Gonorrhea in Women

Gonorrhea in Women

Reviewed By:
Joanne Poje Tomasulo, M.D., ACOG
Marc Kaufman, M.D., ACOG

Summary

Gonorrhea, also known as “the clap,” is an extremely contagious sexually transmitted disease (STD). It is the second most reported infectious disease in the United States (after chlamydia), according to the Centers for Disease Control and Prevention (CDC).

The gonorrhea bacteria gains access to the body from the body fluids associated with sexual activity. Transmission can occur during any kind of sexual contact – vaginal, oral or anal. In women, the disease usually first infects the opening of the uterus (cervix) or the urethra, the tube just above the vagina that leads to the bladder. Symptoms may include some unusual vaginal discharge (possibly bloody) or pain while urinating. Most women experience no symptoms. Gonorrhea infection in the anal area may be caused by anal sex or contamination of the bacteria from the genitals. Oral sex may cause gonorrhea of the throat.

If gonorrhea is left untreated, it can spread to other organs. Most commonly in women, it spreads into the upper reproductive organs, such as the uterus, fallopian tubes and ovaries. Inflammation in those sites can cause pelvic inflammatory disease (PID). When PID is untreated, its inflammation can scar the tissue within the fallopian tubes and can cause infertility. In rare cases, untreated gonorrhea may spread to other systems in the body and infect the heart, brain or joints.

Some nonsexual transmission of gonorrhea can also occur. A pregnant woman with gonorrhea can transmit it to her baby during childbirth, frequently causing an eye infection. In addition, an infected person can transmit the bacteria from their original infection site by touching that area and then touching another susceptible body part, such as the eyes.

Sexually active young people are at greatest risk for gonorrhea. The majority of cases reported to the CDC occur in sexually active people under age 24. People who have unprotected sex, have multiple sexual partners or have sexual partners who have multiple sexual partners are most likely to contract gonorrhea.

Gonorrhea can be diagnosed with several tests, including a urine test that detects the bacteria’s genes and gram stains and cultures that use samples from the infected area. After diagnosis, a patient’s sexual partners should be notified so they may be tested and, if necessary, treated for gonorrhea.

Antibiotics are the standard treatment for gonorrhea. They are usually given orally or by injection. Antibiotic eye drops may be given to newborn babies of pregnant women with gonorrhea to prevent infection.

Gonorrhea can be prevented by practicing safe sex, which includes limiting sexual partners, knowing the sexual history of partners and using latex condoms and dental dams during sexual activity.

About gonorrhea and women

Gonorrhea, also called “the clap,” is a type of sexually transmitted disease (STD) caused by bacteria. The bacteria that cause gonorrhea (Neisseria gonorrhoeae) thrive in moist areas of the body in both women and men. Gonorrhea can be spread through any kind of sexual contact (vaginal, oral or anal) with an infected person. Ejaculation is not necessary to spread gonorrhea. Other physical contact with an infected area may lead to spread of the disease (e.g., touching one’s genitals and then touching an eye or the inside of the mouth). However, it cannot be spread through kissing.

In women, the gonorrhea bacteria frequently enter the body during vaginal intercourse. Tissue types in two areas provide good receptors for the bacteria and are the primary infection sites. The cervix (entrance to the uterus) is the most likely site of gonorrhea infection. It may cause an inflammation of the cervix called cervicitis. The bacteria from vaginal intercourse may also reach the tube that leads to the bladder (urethra) and cause an inflammation there called urethritis.

Gonorrhea may also lodge in the vagina and glands near the entrance to the vagina (Bartholin glands). This can result in painful, enlarged swelling of the gland usually unilaterally. The structure of vaginal membranes undergoes changes from the hormone estrogen as part of puberty. The gonorrhea bacteria cannot readily adhere to these membranes in adults. As a result, gonorrheal inflammation of the vagina is uncommon in adult women. However, in girls who have not reached puberty, the gonorrhea bacteria can adhere to these vaginal membranes and cause an infection of the vagina called vulvovaginitis. The appearance of this condition, which may be the result of sexual activity in a preadolescent girl, may indicate sexual abuse.

Gonorrhea may spread through the cervix and infect the upper reproductive organs (uterus, fallopian tubes and ovaries). If left untreated in those organs, gonorrhea may cause pelvic inflammatory disease (PID). PID may scar the reproductive organs and make it difficult or impossible for a woman to become pregnant (infertility) or to carry the pregnancy to term (miscarriage). The scarring also increases the possibility of an ectopic pregnancy, a dangerous condition where a pregnancy develops outside the uterus, frequently in a fallopian tube. Like gonorrhea, PID may produce no symptoms but can cause serious damage.

In addition, gonorrhea can occur in the anus, either from anal sex or by spreading there from the genitals. People may also contract gonorrhea in the throat from having oral sex with an infected partner. If a person touches an infected area and then touches their eyes, gonorrhea may spread to the eyes, a condition called gonococcal conjunctivitis. However, the gonorrhea bacteria can only live briefly away from a moist surface. It cannot survive or be transmitted from inanimate objects or surfaces.

In extreme cases that are left untreated, gonorrhea can spread to other parts of the body and infect the brain and spinal cord (meningitis), heart (endocarditis) or joints (arthritis).

Gonorrhea presents more complications for pregnant women. A woman with gonorrhea may transmit the disease to her child while giving birth. The baby may first be infected in the eyes, a condition called ophthalmia neonatorum. This can result in blindness. If the infection is not treated, it can spread and cause joint infection or a life-threatening blood infection.

People with gonorrhea frequently have chlamydia at the same time, another STD that may have few symptoms. Gonorrhea has fewer complications for men, most commonly infecting the urethra.

More than 339,500 cases of gonorrhea were reported to the Centers for Disease Control and Prevention (CDC) in 2005, the last year for which figures are available. However, the CDC estimates that this number accounts for only half of the nation’s gonorrhea cases since many often go unreported. African-Americans remain the group most affected by the disease with 18 times the incidence than found in white Americans. Although there has been a slight decline since 2000, the CDC estimates that 119 per 100,000 women contracted gonorrhea in 2005. For the past five years, the gonorrhea rate has been uncharacteristically higher in women than men.

Risk factors for gonorrhea

Gonorrhea is spread primarily through sexual activity, including vaginal, oral and anal sex. Risk factors are elements that increase the risk of developing a disease. However, women with one or more risk factors may not contract the disease and those without any risk factors may develop the disease. Factors known to increase risk for gonorrhea include:

  • Age. Gonorrhea is most prevalent among sexually active people under age 25, especially African-American women. In 2005, the overall gonorrhea rate was highest among 20- to 24-year-old males and females, more than four times higher than the national gonorrhea rate, according to the Centers for Disease Control and Prevention.
  • Sexual activity. Women who engage in unprotected sex, have multiple partners or who have sex with people who have multiple partners or high risk partners are more likely to contract gonorrhea.
  • History of sexually transmitted diseases (STDs). Women who have had other STDs are at greater risk for contracting gonorrhea.

Signs and symptoms of gonorrhea

Most women who contract gonorrhea experience no symptoms at all or symptoms so mild they are not noticed. Men are more likely than women to experience symptoms, which may include burning during urination or unusual discharge from the penis.

Gonorrhea symptoms may appear several days after exposure to the disease or may take up to 30 days to appear. When gonorrhea in women progresses to the upper reproductive tract as pelvic inflammatory disease (PID), the symptoms from the original infection site (for example, the cervix) may have disappeared.

Gonorrhea symptoms in women may include:

  • Pain or burning during urination (dysuria)
  • Abnormal vaginal discharge
  • Pain during intercourse (dyspareunia)
  • Bleeding after intercourse
  • Rectal pain
  • Itching (genital or anal)
  • Sore throat (following oral sex)
  • Red eyes (in cases where the bacteria has been spread to the eyes)

Signs and symptoms of more advanced gonorrhea may include non-menstrual bleeding, pelvic pain, vomiting and fever. The appearance of these symptoms may indicate the development of PID.

Many of these symptoms are also common for other conditions, including other sexually transmitted diseases and urinary tract infections. A woman who experiences any of these symptoms should consult a physician, preferably a gynecologist, for evaluation and abstain from any sexual activity until the condition is treated.

Diagnosis methods for gonorrhea

Physicians begin diagnosis by taking a complete medical history, including a history of sexual partners. The physician will also conduct a physical examination and, for women, a pelvic examination.

Several laboratory tests are available to diagnose gonorrhea, including:

  • Nucleic acid amplification test (NAAT). This test takes a urine sample or a sample of discharge from the infected area and detects genes from the gonorrhea bacteria.

  • Culture test. Requires swabs from the cervix, urethra, rectum or throat for a culture. The sample is placed in culture media and allowed to grow for at least 48 hours. Culture tests are more accurate than some other tests, but take more time.

  • Gram stain test. Involves taking swabs of cells from the infected area. The cells are stained with dye and the bacteria can be identified under a microscope. Although this test is rapid, it is reliable in only about 50 percent of women with gonorrhea.

  • Enzyme linked immunoabsorbent assay test (ELISA test). This test uses a discharge sample from the infected area. It detects antibodies (substances that fight the infection) to the bacteria. It is more sensitive than the gram stain test but not as accurate as the culture test.
  • DNA probe test. Uses a discharge sample from the infected area and tests for the genetic material (deoxyribonucleic acid [DNA]) of the bacteria. It is less accurate for samples collected from the throat. The DNA probe test may also identify chlamydia, a sexually transmitted disease that frequently occurs with gonorrhea.

Physicians may use two of the above tests to confirm the diagnosis. The NAAT urine test is becoming more widely used. It is more accurate than the Gram stain test and faster than culturing specimens. However, the culture test provides information about drug-resistant strains of bacteria, which can help determine which antibiotic to use for treatment.

In addition, there have been pilot studies on the use of home tests for the diagnosis of gonorrhea. Early research has indicated that self-collected vaginal swabs are as effective as doctor’s cervical examinations for diagnosing STDs. Researchers plan to continue work on the development of home test kits for the general public.

All diagnosed cases of gonorrhea must be reported to the Centers for Disease Control and Prevention (CDC) and usually to local and state health agencies as well. CDC monitoring of certain “notifiable” diseases assists with control and prevention. An infected woman should notify her sexual partners of the diagnosis so they may seek medical testing and treatment. All sexual contacts from 60 days prior to the appearance of symptoms or the medical visit should be notified. If the infected person does not notify partners, the local health agency will attempt to do so.

Treatment options for gonorrhea

Gonorrhea is treated with antibiotics, usually given in the form of a pill or an injection. In recent years, some strains of the gonorrhea bacteria have become resistant to various antibiotics. A culture of the gonorrhea may indicate if it is a resistant strain. Because of the increase in resistant strains, physicians may treat all gonorrhea cases as if they were drug-resistant strains and use nonresistant antibiotics.

Pregnant women with gonorrhea have additional treatment considerations. They cannot take certain antibiotics because the drugs may affect fetal development. For example, tetracycline antibiotics may discolor the developing baby’s teeth. Gonorrhea also makes women more likely to have a miscarriage or a premature birth. In addition to treatment with antibiotics, they may be treated with other drugs to avoid preterm labor.

Most antibiotics can be administered in a single dose or a week’s worth of pills. The patient should refrain from sexual activity for seven days (for either medication) to give the medication time to work. Patients should have a follow-up physician visit after a week to recheck cultures and verify that the gonorrhea has been cured. They should be certain to complete any oral medication or the infection may not be eradicated. Patients treated for gonorrhea can be reinfected with the disease if they have sexual contact with another infected person.

People infected with gonorrhea are frequently infected with chlamydia, another sexually transmitted disease with few symptoms. When gonorrhea is diagnosed, physicians may prescribe a combination of antibiotics in order to treat the patient for chlamydia, as well.

Due to the continued increase in drug-resistant strains of the disease, the Centers for Disease Control and Prevention issued a recommendation in early 2007 for gonorrhea to now be treated with a single class of newer antibiotics known as cephalosporins. The agency is also calling for increased research efforts into developing more nonresistant antibiotics to combat the growing scarcity of treatment options for the disease.

Prevention methods for gonorrhea

Although scientists are working to develop a safe, effective vaccine for gonorrhea, no vaccine exists at this time. However, women can help prevent gonorrhea by practicing safe sex. This includes always using latex condoms during sex, minimizing the number of sexual partners, knowing the sexual history of sexual partners and testing for sexually transmitted diseases (STDs). The use of a latex dental dam during oral sex can minimize the risk of contracting gonorrhea in the throat. Abstinence from all sexual activity can completely prevent the disease.

Regular gynecological examinations and frank discussions with physicians about sexual activity can help women monitor their health and exposure to gonorrhea and other sexually transmitted diseases. STD testing is not standard for gynecological exams, so women should request tests if they are concerned about their exposure.

Pregnant women should be tested for gonorrhea and treated if necessary. Babies born in hospitals are treated with silver nitrate eyedrops to prevent gonorrhea in their eyes.

Ongoing research regarding gonorrhea

Researchers continue to study gonorrhea to gain information about treatment and prevention of the disease. Scientists from the National Institute of Allergy and Infectious Diseases (AIAID) are working to understand the bacteria that cause gonorrhea in an attempt to better diagnose, treat and prevent the disease. Some of the most current research is focused on the following areas:

  • Antibiotic resistance. Researchers are trying to determine how the Neisseria gonorrhoeae bacteria become resistant to antibiotics. Scientists have developed a laboratory method to detect the resistant strains, which can help physicians choose an appropriate treatment. 

  • Process of infection. Some studies are aiming to discover how the bacteria infect the body’s cells while evading the immune system. This research may lead to the development of an effective vaccine.

Questions for your doctor regarding gonorrhea

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor or healthcare professional the following questions about gonorrhea:

  1. How can I tell if my symptoms are due to gonorrhea?
  2. What tests will be used to diagnose my condition?
  3. How can I tell if the infection has spread elsewhere on my body?
  4. Do I have any other sexually transmitted disease?
  5. What type of antibiotic will you prescribe for me?
  6. How long will it take for the medication to work? What happens if the medication doesn’t work?
  7. How long will I need to abstain from sexual relations?
  8. Is there any way to tell if my sexual partner has gonorrhea?
  9. Do I need to contact all of my sexual partners?
  10. Is my case reported by name to any health officials?
  11. Is my gonorrhea likely to return?
  12. What will be done if the antibiotic does not work?
  13. Will having gonorrhea affect my or my partner’s fertility?
  14. How will I be treated if I’m pregnant?
  15. What can be done to prevent spreading gonorrhea to my baby during delivery?
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