Sexual health of women aged 40 and over attending an inner city integrated sexual health clinic

Abstract

Sexual health policy remains focussed on younger adults. However, rates of sexually transmitted infections (STIs) in older people continue to increase. We explored the sexual healthcare needs of women aged 40 and over attending an integrated sexual health clinic in South London. We conducted a retrospective case note review and found that almost 20% of these women had STIs. These included genital herpes, trichomoniasis, genital warts, chlamydia and gonorrhoea. Less than a quarter of women reported use of condoms during most recent sexual contact, indicating sexual risk-taking behaviour. 38% of women attended for contraception. The sexual health needs of older people can only continue to increase, given our rapidly ageing population. Age-specific health promotion strategies are needed.

Keywords

Epidemiology high-risk behaviour screening sexual behaviour women sexually transmitted infections

Introduction

National screening programmes and research studies in sexual health have traditionally excluded individuals over the age of 44. However, when surveyed, 8.9% of women aged 45–54 years reported at least one new sexual partner in the preceding year¹ and more than a third of adults aged 70–79 stated that they had frequent sexual activity.² A 2001 study found that 7% of older individuals engaged in sexual practices that could put them at risk of contracting an STI³; there is otherwise a paucity of UK data on sexual risk-taking amongst this group. Fish et al.⁴ found that the total number of older women accessing GUM services at a North London clinic quadrupled between 1998 and 2008. Rates of new STI diagnoses in the 45–64 age group continue to increase across England (191 per 100,000 in 2012 vs. 202.2 per 100,000 in 2014).⁵ In contrast, rates within the 15–19 and 20–24 age groups have decreased.⁵

The reasons for an increase in STIs may be partially due to advances in healthcare provision, which have allowed people to live longer. Physiological changes,⁶ the advent of online dating⁷ and delays in presentation due to the perception that older people are not at risk of STIs may also be contributing factors.⁸ A literature review by Hinchliff and Gott⁹ noted some significant barriers to seeking help for sexual health concerns, including ageist physician attitudes and patient embarrassment.

The few recently published studies that have examined sexual health in older people are largely from the United States¹⁰ or UK Caucasian cohorts.⁴ Southwark is an ethnically diverse borough with a high level of poverty and deprivation. Rates of STIs in 2015 were the third highest in London (and England);¹¹ this study is the first to specifically focus on both STIs and contraceptive needs of older women living in and around this area.

The proportion of women diagnosed with an STI is higher in our study compared to a recent UK analysis,⁴ and we have described the types of infections in this paper. The second commonest reason for women over 40 to attend our centre was contraception, which is important in the premenopausal women of this cohort.

We chose to include women over the age of 40 as this is an age group with increasing rates of abortion.^12,13 Furthermore, the average age of divorce in UK women is 42.6 years;¹⁴ this is a cohort therefore that may encounter new sexual partners after coming out of long-term monogamous relationships. The onset of menopause may fall within this age group, increasing risk of unprotected sex due to a perceived lack of risk regarding unwanted pregnancy.¹⁵

Methods

We undertook a retrospective case note review of 200 randomly selected (every eighth in date order) female patients aged 40 and over attending clinic in an ethnically diverse borough of South London between 2 June 2014 and 30 May 2015. Data collected included demographics, reason for attendance, condom use during most recent sexual activity, need for contraception and STIs diagnosed.

Symptomatic women (by physician-taken cervical swab) and asymptomatic women (by self-taken vulvovaginal swab) were tested for Chlamydia trachomatis and Neisseria gonorrhoeae by Hologic GenProbe Aptima Combo-2 nucleic acid amplification test. Symptomatic women also had microscopy using wet mount of the vaginal and cervical discharge (Gram stain). Venous samples were taken for HIV testing (fourth generation antibody/antigen assay), syphilis (treponemal serology) and hepatitis B (antibody test). Samples for herpes simplex virus (HSV) were placed in viral transport media and assessed by in house real-time polymerase chain reaction (PCR) for HSV types 1 and 2 DNA.

Results

During the year, a total of 5039 women attended a large integrated sexual health service in South London. A total of 1728 (34%) were aged 40 and over. Of the sample of 200, mean age was 46.6 years (range: 40–73 years). A total of 114 women (57%) were aged 45 and over. A total of 60 women (30%) were peri- or post-menopausal at time of visit. Ethnicities: Black 111 (55%), White 57 (29%) and other 32 (16%). A total of 163 women (81.5%) identified as heterosexual, 2 (1%) as bisexual and 1 (0.5%) as lesbian. Sexual orientation was not specified for the remaining 34 patients.

170/200 notes recorded whether there was a history of termination of pregnancy (TOP) or not. Sixty women (35%) previously had a TOP; age at time of TOP was not recorded.

Figure 1 shows the reasons for visit (some attended for more than one reason). A total of 76 women (38%) requested contraception (mean age 45, range: 40–55 years). A total of 95 women (47.5%) were symptomatic.

Figure 1.

Documented reason for clinic attendance. *Other STI-related refers to partner notification, symptoms in a recent sexual partner or returning for treatment/follow-up.

Of 150 women who received testing or examination, 29 (19.3%) were found to have an STI (Table 1). 28/29 (96.6%) were aged 40–59 at time of diagnosis (mean age 47.1 years). The remaining 50 of 200 women attended for contraception and had reported STI checks in the preceding year. A few women declined examination/testing due to being in long-term, monogamous relationships and their perception that they were not at risk.

Table 1.

STI diagnoses.

STI	n	%
Genital herpes	8	5.3
Chlamydia	2	1.3
Gonorrhoea	1	0.7
Trichomonas vaginalis	7	4.7
Syphilis	3	2.0
Anogenital warts	5	3.3
Pelvic inflammatory disease	2	1.3
Hepatitis B	1	0.7

Documentation of condom use was found in 170/200 notes (85%). 38/170 (22.4%) reported that they used condoms during their most recent sexual contact. 106/200 (53%, mean age 45.4 years) were using a method of contraception. A total of 42 women (21%) were using an intrauterine device/system as their main method of contraception. A total of 17 (8.5%) had a contraceptive implant in situ; five (2.5%) were receiving depot medroxyprogesterone acetate injections and 15 (7.5%) were established on an oral contraceptive pill.

Long-acting reversible contraception (LARC) was the most common contraceptive request 36 (47.4%), followed by LARC removal 19 (25%) and oral contraceptive pill 8 (10.5%). Four women (5.3%) requested emergency contraception.

Discussion

Greater than one-third of all women accessing GUM services were over the age of 40. Compared to Fish et al.,⁴ our sample population had a significantly higher proportion of patients of black ethnicity. The numbers of STI diagnoses were high in our study.

Trichomonas vaginalis (TV) is associated with asymptomatic infection in 10%–50% of women.¹⁶ Therefore, it is likely that the incidence of TV has been underestimated in our study as we did not screen asymptomatic women. Furthermore, symptomatic women were tested using wet microscopy only, which has a reported sensitivity of only 45%–60%.¹⁷

There are few data available regarding the epidemiology of TV in the UK. However, the prevalence of TV in a recently published British study was 0.3% in females.¹⁸ Rates of TV are consistently higher in black women versus women from other racial/ethnic groups.^19,20 Our results demonstrate a 15-fold higher prevalence (3.5%) compared to the British study, most likely reflecting the ethnic diversity of our local population compared with the rest of England. It is well established that rates of trichomoniasis are higher in older women, which may also explain the very high prevalence seen in this study.²¹ Indeed, a retrospective analysis undertaken in the US found women aged 46–54 had the highest rates of trichomonal infection (6.2%), followed by those in the 56–65 (6.1%) and 12–25 (4.6%) age groups.²¹

Condom use was low, indicating sexual risk-taking behaviour. Thirty-five percent of women had previously undergone TOP. As age at time of TOP was not recorded, this parameter cannot be used to reliably distinguish past from current risk-taking behaviour. Interestingly, the number of abortions in English and Welsh residents aged 40 and over increased from 6988 to 8469 women between 2002 and 2015,^12,13 indicating that this cohort remain at risk of unplanned pregnancy. More women attended following the appearance of symptoms rather than for asymptomatic testing. This indicates that women in this age group may lack awareness about the asymptomatic nature of many STIs or may not perceive themselves to be at risk.

This study is limited by its small sample size and retrospective design. We excluded older men, a group arguably even more underserved in the literature.

Our study represents an ethnically diverse, inner city population accessing sexual health services in South London. Therefore, our findings may not be generalisable to the rest of the UK. There is a lack of consensus regarding the definition of the older women; by including women aged 40–45, comparison to other studies may be limited.

The sexual health needs of older people can only continue to rise, given our rapidly ageing population. There is therefore a need to challenge assumptions regarding sexual activity in older age and to develop health promotion strategies specific to this age group.

Footnotes

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

References

Mercer

Tanton

Prah

. Changes in sexual attitudes and lifestyles in Britain through the life course and over time: findings from the National Surveys of Sexual Attitudes and Lifestyles (Natsal). Lancet 2013; 382: 1781–1794.

Lee

Nazroo

O’Connor

. Sexual health and well-being among older men and women in England: findings from the English longitudinal study of ageing. Arch Sex Behav 2016; 45: 133–144.

Gott

. Sexual activity and risk-taking in later life. Health Soc Care Community 2001; 9: 72–78.

Fish

Robinson

Copas

. Trends in attendances to genitourinary medicine services by older women. Int J STD AIDS 2012; 23: 595–596.

Public Health England. National STI surveillance data tables 2015, www.gov.uk/government/uploads/system/uploads/attachment_data/file/534555/2015_Table_2_New_STI_diagnoses___rates_by_gender__sexual_risk___age_group__2011-2015.pdf (2016, accessed 01 October 2016).

Minkin

. Sexually transmitted infections and the aging female: placing risks in perspective. Maturitas 2010; 67: 114–116.

Brown

Pugsley

Cohen

. Meeting sex partners through the Internet, risky sexual behavior, and HIV testing among sexually transmitted infections clinic patients. Arch Sex Behav 2015; 44: 509–519.

Grant

Ragsdale

. Sex and the ‘recently single’: perceptions of sexuality and HIV risk among mature women and primary care physicians. Cult Health Sex 2008; 10: 495–511.

Hinchliff

Gott

. Seeking medical help for sexual concerns in mid- and later life: a review of the literature. J Sex Res 2011; 48: 106–117.

10.

Tuddenham

Page

Chaulk

. Patients fifty years and older attending two sexually transmitted disease clinics in Baltimore, Maryland. Int J STD AIDS 2016. Epub ahead of print 21 April. DOI: 0956462416646687.

11.

Public Health England. Sexually transmitted infections in England, 2015, www.gov.uk/government/uploads/system/uploads/attachment_data/file/535085/England_STI_Slide_Set_2015.pdf (2016, accessed 8 October 2016).

12.

Department of Health. Abortion statistics, England and Wales: 2002, http://webarchive.nationalarchives.gov.uk/20130123231223/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_4069635 (2003, accessed 8 October 2016).

13.

Department of Health. Abortion statistics, England and Wales: 2015, www.gov.uk/government/statistical-data-sets/abortion-statistics-england-and-wales-2015 (2016, accessed 8 October 2016).

14.

Office for National Statistics. Statistical bulletin: divorces in England and Wales: 2013, www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/divorce/bulletins/divorcesinenglandandwales/2013 (2015, accessed 13 October 2016).

15.

Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit. Contraception for women aged over 40 Years, www.fsrh.org/standards-and-guidance/documents/cec-ceu-guidance-womenover40-jul-2010/ (2010, accessed 13 October 2016).

16.

Sherrard

Ison

Moody

. United Kingdom National Guideline on the Management of Trichomonas vaginalis 2014. Int J STD AIDS 2014; 25: 541–549.

17.

Patil

Nagamoti

Metgud

. Diagnosis of Trichomonas vaginalis from vaginal specimens by wet mount microscopy, in pouch TV Culture System, and PCR. J Glob Infect Dis 2012; 4: 22–25.

18.

Field

Clifton

Alexander

. Trichomonas vaginalis infection is uncommon in the British general population: implications for clinical testing and public health screening. Sex Transm Infect 2016. Epub ahead of print 29 September. DOI: 10.1136/sextrans-2016-052660.

19.

Johnston

Mabey

. Global epidemiology and control of Trichomonas vaginalis. Curr Opin Infect Dis 2008; 21: 56–64.

20.

Sutton

Sternberg

Koumans

. The prevalence of Trichomonas vaginalis infection among reproductive-age women in the United States, 2001-2004. Clin Infect Dis 2007; 45: 1319–1326.

21.

Stemmer

Adelson

Trama

. Detection rates of Trichomonas vaginalis, in different age groups, using real-time polymerase chain reaction. J Low Genit Tract Dis 2012; 16: 352–357.