Latest news with #medicalguidelines
Medscape
14-07-2025
- Health
- Medscape
Are You Asking These Seven Sexual Health Questions?
At the 2025 Argentine Society of Infectious Diseases (SADI) Congress held June 12-14 in Mar del Plata, Argentina, updated guidelines for the diagnosis and treatment of sexually transmitted infections (STIs) were presented. The chapter, developed by the HIV and STI Commission on a comprehensive approach to sexual health, offers step-by-step recommendations for taking a sexual history, designed for both specialist and primary care clinicians. Romina Mauas, MD, one of the chapter's authors, is an outpatient physician at Hospital de Infecciosas F.J. Muñiz and a researcher at the Center for Studies for the Prevention and Control of Communicable Diseases at ISALUD University, Buenos Aires, Argentina. 'This content is entirely new. This highlights the key questions that should never be missed when taking a medical history. It also promotes an inclusive, respectful environment free from stigma, prejudice, or moral judgment while protecting privacy, confidentiality, and individual rights,' she said. The chapter was co-authored with José Barletta, MD; Franco Bova, MD; Iael Altclas, MD; Adriana Basombrío, MD; Luciana Spadaccini, MD; Mara Huberman, MD; and Sergio Maulen, MD, PhD, all of whom are medical professionals. 'This material hasn't been available before, isn't covered in other guidelines, and can benefit any healthcare professional in the region,' said Alejandra Cuello, speaking with Medscape Spanish. She was one of the two coordinators of the recommendations. Cuello heads the Infectious Diseases Service at the Juan D. Perón Regional Polyclinic and was an adjunct professor of infectious diseases at the National University of Villa Mercedes, both in Villa Mercedes, Argentina. The new guide included 21 chapters covering a wide range of topics, including urethritis, acquired syphilis, genital herpes, human papillomavirus, viral hepatitis, gonorrhea, Zika virus, sexual abuse and rape, STIs in pregnant women, and emerging STIs, such as mpox. 'Instead of just copying the international guidelines, this version includes local epidemiology, available diagnostic methods, and treatments tailored to the regional context,' Cuello said. Patient Interaction A unique feature of the updated guidelines is that they begin with recommendations on how to explore aspects of a patient's sexuality during consultations, an area often avoided due to 'lack of knowledge, modesty, or discomfort,' Cuello noted. Mauas, speaking to Medscape Spanish said, 'We need to be warm because we are asking intimate questions. You cannot rush into conversations about sexual practices without creating a comfortable environment. She emphasized that a lack of empathy is often the first barrier to timely and appropriate care. These guidelines highlighted the importance of the first interaction in building trust and obtaining the patient's accurate sexual history. Clinicians are encouraged to pay attention to initial greetings, maintain appropriate eye contact, and use supportive body language. 'Consultations should begin with open-ended questions. Clinicians are advised to first explore general concerns and then gradually move into more sensitive topics. Each question should be explained clearly using simple and respectful language. The approach should accommodate explicit sexual terms when necessary and be responsive to signs of anxiety or distress,' she said. Core Components The guidelines outlined seven key areas to consider in sexual health consultations. Reason for consultation. Begin by understanding the reason for the patient's visit. Review any signs or symptoms to help guide the examination and diagnostic tests. History of STIs. Inquiring about a patient's history of STIs is important, as this can affect the current risk assessment, choice of diagnostic tests, and interpretation of results. 'Some people are aware of this; others are not because the infection may have been asymptomatic,' Mauas noted. Assess personal and partner(s) risk perception, including prior testing for HIV, viral hepatitis, and other STIs. Ask whether the patient has received postexposure prophylaxis for HIV, especially in the past 6-12 months. Sexual partners. Determine the time since the patient's last sexual contact. When possible, estimate the number of regular and casual partners in the past 3 months or during the 3-month period. Avoid making assumptions about a person's sexual orientation; instead, ask respectfully. 'What is your sexual desire? Do you like being with a woman or a man? What is your orientation? How do you perceive or define yourself?' Mauas explained. Sexual practices. Gather information about the sites of potential exposure and specific practices, including oral, vaginal (receptive/insertive), and anal (receptive/insertive). Also ask about group sex, transactional sex (in exchange for money, drugs, or services), use of sex toys, dating apps, and recreational drug use — including alcohol and sex-related substances. 'These are individual situations that need to be considered,' Mauas emphasized. STI protection. Ask about the frequency of condom use during vaginal or anal intercourse over the past 3 months. Discuss any barriers to condom use. In addition, the vaccination status for hepatitis A, hepatitis B, and human papillomavirus must be assessed. Pregnancy prevention. Discuss pregnancy planning, contraceptive use, and access to safe abortion services when relevant. If necessary, refer to the appropriate specialized health departments. 'Although it depends on the specialty, we can — and should — work together with the sexual and reproductive or nonreproductive health department, depending on what the patient wants, such as whether they need counseling on contraception,' Mauas said. Other sexual health issues. Screening for problems related to sexual satisfaction, function, or psychosexual concerns. Ask about experiences of gender-based violence and offer appropriate referrals to the relevant services. These guidelines also encourage clinicians to leave room for patients to raise additional personalized concerns. Practical Recommendations The guide outlines general recommendations for consultations with key populations and priority groups at a higher risk of STIs, including transgender people, sex workers, men who have sex with men, adolescents and young adults, incarcerated individuals, people who use drugs, and migrant populations. The guide offered several recommendations to improve consultations, as follows. Avoid making assumptions about sexual orientation. Ask open, respectful questions about sexual practices, such as the gender of sexual partners, relationship status, and whether the patient is monogamous. Ask about self-identified gender at the beginning of the consultation to avoid mistakes or assumptions regarding sex or gender based on appearance. Gender-neutral languages should be used wherever possible. Ask questions such as, 'Are you taking any medication?' instead of 'Are you on any medication?' Genital examination should be delayed unless clinically necessary. This can be postponed until a greater level of trust is established. Recognize that not all individuals are sexually active or wish to initiate sexual practices. Offer flexible services to accommodate different needs. For example, evening clinic hours may better serve those with nighttime work schedules. Training the entire healthcare team to promote, inclusive stigma-free care is essential. 'Anyone who chooses to work in sexual health must be properly trained — not only in clinical knowledge but also in addressing personal biases that may come from cultural or religious beliefs. Primary care providers should familiarize themselves with these guidelines and build their capacity to manage consultations. If they are unable to complete the assessment, they should be referred appropriately; however, they must not become a barrier to care. When a patient feels mistreated due to administrative or bureaucratic hurdles, they often choose not to return,' Mauas said. Mauas and Cuello reported having no relevant financial relationship. This story was translated from Medscape's Spanish edition.
CNN
01-06-2025
- General
- CNN
What a urologist wants you to know about prostate screening
When I learned that former President Joe Biden had not undergone prostate-specific antigen (PSA) screening since 2014—and was later diagnosed with metastatic prostate cancer—I knew there would be renewed interest and debate about prostate cancer screening guidelines. As a urologist, I regularly discuss the complexities surrounding PSA testing with my patients. The PSA test remains valuable for early detection, but it continues to generate controversy due to its limitations. Here's what you should know about PSA screening, why medical guidelines vary and why individualized approaches are essential. Prostate-specific antigen, or PSA, is a protein produced by the prostate. The PSA blood test measures this protein to help screen for prostate cancer. Typically, a PSA level above 4 on lab results is flagged as 'abnormal,' prompting further evaluation. However, even PSA numbers below 4 can be concerning if they're rapidly increasing. That's why PSA tests are done annually: to monitor trends over time. Elevated PSA levels don't always mean cancer. Noncancerous conditions like an enlarged prostate, prostatitis (inflammation), recent ejaculation, stress or even strenuous activity can temporarily raise PSA. Ultimately, the PSA level is just a starting point for a deeper investigation (or conversation). Additionally, not all prostate cancers cause elevated PSA levels. Some aggressive cancers may produce normal PSA results. Ultimately, the PSA level is a starting point for further evaluation and deeper conversations with your doctor. The controversy around PSA testing isn't really about the test itself, but about how its results are interpreted and acted upon. Before 2012, PSA screening was routinely recommended for all men over age 50. I completed my urology training that same year, witnessing firsthand how dramatically the screening landscape changed almost overnight. In 2012, the U.S. Preventive Services Task Force (USPSTF) recommended against routine PSA screening due to concerns of 'overdiagnosis.' The worry was that screening could detect slow-growing cancers that may never cause harm but still result in unnecessary biopsies, anxiety, and treatments—some of which caused more harm than good. The recommendation led doctors to scale back, causing routine PSA testing to decline sharply. However, by 2018, new research and rising concerns about aggressive prostate cancers led the USPSTF to revise their recommendations again, advising men aged 55 to 69 to engage in shared decision-making with their providers. This current stance emphasizes personalized discussions between patients and doctors, acknowledging that there's no one-size-fits-all approach to PSA testing. According to their website, the USPSTF is now working on another update, so we can expect further adjustments in the near future. As someone who experienced this shift firsthand early in my career, I deeply appreciate how critical shared decision-making and patient involvement are in navigating these complex screening choices. These ongoing changes in recommendations have also reinforced the importance for me as a physician to stay informed, continuously adapting my practice as new research and technologies emerge. Several organizations provide prostate cancer screening guidelines, including the USPSTF, the American Cancer Society and the American Urological Association (AUA). Each offers slightly different recommendations for both patients and health care providers. The USPSTF generally focuses on minimizing potential harm from overtreatment, while the AUA provides detailed, individualized recommendations based on clinical factors and risk profiles. Even after practicing urology for more than a decade, I still sometimes find it challenging to navigate these subtle differences in guidelines. Although I primarily follow the AUA guidelines—my overarching professional body—I've established a balanced approach that feels comfortable for me and, I believe, best serves my patients' interests. I start PSA testing at age 40 for men at higher risk, such as African Americans or those with a first-degree family member who has prostate cancer. For most patients, I typically initiate annual PSA screening at age 50. It's important to know that primary care doctors perform most prostate cancer screenings. Depending on their training, clinical judgment and professional guidelines, their approach may differ slightly from my take as a urologist. This highlights the importance of clear communication among you the patient, your primary care provider and your specialists. Only through these conversations can we create personalized screening strategies that align with your health goals. President Biden's case raises a question: Could earlier PSA screening have detected his cancer sooner, at a more treatable stage? We will never know for certain. According to current guidelines, stopping screening in one's 70s is considered appropriate. Perhaps there was a shared decision to stop testing. From a guideline perspective, nothing was necessarily done incorrectly. Still, Biden's diagnosis highlights the potential consequences of discontinuing prostate screening for an otherwise healthy older adult. Men in the United States now have an average life expectancy of approximately 76 years, with many living healthy, active lives well into their 80s and beyond. Older guidelines based on shorter lifespans now need updating to reflect today's longer, healthier lives. I believe that decisions about prostate screening in older adults should thus focus more on individual health status rather than chronological age alone. Changing guidelines based on longer life expectancy will require thorough research and evidence-based data. Consequently, updates to recommendations will take time. What you can do in the meantime is be proactive in your conversations with your doctors about not just prostate cancer screenings but all cancer screenings. Prostate cancer isn't the only medical condition subject to evolving guidelines. Screening recommendations for colorectal and breast cancers have also changed recently. Colon cancer screening now generally starts at age 45 instead of 50 due to rising cases among younger adults. Breast cancer guidelines continue to vary among organizations, but the USPSTF updated its recommendation last year to say that most women should start getting mammograms earlier. These frequent shifts reflect ongoing research and the importance of personalized, informed conversations between patients and health care providers. Historically, an elevated PSA test led directly to a prostate biopsy, potentially causing unnecessary anxiety and sometimes overtreatment. Today, however, we have more advanced PSA-based tests that help better identify significant prostate cancers. Advanced imaging, like prostate MRI, allows us to pinpoint suspicious areas before performing a biopsy, increasing accuracy and decreasing unnecessary procedures. Biopsy techniques have also improved, some shifting from traditional transrectal biopsies to transperineal methods, reducing infection risks. Treatments have similarly evolved, emphasizing active surveillance of low-risk cancers and minimally invasive focal therapies. These advancements have significantly reduced side effects and improved quality of life, even among older patients. In my office, I frequently discuss PSA screening with patients who are over 70. If a patient remains active and healthy and we anticipate good life expectancy, I generally recommend that we continue regular PSA tests. However, the final decision always belongs to the patient, after we carefully weigh the pros and cons together. If your doctor hasn't initiated this conversation yet, it's important for you to bring it up. And remember, regardless of age, promptly inform your health care provider about any new urinary symptoms or health concerns. Staying proactive gives you the best chance to maintain good health this year and next.
