Letters to the Editor

Sexual History Taking Should Be Taught in Medical School

TO THE EDITOR: We were delighted to see and enjoyed reading the article entitled, "The Proactive Sexual Health History,"¹ in American Family Physician. We found it to be highly informative and important for physicians, especially for those taking care of adolescents and young adults who have the highest rates of sexually transmitted diseases (STDs). Sexual history taking is an important part of a comprehensive history. It affords the physician the opportunity to evaluate for STDs, contraceptive history, sexual abuse, and sexual dysfunction. In addition, it gives the physician the opportunity to administer appropriate diagnostic tests, treatment, and prevention counseling.

The article¹ reports that only a small percentage of primary care physicians in the United States actually elicit sexual histories. There are many potential barriers to sexual history taking, including embarrassment, inadequate training, time constraints, and a belief that a sexual history is not relevant.² The barrier we would like to address further is inadequate training of medical students and residents on how to elicit a sexual history.

It is imperative for medical students and residents to receive proper instruction on how to elicit a sexual history. This includes didactic as well as clinical instruction on taking a sexual history. Modeling is a valuable tool in the learning process, and it is important that medical students and residents observe their preceptors eliciting a sexual history. This modeling is necessary for instructional purposes and for validation of the importance and relevance of taking a sexual history.

In our experience, the majority of medical students and residents are not expected to obtain a sexual history as a regular part of a comprehensive examination if there is no chief complaint that warrants a history. Their only opportunity to obtain a sexual history may arise when a patient has a chief complaint that requires a sexual history, and many times they are not supervised when they elicit those histories to ensure they do so appropriately. Increased training of practicing physicians, medical students, and residents on sexual history taking has the potential to have a positive impact on the number of physicians that elicit sexual histories. Sexual history taking and increased interaction between the physician and patient are vital to potentially decreasing the rate of transmission of STDs in the United States.

YOLANDA WIMBERLY, M.D., M.S.C.
SANDRA MOORE, M.D.
720 Westview Dr., SW
Atlanta, GA 30310

REFERENCES

1. Nusbaum MR, Hamilton CD. The proactive sexual health history. Am Fam Physician 2002;66:1705-12.
2. Merrill JM, Laux LF, Thornby JI. Why doctors have difficulty with sex histories. South Med J 1990;83: 613-7.

Should Pelvic Examination Be Continued After Hysterectomy?

TO THE EDITOR: I read with some interest the editorial¹ on the American Cancer Society guidelines for the early detection of cervical cancer in American Family Physician and found it generally well written. However, the following statement caused me some concern: "...vaginal cuff smears after hysterectomy for benign conditions appear to be a common clinical practice, accounting for untold medical costs and patient discomfort." Does this imply that after hysterectomy, no further pelvic examinations are necessary because they are the painful part of the procedure rather than the swab of the cuff with a tongue blade, cotton-tipped swab, or brush? I do not believe that the smear accounts for "patient discomfort," but if this has been clinically documented I would appreciate the appropriate literature references.

I do not believe there is any support for implying that the pelvic examination, including the speculum examination of the vagina and the bimanual examination, should be discontinued after total hysterectomy, with or without ovaries present.

CLARK SMITH, M.D.
UT-Saint Francis Family Practice
1301 Primacy Pkwy.
Memphis, TN 38119

REFERENCE

1. Mahoney MC, Saslow D, Cohen CJ. ACS guideline for the early detection of cervical cancer (editorial). Am Fam Physician 2003;67:1677-80.

IN REPLY: If the hysterectomy was completed for a benign indication, the yield from vaginal cuff smear is exceedingly low, and is, in fact, exceeded by issues of false positive work-ups and patient discomfort. This is the basis for our recommendations. There are no data to support utility (or lack thereof) from bimanual examinations in this subset of patients, and I would defer to clinical judgment.

MARTIN C. MAHONEY, M.D., PH.D.
Roswell Park Cancer Institute
Elm & Carlton Streets
Buffalo, NY 14263

Diagnostic Testing for HIV Infection

TO THE EDITOR: I would like to point out a minor, but potentially significant, error in the article "Lymphadenopathy and Malignancy"¹ in American Family Physician. The authors appropriately include primary human immunodeficiency virus (HIV) infection in the differential diagnosis of lymphadenopathy. However, in Table 1 they list "HIV antibody" as the diagnostic test of choice.

It has been reported that between 40 and 70 percent of patients experience diffuse lymphadenopathy following primary HIV infection. However, patients will not seroconvert until about 22 to 27 days postexposure.² Thus, the standard HIV enzyme-linked immunosorbent assay (ELISA) will be negative if performed during the period of acute infection. The recommended test to obtain in this setting is an HIV RNA level by either polymerase chain reaction or branched DNA. Serologic testing for p24 antigen also may be used, but the reported sensitivity is only about 75 to 90 percent. In the majority of cases, the HIV RNA level will be exceedingly high (more than 100,000 copies per mL) and thus confirm the diagnosis. These patients can then be promptly referred for consideration of treatment with antiretroviral agents, concurrent with the current recommendations of the U.S. Public Health Service treatment guidelines.³ Risk-reduction counseling also can be addressed during this time because there are epidemiologic studies suggesting that a significant amount of HIV transmission occurs from persons with early infection.⁴

JEFFREY T. KIRCHNER, D.O.
Comprehensive Care Clinic for HIV
Lancaster General Hospital
555 N. Duke St.
Lancaster, PA 17604

REFERENCES

1. Bazemore AW, Smucker DR. Lymphadenopathy and malignancy. Am Fam Physician 2002;66:2103-10.
2. Kahn JO, Walker BD. Acute human immunodeficiency virus type 1 infection. N Engl J Med 1998; 339:33-9.
3. Dybul M, Fauci AS, Bartlett JG, Kaplan JE, Pau AK. Guidelines for using antiretroviral agents among HIV-infected adults and adolescents. Recommendations of the Panel on Clinical Practices for Treatment of HIV. MMWR Recomm Rep 2002;51(RR-7):1-55.
4. Hecht FM, Busch MP, Rawal B, Webb M, Rosenberg E, Swanson M, et al. Use of laboratory tests and clinical symptoms for identification of primary HIV infection. AIDS 2002;24:1119-29.

EDITOR'S NOTE: A copy of this letter was sent to the authors of "Lymphadenopathy and Malignancy," who declined to reply.

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@aafp.org. Please include your complete address, telephone number, and fax number. Letters should be submitted on disk, double-spaced, fewer than 500 words, and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.