genetic diversity amongst ciprofloxacin-resistant isolates has increased significantly. CONCLUSION: The incidence of gonorrhoea in the Auckland population is steadily rising, with the main risk factors being age under 25 and being of Maori or Pacific ethnicity. Genetic diversity amongst ciprofloxacin-resistant isolates is increasing, thus indicating high levels of endemic infection. Urgent action needs to be taken to control the current gonorrhoea epidemic in Auckland and more research is required to investigate reasons for ethnic differences in disease incidence.