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Husband will interpret for wife with STI

Three GPs share their approach to a practice conundrum

Case history

Mrs Choi is 44 years old and consulted your locum with intermenstrual bleeding last week. As part of the work-up, your locum checked for chlamydia and the results are positive. Mrs Choi has come in to get her results. Unfortunately Mrs Choi speaks extremely limited English and has brought her husband as an interpreter. From the locum's notes you surmise that she came alone last week and you think it unlikely that she really understood what tests were being done. Mr and Mrs Choi have two children aged 10 and 14 and Mrs Choi has been sterilised. What do you do now?

Dr Sarah Humphery

'I would offer to arrange for an interpreter – but neither may want this'

First, I would want to see how much Mr and Mrs Choi understood about the reasons for the tests. If they do not know, I would begin with an explanation about the various causes of intermenstrual bleeding (IMB) and how we would establish the cause. If they understood I would then have to give them the result.

I would allow them time to ask questions. They are probably starting to wonder why Mrs Choi has a sexually transmitted disease. This is when it is going to get tricky.

There are several possibilities: she could have had the infection for a long time; she could have caught it off the husband because he has been having extramartial sex; or she may have been having sex with another man.

The other problem is that I am completely reliant on Mr Choi translating honestly to his wife. I could offer to arrange for an interpreter, but as we are discussing such personal matters they may not want this.

I would explain that the infection may be the cause of her IMB and that Mrs Choi needs treatment with antibiotics. I would tell them how chlamydia is spread. Maybe this would suddenly bring out a confession, or they may prefer to discuss it at home.

I would suggest Mr Choi is tested too. I would give the usual advice about avoiding sex until they are both clear. Ideally they should go to the local GUM clinic to rule out the presence of any other STIs. Then there is the issue about tracing any other partner(s).

I would want to arrange follow-up individually to clarify all we had discussed.

I would still like to refer Mrs Choi to the gynaecologist to assess her IMB even after treating the chlamydia, because of her age and wanting to rule out a malignancy.

Sarah Humphery is a GP retainer in north London and completed the VTS in 1997

Dr Ian James

'Infection can be dormant and asymptomatic'

The locum is clinically correct but in retrospect, this knee-jerk response to the intermenstrual bleeding has left me in a difficult position. It is unlikely her verbal consent was obtained for the investigations that were actually carried out, although in fairness, if she had been fully aware of the potential seriousness of her symptoms, consent would have doubtless been a formality.

It is of course crucial that Mrs Choi and her husband are now counselled as to why the test was done and of its significance. They will need to be aware that Mrs Choi has an infection that may be responsible for her intermenstrual bleeding and that it may have been dormant and asymptomatic for up to 10 years. Her husband needs to be questioned as to whether he has any genitourinary symptoms and he should be tested for chlamydia.

One must bear in mind the possibility of marital infidelity. A solid doctor-patient relationship can reap dividends in this delicate situation. This will clearly have to be approached tactfully, but if the opportunity can be taken to carry out investigations on Mr Choi separately, maybe an extramarital relationship will be revealed with the chance to contact-trace if necessary. A full explanation must be given of why treatment is necessary, emphasising the risks of adhesions and chronic pelvic pain, which may result from untreated cases.

Treatment with doxycycline 100mg bd to both patients is required with abstention from intercourse until a week after treatment ends.

Ian James is a partner in Bolton, Lancashire, with more than 20 years' experience in practice

Dr Jane Bowskill

'The case raises a

number of implications – both medical and legal'

I first looked at this history and thought 'What a nightmare' but on rereading it doesn't seem to be so bad. Trying to get a proper history including contacts/possible sources of infection is not going to be easy and referring both of them to the local sexual health clinic is one option.

Mrs Choi will obviously need antibiotic treatment for her chlamydial infection with doxycycline 100mg bd daily for seven days. She will also need to be screened for other sexually transmitted diseases, on the basis that if you have one sexually transmitted disease it is possible that you have another. The same applies to Mr Choi.

What I would do is issue a prescription for Mrs Choi, explaining she has an infection that may be causing the bleeding. I would tell her she needs to have a repeat examination and further swabs – to check for gonorrhoea – when she has finished the antibiotics. I would also tell her she needs to have some blood tests 'because of the bleeding' and check for hepatitis B and syphilis. Ideally she should also be tested for HIV but this shouldn't be done without informed consent.

It is extremely difficult to know how best to treat this woman and I may be tempted to seek advice from my defence organisation. The case raises a number of problems, including the implications of her STD and the legal implications of testing without understanding or consent.

As far as Mr Choi is concerned, he is going to need to know that his wife has an infection and that he will need to be screened and treated as well. I would treat him as a chlamydia contact, with doxycycline, and refer him to the sexual health clinic with a tactful letter asking for full screening.

It is always difficult to use the family as an interpreter, especially a male relative for gynaecological or sexual problems.

Jane Bowskill is a part-time GP in Kingston upon Thames and completed the VTS in 1985

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