The Australasian Chapter of Sexual Health Medicine (AChSHM) is a Chapter of the Royal Australasian College of Physicians (RACP) Adult Internal Medicine Division that connects and represents Sexual Health Medicine Fellows and trainees in Australia and New Zealand.
Recommendations and resources
1) Do not order herpes serology tests unless there is a clear clinical indication.
Herpes serology is not an appropriate screening test in asymptomatic patients and does not accurately confirm whether the person is infected or is a transmission risk to others from asymptomatic shedding. Clinicians also need to consider whether test results will influence treatment or outcomes because, if they do not, then testing is a waste of finite health resources and is not indicated.
Selective use of herpes serological tests may be justified for particular groups such as those at high risk for STIs and human immunodeficiency virus (HIV) infection who are motivated to reduce their sexual risk behaviour; HIV-infected patients; patients with sexual partners with genital herpes; and in cases where a woman appears to have a first episode of herpes simplex virus (HSV) during pregnancy. However, generally herpes serology tests only have good sensitivity and specificity in high prevalence populations, and so should be used accordingly.
2) Do not screen for chlamydia using serological tests.
There is no role for chlamydia serology as a screening test as antibodies elicited during infection are long-lived, meaning a positive antibody test will not distinguish between a previous and a current infection and are non-specific for genital serovars. Chlamydia serology may be useful in specific circumstances, for example, investigating atypical pneumonia in babies or in identifying late stage Lymphogranuloma Venereum (LGV) infection.
Laboratory tests based on nucleic acid amplification (NAAT) technologies remain the first choice for diagnosis of chlamydial infections during pregnancy and in other settings. NAAT testing for identifying LGV serovars of Chlamydia trachomatis has superseded the use of serology for diagnosis but is only available in some specialist settings.
3) Do not treat recurrent or persistent symptoms of vulvovaginal candidiasis with topical and oral anti-fungal agents without further clinical and microbiological assessment.
While topical and oral anti-fungal agents are the recommended treatment for candidiasis, an adequate clinical and microbiological assessment should be undertaken before they are prescribed or self-administered by patients for recurrent or persistent symptoms of vulvovaginal candidiasis.
It is important to rule out other causes of vulvovaginal symptoms such as bacterial vaginosis or genital herpes first so that the other infections are not left untreated. Moreover, inappropriate use of antifungal drugs can lead to increased fungal resistance, especially in non-albicans species of candida.
4) Do not test for ureaplasma species in asymptomatic patients.
Ureaplasma species are part of the normal genital microbiota and there are typically high rates of colonisation of the organism in sexually active adults. Testing or screening for genital infection with ureaplasma species is not recommended outside specialist or research settings as they have not been established as a cause of lower genital tract disease.
5) Do not prescribe testosterone therapy to older men except in confirmed cases of hypogonadism.
Hypogonadism justifying testosterone therapy regardless of age is confirmed based on measurement of circulating testosterone, luteinising hormone (LH) and follicle-stimulating hormone (FSH) concentrations. There is limited high-quality evidence to justify testosterone treatment in older men, usually with chronic disease, who have low circulating testosterone levels but without confirmed pathological hypogonadism, whether due to hypothalamic, pituitary or testicular disease. Moreover, excess cardiovascular events have been associated with testosterone treatment of older men without pathological hypogonadism. While the evidence on these side effects is mixed and additional studies are needed to clarify whether testosterone therapy increases cardiovascular risk, this provides an added reason to restrict the prescription of testosterone therapy to confirmed cases of hypogonadism.
- Guerry SL, Bauer HM, Klausner JD, Branagan B, Kerndt, PR. Recommendations for the selective use of herpes simplex virus type 2 serological tests. Clinical Infectious Diseases 2005; 40(1): 38-45.
- New Zealand Herpes Foundation. Guidelines for the Management of Genital Herpes in New Zealand. 10th Ed, 2013.
- Scoular A. Using the evidence base on genital herpes: optimising the use of diagnostic tests and information provision. Sexually Transmitted Infections 2002; 78(3): 160–165.
- Strick L, Wald A. Type specific testing for herpes simplex virus. Expert Review of Molecular Diagnostics 2004; 4: 443-53.
- Chernesky MA. The laboratory diagnosis of Chlamydia trachomatis infections. The Canadian Journal of Infectious Diseases & Medical Microbiology 2005; 16(1): 39–44.
- Papp JR, Schachter J, Gaydos CA, Van Der Pol B. Recommendations for the Laboratory-Based Detection of Chlamydia trachomatis and Neisseria gonorrhoeae — 2014. Morbidity and Mortality Weekly Report (MMWR) 2014; 63(RR02): 1-19.
- Davies S, Johnson E, White D. How to treat persistent vaginal yeast infection due to species other than Candida albicans. Sexually Transmitted Infections 2013; 89: 165–166.
- Dun E. Antifungal resistance in yeast vaginitis. Yale Journal of Biology & Medicine 1999; 72(4): 281–285.
- Sobel JD. Vulvovaginal candidosis. Lancet 2007; 369: 1961–71.
- Patel MA, Nyirjesy P. Role of Mycoplasma and ureaplasma species in female lower genital tract infections. Current Infectious Disease Reports 2010; 12(6): 417-22.
- Calof OM, Singh AB, Lee ML, et al. Adverse events associated with testosterone replacement in middle-aged and older men: a meta-analysis of randomized, placebo-controlled trials. J Gerontol A Biol Sci Med Sci. 2005;60(11):1451-7.
- Corona G, Maseroli E, Rastrelli G, et al. Cardiovascular risk associated with testosterone-boosting medications: a systematic review and meta-analysis. Expert Opin Drug Saf. 2014;13(10):1327-5
- Finkle WD, Greenland S2, Ridgeway GK, et al. Increased risk of non-fatal myocardial infarction following testosterone therapy prescription in men. PLoS One. 2014 29;9(1):e85805
- Xu L, Freeman G, Cowling BJ, Schooling CM. Testosterone therapy and cardiovascular events among men: a systematic review and meta-analysis of placebo-controlled randomized trials. BMC Med. 2013 Apr 18;11:108.
- Yeap BB, Grossmann M, McLachlan RI, et al. Endocrine Society of Australia position statement on male hypogonadism (part 1): assessment and indications for testosterone therapy. Med J Aust. 2016;15;205:173-8.
- Yeap BB, Grossmann M, McLachlan RI, et al.Endocrine Society of Australia position statement on male hypogonadism (part 2): treatment and therapeutic considerations. Med J Aust. 2016;205:228-31.
Last reviewed September 2018
How this list was developed
With the assistance of the Royal Australasian College of Physicians, the Australasian Chapter of Sexual Health Medicine (AChSHM) Council produced and distributed to its membership an online survey. The survey listed 5 examples of clinical practices in sexual health medicine which may be overused, inappropriate or of limited effectiveness in a given clinical context.
Members were asked to comment on these examples and to suggest other low-value practices which may be a sizeable issue in the specialty. Based on the feedback, 8 items were identified for further investigation by AChSHM Council through an evidence review. This resulted in the final list of 5 recommendations which were endorsed by the Council on December 15, 2015.