Sexual health screening in adult primary care is uneven, largely because both patients and clinicians are uncomfortable initiating the conversation. That discomfort is expensive. Rates of syphilis, gonorrhea, and chlamydia have all risen substantially in the past decade, and many of the associated harms, from infertility to congenital infection, are preventable with a routine test.
A useful preventive visit includes a sexual history that is specific enough to guide testing. Not intrusive, but specific. Number of partners in the last year, gender of partners, and use of barrier methods each change which screenings are indicated.
What routine screening actually covers
The CDC and USPSTF broadly agree on a core set of adult screenings.
- HIV at least once for every adult aged 15 to 65, and annually for anyone at ongoing risk. Fourth-generation antigen/antibody tests detect infection within a few weeks of exposure.
- Chlamydia and gonorrhea annually for sexually active women under 25, and for older women with new or multiple partners. Men who have sex with men should be screened at least annually at all exposed sites: urethra, rectum, and pharynx.
- Syphilis for anyone at increased risk, and universally during pregnancy. Rates in the U.S. have risen sharply, including congenital syphilis, which is entirely preventable.
- Hepatitis B and C screening at least once for all adults, with periodic retesting for those at continued risk.
- Trichomonas in women with symptoms and, in some guidance, in higher-prevalence settings.
Any sexually transmitted infection diagnosis is a prompt to retest for the others, since coinfection is common.
HPV, cervical screening, and anal cancer
Cervical cancer screening is one of the clearest wins in preventive medicine. Current USPSTF recommendations offer several acceptable options for those with a cervix aged 21 to 65, including cytology alone every three years, primary HPV testing every five years starting at 25 or 30, or co-testing every five years. Vaccinated status does not change the schedule.
Anal HPV-related cancer is far less common than cervical cancer but has been rising, particularly in men who have sex with men, people living with HIV, and women with a history of high-grade cervical or vulvar dysplasia. Anal cytology screening is offered in some centers for these higher-risk groups, and high-resolution anoscopy for follow-up. Evidence from recent trials supports treating high-grade anal precancers to reduce cancer incidence.
Screening decisions should follow anatomy and behavior, not identity. Ask what body parts are involved and what happens with them.
Prevention beyond condoms
A modern sexual health conversation should include, when relevant, several tools that many patients do not know are available.
- PrEP for HIV prevention: daily oral tenofovir-based regimens are highly effective for people at ongoing risk, and injectable options extend intervals to every other month.
- DoxyPEP: a single dose of doxycycline within 72 hours of condomless sex reduces bacterial STI incidence in men who have sex with men and transgender women, per CDC guidance issued in 2024.
- HPV vaccination through age 26 for all, and shared decision-making up to age 45. Catch-up vaccination is worth discussing even for adults who missed it as adolescents.
- Hepatitis A and B vaccination for anyone unvaccinated, particularly with new partners or travel.
Emergency contraception, expedited partner therapy for chlamydia and gonorrhea, and mpox vaccination for eligible groups round out the list.
Menopause, andropause, and the visits that fall through
Preventive sexual health does not end at midlife. Postmenopausal changes, including genitourinary syndrome of menopause, are common, treatable, and rarely raised without prompting. Erectile dysfunction can be an early marker of vascular disease and deserves a workup, not just a prescription. Both are legitimate reasons to occupy a portion of the visit.
The bottom line
Sexual health screening is quick, inexpensive, and often quietly skipped. A specific sexual history yields a specific set of tests and vaccines, most of which prevent disease that is otherwise easy to miss. If your clinician does not ask, offer the information anyway; it changes the visit.