STDs in Women and Infants

Public Health Impact

Women and infants are at significant risk for long-term consequences of STDs. A woman’s relationship status with her male partner, in particular, has been identified as an important predictor of her sexual health.¹ In addition to social factors such as poverty and lack of access to quality STD services, a woman may be unable to negotiate safer sexual practices, such as condom use, which can significantly affect her sexual and reproductive health, as well as the health of her unborn baby.^2,3

As an example of how social factors can impact women’s health, a perceived shortage of available men in a community can cause women to be more accepting of their partners’ concurrent sexual relationships, and partner concurrency is a factor associated with increased risk for STDs.⁴ Because it may be her male partner’s risk, rather than the woman’s that increases a woman’s risk for STDs, even a woman who has only one partner may be obliged to practice safer sex such as using condoms.⁵ A number of studies have found significant associations between condom use and socio-demographic characteristics, including age, income, education, and acculturation.⁶

Women infected with C. trachomatis or N. gonorrhoeae can develop pelvic inflammatory disease (PID), which, in turn, can lead to reproductive morbidity such as ectopic pregnancy and tubal factor infertility. An estimated 10%–20% of women with chlamydia or gonorrhea may develop PID if they do not receive adequate treatment.^7,8 Among women with PID, tubal scarring can cause infertility in 8% of women, ectopic pregnancy in 9%, and chronic pelvic pain in 18%.⁹ 

About 80%–90% of chlamydial infections¹⁰ and up to 80% of gonococcal infections¹¹ in women are asymptomatic. These infections are detected primarily through screening. Because the symptoms associated with PID can be nonspecific, up to 85% of women with PID delay seeking medical care, thereby increasing the risk for infertility and ectopic pregnancy.¹² Data from two randomized controlled trials of chlamydia screening suggest that such screening programs reduce PID incidence. ^13,14

Human papillomavirus (HPV) infections are highly prevalent in the United States, especially among young sexually active women. Although most HPV infections in women resolve within 2 years, they are a major concern because persistent infection with specific types of the virus can cause abnormal cervical cells to be noted on a Papanicolaou (Pap) smear. These abnormal cells can progress to cervical cancer. Other types cause genital warts, low-grade Pap smear abnormalities, and, rarely, recurrent respiratory papillomatosis in infants born to infected mothers.¹⁵

Impact on Pregnancy Outcomes

Chlamydia and gonorrhea can result in adverse outcomes of pregnancy, including neonatal ophthalmia and, in the case of chlamydia, neonatal pneumonia. Although topical prophylaxis of infants at delivery is effective for prevention of gonococcal ophthalmia neonatorum, prevention of neonatal pneumonia requires prenatal detection and treatment.

Genital infections with herpes simplex virus (HSV) are extremely common, can cause painful outbreaks, and can have serious consequences for pregnant women and their infants.¹⁶

When a woman has a syphilis infection during pregnancy, she can transmit the infection to the fetus in utero. Transmission can result in fetal death or an infant born with physical and mental developmental disabilities. Most cases of congenital syphilis are easily preventable if women are screened for syphilis and treated early during prenatal care.¹⁷

Observations

Chlamydia — United States

Chlamydial infections in women are usually asymptomatic and screening is necessary to identify most infections.¹⁸ Routine chlamydia screening of sexually-active young women has been recommended by CDC since 1993.¹⁹ Rates of reported cases among women increased steadily from the early 1990s likely reflecting expanded screening coverage and use of more sensitive diagnostic tests (Figure 1). During 2011–2013, rates decreased from 643.4 to 619.0 cases per 100,000 females and then increased 1.3% to 627.2 per 100,000 in 2014 (Table 4).

Chlamydia rates are highest among young women, the population targeted for screening (Figure 5, Table 10). During 2013–2014, rates of reported chlamydia decreased 4.2% among females aged 15–19 years and increased 1.6% among females aged 20–24 years. Regionally, chlamydia case rates are highest among women in the South, with a rate of 694.4 per 100,000 females in 2014 (Table 4). Rates of reported chlamydia exceeded gonorrhea rates among women in all regions (Figures A and B, Tables 4 and 15).

Gonorrhea — United States

Like chlamydia, gonorrhea is often asymptomatic in women. Thus, gonorrhea screening is an important strategy for the identification of gonorrhea among women. Large-scale screening programs for gonorrhea in women began in the 1970s. After an initial increase in cases detected through screening, rates of reported gonorrhea cases for both women and men declined steadily throughout the 1980s and early 1990s and then declined more gradually in the late 1990s and the 2000s (Figure 12). After reaching a 40-year low in 2009 (104.5 cases per 100,000 females), the gonorrhea rate for women increased slightly each year during 2009–2011, but then decreased each year during 2012–2014. In 2014, the gonorrhea rate among women decreased to 101.3 cases per 100,000 females (Figure 13, Table 15).

The gonorrhea rate among women was slightly higher than the rate among men during 2001–2012, but the rate among men was higher than the rate among women in 2013 and 2014 (Figure 13, Tables 15 and 16). Gonorrhea rates are highest among young women (Figure 17, Table 21). Among young women and adolescents, rates were highest in 2014 among 19-year old females (643.9 per 100,000 females) (Table 23).

Congenital Syphilis

Trends in congenital syphilis usually follow trends in primary and secondary syphilis (P&S) among women, with a lag of 1–2 years (Figure 46). The rate of reported P&S syphilis cases among women declined 95.4% (from 17.3 to 0.8 cases per 100,000 females) during 1990–2004 (Figure 33). Since 2004, the rate has fluctuated. It increased during 2005–2008 to 1.5 cases per 100,000 females in 2008, decreased during 2009–2011 to 0.9 cases per 100,000 females in 2011, and plateaued at 0.9 cases per 100,000 females during 2012–2013. In 2014, the P&S syphilis rate among women increased to 1.1 cases per 100,000 females (Table 28). This represents a 22.2% increase relative to 2013.

Similarly, the reported rate of congenital syphilis cases declined by 92.4% during 1991–2005, from a peak of 107.6 cases per 100,000 live births in 1991 to 8.2 cases per 100,000 live births in 2005, but has fluctuated since 2005 (Table 1). The congenital syphilis rate increased during 2006–2008 to 10.5 cases per 100,000 live births in 2008, decreased during 2009–2012 to 8.4 cases per 100,000 live births in 2012, and subsequently increased each year in 2013 and 2014, to 11.6 cases per 100,000 live births in 2014. This increase in 2014 represents a 27.5% increase relative to 2013 and a 19.6% increase relative to 2010 (Table 42).

As in previous years, the highest rates of P&S syphilis among women and the highest rates of congenital syphilis were observed in the South (Figures C and D, Table 28 and 42). However, all regions experienced an increase in the rate of P&S syphilis among women and the rate of congenital syphilis during 2013–2014. The largest increases in the rate of P&S syphilis among women were seen in the West (50.0%), followed by the Midwest (28.5%), Northeast (25%), and South (7.1%). The largest increases in the rate of congenital syphilis were seen in the Northeast (74.1%), followed by the West (63.6%), the Midwest (32.8%), and the South (9.2%).

Although most cases of congenital syphilis occur among infants whose mothers have had some prenatal care, late or limited prenatal care has been associated with congenital syphilis. Failure of health care providers to adhere to maternal syphilis screening recommendations also contributes to the occurrence of congenital syphilis.²⁰

Pelvic Inflammatory Disease

Accurate estimates of PID and tubal factor infertility resulting from chlamydial and gonococcal infections are difficult to obtain, in part because definitive diagnoses of these conditions can be complex. Published data suggest overall declining rates of women diagnosed with PID in the United States in both hospital and ambulatory settings.^21-23 The National Disease and Therapeutic Index (NDTI) provides estimates of initial visits to office-based, private physicians for PID (NDTI; see Section A2.5 in the Appendix for more information). NDTI estimated that from 2004–2013 the number of visits to such physicians for PID among women aged 15–44 decreased (39.8%) from 123,000 to 88,000 visits (Figure E). The 2014 NDTI data were not obtained in time to include them in this report. Several suggestions have been put forth as factors that could influence PID rates, including increases in chlamydia and gonorrhea screening coverage, more sensitive diagnostic technologies, and availability of single-dose therapies that increase adherence to treatment.^22-24 While PID is declining nationally, it still causes an enormous amount of unnecessary and expensive morbidity.

Differences in PID diagnoses or treatment by race/ethnicity have been observed in earlier research.²¹ Using data from the National Survey of Family Growth, the overall proportion of sexually experienced women who have been treated for PID declined from 8.6% in 1995 to 5.7% in 2002 and leveled off to 5.0% in 2006–2010 (Figure F).²⁵ While this pattern was observed across all racial/ethnic groups, the proportion who had received PID treatment was higher among non-Hispanic blacks than those among Hispanics or non-Hispanic whites. These disparities are consistent with the marked racial disparities observed for chlamydia and gonorrhea. However, because of the subjective methods by which PID is diagnosed, racial disparity data should be interpreted with caution.

Ectopic Pregnancy

Ectopic pregnancy (EP) is a potentially life-threatening adverse pregnancy outcome that requires prompt evaluation and treatment, and an important cause of pregnancy related mortality. Past studies have found that it affects 1–2% of all pregnancies.^26-27 Fallopian tube pathology is the most common etiology of EP.²⁸

In the past, the National Hospital Discharge Survey, which collects information on discharged hospital in-patients in the United States, was used to estimate trends in the rate of EP. However, medical and surgical treatment of EP is currently provided in both inpatient and outpatient settings, making the task of tracking reliable estimates at the national level difficult.²⁹ More recent attempts to estimate EP incidence use data from surveys or administrative databases of public and private insurance and managed care systems.³⁰ Data from a large administrative claims database suggests the rate of EP increases with age among pregnancies in girls and women aged 15–44 years during the period of 2003 to 2013 (Figure G). In 2013, EP rates were highest among women aged 35–44 years. During 2012–2013, the EP rate decreased among all age groups, most notably in the 25–29 age group (21%).

     

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1 El-Bassel N, Gilbert L, Krishnan S, Schilling R, Gaeta T, Purpura S, et al. Partner violence and sexual HIV-Risk behaviors among women in an inner-city emergency department. Violence Vict.1998;13(4):377-393.

2 Pulerwitz J, Amaro H, De Jong W, Gortmaker SL, Rudd R. Relationship power, condom use and HIV risk among women in the USA. AIDS Care. 2002;14(6):789-800

3 McCree DH, Rompalo A. Biological and behavioral risk factors associated with STDs/HIV in women: implications for behavioral interventions, In: Aral SO, Douglas JM,Lipshutz JA (editors). Behavioral Interventions for Prevention and Control of Sexually Transmitted Diseases (p. 310-324). New York, NY: Springer.

4 Hogben M, Leichliter JS. Social determinants and sexually transmitted disease disparities. Sex Transm Dis. 2008;35(12):S13-S18.

5 O’Leary A. A woman’s risk for HIV from a primary partner: balancing risk and intimacy. Annu Rev Sex Res. 2000; 11:191-234.

6 Manderson L, Chang T, Tye LC, Rajanayagam K. Condom use in heterosexual sex: a review of research, 1985–1994. In: Catalan J, Sherr L, Hedge B (editors). The impact of AIDS: psychological and social aspects of HIV Infection. p. 1-26. The Netherlands: Harwood Academic Publishers.

7 Paavonen J, Westrom L, Eschenbach. Pelvic Inflammatory Disease. In: Holmes KK, Sparling PF, Stamm WE, Piot P, Wasserheit JN, Corey L, Cohen, MS, Watts DH, (editors). Sex Transm Dis. 4th ed. New York: McGraw-Hill; 2008:1017-1050.

8 Hook EW III, Handsfield HH. Gonococcal infections in the adult. In: Holmes KK, Sparling PF, Stamm WE, Piot P, Wasserheit JN, Corey L, et al, (editors). Sex Transm Dis. 4th ed. New York: McGraw-Hill; 2008:627-45.

9 Westrom L, Joesoef R, Reynolds G, Hagdu A, Thompson SE. Pelvic inflammatory disease and fertility: a cohort study of 1,844 women with laparoscopically verified disease and 657 control women with normal laparoscopy. Sex Transm Dis. 1992;9:185-92.

10 Stamm WE. Chlamydia trachomatis infections in the adult. In: Holmes KK, Sparling PF, Stamm WE, Piot P, Wasserheit JN, Corey L, et al, (editors). Sex Transm Dis. 4th ed. New York: McGraw-Hill; 2008:575-93.

11 Marrazzo JM, Handsfield HH, Sparling PF. Neisseria gonorrhoeae In: Mandell GL, Bennett JE, Dolin R (editors). Principles and practice of Infectious Diseases, 7th ed. Philadelphia, PA: Churchill Livingstone; 2010: 2753-2770.

12 Hillis SD, Joesoef R, Marchbanks PA, Wasserheit JN, Cates W Jr, Westrom L. Delayed care of pelvic inflammatory disease as a risk factor for impaired fertility. Am J Obstet Gynecol.1993;168:1503-9.

13 Scholes D, Stergachis A, Heidrich FE, Andrilla H, Holmes KK, Stamm WE. Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. N Engl J Med. 1996;34(21):1362-6.

14 Oakeschott, P, Kerry S, Aghaizu A, Atherton H, Hay S, et al. Randomised controlled trial of screening for Chlamydia trachomatis to prevent pelvic inflammatory disease: the POPI (prevention of pelvic infection) trial. BMJ. 2010;340:c1642.

15 Centers for Disease Control and Prevention. Prevention of genital HPV infection and sequelae: report of an external consultants’ meeting. Atlanta: U.S. Department of Health and Human Services; 1999.

16 Kimberlin DW. Herpes simplex virus infections of the newborn. Semin Perinatol. 2007;31(1):19-25.

17 Centers for Disease Control and Prevention. Guidelines for prevention and control of congenital syphilis. MMWR Morb Mortal Wkly Rep. 1988;37(No. SS-1).

18 Farley TA, Cohen DA, Elkins W. Asymptomatic sexually transmitted diseases: the case for screening. preventive medicine. 2003;36:502-9.

19 Centers for Disease Control and Prevention. Recommendations for the prevention and management of Chlamydia trachomatis infections. Morb Mortal Wkly Rep. 1993 Aug 6;42(RR-12):1-39.

20 Centers for Disease Control and Prevention. Congenital syphilis — United States, 2003–2008. MMWR Morb Mortal Wkly Rep. 2010;59:413-17.

21 Sutton MY, Sternberg M, Zaidi A, St. Louis ME, Markowitz LE. Trends in pelvic inflammatory disease hospital discharges and ambulatory visits, United States, 1985–2001. Sex Transm Dis. 2005;32(12):778-84.

22 Bohm MK, Newman L, Satterwhite CL, et al. Pelvic inflammatory disease among privately insured women, United States, 2001–2005. Sex Transm Dis 2010;37:131–136.

23 Whiteman MK, Kuklina E, Jamieson DJ, et al. Inpatient hospitalization for gynecologic disorders in the United States. Am J Obstet Gynecol 2010;202:541 e1–6.

24 Owusu-Edusei, Kwame Jr. Bohm, Michele K. Chesson, Harrell W. Kent, Charlotte K. Chlamydia screening and pelvic inflammatory disease: Insights from exploratory time-series analyses. Am J Prev Med. 2010;38(6):652-7.

25 Leichliter JS. Chandra A. Aral SO. Correlates of self-reported pelvic inflammatory disease treatment in sexually experienced reproductive-aged women in the United States, 1995 and 2006-2010. Sex Transm Dis. 2013;40(5):413-8.

26 Centers for Disease Control and Prevention. Current Trends Ectopic pregnancy–United States, 1990–1992. MMWR Morb Mortal Wkly Rep 1995;44:46–8.

27 Van Den Eeden SK, Shan J, Bruce C, Glasser M. Ectopic pregnancy rate and treatment utilization in a large managed care organization. Obstet Gynecol 2005;105:1052–7.

28 Medical management of ectopic pregnancy. ACOG Practice Bulletin No. 94. American College of Obstetricians and Gynecologists.Obstet Gynecol 2008;111:1479–85.

29 Zane SB, Kieke BA Jr, Kendrick JS, Bruce C. Surveillance in a time of changing health care practices: estimating ectopic pregnancy incidence in the United States. Matern Child Health J 2002;6:227–36

30 Hoover KW, Tao G, Kent CK. Trends in the diagnosis and treatment of ectopic pregnancy in the United States. Obstet Gynecol. 2010;3(115):495-502.

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