Abstract
We sought to analyse reasons for attendance of older women (defined as aged 46 years and over) to genitourinary (GU) medicine services at two UK clinics. We used KC60 coding data to count new episode attendances by year from 1998 to 2008 and to further dissect reason for attendance in 2827 new episodes during 2003–2008. The total number of new episodes of attendance in older women increased from 167 in 1998 to 701 in 2008. Within this overall increase, there was a stable proportion of acute sexually transmitted infections (STIs) over time, alongside significant increases in the proportion of women requesting STI screening and HIV testing and those attending GU medicine for other reasons, such as dermatological or gynaecological complaints. In our clinic population it was encouraging to see that older women increasingly use GU medicine services for STI screening and HIV testing. Services may need to adapt to older women's specific health-care needs.
BACKGROUND
Rates of sexually transmitted infections (STIs) in older women in the UK have increased over the past 10 years, with proportional increases of STIs in 45–64 years old comparable to those seen in 16–25 years old. 1 Our aim was to analyse reasons for attendance to genitourinary (GU) medicine services of women aged 46 and over and identify how episodes of attendance are linked to clinic, ethnicity and year of attendance.
METHODS
KC60 diagnosis coding data 2 on new attendances from all women aged 46 and over attending two GU medicine clinics (clinics 1 and 2) in London, UK, during 1998–2008 were collected. A linear trend over time in the annual total number of attendances was tested using the Spearman correlation coefficient.
Total number of new episodes of attendance of women aged 46 years and over during 1998–2008 and hierarchical distribution of KC60 diagnoses 2003–2008, n (%)
†The following KC60 codes were assigned to a diagnosis of:
(1) Acute STI: Infectious syphilis A1, A2 uncomplicated gonorrhoea B1, B2 complicated gonorrhoea B5 chancroid, lymphogranuloma venereum, donovanosis C1, C2, C3 chamydial infections (uncomplicated/complicated) C4a, C4b, C4C uncomplicated non-specific urethritis in men C4h complicated non-gonococcal/non-chlamydial infection (PID, epididymitis and prostatitis) C5 trichomoniasis C6a herpes simplex first attack C10a genital warts (first attack) C11a HIV/AIDS E1a, E2a, E3a
(2) Non-sexually transmitted infections (STI): candidiasis C7A, bacterial vaginosis C6B
(3) Other reasons: D2B D3
(4) STI screen including HIV test: S2
(5) STI screen excluding HIV: S1
P values: *Test for linear trend in number of attendances, **Test for linear trend in proportion of attendances for each reason
Associations with reason for attendance were tested using the chi-squared test. Clustering of attendances by patients was accounted for using the survey analysis commands in STATA (Stata Corp, College Station, TX, USA).
A detailed retrospective case-note review of 120 randomly selected women attending clinic 2 in 2007–2008 was also performed, with the first episode only being reviewed.
RESULTS
About 3457 women attended 5912 times across 1998–2008. There were 3573 new episodes from 2524 women (1526 at clinic 1, 1998 at clinic 2). Women attending clinic 1 (75% white, 7% black-Caribbean, 6% black-African, 5% Asian and 7% other) were more frequently white and less frequently of black-Caribbean ethnicity than women at clinic 2 (66% white, 15% black-Caribbean, 7% black-African, 5% Asian and 7% other), P < 0.001. This reflects the local demographic data of the clinics location.
The age distribution was similar at the two clinics (median 49 and 50 years at clinics 1 and 2, respectively).
During 1998–2008 the number of new episodes of attendance from older women increased in both clinics (P = 0.057 clinic 1, P < 0.01 clinic 2).
There were 2827 new episodes in 2003–2008 from 1969 women. Total attendances for STI screening including HIV increased significantly and attendances for ‘other diagnoses’ increased significantly over time. There was a relatively stable proportion of new episodes presenting with an acute STI over time and a modest, though statistically significant, decline in the proportion of women attending with non-STI vaginal infections (see Table 1, second row of P values). The proportion having an STI screen including an HIV test increased significantly, while the proportion having an STI screen without an HIV test declined.
Black-African and black-Caribbean women were more likely to have an acute STI (P < 0.001). Black-Caribbean and white women were more likely to decline an HIV test. Clinic 2 had significantly more new episodes due to acute STIs and non-STI vaginal infections (P < 0.001).
A subgroup analysis of 120 women (median age 51 years) attending clinic 2 showed that 70% had been sexually active in the preceding three months, the number of partners ranging from 0 to 6, 66% reporting one partner only; 59% never used condoms. Thirty (25%) were found to have an acute STI. Of these, 12 presented with a first episode of genital warts, four with a first genital herpes episode, three chlamydia (with the oldest patient 70 years old) and three Trichomonas vaginalis; two had PID and one had late latent syphilis.
Forty-six of the 88 women (52%) in whom contraception would have been recommended were not using any. One woman presented with an unwanted pregnancy.
Twenty (17%) women presented with dermatological or gynaecological complaints. The majority (18/20) had been seen by another health-care provider for their presenting condition before attending the GU medicine clinic.
Nearly half (n = 59) of the women had never had an HIV test and data on previous testing history was unavailable for 12 women. About 20% had tested in the preceding five years.
CONCLUSIONS
This review of attendances shows that the total number of new episodes of attendance in older women has quadrupled over a 10-year period.
Although numbers of new episode attendances due to acute STIs in older women increased over time, this occurred as part of a large increase in new episode attendances for STI screening and HIV testing as well as other reasons, resulting in only a stable proportion being due to acute STIs, which were more common in the black ethnic minority groups (P < 0.001). Our data are not directly comparable to HPA data (1) given our hierarchical definition; however, it is possible that local clinic demography and potentially the increased use of GU medicine services for a variety of reasons in our population may account for the stable proportion of acute STIs over time. Other reasons for attendance were often linked to complex skin or gynaecological conditions. GU medicine services may need to work together other specialist services to provide appropriate care for complex cases.
Sexual attitudes and lifestyles of older women in an age of increased financial independence and instant communication merits further research.